40 CEDAR ST - BUILDING INSPECTION I �
l The Commonwealth of Massachusetts
Q k Board of Building Regulations and Standards Town of
Oman
Massachusetts State Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Too-Fumill Duelling
This Section For Official Use Only
Building Permit Number: Date Applied: ..
Signature: �—
Building Conrilmissionerl Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property LZ :;V AdFdress: R Sr 11 r r Assessors Map& Parcel Numbers
I.I a 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 B) Frontage(it)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Sypply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage DIIgpossl System:
9�/ Zone: _ Outside Flood Zone? Municipal f 7,site disposal system ❑
Public Private❑ Check if es❑ p po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
T(�, _ gr, ,6 V 4A 40 C&AgIc S;
Name(Print) Address for Service:
999 -7g r44V'/Z.
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alleration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': FIA,9SA C'fOY 5 7detenmnined.-
0-1/1-y b6, --r`K�NfrP FolbSECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
r and MateriI. Building E 1. Building Permit Fee: E Indicate Standard City/Town Application Fee
2. Electrical E ❑Total Project Cost'(Item 6)x multiplierJ. Plumbing E 2. Other Fees: E
4. Mechanical (HVAC) S LisC5. .Mechanical (Fire SSu ressionTotal All Fees: E
Check No. Check Amount: _
6. Total Project Cost: S 33OW, 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Nuummber/r Expiration Date /
N:me ul'C L- Hylder /� _ List CSL Type(see below) (�
/rru� /1� Cray /�Ia
AJd RDRcsi"'Icd
Descn non
tncted u to 35.000 Ca. Ft.)
cted 1&2 FamilyDwelling
igr ure Only
ntial Roofing Covering
Telephone �7 ntial Window and Siding
�g/ 271 ntial Solid Fuel BurningA liance Installation
ntial Demolition
5.2 716tered Improwmeot Contratator(HIC)
HIC .m p ame orHIIC R - tram e eww Registration Number
�•O G��L(ro Y/ Expiration Date
Sign toref V- Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.S 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 f the building permit.
Signed Affidavit Attached? Yes .......... No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, SEc— co,M^"fT as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, BLS* `•'46d e!::&✓/ , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Fri me
S n ure o wner o Authorized Agent Date
(Simn&Wndcr the pains and penalties of perjury
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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 half/baths
Tv
pe of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for 'Total Project Cost"
CONTRACT Customer Name—losoaL ivie VctlAhCustomer Signature '
SKETCH Contract Date ( l9 09 Sates Representative Signature
®' ATTACHMENT customer Phone 9')R 2 157 9 Y4 L contract Pace 3
) x a . 6 e ) a 1 )o n 0 11 L is ie )) )e Iv A ]I a a N m m n m ar se ar L S JI R X ]) a L .o a U' o .5 .e n a o b 91 6] er & m N . es ® w
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NOTES: Each box equals one loot unless otherwise noted.This sketch is a good lallh
representation of the work to be done,II Is understood that all dimensions
--- __ derived from this sketch am approximate,and that all locations of oullotS,light
fixtures,plugs,jacks and/or swilGtes are subject to change A nocess—
CONTRACT Customer Name TOWL J- —Upmelipiec Customer Signature 2Z ]
SKETCH Contract Date- (411 OQ Sales Representative Signature
ATTACHMENT Customer Phone_��$ 245' 914L Contract Price 33.001,6
B 10 11 Is 1] 1. 15 Is 1] 1] 1. M ]I O 0 N M
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NOTES: Each box equals one loot unless otherwise noted.This sketch Is a good laith
representation of the work to be done, II is understood that all dimensions
-- derived from this skelcb are approximate,and that all locations of outlets,light
fixtures,Mugs,jacks and/or switches are subject to change it necessary.
CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM
Owens Corning Basement Finishing Division(the contractor)hereby submits this proposal to sell and install the Owens Corning Basement
Wall Finishing System and related items as described herein at the residential premises set forth below.This proposal shall not become a
binding commitment unless and until it has been signed by the Contractor and the Customer.
Contractor:
Owens Corning Basement Finishing Systems
a division o/Bay State Basement Systems,LLC.
