B-20-858 - 0027 ALBION STREET - Building Permit The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
06 This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) ' Signature V Date
` SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.la 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.-Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 �wner'ofTOW-4
ecord: J � I
C,.re C(_ 4s �1— A Vy\�--��--►-� CribName(Print) --'
2c] �1` City,State,ZIP
b 1 Dn �—
No.and Street q-7"Telephone�S Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 0 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Nu r of U its Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $ &0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:__ � g � �b{�
5.Mechanical (Fire
Suppression) $ Total All Fees: $
6.Total Project Cost: $ 5, 9 BO Check No. Check Amount: Cash Amount:
❑Paid in Full ❑ Outstanding Balance Due:
AUG .51
AUG 10 PM 2'
SECTION 5: CONSTRUCTION SERVICES
5.1..Construction Supervisor License(CSL)
Name of CSL Holder
Li
Number Expiration Date SoDn
� �fix 00� ; List CSL Type(see below)
No.and Street Type Description
cV .k S U Unrestricted(Buildings u to 35,000 cu.ft.
ity/Town,State MP., R Restricted 1&2 Family Dwelling
M. Masonry
RC Roofm Coverin
Construction Supe so s i ture or(Electronic Signature) WS Window and Siding
2a th R� SF Solid Fuel Buming AppIiances
Tele hone ✓'U �Q V e� ""r��t n e� I Insulation
Email address D Demolition
5.2 Regist ed Home imp Qvement o tractor,(H �)
LAP 0 �a�t �®w �vtr
HIC Com a"Nar IC Regis nt Na HIC Registration Number Expiration ate
No. ®4 Street
® HIC Registrant's Signature
City/Town,S te,ZIP a Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.O.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 Issuanc 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
I,as O the subject pr perty,hereby authorize
to act o my ehalf,in all m tters elative to work authorized by this building rmit application.
Owner's/Authorised Agent's Signature - —7® m c�(�
Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By ente ' my name below,I hereby attest under the pains and penalties ofpetjury that all of the information
contai d i this a plicat on is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature)
® > V
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
w— w-mass.gov/oc:a Information on the Construction Supervisor License can be found at ww»>.nlas;.=�o�/c;t�s
2. When substantial work is planned,provide the information below:
Gross living area(sq.ft.)
Number of fireplaces Habitable room count
Number of bathrooms Number of bedrooms
Type of heating system Number of half/baths
Type of cooling system Number of decks/porches
❑Enclosed 0 Open
MMMMM
�_, :i;rig C��zz;tz�n3va,71a'it oftl!>ti:;soc�l^iIJL�Y'J
fi �ep�r l'ne>tr Of JEHdrastrkil A0r_irdzn.,-;
of nvestiff2til tYS
J•
3osa'on,Aj,4 02111
ivPvtv.jnass.;ov/dia
Workers' Compensation lasuiraaase.AMidavi>t: BuildesslConga-actorsfttectrsci2.us/Plumbers
lul;iant tgarma�,loa
""Tanle(Businesslorgunization/Indi�rfdutil): C_ Please Print I:,e��I
5 ayL �'; lct,-><�rl �,Ji>'tclvr� �,Icrlc( o ld�f�.t
address: %`� ry r , , rn nG S !'GL✓�G
CityiStateiZip; VGplGC t'(� L/1C( G j ;���f P -��� - t j�01 (AFG Phone rr. �
hre y u an employer?Cheelc the appropriate box:
t. I am a employer%,ith so 4. Q r am a general contractor and I7[E3)NqeNw,,
Typeect(regrrirsd);
employees(full an
part-one).= have hired the sub-contractors onstruction
•❑ I am a sole proprietor or partner- listed on the attached sheet eling
ship and have no employees These sub-contractors luavewor?arug for mein any capacity. employees and have water,' ' ❑Demolition
lNo:vorkers' comp.insurance cornp.inm ance.t 9• []Building addition
required.] 5. [] We are a corporation and its 10.[]E additions
repairs or additio
3.❑ f am a homeowner doing all:work officers have exercised their
myself 1 t.❑Plumbing repairs or additions J
GVo workers conro. right of exemption per MGL
insurance required.] t c.I52,§I(?.),and we have no 1'`"�R repairs
employees. [bio.Voker, 13. ther
corm.insurance required.]
any applicant that chks boxjl Tust also till out the section below showing tltrir wort: 4�
crs'compensation policy int"ornation.
iiorneowners wilo subunit this aindavit indicating thr_y are doing all work and ulrn sire outside contractors must submit a new atitdavit indicating such
Contrtcto:s;hat check this boo swat.-cll :d
if the sub can actors have err an additional sheet showing the name of the sub-contmclors and state wholhr or not those entities nave
=mpioycc;. ployeea,they mustarovide their tvorkeis'comp.poHtty number.
