5B DEWEY DR - BUILDING INSPECTION JACKET ----
S/� PUBLIC PROPERTY
DEPARTVIEINT
KIsIBERLEY DIUSCULL +.IYI y . .rti s lil e
MAYOR 120 WASHING ON S rREEr,,*SAL^MASSACHLUX S 01970
Tl••7-, 78-745.9%5♦FAx:976-740.98"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: ' Building: j 3 oOeL✓e
Property Address:
properly is located in a;Conservation Area Y/N A/ Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land _
tjT nil _ L
$ �re� p2
�! C ^ — $/
3.0 COMPLETE THIS SECTION FOR WORK IN PY1CTtNr: BUILDINGS ONLY
Addition Existing
Renovation v Number of Stories Renovated
Change in Use y New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation I New
of existing building
Brief Description of Proposed Work:
The Chimney Guy
P.O. Bog 4074
--Peahody,-MA 01960- _
Mail Permit to:
What is the current use of the Building?
Material of Building? If dwelling, how many units?
Will the Building Conform TfltoebUY3 Asbestos?
Architect's Name R 0 Rea 4074
Address and Phone Peabody,MA 01960 t
Mechanic's Name 978-977-9900
Address and Phone
Construction Supervisors License# HIC Registration#
Estimated Cost of Project$ `�r�5� Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date 3
of
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards ��NA�A �(�`�•
Massachusetts State Building Code, 780 CMR IpSPEC
Revised Mar 2011
Building Permit Application"ro Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use ly
Building Permit Number: Date Applie
Building Official(Print Name) SignalurIfDate
SECTION 1:SITE INFORMATION
1.1 Property Addre V 1.2 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 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(NLG.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check iryes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Roexrd:
Name(Print) City,State,ZIP
��«a
No.and Strcc � elophonc Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check a 1 that apply)
New Construction ❑ Esisting Building❑ Owner-Occupied ❑ Repairs(s)P1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Speciry:
Brief Description of Proposed Work':
SECTION 4: F.STINIATED CONSTRUCTION COSTS
Item Estimated Costs: Official se
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2. Electrical $ ❑'rotal Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: ❑ Paid in Full ❑Outstanding Balance Due:
M 1D�1 I C�TZ� NUJ f0 L 1.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction S isor License(CSL)
` '% :'.'i'�� �11Y►��(� License umber Expim on at
r „Name of CSL Holder
-1
1 List CSL"1'Ypu(see below)
No.and Sir et Type Description _
U Unrestricted Buildin s up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,' IP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
T eeleel hone Email address D Demolition
5.2 Registered Home Iml overn n Ca actor(HI )hop ��
111C Registration Number Expi [io Datc
A
MState,ZIP
rant Name
�,,.y A Email address
City/Town, Tel--�hr en�e/��J�J d
SECTION 6: WORKERS'COMPENSATION INSURAN E AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan 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
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this bwlding permit application.
e-
Print Owner's Name(@lectronic Signature) q.rte
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perju that all of the i rformation
contain in is a li •tion is true and accurate to the best of my kn •e a unders[, ing.
Print Owner's or Authorized Agent's Name(Electronic Signature) D,
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hire§an unregistered contractor
(not registered in the Flome Improvement Contractor(FIIC) 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.£ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Flabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms_ Number of half/baths
Type of heating system_ _ Number of decks/porches
Type ofcooling system Enclosed Open_
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
-•� -� PLEASE READ THIS
Sold,Furnished and Installed by;
Branch Name:Boston North&South Dale:S/ y!Xq TDD At-Ilome Services,Inc.
d/b/a The Hnnw Depot At-Homc Services
Branch Number:31 end 33 908 Bo+ton Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 577.903.376E
Federal rD N 75-2698460;M E Lic N C 02419:RI Cont Lick 16427
C (T Lic#H_I`C-.0565522;MA Home Improvement Contractor Reg h 126993
Installation Address: . J 4�ey .�r J eM MA 01000
City State Zip
Purehaser(s): Work Phone: Home Phone: Cell Phone:
Otme le�e9 [ ] [`I31-2 -4610 [ ]
Home Address:
(IfdilFerent from Installation Address) City State Zip
E-mail Address(ter receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing emails from The Home Depot
Proiect Infermatiml: Undersigned("Cuirtomer'j,the owners of the properly located at the above installation address,agrees to buy,
and THD At HomeServices,Inc.(."The Home Depot")agim to furnish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the reference)Sp.Shcet(s), all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job 4: soducts: Srec ShMt x)k: Prn'ett Amount
5134�n Wohng Siring Window Insulation
4 []Gnncrs/O vers ❑Fnuy Doors ❑ L �
Roofing Siding Windows Insulation
❑(nmcm/Co cis ❑E.my Doors ❑ _ $ //
g Sidiiz C1 Windows Insulation $
❑Ounem/Covers ❑Entry Devils❑
Rocliog Siding Winduwa hrsulatirni
❑(,tunas/Covers ❑Entry Deare ❑
Minimum 25%Deposit of Contract Amount due upon execution Mthu contract. Total Contract Amount $
M.i Kr ,J�
Maine Purausers may not deposit more than vn"I ird order Contrast Aramaic
Cusmmer agrees that, norms iamly upon completion of the work for each Product,Customer will execute a.Completion Certificate
(one for each Prndu&as defined by an individual Spec Shed) and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated mid liable hereunder.
The Hoare Depm reserves the right to issue a Change Order or terminate ate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety cancans,pricing arms or because
work required to complete thejob was not included in fileContract
2 Pavm qent Summary: The Payment Summary N 6� 8 / 1 included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
Von are entitled to a completely filled-in coppv of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate fur eaeh'ltsted Product as defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this Agreement err allowed under applicable law. THE.HOME DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acce dance sold .Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Ilume Depot with regard to the Products and Installation services and supersedes all prior 6.%cussmns and agreements,either
oral or written,relating to said Products and Installation,This Agreement cannot be assigned m amended except by a writing Signed
by Customer and The Hume Depot.Customer acknowledges and ainces that Customer has rend,understands,voluntarily accepts the
terms of and ties received a copy of-this Agreement.
Acce a y: _ Suhmi cd by:
sy 2
Cu is Signature Date Sa Consultant's Si ire Date
X _ '1'etephtmeNo. C3 )927-
Custemcr'.s Signature Date
Sales Consultant License No
CANCELLATION: CUSTOMER MAY CANCEL THIS (as apphwbla)
.AGREF..MF.NT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE,rO TILE HOME
DEPOT RV MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SIIPPI.F.MRNT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE. IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
Nlll'1(lI.-ADIA I RINAL I'F.RMS ANI)('ONDI'IIDNS ARE S'I A I ED ON'111L,REVERSE SIDE AND ARE PAR"Of'11115(TIN'1'RAM
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