60 Shawmul Road,Canton,MA 02021
Telephone it(781)821-0060
Facsimile N(781)821-8552
Federal Tax ID#14-1855297
/ Mass.Home Improvement Contractor Reg.p 137943
Date r 5
Customer: -�{I'
Customer Name �� 4 J.,:4,ejl V(�ll
Street Address
City,State,zip SSL`-` t � OIH'70 p
Telephone( K ) ���- ly��
This is a contract between the Contractor and the above named Customer to sell and install the Owens Corning Basement Wall Finishing
System and related items specified herein at the Customer's residential premises identified below:
Installation Premises: c
Street Address ✓tip^-P ,
City,State,Zip
Scope of Work: ��/
Are Sketches and/or specification sheets attached' � el C No
'All attachments are mach inmeb'mto and beta pan of thisob tray, /I �`^ --//
Description of Work/Specifications: kS/�!/� Or w4lls SLeP� Jt(, -"de,u oO t✓dI,
Orod ge4wlr FJraO a;�e', S�iH �s Q�� Lost h�derSl�hs Cldsc (3)Qao✓Y
C2� lirlirl1 H fr ti 0,9)eel � Y1f O1I7tlPYS M nd? Q)SU/ 1c4 taSlaa�e
� r > r
60d,- oi IleT l
Cl fV r,w
Work Schedule':
Approximate Commencement Date: 'N Q/s
Approximate Completion Date: 2 a Q—1
"The proposed work schedule is approximate and subject to change _
Contract Price: �1//��/�l
Total Contract Price: $ 3 3 v UV v / n
Deposit with order: $ 33C)0�1 ❑ Cash Check#
Balance Due: $ I aIJU
Terms: Nash ❑Finance
(Cash terms ar 1 /deposit,50%on commencement,40%on completion)
$ (far.5-OQ Due on Commencement
$ 13 7 n C I Due on Completion
t
DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ
AND UNDERSTAND THE ENTIRE CONTRACT,INCLUDING ANY ADDENDUM ATTACHED HERETO,AS WELL AS ANY ATTACHED
SKETCHES,MATERIAL LISTS OR THE LIKE,AND THE TERMS AND CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT.
YOU ARE ENTITLED TO A COMPLETE,FULLY EXECUTED COPY OF THIS CONTRACT AT THE TIME OF EXECUTION.
Witness our hand(s)and seal(s)below on this ( / day of TW i,�e
Bay to Basen.edit Systems,LLC./Authorized Representative:
Signatur nd Title
Print Name ✓
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Customer...
x/ i ,
mer Signature
Jar EPH I�AcATkA
Print Name
llihnnG ce-
�sinn=t,m
CITY OF S.ULE.`I, NL LAsSACHL;SETI'S
BUI DIING DEPART\I INT
120 WASHINGTON STREET, 3'a FLOOR
TEL (978) 745-9595
F.ax(978) 740.9&M
K1, FY DRISC011
MAYOR THoMAs ST.Fmm
DIRECTOR OF PL BLIC PROPERTY/BL'IIDLV G CO%MUSSION ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annllcant Information ,�v`1. �Q✓G_ c Please Print Leilibly
Natne (Bufincv.Orstnirat��iomllndsvtdual): ppt��Z��6j a�tA�r �t 04e5i7✓TJY.S/�}ryH
Address: Gd ,.7 wwalr FOCI
City/Stateizip: (fhNTO.() AW D0d1 Phone#: 7�) P
\re as employer?Check d):
a appropriate box: Type of project(require
1. - I am a employs with 4. ❑ 1 am a general contractor and 1
have hired the sub-contractors 6. ❑N con
employees(full and/or part-time).*
sttuction
2.❑ 1 am a sole proprietor rt or paner- listed on the attached sheet I 7• Remc eling
ship and have no employees These sub-contractors have s. ❑ IXmolition
working for me in any capacity. workers'comp.insuniace. 9. ❑ Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I-❑Plumbing repairs or additions
myself.(No workers'comp. C. 152.§I(4),and we have no 12.0 Roof repairs
insurance required.)t employees. (No workers' IJ.❑Otha
comp. insurance required.)
-Any applicant this checks boa et mum,slow rill ow, he section below showing their worker n'compensation policy infornmio
t 1 Lvrwownen who submit this aRldavil indicitinr They ant doing all work and then hire ataide connoctars tonal suhmil a new affldsvil indiurine seek
-C.mlraeten flat chink this line muss anache i an additional altar showing do rams of dw mb comnsclon and their workers'comp.policy inssmiss es.
I am an employer that is providlnr Ivorkers'compensadon Intarranee for my employees Below IS the policy and fob rite
information. �/J
Insurance Company Name: &Ng) X#f-lck�/�sex6K ) '-
Policy N or Self-inn. Lie..H: -K/r �7).5��_� Expiration Date:_
7
Job Site Address: yen Cepw Sr City/Statr/Zip: 7//C�7►1 t/'f9 (�/ I��
,%ttach a copy of the workers'compensation policy declaration page(skowing 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■
fine up to S 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$230.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Invc5oganion11 of IA for insurance coverage verification.
