29 WILSON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
t� This Section For Official Use-Only
I�1 Building Permit Number: D e A
Building Official(Print Name) i na Date
SECTION 1: SITE INF16KNIATION
1.1 Property Address: �,r 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwnertofRec rd:
C� �crt� 6uI rwlo or _ `�rcl evn M4 a 9 7a
Name(Print) U City,State,ZIP
c . c-f= 6b 3,-6,rf '636 6
No.and Strc t Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition El
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:
Brief Description of Proposed Work2:
1 CO4t-�o e is
NO 1
SECTION 4. ESTIMATED CONSTRUCTION codrs
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ 2 3po I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ElStandard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other-Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ /
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 2 3Y0 ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ..
5.1 Construction Supervisor License(CSL)
A (� 8 2 1 f 3
n to 3
/ I Aa f l 1)"M I J( License Number Expi atio Date
Name of CSL Holder
—
A 19� List CSL Type(see below)
No. and Street Type Description
��� IYl O l q� U Unrestricted(Buildings u to 35,000 cu. ft.)
C7r R Restricted 1&2 Family Dwelling
City/Town, S[ te,ZIP M Masonry
R RoofingCover in
WS Window and Sid in
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) l 606 �o
I &.y HIC c&11 WA r�'Registration Number Expiration Date
HIC Company Nam or Hl egistrant Name
IBC -ro(h a
No. amend S e t— \QF�In,�ail,,address
be 1rotlrn t (Y)I+ 01-77a- to( ) t 1 C
City/Town, State, IP Tel hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.'§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Iss T
nce of the building permit.
Signed Affidavit Attached? Yes ........... No ........... ❑
SECTION 7a: OWNER 4UTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize -0c4 4 C�h4I6tS�
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(El6etroolic SignatureT Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this applicatio is tie,a'nnd accurr to to theme best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.eov,-oca Information on the Construction Supervisor License can be found at www.mass.eov/des
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed- Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S�U.ENM, NWSACHUSETTS
BUMDING DEP:6RTNIENT
120 WASHNGTON STREET, 3° FtOOR
e TEL (978) 745-9595
Fnx(978) 740-9846
KI-,IBE.RLEY DRISCOLL
MAYOR TmoNus ST.PI&RR&
DntEcroR OF PL:BLIC PROPERTY/BL'IImNr,coNm ssio.NER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
j$01.4t 1.1.11 ri11F
(name of hauler)
The debris will be disposed of in :
L bw,e� /TQm I�twlny y Q�t �l,
( me of facility) .
kS 3
(address of facility)
1
signature of permit applicant
1f,SZ
ate
Jfirivf7.Jcxx
The Commonwealth afMassachusetts
UrDepartment ofIndustrial Accidents
Office of Investigations
600 Washington Street
'
Boston, MA 02111
www.niass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeEibly
Name (Business/Organization/Individua /1/�l): / Il tbd d DeAdly
Address: Jr Bf15}0I&
City/State/Zip: ri(nd 01170 Phone #: 97r- 6_.36- UY
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet. : 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] i employees. [No workers' 13.❑ Other
comp. insurance required.]
"Any applicant that checks box it I must also till oul the section below showing their workers'compensation policy inlixmation.
p Homeownns who subunit this affidavit indicating They ate doing all work and then hire outsideeOulractOIS must Mubmit a new affidavit indicating such
'Contractors that check this box must attached an additional sheet showing the name ol'the sub-eontracmts and their woikets'connp.policy information.
1 am an employer that is providing workers'eontpeasution insurance for my employees. Below is the policy anti job site
information.
Insurance Company Name:_
Policy #or Self-ins.Lie.#: Expiration Date:
,lob Site Address: 2q u)dw n�J'KLI City/State/Zip: Sd term #Ill cI 7a
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500-00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
[do hereby certify under the pains and penalties gfperjury that the information provider/above is true and correct
Signature: � ��� Date:
Phone#:
Official use only. Do not write in this area, to be completed by chy or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
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HOME:IMPROVEMENT, CONTRACTOR
� Registr$tion: 162722 Type. z:
6�Expiration: individual 4/612013•
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Mfl 1 AEL THOMAS DEMI LE
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MICHAEL DEMILL.E r
4- Ai MA 01970 ` ^ Undersecretary °u
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Office of Consumer Affairs&Business Regulation
' .OME IMPROVEMENT CONTRACTOR
r ' � Registration .=IASC88 TyPei
Expiretl6�� 1-1118�2g13 Supplement [
LOWE'S HOMESSr<E RSiNE o
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{i RICHARD CHALCYNE f� tl
i 1 136 TURNPIKE RED?SURTE 10Q'�
SOUTH BOROUGH;fulft=Ot7-72
� Undersecretary �
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80,02901 si1�'_PR Donnelley All rights reserved.-0221
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CONTRACT# 000393.4
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4v3A�SAC�IUSETTS EXTERIOR SOLUTIONS INSTALLED CONTRACT ; E, rz,;,
LIT ALLED.SALES SPECIALIST. /. NUMBER 7 CUSTOMER.a
/- - STRF_ET ADDRESS V
S CFE Np{ I STREETADDRESS
- $TA');E ZIP
I�-- STATE ZIP
TELEPHONE _ TELEPHONE p.
