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5 SCHOOL ST UNIT 6 - BLDG PERMIT APP B-15-1298 7�ICnn, �DrdD � � � 00 CdG Z The Commonwealth of Massachusetts W Department of Public Safety husetts State Building Code(780 CWIR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ,(This Section For Official UseOnl ) (n Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) School 'r LIA, 12w VX,k-4- O14-)o Iii I No.and Street City/Town Zip Code Name of Budding(if applicable) SECTIO 2•PROPO D WORK Edition of MA State CO&used If Ne Construction heck here❑or check all that apply in the two rows below Existing Building❑ Repai " Alteration Addition d I Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: —. Are builalin8 plans and/or construction documents being supplied as rt of this permit application? Yes ❑_No f Is an Independent Structural Engineering Peer view required? ^ se I. Yes ❑ No On Brief Description of Proposed Work: OL i 'z ¢ �m N %=rn :J SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,A DIT104 OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No,of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION S.USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-I❑ F2❑ - H: Hi h Hazard H-t❑. H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional I-1❑ 1-2❑ I-3❑ [-1❑ M: Mercantile❑ R: Residential R-t❑ R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill El IL\ ❑ IIB ❑ 1 IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details an each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: 11,4 11kh,ric C.nuui,si... Rrvw, l'r.q� .: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Critic Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain aur Sprinkler.System?: _ Special Stipulations: t�1 At t--za7 l l 3© SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner /I KGAh(Q&, 1 !V 111 p `—�c,,Le✓-�\ Name(Print) No.and Street - City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If a plicable,the property owner hereby authorizes ` � r �— LA a-zit 30q aos fo., 10c&+-Ed- \1 4 0127 Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Ott hu Nat}�e(Registrant) Telephone No. f� c mail address Registration Number SC�IAt Street Address , , City/Tow State Zip Discipline Expiration Date 10.2 General Contractor Lct- ZXZ 0-e- IT44C, C ,I;NI`m� LSI Ie Q 6 6 Nam of Person Responsible for Construction Pcense No. and Type if Applicable lblt .I ( �l`�� City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKt 1:5'COt,1PFNSAIION INSUR:NICE AF11Ur7\,,flM.C.L.c.152. 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE' Item Estimated Costs:(Labor and Materials) Tota Construction Cost(from Item 6)_$ 1. Building 3 Building Permit Fee-Total Construction Cost x (Insert here 2. Electrical $ / - appropriate municipal factor)=$ 3. Plumbing _ $ d. Mechanical (HVAC) 5 Note:Minimum fee=S (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost 5 (contact municipality)and write check number here SECTION :SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true amt accurate to the best knowledge and understanding. C Vol -ASI OV-( I( ` 3—,r Please print mrJ sign name Tdti Telephone No. Date Street Address City/Town n State Zip Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts -Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02II4-2017 www.marsgov/dia. 'Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plambers. TO BE FIS.ED WITH THE PEPJ ff=G AUTHORITY. Applicant Information t �^ Please Print Le 'bl Name(Business/Organizabon/Individual): ,n I 'p y i n , %6 . Address: � � 'v ., 1)0,S'_ —j�j City/State/Zip:WC, f&Ak Me, 01 ?-t Phone#:_ � " c3 S9 Are you an employer?Check the appropriate box: Type of project(required)' I.�I am a employer with_employees(full and/or part-time).* - 7. ❑New construction 2.❑I am a sole oropriehar or partnership and have no employees working for me in 8. E]Remodeling any capacity.(No wnrkers'rump.insurance required.) 3. I am a homeowner doing all work 9. ❑Demolition ❑ m myself.[No workers'comp.insurance requhed]t 4.❑I am a hommw a and will Ir hhng mnnacmrs to mnduct ell work on 10 ❑Building addition my property. I vdu ensure that all contactors either have workers'compsasation insurance or are sole 11.❑Electrical repairs or additions ompiehors with no employees. 5 i am a 12.❑Plumbing repairs or additions ❑ general contractor and I have hired the sub-mntrarmrs Iisn d on,ffie alIDrbed sheer 13.. - These sobcmhactors have eomloyces and have workers'mmµimm�anc,f � .h_�,[Roof repairs 6.❑We are a corporation and its oincers have exercised thoir right of per ZAGL c I J l Other J z 1 gh exemption _. 152,§i(41 and we Crave no employees.[No workers'comp.insurance required) (/_,K_ *Any applicant that checks box GI must also fill out the section blow showing their workers'mmpmaation policy infomaadoa Homeowners Who submit this affidavit indicating they are doing all work and then hire outside coidractors must submit a new affidavit indicating such '•Contractors that check this box must attached an additional sheatSh ing the name of the sub-comacmrs and state whether oraot those entities have employes, l7the sub-mnaacims;have employees.lhey must provide their workers'comp.policy number. I am an employer that is propfdrng"rkersI compensation insurance for my employees. Below is the policy and job site informmiorr_ �.9 Insurance Company Name: �h E 4.-, f 3 �U`� �7A_t)f ne-e— Co . Policy#or Self-ins.Lic.