I run alt employer that is providing workers'can[pensation insurance for my employees Below is the policy and job site
information .
Insurance Company Name: rc5 S c e �l I G
Policy m or Setf-ins.Lic_h 1 LO 0�_ i
Expitatioa Daie:�- 5 '��
Job Site Address: ¢/
City /Zip:
�ttaclr a copy of the workers'compensation policy declaration page(showing thehe policy
policy number and expiratio date).
Failure to secure coverage as required under Section 25A of lviGL c.IS2 can lead to the imposition of criminal penalties of a
fine up to$1,So0.00 and/or one impcisomnent,as welt 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
fnvestie 'ens of the D for insurance coverage verification.
I do hereby certify rr n pen of ,yury that the- —
/ �° an Provided above fs true and correct
Simature: ,-✓I bates: O
0 'ctel use only. Do not write in this area,tb be completed by city or town offtcia!
City or Town: Permit/-Ticense
issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityiiown Clerk 4.Electrical Inspector 5,Plumbing inspector
6. Other
,_ Contact Person: Phone
i
— a CITY OF SALEM, MASS.ACHUSETTS
BUILDING DEPARTMENT
� 98 WASHINGTON STREET,2ND FLOOR
TEL: 978-745-9595
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(requiredfor all demolition & 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,S54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111, S150A.
The debris will be transported by:
AQ O-D(i2l
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of fa ility)
0
Signature of applicant
(today's date)
r Window World.of Boston MA HIC Registration
Offices&Showrooms . Number:
r ❑15A Cummings Park ❑295 Old"**4rOak Street 01000 Boston Turnpike 166026
Wobum,MA 01801 Pembroke,MA 02359 .Shrewsbury,MA 01545 Federal ID#
(781)932-4805 (781)826-6281 .. (508)845.6676 824898432
♦♦♦ nn (n www.WindowWorldof8oston.com f
Customer: flee. !d,CA POCLNet b - Phone(h) ?v r i3
Install Address: -Phone(c)
City: cs State:MA Zip C4(YQ 0 E-mail
WINDOW WORLD GLASS OPTIONS
1000 Series.Single-hung All-Weld $249 !d SolarZone U-Factor;27 or Lower $129 Z Z(a ;
2000 Series DH All-Weld $259
LO 4000 Series DH All-Weld $289r7� _Triple Pane $299
6000Series DH All-Weld $309 WINDOW OPTIONS
2 Lhe Slider $429 Glass Breakage Warranty(4000/6000) $15.INCLUDED
3 Ute Slider on.rn rm tua,r¢tin $669 _y_A/2 Screens $9 INCLUDED
Picture/Fixed Cite (0-83 UI) $419 t,-,foam Insulation on Jambs and Head $11 INCLUDED
_Picture i Fixed Ute (84-130 UI) $539 ble Strength Glass(4000t600D) $15 INCLUDED
Awning $359 C/poubie Locks(>26") $5 INCLUDED
_Casement Plus$49(DH Sash.Rail)$379 Full Screens $25
_2 LifeCasement $659 _Colonial Grids(Contoured/Flat) $65
31-Re Casement na,n.im prr,to t;,, $1029 Prairie Grids $75
_Basement Hopper $469 _Simulated Divided Lite $182
Bay Window-Soffit Mount./INS Seat$2859 _Tempered DH"Sash(BSO)(TSO) $75
_Bow Window-Soffit Mount/INS Seal$2999 _Obscure Glass(BSO)(TSO) $75'
_Garden Window $2179 Orlel Style(40/60 or 60140) $75 -
_Bay,Bow,Garden Oversize (+109 UI) $979 Foam Enhanced Frame
Beige/Almond $49 PRE 1978 HUI T HOMES RRP SAFE-RENOVATION)
9 4 ( )
_.Wood Gralnlntertor(Series 4000/6000 only)$100 MY HOME WAS BUILT IN THE YEAR_Ze/Initial
(Light Oakl.OarltOakl Cherry l FoxWcoq 1 MISCELLANEOUS
Rich Maple)
Designer Color Exterior $179 _Custom Exterior Aluminum Cladding(Two-Bend) j
Speciality Window $ _ OTextured$99 ,Q G-8 Smooth$99 $
Facing Color
Window Color ,.'1 Cry ` Multi-Bend Cladding $20 j
Inside outside aftisla enor xterior Stops $59 S`PQ_
NON CUSTOM DOORS Instal nterior/Exterior Casing.Starts Al$95 '
_vinyl Rolling Pado Door 50.oX6ft. $l 9� _Repair sill;Jamb or replace sill"nosing $75
_�ny1 111ngPatio Door 8f1. 9 Fulf.Sub-Sill(Single)replacement $t75
add to b price fm Custom Rali9 Insulate Weight Boxes $25
