18 BOARDMAN ST - BPA-14-500 ROOF The Commonwealth of Massachusetts
Board of Building Regulations and Standards s
Massachusetts State Building Code, 780 CMR
a
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised
�— One-or Two-Family Dwelling March 2011
This Section For Official Use Only
Building Permit Number: I Date Applied:
ghv�(IJ * Iz Z
Building Official(Print Name) I Si re Date
SECTION 1:SITE INFORMATION
1.1 Progeny Address)) A C 1.2 Assessors Map&Parcel Numbers
Lla Is this an accepted street?yes_ no Map Number Parcel Number
13 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) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1TIT er'of Record:
1 Sb N ` ' 1 \d'C
Nam (Print) --�— City,State,VP
/t��- 51
No.an' d Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify:
Brief Description of Proposed Work : foeD dL
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ vD 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
.�/ Check No._Check Amount: Cash Amount:
6.Total Project Cost: $ Ll �j 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1-tDgq b k,L
_) _ rr-e VA-5.)o License Number Expiration DA�te
Name of CSL Holder
5)1 List CSL Type(see below)
�oI No N�
No.and Street Type Description
p 100 �'Q l Unrestricted(Buildings u to 35,000 cu.ft.
r"g y , 6 lY^ t y Restricted 1&2 Family Dwelling
City/Town,Stdte,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
� r /V���, l SF Solid Fuel Burning Appliances
7e'
�"D }'� I Insulation
Telephone Email address D Demolition
5.2 Registered HBme Improvement Contractor(HIC) 0 qqq .31 1O(.
�r �Ayml,1 Tfa —:%1 HI "Registration Nuor E pira�t b_n Date
H i�mpany a or HIC Registrant ame
GG W Na7JA
����
N and carts Email address
City/Town,-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 ..........a 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 Wea/ Cl.) f&IS50l
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name( lectroni ignature) 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
contained ii/n this application is true and accurate to the best of my knowledge and understanding. 1
Print O ner's or�thorize�Name(Electronic Signature) l�. ` Dale
. 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number,of fireplaces Number of bedrooms
Number of bathrooms Number of haWbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
i`
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): (A/arre.AJ ZV56lJ
Address: 15 ��� IN!A ONJ _ �,
City/State/Zip: -Pe L) 000 Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.Ja I am a employer with 6 4. ® I am a general contractor and I
: have hired the sub-contractors 6. New construction
employees (full and/or part-time).
2.® I am a sole proprietor or partner- listed on the attached sheet. 7. ®Remodeling
ship and have no employees These sub-contractors 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 I I.®Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.b Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.®Other
employees. [No workers'
comp. insurance required.] .
Any applicant that checks box#1 must also fill 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 new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the time of the subcontractors and state whether or not those entities have
employees. If the subcontractors 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: —
nJp -t` 1 1 � ry111I
Policy#or Self-ins. Lic.#�/U tS`0 IS�nc 1� ! Expiration Date:5016M,
Job Site Address: 1I t r rl PUA City/State/Zip: Jal6 M
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.
I do hereby certify u der the pand penalties of perju� ry that the information provided above
/iis true and correct.
�
Simafore � Date*
Phone#
Official 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#•
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LAUGHLIN HOMES w�` �C�Cvtf/ii/ 4'I'�fG�6
MEMBER BETTER BUSINESS BUREAU MASS REG. #fBe?gJtR—
C 9 Charles Street/P.O. Box 252`'- � 122S
' MEMBER BEVERLY CHAMBER OF COMMERCE 1978
MEMBER BEVERLY KIWANIS Beverly Massachusetts01915
/ / I (918) 922-
SPECIFICATIONS�7SSUBMI ED TO: I Tl 7/ lP//�' /f1�L6J-ll/PHONE:
DATE
STREET: s/ �i � l/-l.(// //YL/,vp/ s' � _ JOB NAM
CITY, STATE, ZIP' // �/�'}'I ® Ct ` JOB L CATIO
ARCHITECT: (f� � DATE OF PLANS: / JOB PHONE:
Installation of a complete Certainteed 606 oQ!f �2 Shingle roof to the ent' house.
Color. — f tn_p� "e C
I. Includes strip all old shingles, we haul all debris, clean jobsite thoroughly and pay all dump and permit flsst- yY.
Includes Install: Gtu few
ice and water membrane to main house eaves, arou d�Ihai-mon-�efyZan', m valleys f !�C G
tarpaper base and flanges4elstacks
Jck
--8" aluminum
dripedg9 to all edges. Color. Gv�f I 0� �
- starter shingles to all rakes and fascias
-cobra ridge vent to all heated ridge areas ----
- r reinforce as nece"�A'�j ary and n ly se I chimn y flashings, any step and apron flashings.
iT rr c�wn.,�7/
Optlo i/7 /� �G�7 cC
o same specifi9AUQnc as ahnva but we will go.0 (�e stFiry ing)the exictiag ree€and sxcludes ic@ an�w�aor-
bran= a��per base.
l!
Customer responsible to cover/tarp attic items and clean any resultiFfg debris i 1c.,
Ten Year workmanship guarantee fin/
We Propose hereby rti)mish material and labor-complete in aacc�ord�anncce with above pe ' tu cations for the sum of:
Is
Payment to be made as follows:
1/3 start, 1/3 at half complete and balance upon completion.Tha�.
All material is guaranteed to be es specified.All work m be completed in workminflke manner --
according to smndaN precrices.Any alteration or deviation amp above speciamdom involving Authorized
extra costa will be executed only on wrinm ordem,and will beemne an extra chmge over
and abort the timorous.All agreements conringent upon strikes,accidents or delays beyond om Signature:
control.Owner to carry fire,tornado and other necessary insurance.Our workers are covered
by wod,em compensation inscormu,
Note:This proposal may be
turnerOwns agrees that in the event of his breach of this concoct betom work petered.Conoamm may withdrawn by us if not accepted wit days.
demand turner rive percent pd°/.)ofthe conne tt prim a in stipulettd damage
f fro the brmch.
Acceptance of Contract
The above prices,specifications and conditions are satisfactory ^
and are hereby accepted.You are authorized to do the work Signatur
as specified.Payment will be made as outlined abov -
Date of Acceptance ��" 3
Signature
You may cancel this Agreement if it has not been consummated by a party thereto at a place other than an address of the Seller,which may be his main office
or a branch thereof,provided you notify Seller in writing at his main office or branch by ordinary mail posted,by telegram sent,or by delivery,not later than
midnight of the third business day following the signing of this agreement.