1 CM.H BIwN LCC REG
E r f OWE S HOME CENTERS,INC'S MA HIC NO., 148688 GqR CHnRGE p
FEIN'.530748358 .,.�. ,,,�.
TI only a poet f r a me cnandse and services.printed below. Ths becomes an agreement upon payment. Upon payment the entire agreement Including the specifically completed pages of this ti
tl urent tinetneirs nd conditions included withth s document and any other addenda and attachments hereto•shar be referred to herein debris'Goofrect
PIUASr,READ AI FRMS AND CONDITIONS ON THE REVERSE SIDE OFTH IS PAGE AN D FOLLOWING PACES BEFORE SIGNING 1-
I CITY STATE ZIP
` INSTALLATION STREETADDRFSS
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(t ��:1; e.iA i n� 3 ?e3 i•^i�/e,F3S cr s1 Ys �.+
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I Contract Total aF
C; IAre permits required for this installation?: [}a Yes [ ] No applicable tax included / xaC 0
NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right.By signing this Contract,Customer
acknowledges having received a copy of this pamphlet before work began informing Customer of the potential risk of the lead hazard exposure
from.renovation ectiv ty to be performed in Customer's dwelling unit. -
f PHJTO REL-ASE:Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this
Contract,and Irrevocably grants to Lowe's all right,title and interest in and to the photographs for use in all markets and media,worldwide,in perpetuity.,-
i I Customer auth��nzes Lowe's to copyright, use and publish the photographs in print and/or electronically, and agrees that Lowe's may use such ,
hoto rala'1s for an lawful purpose, including, but not limited to,marketing, advertising, publicity, illustration: training and Web content. By initialing
P 9 Y P P g�
(t.. tomtr agi ees to the foregoing. [Customer to initial to the left].
I ' Work, -n s to comapcc upon reasonable availability of Contractor and/or any special order or yust�}!�'er made Good(s)wtiich is anticipated to be r
I. ) ,/,. ✓5 / ;F, [fille in date]..Estimated completion date is P2:!i:f 7�^ -[fill in date].
Said estimated substantial completion date is not of the essence. A statement of any contingencies that would materially change said estimated substantial
l I completion date is as follows: -
(if applicable, inserter statment of such contingencies).
�IF 7HE CONTP\r'T TOTA.i.i5$1,000.00 OR LESS Customer must pay in full ', - -
CUElIPLETF !"H9�SCI�i ION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:. _
m - nl ru!P OR 1 Customer to use the following payment schedule: - -
• rto-rs [
'I P•r W s. Y- k I contract rice and
j 'I)Deposit $_ robe paid upon siging contract.Deposit should be 1/3 the toter p >.
',(�)Faym=nt of 8 to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's -
i Ito rc one.of if Is fc'oWing(ch=ck appropriate box below):
} I[ �C�arpe m}!rnr c edit card for the amount of the payment indicated above anytime after the date this Contract is signed; f'
or
{ ]Deposit my/our check for the amount Df the payment indicated above anytime after the date this Contract is signed; and
(3)Final payment or$100.00 to be paid upon completion of the installation and both parties'satisfaction. —l
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c,I=QA - -
r�rnmico uCPPRV I,AI ITI IAI I_Y AGREE IN ADVANCE THAT IN THE EVENT LOWS S HAS A DISPUTE CONCERNING THIS CONTRACT THAT I`;
' ''
jr
Contract Total � ��
No -applicable tax included
g y g 9 customer
{Arc Per required for this installation?: [7C]Yes [ ]
_ )
off this pamphlet before work be an informing Customer of the potential risk of the lead hazard exposure
NaTICE TO CUSTOMER.- Federal law requires Lowe's to provide you with the pamplet Renovate Right.B si nm this Contract,
acla±o•niiedges havinrq received a copy P p this
e,orr,r_nov=4toa_activ;`=. to be erformed in Customer's dwellin unit. worldwide,in perpetuity-.
