5 SCHOOL ST UNIT 7 - BLDG PERMIT APP B-15-1268 �� 259 r=ae 1-7
The Commonwealth of Massachusetts
PV Deparhnent of Public Safety
.9 Massachusetts State Budding Code(780 CMR)
I Building Permit Application for any Building other than a One-or Two-Family Dwelling
- (This.Section For Official Use Only) . . -
Budding Permit Number: Date.Applied: _ IBuilding Official:
SECTION 1:LOCATION(Please indicate Block ft and Lot X for locations for which a street address is not available)
SC, le w, MA l 47'20
No.and Street - City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK -
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
f Existing Building❑ Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: _
4 t
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,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.)
SECTIONS:USE GROUP(Check as a licable) - - -- -
A: Assembly A-1❑ A-2 Cl Nightclub Cl A-3 ❑ A4❑ A-S❑ B. Business ❑ E. Educational ❑
F: Facto F-1❑ F2❑ H.
Hi h Hazard H-1❑ H-2❑ -H-3 ❑ H4❑ H-S❑
I- Institutional Id Cl I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ 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)
[A ❑ IB ❑ IIA ❑ IIB IIIA ❑ IIIBO 1V ❑ VAD VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)-
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal.Cl A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed Cl
Railroad right-of-way: Hazards to Air Navigation: NLA I listonc Commission ke,ww_Pnxcis.
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ 1 Ycs O or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
11104th ttS Si:�'stis
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Pryperty Owner 1-r
ILI-G M U K ,)'1tt, e5 5t h 001 3 C.V1-f ! �Gi�� �
Name(Print) No.and Street City/Town Zip
Pro rty Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If. licable,the property owner hereby authorizes j
oherI �glly 30 r siol �aSt" o-d c Igexj t 4 (telq,2l
Neuse Street Address City/ State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building ermit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2).
If buihlinR is less than 35,000 cu.0:of enclosed space and/or/ not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
�sy�
Nge( egistrant) t7 Telepho a No e-mail address Registration Number
L2 , S�n
� e�BS-Fu� fca� (ed �aV )cAu N, kW � °2
Street Address City/Town - State Zip Discipline Expiration Date
- 10.2 General Contractor
Compan a Ce
Nene of Pe on Responsible for Construction License No. and Type if A plicable
3DB 05,k - Pw� 0-6 � a�r f a 70 of ?-)B
Streetess City/Town State Zip
Vol
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSA'I'[ON INSURANCE AFFIDAVIT M.G.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❑ No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
S.Mechanical Other $ Enclose check payable to
6.Total Cost I $ UD-co (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERbIIT 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 and accurate to the best of my knowledgeand understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: �
Nam Date
The Commonwealth ofMassadhusetts
-Department oflndustrialfaccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
w1vorkers'Compeasation Insurance Affidavit:Builders/Contractors/Electridins/Plumbers.
TO BE MED WITH THE PERI19.TI'ING AumoRITy.
A IicantInformation f - �^ Please Print Le "bl
Name(Business/Orgmiizafion/Individual): ,/� I{ D�1 n ry L
Address: 16q V(S_t- RA
City/State/Zip:WGt 'tea V46L 017-79 Phone#: c 579
Fensura
ou an employer?Cheek the appropriate box: Type of project(required):
I am a emplayer"_employees(fill and/or parttime).'' 7. ❑New construction
I m a sole proprietor orparmership and have no employees working forme in 8. ❑Remodeling
any capacity.[Ne workers'comp.insurance required)
am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. ❑Demolition
am a homeowner and will be hiving corbacmrs m conduct all work on my property. I will 10 ❑Building addition
that all contractors either have workers compo narion insurance m ere sole 11.❑Electrical repairs or additions
proprietors with no employees.
5. I am a 11❑Plumbing repairs or additions
❑ genal contracmrand I have hived the sub-connaeIus listed on the attached sheer.
Tnese sub-conhacmrs have employees and have workets'comp.insvancet 13.. 1.Roof rcpaliS r C
6.0 We are a corporation and it,officers have exercised their right of 14.kD Other g K(
gh excretion per jJIf1 c.
_. .
152,§I(4),and we have no employes.(No workers'camp.insurance required.)
•Any appticantthzt checla boz�l muY also fll our the sen[ioo blow showing they workers'coiryiensa5on policy information.
'Homeowners who submit this rardavit irrdirating they as doing all work and then h'va onside mnhacmrs must submit a new affidavit indicating such
zContacmrs that dreck th@ hox must attached an additional sheet stiowing the name ofthesub-contractors end stere whether or not those entities have
employes. if the subc�nuacmts have eruoloyees,they must provide their workers'comp.polity number. -
I¢m an employer That is providing workers'compensation insurance for my empl'oyeec. Below is the policy and job site
information. G ,,_,g
Instu-anceCompanyName: /�Ch`� ,,1�Rr�•�TU`1�/' �f,��J(tn.t�G--Q� �� '
Policy#or Self-ins.Ltia Expiration Dam: - I G
Job Site Address:_S 7 �G�o S T lr� / (ity/State/Zip: —C,; 1 9-02 MA-
Attach a copy o£the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure Coverage as required under MGL c.15Z§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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Once of Investigations of the DIA for insurance
coverage verification.
I do hereby ajnds e p ' and p , ircry that the information provided above is trae and correct
Signature-. l Date
Phone#
Official rise only. Do not write in this area,to be completed by city or town offw i
City or Town: Permit/i.icenst:#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Chy/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#.
