23 CLIFTON AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised ar 2011
Building Permit Application To Construct, Repair, Renovate Or-Demolish a
One-or Two-Family Dwelling
This Section For OfficjaMse Only
Building Permit Number: Da Applied:
Building Official(Print Name) Signature t7 Date
SECTION 1: SITE INFORMATION
1.1 Property A ss: / /� u 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes o o 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) 1.7 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 OW ERSHH''
2.1 Owner'of Rec d. --�
nN nW ( cA�c�O1i
Name(Print) City St te,ZIP
�_2 Cl/�fGN /� fly �31 �-
No.and eet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building Owner-Occupied X1 Repairs(s) KI Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Prop ed , rkZ:
1;1tl5 C m f GurP
SECTION 4: ESTIMA ED CONSTRU&I614 COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 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:
5.Mechanical (Five $Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supe '�'icense CSL)
Q �1 License Number Expiration Date
Name of CSL ffrr r
List CSL Type(see below)
W
No. n treet / n Type Description
��� 1/ � a�/' /� /ate` U Unrestricted(Buildings u el ing cu.ft.
111 /�l/1�d— VQ R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Te a hone Email addWs D Demolition
5.2 Re iste d me Improvemen Coat ct r C) ) f
I! c) IC Registration Nurn gxpirafion ate
HI C any N e r C Re at ame
w n " �
No.an Str t Y rJ 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 o the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOIR BUILD PERMIT
[,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.
L�Nt CrSec1�Vc`IGtti
Print O ner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By enter' g m ame bel hereby art under the pains and penalties of perjury that all of the information
contain in this pplicati n is a and orate to the best of my knowledge and understanding..
Print Owner'tor A fthojized Ag nt's a(Electronic Signature) Date
NOTES:
1. An Own r ho 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dQs
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 halfibaths
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"
CITY OF SM.ENI, 2UNSSACHUSETTS
• BUILDING DEPARTMENT
• 120 WASHLNGTON STREET, Yo FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJIBERLEY DRISCOLL
MAYOR T1�tOatAs Sr.PIERRe
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CONDUSSIONER
Construction Debris Disposal 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 c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by: l' Ytc
(name of hauler)
The debris will be dispos d of in : j
(name U. facility)
OIA-
(address of facility)
s natur o ermt pplicant
to
Jebri. �T.Jx
i CITY OF Siuximll, NLxS&A CHUSETTS
BuILDLNG DEPARTNEVNiT
f 130 WASHINGTON STREET, 3"a FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
[CIN.(BERLEY DRISCOLL
lliobfAs ST.PIERRS
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CONMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 17
Plea Pleag Print Le ib
Name (BusimssiOrpnizatio vidtlall: I
Address: S �.
City/State/Zip: . Phone #:
Are you an employer?Cheek the appropriate box: Type of project(required):
1. am a employer with 2 _ 4. ❑ 1 am a general contractor and 1 ❑
employees(full and/or part-time).* have hired the sub-contractors 6. eon conswction
2_❑ 1 am a sole proprietor or partner- listed on the attached sheet.t �• .'Remodeling
ship and have no employees These sub-contractors have g Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152.§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers'
Other—
comp. insurance required.] l3.❑Other
•Any applicant that dtaks box pl most also till out the section below showing their worker'comprnaation policy information.
t l inmenemen who submit this affidavit indicating they are doing all work and then him outside comracsoIs must submit a rtew affidavit indicating such
=Canuacton that cheek this box most anached an additional sheet showing the name of the sub.commgoris and their wod on'comp.policy miumtalion.
I am an employer that Is providing Iv rkers'compensation insuranc far my a luyees. Below Is the policy and job site
information.
Insurance Company Name: �/
Policy#or Self-ins. Lic. #: Expiration Date. 0 /1
Job Site Address: C2S ( �(,�l UhU 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 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 5250.othe
against the violator. advised that a copy of this statement may be forwarded to the Office of
InvesliggliunsIA f umnce cov age verification.