French-Aail In9 Polio-Doo9 Muff to Form Multi Unit $30French RaB SIi PadaDoo9 Mullion Removal $50
French Rail Sliding So' 9 Metal Window Removal $76
_Custom Exterior Cladtlr S300
SolarZbne $309 New Construction Platinum installation $749
Gritls Patio Oaor $210 New Cionst..ExtRetro FiVAerhoval $325
_, Woodgrain dors $3s9 Root for Bay/Bow Windows $500
_Exterior skjner colors $599 TRemoval of Existing Bay/Bow $250
_Infect using 2rR 312 $279 _Bay/Bow Conversion Exl,Refro Fit $450 j
dleset options S New Sidin Will Not Match
Witter at
(six foot only) $8 If-Customer cancels attar three (3) business days,Window
World shall.be entitled to a cancelation tee equal to 33%percent j
Door Calor / of the contract price as reimbursement for t expenses
Inside Our associated with a custom made order.Initial
Customer declines exterior wrap and understands: ai ling and/or repair may be a uirad Initial
Customer declines grids on windows/doors Initial
DISCLAIMER:Customer is respnnsibte for the following in connection wlth this contract Paintrig,Staining,Alarm SysWo d'acomacVrecori ed Boding Perms fees In )
excess of$25.00,Homeowner and or Condo Association Apiw al,Historic District Approval.City of Boston parking&sidewalk Permit tees in connection with Installation. I
NO EXTRA WORK IF NOT IN WRITINGI Customer agrees to the terms of payment as follows:
Extra Labor&Materials $
Site Set Up;Permit,Disposal&Delivery Fees$ $399.00
Total Amount $ •571(0
Custom Order Qeposit 33 0 $ /:2,23 ck# i
Project Start Payment 33%$
Balance Due Day of installation $
�S Amount Financed $
Window World at Boston anticipates 'patessterlingthisworkon (O �8^�and being substandally completed M(3days.Security interest.Yes, Now
Any deposit required In advance at the start at the work SHALL NOT excead 33113%of the tote contract price or Iha actual cost of any material or equipment of a
special order or.custom made nature,which must be ardered in advance of the start of.the work to assure that the protect All proceed an schedule.Na gnat payment
shall be demanded unhl the contract is completed to the satisfaction of both parties.
Ali home improvement contractors and subcontractors shall be registered and that any inquires about a contract at subcontractor relating to a-tegistra tan should be
dected to'Office of Consumer Affairs and Business Inegulallon,Ten-Park Plaza,Suite 5170 Baslon,MA 0211B.Phone:(517)973.870D
No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract, i
1+Ndow World of Boston under piovislenof Chapter 142A of the general laws is requited to apply for and obtain all construction-related permils.Window World of I
Boston Shan net be deemed responsible for delays in 89rwork described in this agreement caused by regulatory,permit grati0ng agendes,authoritles orhuNduais. t
flotiee:If the PURCHASER(S)obtains his awn construction related permits for the work described under[his agreement or deals with unregistered contractors; I.
the PURCHASERS)is hereby advised that in the event of a dispute,judgement and nonpayment,the PURCHASER(S)will not be entitled to make a claim or
cotlestlon from the guaranty fund esieblished by chapter 142A,M.G.L. -
You the buyer may cancel this transaction at any time prior to midnight of the third s ness day after the dale of this transaction. I
Notice of cancellation must be In writing postmarked no later than midnight of the following third business day:
THIS IS A CUSTOM ORDEB NOTRESALEI
TT
s Window.World'Franchisa is independently armed and a ted• L&P Boston Operatl2g,Inc.under license from Window World,Inc. f
}
Owner:Do not sign It that are any blanks es. Date
t.� 7vJrJ
�I
Consultant:Do not sign It there:are any blank spaces. Date Z—T Owner.Do not sign Ilahere are any blank sifas;"Date I