23 GALLOWS HILL ROAD, BPA B-15-1334 L�51, 1
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
T One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied
Building Official(Print Name) Signature ate
SECTION 1: SITE INFORMATION
i 1.1 Property�AiddreSs:�r..� �I�3,d 1 n,( 1.2 Assessors Map & Parcel Numbers
T
ty t L 1 a is this an accepted street'?yes no Map Number Parcel Number
o
1.3 Zoning Information: 1.4 Property Dimensions: ..,,
0
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) t->
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard r -C
rn
Required Provided Required Provided Required Provide ;r CJ
CR
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: co
Zone: Outside Flood Zone? r1
Public❑ Private❑ Check if yes❑ Municipal 11On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Moi �k ID—ti4l l 5 M A- s `�°
Name(Pant) ( City,State,ZIP
23 CC a I l0�541 t gGI- �-if Lf 3o`Y 3 3 5
No.and Street �T Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
lot
SECTION 4: ESTIMATED CONSTRUCTION CO TS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ w 66 5. 97 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ / ❑Standard Cuy,town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ / 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire /Suppression)
/
Su ression) Total All Fees: $
065• 7 Check No. Check Amount: Cash Amount:
6. Total Project Cast: $ j 1 ❑Paid in Full ❑Outstanding Balance Due:
Ma,t.AL.o -To -i
l-C w Ips
Y=
SECTION 5: CONSTRUCTION SERVICES
5.1 Con traction SuperviXT-
soenLse(CSL) 1 11 -
IP
� 6 License Number Exprr do ate
Name of SL Hoer bbbbbb
List CSL Type(see below)
No. td Street -vType Description
_r U Unrestricted(Buildings up cu.ft.)
R Restricted I&2 Family Dwelling
City/ rrr, ate,�W M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Tele hTele h re Email address D Demolition
5.2 egistered Home Improvement Contractor(HIC)4AA 49 j
T`^ HIC Re��istration Number Expiration Date
HIC on any am or H16 egistra arae
i C [ � a�cyte
No.ar Street' 0,�1� ' ,2C 470 Emailaddress-
/ 6
Cit own, State,ZIP Telephone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize :BOJW� (�A6V
to act o my behalf,in all matters relative to work authorized by this building permit application.
Prin ner , me( lee ionic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
conta n in t is applica on is true an accurate to the best of my knowledge and understanding.
t C f^
Print or Auto ed A6 s sratAc(Electronic Signature) Date
NOTES:
I. 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
loInformation on the Construction Supervisor License can be found at w��
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basemenUattics,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"
-' The Conmuonkoealdr of Alti.v.sachrr.setts
Departinent of lndu.strtrirrl Accidents
I Congress Street, Suite Il10
- Boston, .h1.F1 0211=1-2017
- rvtrtt:rno.cv.gnr/din
%n-kers'Compensation htsura ace Affidavit: Ilei l(Iers/Contractors/Eteco icians/plumbers.
TO 1st: OLED MTI 11 111F. PF:RIMI"I I'INC: AU I TOM FN.
Applicant Information ] Please Print Lee•ible
Name Il4uancsrprl:Iniiali,xn lndi ciJua l: Form la U�Aflp
Address: )d*� TUGK.tIs �
CI(-y Slala zip:_ PfALCJil 1 M14 0106 Phone 0: fil- 5.'i2-035.2
:Arc lou an Imp/oIt f heck(he Ipproplt ne h,)x
'type of prolut (required):
1 Iain', int 1,' I',-ilh nyl I rr dull and rpen rim i'
] -
- El New a mlrurunn
I ant-,.ole pr prnLa of parina lap uvl hove n, uy9,rcca 1 rkine ILr me in
an: -:,•acny. R„w:,lkcl5'col„,.� S. ❑ Rcnwil•link
• 6 ( I. Insurmcc I'cyui,id.�.