!do here n ...ai ...
b1'refit v p and na allies ojperJury that the information provide� e Is t*e and correct.i itat ire' Date•.
Phone#:
Oricial use on not write in this area,to he completed by city or town o flic iaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of lleaith 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:— Phone#:
CERTIFICATE OF LIABILITY INSURANCE 0511 012)
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OOHS HOT AFPIm9'PIVE= OR xxsh=V A , � OR� ffi A� HY SRS POYLOCi= BELOW SEIS C3BY3MICM OP
MSURM= HOES HOS COHSZ== a ConnaT Humes WE ISSUna IMUMH(S), AVERMUZED H MMMM MV' P OR MMVCM, MM SHE
CZMTXF3CCras R=MR. �.���p,�
MOOHRHHR: If the certificate h"dQ is i AFL Imo, tae POlieY(iGa) mt bC eado & If SOHBO� IH „ ZVM' aobjeet
to the tams affi madttiona of the PolicY, c="l. W iciep -mY MTLI .e i andma=mt. A ctatemmt oa this aXtaf.1cate does smt
confer rights to the ...Wuf .eta holder in sie.. of such esderammt(s).
Dan Hurley Insurance Agncy Inc
7 F*edexal Street
Danvers, MA 01923
msYcm ms.
t®f a.anaos mamws e•ss
A_I_N_ )mtaat Inrnrar„a m 133758
James Shields
dba North Shore Window 6 Sidings
40 Preston Street
Somerville, MA 02143 tea=
]Opus[P.
COVERAGES CERSIFICITS Nobamm: RHVISICN Nam:
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AND SNPICIPP.S LSAaII.TrT -
2116 epoPAimOS/pA0.'O@ts/ _ - s.y. ma�YT s 500,000
A me rl Op aom ass
❑ incl ® excl 7025974012012 s-r- aYm�-Tmxa 4m s - 500, 00
OS/18/2012 05/18/2013 -
s.r- o>mo-sA m,mo c 500,000 III
omrsse a®®sa WWmtm as xoouW¢: �
IMES MUM IS
NOT COVERS HY THE WORNMR.S'OOMERSATION POLICY.
NORHERS' CMIMPENSATION 0OVZRhGE APe.XEc TO BLSSACEMISa^TS Ammom NS ONLY
CERTIFICATE H07d)ER -- ._. ._. . . ..._
C'aNY!¢TT.aTT�
SWD AK @'�AHWE�]84D Pm.$'$S 86 CAS 6�Da6 :
Northshore Window&Siding
40 PhMbn Rd wLHs _
Somenfile, Ma. 02143
617-628-7204" 1-800-439-7205 \ SQ
Mass. Reg_ 101562
3�9)' 0XP Q � k 3! .e)
NORTHSHORE WINDOW & SIDING
Residential r Commercial
40 Preston Road `��
SOMERVILLE, MASSACHLISETTS 02143 All home improvement contractors'and subcontractors
1-800-439-7205 (617) 628-7204 engaged in home improvement contracting, unless
specifically exempt from ,registration,by Provisions of
Chapter 142A of the general laws,must be registered with
Submitted MR , & MRS ANDREW TURCHON the Commonwealth of Massachusetts. Inquiries about
To registration and status should be made to the Director,
Home Improvement Contract Registration, One Ashburton
23 CLIFTON se Place, Room 1301, Boston, MA 02108` (617) 727-8598.
Owners who sectire their own crtruction related
SALEM, MA. 01970 permits or deal with unregistered contractors will
be excluded from the Guaranty Fund Provision of
MGL c.142A.
PHONE DATE _ REGISTRATION NO.
