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1 AUTUMN VW - BPA-13-865 INSTALL NINE (9) WINDOWS �I The Comnionwcalth of Massachusetts ary Board of Building Regulations and Standards SAL OJ2011 Massachusetts State Building Code, 780 CMR Sd X/ar '�17 Revised Mcrr Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dtvelling This Section For Official Use Onl Bujlding Permit Number; Date Applie Building Official(Print Noma) Signat / Date SECTION I:SITE INFORt TI 1.1 Property Add 1.2 A+��6,1) l.2 As ssors�ap g Parcel Numbers L.t t.l /�� 1.1 a Is this an accepted street?yes_ no Mapt4upffer Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard RequiredProvided 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 13Private❑ Zone: _ Outside Flood Zone? Municipal 13On site disposal system 13 Chif es❑ SECTION 2., PROP ERTY'OWNERSHD?t ' 2.1 Owners of] ec Qn VIV\ r I/,'41 Name(Print) �t �-1, City,State,ZIP L 4t1 Ia.I ph rl teo 2h51-=" No.and Street - Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORIO'(check a at apply) New Construction ❑ Existing Building❑ Owner•Occupied ❑ 1 Repairs(s) ZI Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTINJUkTED CONSTRUCTION COSTS- [rem Estimated Costs: Offielal Use Only, Labor and Materials I. Building $ 1. Building PermitFee:S -Indicate how fee is determined: ❑ Standard.Cityrrown Application Fee 2. ElectricalS ' r . ❑'Cota1 Project Cost (Item.6)x multiplier x J. Plumbing S 2. Other Fees: $ / List: r�t �6 L MechMechanical (IIVAQ S /y ?. \[eehanical (Fico S ,oral:\II Fees:.S lll ) pei51U❑� Check No. _Check Amount: Cash lnwmtt-. 6 Total Project ('ust: 3 p Paul m Fill[ 0 Outstandm" Il.dince IJII — SECTION 5: Co.wrRUc TION SERVICES 5.1 Cotstructiot Supervisor License (CSL) r� Lixns umber E.epirat on` DL Name of CSL 11 Ide o List CSL'rype(sce below)�W S No. and Stype Description t //'��-� U Unrestricted(Buildings up to 31,000 cu. ft. R Restricted 1&2 Family Dwellin City/Town, State, ZIP � im Masonry RC Rooting Covering \VS Window and Siding SF Solid Fuel Burning Appliances Q)D( , 1 Insulation fele hone ° Email address LD Demolition 5.2 Registered Hone Im rovemen Contractor(f IC) � r S HIC Registration Number Ex inti D e I IIC Compa y C agi- an Ni No. rad Email address Ci /Town, Stile, '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 9,Fthe building permit. Signed Affidavit Attached? Yes .......... No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT f, as Owner of the subject property, hereby authorizeP to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Dote SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby est under the pains and penalties of perjury that all of the information contained in this application is true a d ac ur a to a bet of my knowledge and understanding. — s Print Owner's or Authorimd:\;ant's Nunte Elec rune Signanire) 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. 112A. Other important information on the HIC Program can be found at wvwwv.m;ts;.� ovbea Information on the Construction Supervisor Licensee,n be tbund at wwvwv.nrt>s.�.�u��,dL 2. When substantial work is planned,provide the information below: Total floor area(sy. R.) (including garage, finished basement/attics, decks or porch) t cosi livim; :trca(,Il ft.l Ifabictble room count Number of tirapl.tcci .----"----— Number of bedrooms --_-- Number of h,uhroom; Number of hultrbaths __---_----- 1'cpaothe.uing ,yilent . _ ---_ _--- Nwnberofdccks;poi ches I)p;cofcoolim; ;yitent (?nelu,al _ Opcn ---- -tai I�rt.il P _ ' I',>t it Pngtet tiyu ua Fant i � ' in.iy h� ,ub;hhit I ' nijcd ('oiP' aiffY�iS'=Y+ni2Mrv':aey'jyElTfv+LvnSA)i"-C'z'N#a� •.••• '�.fJPYf�4Y4�?W� r�-'Y!HnYWe y+i�LaR.PRIY.£�".WSm'�scuu�:rvv+i'l:-w+iY ``,fry �;c�ert;✓z�rrretes>r�t�� c: z �1�'x.�skn�>��et�.�tr�t Office ofTonsumer Altair-, and I RtE,et'ation � t ' 10 Park. Plaza- Stuta 5170 Boston, Massachusetts 02116 Home Improvement CoTttractor Registration . Rcs�kati[in- S IS535 Ty", F vow C.Cpcialion E><pka4lpn'. 71242013 Trs 213,511 MOON ASSOC INC JAMES MOON 1137 PARK EAST DR, WOONSOCKET, RI 02895 Update Add,mi and rcum runs.51ark resaaa tar cpan;,n. Address 1. Rm,,%'31 - Empiu+nent _ . Ln+st Curd IIIGr oT erofumii'A`i7tiin t lii�inrri RtF, lhl,itl k.KCn4r Ur registra%ion Valk](n,lndiv Ida111nvonb ej t NOME IMPROVEMENT CONTRACTOR Eekore 1be ripkrutHlp dukr, it fongd rekuio to: Istr Won. 119534 Typq once n11 onmme,AL(Un and Rusinns Rtgnlat'mc y10 Park plata,Soitc 5170 '.. Eapdra&on: 7Ricd'3 NueeRr Caryuratcn Ros4ow.M.1 02114 AS50C. ,A.MiS MOON 713'1PARK EA':T OR .:.r�.w.e':.T. .