9. ❑Demolition
�.❑I:nn a hrnuuwner doing all.cork ntcselC iAu av n'kers'ton,p_insannce rcyuired.l
10 ❑ Buildna vulklmon
_
El :un',It m mnu I 'Ind,'dl I e huin,. nn ten 1, I' n lac(all sock on un pt'1. uv. I ,till
ot,1111 111(.01 e(nllll lt,' .Illtcl'haw kec, tonilivn,31 ion mCnlarc c... ... vele II,❑ Electrical lcplil'i('Iadditions
In. 1 t'S,ellh, ' 'llpl t•T,
12.❑Plunillm Icpairs or additions
�.�I mn 11 n r:d C. r r r and I IMI C hired the Sul nn,'InIF h'(it,n(he.machcd?heel_
Ih :ul nu:, I ,'htanpl 1 C11MIJ lou u' rken coop lnwm
I3.❑Rool repairs
6.❑N' u' 'I gn'lt n'mlit'nlll rhl '."No,i 1111 it n_hl le, rplmu per M(A'c. 14.91Qlhu'_
15 ;l(1).aud ai ha\, n, c,npluyiu. I No,n,,krs "amp.it"m ano l cquir d,I
'rylplu,(n th,,I eh,ek I e I nu,el d' Illi out IIIa n halo, 'h u,g 111011 , rk r .... n cion It„lie I I nnvi on,
I i ..... 11, ho euhnul au. :Idavil n li,.m ing Ihc� art d ins all Ieork.md(hen]lit I nuleldr e.nlln.1,r>nidal 11 l nal a nen''1IM.. I and%:,aim_
'(lnul acb n'+duitcheeklhis lu•e must atlachedenaddu mulcheer4u.mg Me nam.of We..slho,m(r ms.,nd &M a&u col i(ie..
cmplm ce lI the.uh-tom ao"I'I ha v e emplovecs.I111 lnuJ pnn'idc(1161 e'nrkn'a'Ivnnp.policy math.'.
1 ant an entphgrer that is providit,Yorkers'compensation insuram-e for nn'enplorees. Below is the poli(;r and joh sit,,
infurnuuinn.
In urnceCompam Company
I
Ui3- w Bos t
alr-y 11 ,n S..It ills. (c r: Po)A-*_ _.
I eeJ, _ \pu' __
alion D tc: _�_��
4bSue \ddle's:_ 2�J �r^t`�OsIIJ$4-A eA CityStaleVIII:_ _gklrylr_ . C�y7G
Attach a cups'or the workers' compensation pulics declaration page(showin(;the policy number and expiration dalc).
I ailule (o.,ccure co\ciage ;is required under MGL, c. 152. 421A is a criminal violation punishable by a fine up to SI SOU INI
and 111'011C-veal imprisomnenl.as well as civil pumhics in the Brun of a STOP WORK ORDER and a line of up(o 5250.911 a
Lin aeainst the violator. A cnpv ufdlis statement may be 6:v%varded to the()nice of Intvsli w%s ofdw DIA Ar insurance
ancrage verification.
I do herehr cert4j-under the pains an d pemrlties of peljmy that Ihr-in fornutrion provided ahuoe is true and correct.
\ignal� tn_ 'OO �/y L/�-GT� D tl
Phone 'i: / f—f4532 P331;2-
Official use 01111'. Da nor nvrite in this area, to he canpleted Qt•cite•nr town offiriul.
Cite or Mown: Peni it(l.icense h
Issuing Aulhority(circle tine):
1. Roard of Health 2. Bidk in;Department 3.Cih'(I'ossn Clerk 4. Electrical Inspector >. Plumhing Inspector
6.Mher
Contact Person: Phone ii:
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Massachusetts Departmei of Pubic Safety
Board;ot Building Regulations and Standards
License:CS-071187
Construction Supervisor
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RONALD EWACHLIN
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STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- WORK- INT/EXT/PATIO DOOR
N91&, LOWE'S OF DANVERS, MA., STORE# 1094 [Document
TORE PHONE: (978)646-9099
1153 ANDOVER STREET ALESPERSON: EDWIN VELAZQUEZ
DANVERS, MA 01923-1450 ALESPERSON ID: 794346
Print Date: 11/12/2015
- This is only a Quote for the merchandise and services printed below. This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree-
ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, and any
other addenda or attachments hereto, shall be referred to herein as this"Contract."