781-316-2317 7/18/2012 101562 ,
JOB NAME/NO. - JOB LOCATION -
>
We hereby submit specifications and estimates for work to be performed and materials to be used: -
n
FURNISH AND INSTALL ([q) FuFti HARVEY CLASSIC FULLY WELDED WHTRT VIN"YL
DOUBLE HUNG REPLACEMENT WINDOWS. ALL WINDOWS TO HAVE HIGH PERFORMACE
GLAZING WITH LOW E AND ARGON GAS. WINDOWS WILL BE ENERGY. STAR TATED AT il.130' 0
WINDOWS CREE STANDARD WITH 'HALF SAUMINUWSCREENS, NIGHT LATCHES AND
LOCKSTWO N ALL WINDOWS WIDER THAN 30INCHES. BOTH SASHES TILTT IN FOR
CLEANING. / 11 ^ ��• r : .r,
k /}� A✓(J�J � la F U C t/
INSTALLATION INCLUDES REMOVAL OF OLD STORM WINDOWS . WE THEN REMOVE THE ISSIIE
qTnPq PBRTTLT(7VE THE S r
AND PULLEYS AND .INSULATE THE POCKETS WIET FIBERGLASS- INSULATION.TO PREVENT
r m WITH PR ,I1 ED
j BY HARVEY. WE WILL INUEEIREE 'ERIMETER 'HITH- SPRAY FOAM INSULATION. '
j RR TNRTATT WOOD ;TOP-, ANTI cc'AI.--RERIMMrrR frTmu STI>ICON>3 LJis`s"B_ E>rllbi'3"d^
., . '.:,�. « '.:.y.�,.6 ..#'a -+/4'?.{• th„ �d W'"+b.5.rlrrr..ar..M�, h-k. L{.,1. s..w'11: ..A.-'g.*('+tlM,^,... Ywa:r��wt sny . h:.
> Construction related permits: - - UJ N li=A _ l CF /
la_ NDOWRWARRANTY FRr11'f jj,APUPY RUTTDIan- RRr1T1TTCJ+ - I
REMOHE ALL DEBRIS? BUILDING PERMIT FROM CITY
WORK SCHEDULE - - -
Contractor will not begin the work or order the materials before the third day following the signing of this Agreement unless specified herein writing. Contractor will begin the work on or,
about (date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed by (date). The Owner hereby
acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement.
WARRANTY - -
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of following completion and shall
comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contractor,his subcontractors,employees or agents,is
discovered within one year after completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied,
repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the-agreed-upon work.
WPC'PjOpOSe hereby'to furnish materi an labor-{ ompletg in acc da ce)with a rove s fications,for the sumo
2 r r �'
1.(111'F' (1IiC,k� i��i'V(ft Grp C (.� i / lU�. — dollars($
Payment tdbe made as follows:.
"u 4ej h(. �s,f
( ) upon signtog Cd tract, NORTHSHORE WINDOW & SIDING
($ ) upon completion of 40 'Preston Road
Somerville, MA 02143
_% ($ ) U on completion of
p^! n shall be madeforthwith.upon 1-800-439-7205 (617) 628-7204
% ($ ) completion of work under this contract. r
Notice: No agreement for home Improvement contracting work shall require a Li � `
v
>down payment(advance deposit)of more than one-third of the total contract price
Name of Salesman
or the total amount of all deposits or payments which the contractor must.make,In __.. —y 1,
advance,to order and/or otherwise obtain delivery of special order materials and Authorized Signature
equipment,whichever amount is greater. +r Note:This pmglosal m/Iay be Withdrawn by us g not acceptnd wnhin days.
Acceptance Of Proposal -I have read both sides of this document and all attached documents and accept the prices,specifications.&nd conditions stated.
I understand that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlihed above.
You,the Buyer, may cancel this transaction at any,time prior to.midnight of the third,businessAay after the date of
this transaction. Cancellation must be done in wntipg .
DO NOT SIGN T IS CONTRA T IF THERE ARE ANY BLANK SPACES.
Signature ` 'j r f Dale � Signature Date
( _ ' IMPORTANT INFORMATION ON BACK Op-