-II`.'�•cD "tea...--. 1;e:Fi:+hSt'CK6T.PiO2695 i pileneerekary e;l•'• ;tit+k iuini aiklmot sigAitnn ' `lassa c��k«��i • �.., ftk�ry�; l`C.1,5. �I6$'a•6 �:�,��t;! 'i VOk.0 k,= �#kt.S 3:att,�. � ,re JAMES M00t+ fi 48 PAINE RD" '01 RIMY Cumberland* OAx� 40_ 4 �tr� +► t f�'tk r 03/2312OU The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street L Boston, MA 02111 wtvfv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Orgmiizatioi0ndividual): Address: �� City/State/Zip: hone#: V o Are y an employer? Check the appropriate box: Type of project (required): 1. I am a employer with , 4. E] I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These subcontractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. [:]Building addition [No workers' comp.insurance comp.insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Ro pairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] Any applicant that checks box#I must also 511 out the section below showing their workers'compensation policy information. . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a newaffidavit indicating such. tContraclors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: A�?S� c c Expiration Date: Job Site Address: dy}1�1�t`� City/State/Zip: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ' Investigations of the DIA for insurance coverage verification. Ido hereby cerci under the pains and penalties of perjury that the information provided above is true and correct. Signa - Date: - r Phone Oficial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector 6.Other Contact Person: Phone#: - 1 OP ID:JV CERTIFICATE OF LIABILITY INSURANCE DAT1011610116(1122 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the Certificate holder in lieu of such endorsement(s). PRODUCER Phone:401-769-9500 CONTACT Hunter Insurance,Inc. Fax:401-769-9502 NAME: E FAIC.No: 389 Old River Road,P.O.Box 1 E-MAIL Manville,RI 02838.0001 AI»RE. CUSTOMERID 0,MOONA4 INSURERS)AFFORDING COVE-RAGE RAIC I INSURED Moon Associates Inc. IN$URERA:National Grange Insurance CO 14788 DBA Gutter Helmet INSu R .Beacon Mutual 24017 DBA Moonworks NSURER C: DBA Gutter Helmet Roofing INSURER D: 1137 Park East Drive Woonsocket,RI 02895 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS. INBR TYPE OF INSURANCE POLICY NUMBER MMI6DfYYYY MM�OY LIMITS LTRIUMMM GENERALLIAe1LITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY MPS26619 09!16112 09116/13 PREMISES Ea occurrence) $ 500,00 CLAIMS MADE ®OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: _ _ PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO- $ JECT LOC _ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 A X ANY AUTO B1 S26619 09/16112 .09116113 (En accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS _ BODILY INJURY(Per accident)S -' SCHEDULED AUTOS _ `"PROPERTY DAMAGE $ HIREDAUTOS (PereccidentJ NON-OWNEDAUTOS $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS LIAB CLAIMS-MADE CUS26619AGGREGATE $ 09/16112 09/16113 DEDUCTIBLE $ X RETENTION $ 10000 $ WORKERS COMPEINSATIONX WCSTATU- 0TH- AMEMPLOYERS'LIABILITY TORY LIMITS ER YIN B.'' ANYPROPRIETORIPARTNERIFYECUTIVE8586 10(07(12 10/01/13 E.L.EACH ACCID�NT Is 500,000 OFRCERIMEMBES EXCLUDED? MIA (Mandatory In NFO E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS IV HICLE$ (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION MOONASS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Moon Associates,Inc ACCORDANCE WITH THE POLICY PROVISIONS. 1137 Park East Drive Woonsocket, RI 02895 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD CITY OF OF S'U- ,ti[ a.kSS � � : CHLSETTS \tl ;' BL'ILDLNC;DEPA&TStENT + 130 TU sHL`IGTO . s N STREET 3 ti T. FLOOR x- (978) 745-9595 KI IIBERLEY DRISCOLL FIA(978) 7.10-9344 ,bL�YOIt T1I0scAs ST.PIERILS 01"MCTOR OF PUBLIC PROPERTY/gCILDLNG CObL%IISSIONER Construction Debris Dis osal (required for all demolition and renovation work) Vlt In accordance with Debris, and mho pro visithe sixth edition ofthe State Building Code, 730 CUR section III 5 ons Of MGL c 40, S 34; Building Permit is issued with the condition that the debris resulting Brom this work shall be disposed of in I 11, S ISOA. a properly licensed wasta disposal facility as defined by tNfGL e The debris will be transported by: r (nin of hauler) The debris will be disposed of in : (name Of facility) hddress uf'tacilit n n� re ufperntit nppile,,,, 1137 Park East Drive - 1. 