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HOME iMPROVEMEM"' Ci M T RA TOR
ApgisfiraCion: 15�10Eb
, Type: ;
Expiration: 2/5/2017 Private Corporatior
LABE.LLE ROOFING, INC.
LABELLE
3 �? E iIOSTC l POST' RG.
1()eacgeaseTa•etiry ' .
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n
_. Massachusetts Department ent
-
of Public Safety
- - _ Board of Building n Regulations and St
andards
' Cns`.rcdio�5 Sunerisnr � -
License:Cs4g8666 -
ROBERT LABEYLE
304BOSTONPO$Ti4=# i- - -
Wayland ASA 01718Iw
Expiration
_ Commissioner 05/09/2017 '
CITY OF SALEA MASSAaA SE TTS
Bu7DjwDEPAR7mw
120 WW9mYGwNS7REET,3IDFioax
7kL(978)745.9595.
FAX(978)740.9846
%IIv>BERLEYDRISODLL
MAYOR 7)KMAS STAF"
DntEcrcut cFPmijcPxcFut7y/jjuaDmamawomR
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 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit g is issued with the
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, S 150A.
The debris will be transported by: Qv k -fa uc i<
(name of hauler)
The debris will be disposed of in:
(name of/ facility)
✓l
(address of/facility)
Signature of applicant
ll\ l
Date
i
OWNERAUTHORIZATION
i
Job#_ 7 ��
1
TO BE COMPLETED WHEN OWNER'S AGENT OR
CONTRACTOR APPLIES FOR A BUILDING PERMIT
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1, krg 014454 as owner of the
subject property,er
hereby authorize LaBelle Roofing to act on my behalf in all
i
matters relative to work relating to this building permit
I
application,and all permitted work
t
I'
Signature of Customer D
j
f
i
ji HOME IMPROVEMENT CONTRACT
Date: �Vl Sold,Famished and Installed by:
Job# LaBelle Roofing.Inc.
i 304 Boston Post Road,Wayland,MA 01778
Phone:508-358-7663;Fax:508-358-7662
Federal ID#20-8350649
b MA Home Improvement Contractor Reg.#154084
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-
Installation Address: J 9{L.�'ltl-yC.7� �vf Un t lh 7 Qt', /'I)jq e 19 xi
mtr e 1 Work Ph..: Ctly Some hon Zip
Parehr� Nome ee:
IrArtt rio G Sc- } ( ) ( ,q Z 3 �S6o
j ( ) ( )
Y 1
Home Address: -.[.
(If different from installation Address) City.- y .5[am Zip
$ Proiect Information:V WdYou('ilba hasee'),the owners of the property located at the above installation address,offer to contract with
LaBelle Roofing,Inc.to furnish,deli 4 er and arrange for the installation of all materials as described on the attached Spec Sheet#:.__�._(�
_ 0 LaBelle Roofing,Inc.reserves the right to cancel this contract if,upon re-Inspection of the job,LaBelle Roofing,Inc determines
that it cannot perform its obligatio s due to a structural problem with the home or because work required to complete the job was
r not Included In the contract
DEPOSIT PAYMENT OPTIONS
`� (Subject to fond verification and/or credit approval)
CONTRACT AMOUNT $ i/ w Check,Cashiers Check or US Postal Service Money Order
(Made payable to LaBelle Roofing,;1=)
„ _�� •\\ 2. Credit Card• paymmto norxCircle One Below
�7�Ov p
LESS DEPOSIT $
t Visa MasterCard Discover American Express
BALANCE DUE 2 O6 a� Aceol. Exp.Date:
ON COMPLETION $ -
j Name as it appears on card:
Indicate Payment Melbod For "By my/our signature below,Uwe agree to allow LaBelle Roofing,Inc.to
BAALLANCE1 DUE ON COM LETION: charge the above referenced credit card for the deposit indicated.
e C. Cardholder's Signorine Date
Purchaser agrees that,immediately u I
pan satisfactory completion of the work,Purchaser will execute a Completion Certificate and pay any
balance due.Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire A¢reement:This agreement and its attachments,including any financing agreement,contain the complete agreement between the
parties and cannot be amended or modified unites in writing in a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do not sign this contract before you read It You are endued to a completely filled-in copy of the coutract at the time you sign.Keep it to protect
your rights.Do not sign any wmpledoniCertificate or agmemeat stating that you are satisfied with the entire project before this project is
complete.Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual
completion of the work to be performedunderthe contract.
I
You may cancel this transaction at any Jame prior to midnight of the third business day after the date of this contract.See Notice of Cancellation
for an explanation of this right.There will be a service charge equal to 25%of the contract amount if the job is cancelled by Purchaser AFTER
the third business day.
BY MYlOUR SIGNATURE BELOW,1/*E AGREE TO BE BOUND BY THE TERMS OF TMS CONTRACT.UWE ACKNO WLEDGE RECEIPT
OF A COPY OF THIS CONTRACT Ll TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION.DO NOT SIGN THIS
CONTRACTIRTHE AREAN B OKSPACES. _
SUBMITTED BY: Date
es Cans item _
ACCEPTED BY: F--'�-oDate
memvnerI
I Date
HomeowncrI
NOTICE:ADDITIONAL TERMS,CONDITIONS AND WARRANTIES ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT.
White-Off. YellowCmtomer Pink-Sales Comuitant