/Jo herr errs' to r th n o f/�tableles of perjury that the information provided above is true and correct
Phone A: /X/ ?7/ ,5qY7
iOfcia!USe attly Do nor write in this area,to be runrpleted by city or town official
City or ruwn: I crmit/Llccnse iY__._
issuing.%ulhorily (circle one):
I. Board of lleallh 2. Building Department J. City/town Clerk 4. Electrical Intpector 5. Plumbing Inspector
6. Other .. _..
GmmlactPerson: _. .. _ __. _,_ Phone6•
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE/ /YYYY)
5 22 2 009
PRODUCER Phone: 781-659-2262 Fax: 781-659-4725 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Andrew G. Gordon, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
680 Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. O. Bo)2 299 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Norwell MA 02061
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:P rl n r 4198
Bay State Basement Systems, LLC INSURERS:Pilcirim Insurance CQmr)any 21750
60 Shawmut Road
Canton MA 02021 - INSURER C:Renai IS sance Marketing
INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AWYL POLICY NUMBER POLICYEFFECTWE POLICYEXPIRATION LIMBS
A GENERALUABILITY CPB8512851 9/5/2008 9/5/2009 EACHOCCURRENCE $1 QQ QQQ
X COMMERCIALGENERALLIABILRY DAMAGETOPREMISES RENTrD ESQ OOO
CLAIMS MADE OOCCUR MED EXP(My one Person) $10 0Q
PERSONAL&ADVINJURY $ 1, 000, 000
GENERALAGGREGATE $2 00Q 000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E2 DO O
X POLICY PRO- LOC
B AUTOMOBILE LIABILITY PGC10007161409 1/17/2009 1/17/2010 COMBINED SINGLE LIMIT
ANYAUTO (Ea ecdtlen0 $1, 000, 000
ALLOWNEDAUTOS
BODI Y $
X SCHEDULEDAUTOS (Per personerson))
X HIREDAUTOS
BODILY eracul ent) $
X NONOWNED AUTOS (PereCdtleM)
PROPERTY DAMAGE $
(Per omdent)
GARAGE LIASIIJ AUTO ONLY-EAACCIDENT $
ANY AUTO OTHERTHAN EAACC $
AUTOONLV: AGO $
A EXCESSIUMBRELLA LIABILITY CUS511953 9/5/2008 9/5/2009 EACH OCCURRENCE $1, 000, 000
X I OCCUR CLAIMS MADE AGGREGATE $1 QQQ QQQ
E
DEDUCTIBLE $
RETENTION $10. 000 $
C WORKERS COMPENSATIONAND WC0371527TBI 5/24/2009 5/24/2010 we srwTu- OTH-
FR
EMPLOYERS'LIABILITY
ANY PROPRIETOWPARTNER/EXECUTIVE _
E.L.EACH ACCIDENT $1 O 00
OFFICER/MEMBER EXCLUDED?
E.L.DISEASE-EA EMPLOYEE $j QQQ QQQ
X yes,IALP be
under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ j
, 000, 000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
Owens Corning Basement Finishing Systems BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
9 4 Y WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
60 Shawmut Road CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
Canton MA 02021 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
��- -.
ACORD 25(2001108) 6ACORD CORPORATION 1988
CITY OF SALLM
PUBLIC PROPRERTY
'- --� DEPARTMENT
III ;Fic • 1 �\ "A v: 1;�„
Construction Debris Disposal Affidavit
(relluircd 16r all demolition and rcnu\ation work)
In accurdance %%ilh the sixth edition of the State Building Code, 780 CAIR section I 1 15
Debris, and tltc provisions utAIGL c 40, S 54;
BmIdinS Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris willbe ttianspoorrtcdby:
Le
/
(nunu of hauler)
I he debris will be disposed ofin
(e '��)Y l�IMAf,5i�
(name of facilely) nn
Gb r5W&?14j_ P/ /,"
Luldre.. of I]cJuvl
i
a�n alwc nt p:nuu .q+p hcunl
lal:
Te >°io�nnxa�uoea,��o�./�anoaT/uuelld
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 137943 Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Expiration: >•;2g/p01� Boston,Ma.02108
ry�t AType: Supplement Card
OWENS CORNING-BASEMENTTI
CfA�YI�t^�FVXESH��
a
60 SHAWMUT RC'
CANTON. MA 02021 N
Administrator Not valid withouou*signature