and a tees that Lowe's may use such
?" bile and interest in and to the photographs for use in all markets and media,
r f.r,�>�;-LG.gg:=:Customer grants to t-owe's and Lowe's employees the right to take photographs of all work performed at the Premises relate q
use and publish the photographs in print and/or electronically, 9
y grants to Lowe's all right, i
;fscon;er autncr z_s ..owe's o copyright, publicity,
illustration, training and Web content. By initialing
r .ographs for any lawful purpose, including, but not
to initial to ng,the left)advertising, p Y
-Le,order agrees to the o,egoing. `_j(','
-- }. r05-7',� [fill in date].
e?o,1'ds to comme�^,ce upon
reasonabl[f31 avail;
date].Estimated or and/ r n y special order or lust er made Good(s)which is anticipated to be II
cOmP
�Ibange said
o
;aid est+,ratFd subs rtiai completion date is not of the essence. A statement of any contingencies'nserta that atatment of such contingencies)Iated.substanhal .
completinn date,s as follows. (if applicable,
,
t,
I,p FIE t,UNTRACT TOTAL IS$1,000 00 OR LESS Customer must pay in full. 000.00: -
a meat schedule: :. �.
O114PLETE THIS S C T IUN ONLY WHEN THCustomer to seUthe folTAL llowiing payment XCEEDS 1 I e authorize
Lowe's
i1 CJste, er to Pay-fn Full; OR I ]
to be paid upon sigmg contract.Deposit should be n the total contract pace;an
p to be paid an ,me after this Contract is signed and before commencement of installation,
(2)payment the
$ a eck appropriate box below):
�tado on of the following( ' -
I![ ]Che , ylour credit card for the amount of the payment indicated above anytime after the date this Contract is signed;
this
(8)Deposit
pit MY/c of check
00o to be paid upon completion nt indicatthe d atllation and both partie,,e anytime after thes'sat sfactionntracl is signed;and `
ment
I NOTICE REGARDING RRBITRATION AG EEMENT FOR CLAIMS COVERED BY M.G.ta
L.- 142A TO SUBM4TMTO-SUCHIARBITRATION-'r
o MIT SUCH DIS'P TETO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN,APPROVED BY.THE SECRETARY OF.THE EXEC
LOW E S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOCNE'S HAS A DISPUTE CONCERNING THIS CONTRACT THAT
�LOW,_S MAY SUB
.IVEUFFICE OF CO T SUC DiS F2S TO A P SNE$S REGULATIONS AND4'HE OWNS SHALL BE REQUIREb • )
!AS PROVIDED"IiTI M 6 L„ 14 1� Date: I��" .
Lon sNoohe'C Fters Inc 1. _ Date: / ��'
sl.
8y. J
Owner Signature
E'S.PURSUANT TO M.G.L...c 142A-.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE
J I THE nee SigJRES OF T,�tiE'pARTIESABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIAT
lBY LOW
SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES.
it FOLLOWING
ED ON THE REVERSE SIDE OF THIS PAGE, P D UNDERSTAND AND AGREEI TOHE ACT
p EC NOT SG[3 THIS CONTRACT IF THERE ARE BLANK SPACES AND.UNTIL YOU HAVE READ THE TERMS AND
CONDITIONS BELOW,N
BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE RE THE FOLL
ERNS AND CONDITIONS ENTITLED
O A COPY OF THIS CON�Tts1RERSE ECOT PT HE TF THIS IME OF S GNA�UREWING.PAGES OF THIS
:i CONTRACT.YOU DAY OF -
WITNESS OUR HAND(S)A ND S AL(S IfBELOW THIS
Centers In`c
�.Q4Ue',S 4_jGM9_C jj � r t" �`— J Co-owner or Witness.
'..�I- Owner
v
{� • SS ecialsObe W of this contract which was completely filled in prior to Customer's execution hereof.You,the buyer ma)
Customer acknowledges receipt of a true copy 0 2ooa ny Lowe s®Love's and the gable desyr
j cancel this transaction at.any time prior to midnight of the thud business day after the date of this transaction.Seaeet bK attached red ad arkoe of gabl aeon a ion..
aj form for an explanation of this right. FILE COPY
p
#90981 (Rev. 12110) ' "