259 (Moon Associates In Woonsocket,Rhode Island 02895 nraovea HIG05627251Moon Associat a (800)975-6666 fmua ass. 119535(Moan Astocl sl :� �Purchaser(s)Name: ��t ��w nstallation Address: �"at'+* !fie/ Salt-.s. ./l7A BJ97O Mailing Address: Home Phone: �j� Cell Phone: Sa.�li/ye:+ E-mail: S0N"YGRP4W,al/Gr4-ae Year Home Built: --940 ! Customer Initials:-- Taxes Paid in Town of:_ -!�-o'-'n I/We,the above purchaser(s)("Purchaser(s)")and the owners)of the property located at the above installation address,hereby jointly and severally agree to contract with Moon Associates, Inc. ("Moonworks")to furnish, deliver, and install of all materials as described in this agreement("Agreement"), the attached Spec Sheet(s)and diagrams)which are Incorporated herein by reference and made a part hereof.A Completion Certificate will be executed for all jobs at the end of the installation. Order Number: Order Number: Order Number: Project Type: 4t AAe4JS Project Type: Project Type: Agreement Amount $,� Agreement Amount $ Agreement Amount $ Less Deposit# $ 75t7 Less Deposit# $ Less Deposit# $ Balance Due On Completion $ 3�0 Balance Due On Completion $ Balance Due On Completion $ SMinimum 33%of Agreement amount due upon execution. tMinlmum 33%of Agreement Amount due upon execution. tMlnimum 33%of Agreement Amount due upon execution. x - indicatePaymentMethodForBalance Indicate Payment Method For Balance Indicate Payment Method For Balance DueatTimeoflnstallation: DueatTimeoflnstallation: Due atTimeofInstallation: Estyy.Sta Date: Est.Completion Date: Est.Start Date: Est.Completion Date: Est.Start Date: Est.Completion Date: 3�GJLc'k- DEPOSIT/PAYMENT OPTIQ�S (Subject to fund verification and/or credit approval) 1.Check,Cashier's Check or Money Order Ck# /y3r�' 3.Financing (Made payable to Moonworks) Acct# Approval Code 2.Credit Card*(circle) Visa MasterCard Discover Acct# Approval Code -I/We agree to allow Moonworks to charge the referenced credit card for the deposit amount Acct# Exp Date_Security Code_ Indicated.Balance to be charged to credit card upon completion of installation If noted above. It is agreed by and between the parties that this Agreement constitutes the entire understanding between the parties, and the re are no verbal .. understandings changing or modifying any of the terms of thisAgreement.Purchaser(s)hereby acknowledges that Purchaser(s)1)has read the front and reverse of this Agreement and has received a completed, signed, and dated copy of this Agreement, including the two accompanying Notice of Cancellation forms,on the date first written above and 2)was orally informed of his/her right to cancel this transaction. DO NOT SIGN THIS CONTRACT IF e THERE ARE ANY BLANK SPACES. Purchaser Purchaser Moonw rks .91 4aw;III S' ure Signature Ignature Print Name -Print Name Print Name YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE NOTICE OF CANCELLATION FORM BELOW FOR AN EXPLANATION OF THIS RIGHT. NOTICE OF CANCELLATION NOTICE OF CANCELLATION Date of Transaction Date of Transaction d �� You may cancel this transaction, without any penalty or obligation, You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any within three business days from the above date. If you cancel, any property traded in,any payments made by you under the Contract or property traded in, any payments made by you under the Contract or Sale,and any negotiable instrument executed by you will be returned Sale, and any negotiable instrument executed by you will be returned within 10 days following receipt by the Seller of your cancellation within 10 days following receipt by the Seller of your cancellation notice,and any security interest arising out of the transaction will be notice, and any security interest arising out of the transaction will be canceled.If you cancel,you must make available to the Seller at your canceled. If you cancel,you must make available to the Seller at y our residence, in substantially as good condition as when received, any residence, in substantially as good condition as when received, any goods delivered to you under this Contract or Sale;or you may,if you goods delivered to you under this Contract or Sale; or you may, if you wish,comply with the instructions of the Seller regarding the return wish, comply with the instructions of the Seller regarding the return shipment of the goods at the Sellers expense and risk If you do make shipment of the goods at the Sellers expense and risk. If you do make