# Expiration Date: Job Site Address: S- S Do( �T Un r. + �]Ql�� /�. Attach a copy of the workers' compensation policy declaration page(showing city/statm/zip:_the policy number and expiration date). Failure to secure coverage as required"under MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Oince of Investigations of the DIA for insurance coverage verif-cation. Ido hereby c ander the p ' and Jury that the it formadim prordded above is&ue aced correct Si abut: —* Ga� Date Phone LV --38- tJ (� lit - FBojardof only. Da not write In this area, to be completed by ray or town of meal n• Permit/License# ' ority(circle one): ' ealth 2.Building Department 3.city/Town Clerk 4.Electrical Inspector 5.Plumbing Inspectaor on• Phone#: f' .���. � A1S Z'�• ,3 R� F � �' �, G� f �a d t d 9 v r , ?safe a1 C eesasa s spa ?Ve:i�s r. �>aassn . . I,Ct�,cs5 aRaa as I101)PE INIPROVEMI-N'i' COOI i RA 0OR i:veyistratfoea: 154084 Type: Erpiratioel: 2/512017 Private Corporatior LASELI_E ROOFING, INC. 111�aa9ea seTe�et iry u K r t y r + A assach usetts - Department of P U-b."C Safety €lard' of Building Regulations ations ahs �4a id r Say . cense. CS4)98666 h a 1 04 ©BERT A LABELE r -30411WON P05T 1 0 Wayland.A A r Com�n�ssianr 0510912017 i OTY OF SALEM, MASSAGiUSE M BUILDING DEPARTWNT 120 WASHINNGTON STREET,3P FLOOR IkL.(978)745-9595 KINIBERLEYDRISODLL FAX(978)740-9846 MAYOR 7M)MAS ST.PIERRE DIRECTOR OF PUBLICPROPERTY/BUILDING 00MUSSIONER Construction Debris Disposa/Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR Section and the provisions of MGL c40, 5 54; Building Permit# with Debris, is rlthe condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, 5150A. The debris will be transported by:Oct( �g WII (name of hauler) The debris will be disposed of in: U)qk� M (name of facility) W C'V � (address of faci ' y) Signature of applicant Date f i E OWNERAUTHORIZATION Job# f TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR A BUILDING PERMIT 9 as owner of the M 3 subjectproperty �S� hereby authorize LaBelle Rooflng to act on my behalf in all matters relative to work relating to this building permit application,and all permitted work i i z � -4 / Signature of Owne a E j 1 a i A t k HOME IMPROVEMENT CONTRACT r ( # Date: ` Sold,Furnished and Installed by: LaBelle Roofing,Inc. k Job# 304 Boston Post Road,Wayland,MA 01778 Phone:508-358-7663;Fax:508-358-7662 Federal ID#20-8350699 MA Home Improvement Contractor Reg.#154084 I Installation Address: S Sc � ,nrt- ` City State Zi P"r�91e r Work Phoce: Home P600e: p( ) ( ) Home Address: (If different from Installation Address) Qty State Zip Project Information:I/We/You(`Pumhasere%the owners of thero p perry located iathe above installation address,offer to contract xwith - LaBelle Roofing,Inc.to furnish,deliver and arrange r g.for the installation of all materiels as described I.. bed on the attached Spec Sheet#: .y LaBelle Roofing,Inc.res effes the right to cancel this contract if,upon re-Inspection of the job,LaBelle Roofing,Inc.determines g that it cannot perform its obligations due to a structural problem with the home or because work required to complete the job was not included in the contract t q a' DEPOSIT.PAYMENT OPTIONS t (Subject to fund verification and/or credit approval) $ CONTRACT AMOUNT $ .e !0o 1. Check,Cashiers Check or US Posed Service Money Order (Mad.payable to LaBelle Roofin Inc.) ¢i -LESS DEPOSIT $ ���� 2. Credit Card• payment options-Ciirele One Below q - `Visa Meese Cmd Discover Ametiean Express I BALANCE 1 g Accbf. Exp.Date: ON COMPLETION $ ,t Name as it appears on card. e Indicate Payment Method:For 'By ray/our signature below,fhve agree to allow LaBelle Roofing,Inc.to BALANCE DUE ON COMPLETION: charge the above referenced credit cant for the deposit indicated ( s i I 3. Cordholder's Stgmtum - Data Purchaseragrees Wat,immediately u lisp satisfactory completion of the work,Pumhasm will execute a Completion Certificate and pay any balance due.Purchaser also agrees to be jointly and severally obligated and liable hereunder. Entire As reement:This agreement and its attachments,including any financing agreement,contain the complete agreement between the parties and cannot be amended or modified unless in writing in a separete agreement Signed by both parties. t NOTICE TO PURCHASER Do not sign this contract before you Mad It You aro entitled to a.completely filled-in copy of the contract at the time you sign.Keep it to protect your rights.Do not sign any completion Cerdficale or agreement stating that you are satisfied with the entire project before this project is complete.Low prohibits home repair contractors from requesting or accepting a Completion Certifieste signed by the owner prior to the actual completion of the workto he performed under the contract. You may cancel this transaction at any time prior to midnight of the third business day after the date of this contract.See Notice of Cancellation for on explanation of this right There will be a service charge equal to 25%of the contract amount 1f We job Is cancelled by Purchaser.AFTER the third business day. k! BY MSIGNATURE BELOW, COPY OF A COPY IIWE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT.1/WE ACKNOWLEDGE RECEIPT OF THIS W Cr AND VZO COMPLETED COPIES OF THE NOTICE OF CANCELLATION.DO NOT SIGN THIS ' CONTRACT IF THERE \NY L3ACEXSUBMITTED BY: Datees ConsulACCEPTED BY: . ,�'�� Date �b / ..• J s� Homeowner y Date - Hontownm � y NOTICE:ADDITIONAL TERMS,CONDITIONS AND WARRANTIES ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACP. I. Wfiik-ORw Yellow-Qrntoncer PmkSaies Comultanl t t I