PLEASE READ THIS ENTIRE DOCUMENT INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING
Lowe's Registration or Contractor License Number/Lowe's Contractor Name
Lowe's Home Centers, LLC's MA HIC NO.: 148688 Lowe's Home Centers, LLC's FEIN: 56-0748358
Customer Name Home Phone
S MARY MACDOUDALL 978-430-9335
O Customer Address Other Phone
23 GALLOWSTILL RD
L City State/Province Zip/Postal Code
D SALEM MA 01970
Installation Address
T 23 GALLOWSTILL RD
O Installation City Installation State/Province Installation Zip/Postal Code
SALEM MA 01970
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
76921 : NA : SOS : SOS THERMA TRU CLASSIC CRAFT : QUOTE#15185800 : REEB MILLWORK OF NEW ENGLAND - QTY 1
1049 : 87548 : STK : 1-4-8 RED OAK BOARD : 1-4-8 RED OAK BOARD : BABCOCK LUMBER - QTY 1
1049 : 87548 : STK : 1-4-8 RED OAK BOARD : 1-4-8 RED OAK BOARD : BABCOCK LUMBER - QTY 1
3551 : EC266 : STK : PNELATT 266 1-1/2-INX1/4-INX10-FT: PNELATT 266 1-1/2-INX1/4-INX10-FT : EAST COAST MILLWORK DISTRIBUTI - QTY 2
18302 : STK : PN CSE 351 2-1/2-INX1 1/16-INX8-FT : PNE CASE 351 2-1/2X11/16X8' - QTY 3
19238 : 444 8PINE : STK : PNE CSE 444 5/8-INX3-7/16-INX8-FT : PNE CASE 444 5/8"X3-7/16"X8' : EMPIRE COMPANY, INC. (THE) - QTY 3
131207 : 131207 : STK : 1-8-16 PRIMED FNGR JNT (+333358) : 1-8-16 PRIMED FNGR JNT(+333358) : IRVING FOREST PRODUCTS (MAINE) - QTY 4
185170 : 0028706 : STK : 5/4X6X16 FJ PRIMED PINE : 5/4X6X16 FJ PRIMED PINE : BOISE CASCADE LLC - QTY 2
Store 1094 Project No. 456135636 for MARY MACDOUDALL Page 1 of 8
STORE COPY
474416 : 69124182 : STK : AM 24-IN X 50-FT WHITE TRIM COIL : AM 24-IN X 50-FT WHITE TRIM COIL : AMERIMAX HOME PRODUCTS - QTY 1
585251 : 20297807 : STK : LARSON QUICKFIT HANDLE KIT BRASS : LARSON QUICKFIT HANDLE KIT BRASS : LARSON MANUFACTURING COMPANY -
QTY 1
585259: 14604042 : STK : LARSON TWFV 361N FRAME BRN : LARSON TWFV 361N FRAME BRN : LARSON MANUFACTURING COMPANY - QTY 1
444852 : SIGNATURE CLEAR BRAS : SOS : Signature Cir Brass 36" Brown : LARSON, SIGNATURE CLEAR BRASS EARTH-TONE BROWN 36-IN WIDTH X
81-IN HEIGHT : LARSON MANUFACTURING COMPANY- QTY 1
Materials Price $ 7724.47
INSTALLATION DESCRIPTION -
Stock or SOS : SOS Door Type : Exterior
Select Location : Front Door Select New Door : Single Pre-hung
Hardwood (Mahogany or Oak) Door: No Side Lights or Transoms : Yes
Total Number of Side Lights and Transoms : 2 Hidden Damage Description : None
Number of additional holes bored for accessories : None Install Specialized Mortise Hardware : No
Install Storm Door: No Stock or SOS : SOS
Door Type : Exterior Select Location : Side Door
Select New Door : Single Pre-hung Hardwood (Mahogany or Oak) Door : No
Side Lights or Transoms : No Hidden Damage Description : None
Number of additional holes bored for accessories : None Install Specialized Mortise Hardware : No
Install Storm Door: No Total Linear Feet of Custom Trim to be Installed : 0
Deliver Door: Yes Customer Understands Scope of the Project : Yes
Permit Required : No Additional Miles Traveled over 20 : 0
Bring Up To Code Description : None Local Disposal Fee : Yes
Describe Other Work Needed : build out jamb,cover in trim coil,custom Other Work Charge : Yes
work,cement foundation,fix sill add oak
Comments : No Comment Lead Safe Practices : No
Labor Charges $ 2376.00
Detail Deduction $ 35.00
Additional Specifications:
Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop-
erty is governed by Historic District Regulations.
Store 1094 Project No. 456135636 for MARY MACDOUDALL Page 2 of 8
STORE COPY
d[tionalpea we's to ications:Fe Federal law requires Loprovide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families,
Child Care Providers and Schools. 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 activity to be performed in Customer's dwelling unit.
PHOTO RELEASE: Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photograghs of the Premises where In-
stallation Services will be performed and all work performed at the Premises related to this Contract, and irrevocably grants to Lowe's all right, title, interest in
and to the photographs for use in all markets and media, worldwide, in perpetuity. Customer authorizes Lowe's to copyright, use and publish the photographs in
print and/or electronically, and agrees that Lowe's may use such photographs for any lawful purpose, including, but not limited to, marketing, advertising, publi-
city, illustration, training and Web content. By initialing here, Customer agrees to the foregoing. [Customer to initial to the left].
NOTICE TO CUSTOMER-PRICE CALCULATIONS: In order to properly perform the installation of certain Goods, the Contract Price may include more Goods
than actually will be installed based on the measured square footage of the Project Area. As a result, the parties agree that the lump-sum Price stated in this
Contract is calculated upon both the value of the estimated Goods required to fulfill the Contract(including waste), which may exceed the actual square footage
of the Project Area, and the labor which may be estimated based on the amount of Goods required to fulfill the contract (including waste). By signing this Con-
tract below, Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may not be refunded once the
Installation Services are performed..
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES *where applicable
SUB-TOTAL $ 10065.4
*TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $ 10065.4
BALANCE DUE
Work is to commence upon reasonable availablity of Contractor which is anticipated to be k1bVer [fill in date].
Estimated completion date is ���e �e1 ' / [fill in date]-
NOTICE TO CUSTOMER
All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing
on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation
necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom-
-Store 1094 Project No. 456135636 for MARY MACDOUDALL Page 3 of 8
STORE COPY
er.
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS 1 000.00•
] Customer to Pay in Full; OR
[_] Customer to use the following payment schedule:
(1) Deposit of$ to be paid upon signing contract. Any deposit collected at the time this Contract is signed will not exceed one-third (1/3)
of the contract price; and
(2) Payment of $ to be collected upon or after the commencement of work. I/We authorize Lowe's to do one of the following (check ap-
propriate box below):
[_]Charge my/our credit card for the amount of the payment indicated above upon or after the commencement of work; or
[_] Deposit my/our check for the amount of the payment indicated above anytime upon or after the commencement of work; and
(3) Final payment of$100.00,to be paid upon completion of the installation to both parties' satisfaction.
`-
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
_ TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU
-- HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPYOF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c 142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON-
TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET-
ARY"OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
MIT TO SUCH ARB , RATI NAS PROVIDED IN M.G.L. c.142A.
Byjr��� Date:
LotersCBy - Date: // - /Z . ZO/S
ca
By: Date:
Co-owner or Witness
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
INITIATED BY LOWE'S PURSUANT TOM L c 142A THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES
>Store 1094 Project No. 456135636 for MARY MACDOUDALL Page 4 of 8
STORE COPY
WITNESS OUR HAND(S) AND SEALS BELOW THIS DAY F
Lowe's Home Centers, LLC
By: (Seal)
"
Print Name:
AddressOwner (Seal)
c. 121 DDUy�z[:
tY State/Province Zip/Postal Code Print Name
(Seal)
Co-Owner or Witness
Print Name
_ . Customer acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof. You the customer may cancel this transaction
at any time prior to midnight on.the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of
this right.
Store 1094 Project No. 456135636 for MARY MACDOUDALL Page 5 of 8