20 FEDERAL ST - BUILDING INSPECTION (6) The Commonwealth of Massachusetts
UlfBoard of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM
Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
/Tlhs Section For Official Use Only
Building Permit Number: .,dl e Applied: Z V
gnature: O� 9 l p� Building Com ' sioner/Inspec r uildings Date
ECTION 1: SITE INFORMATION
1.1 Propert/y Address: S 1.2 Assessors Map&Parcel Numbers
b F-2 -2C' S4
1.1a 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 ft) Frontage(11)
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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
R2t<Yl aV�V'cl 20 Pc.je°r0.1
Name(Print) A Address for Service:
a w /L12,6 ` 1 L � ��- TIo — Of/q
Signature ' 7 Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repaits(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': 6fPLcL[P 3 L-w,gdow s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 3 y 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
6. Total Project Cost: $ 3 9 Yp Check No. Check Amount: Cash Amount:
/� / ❑Paid in Full ❑Outstanding Balance Due:
/`70� e C&1 .-, W
SECTION 5: CONSTRUCTION SERVICES -
5.1 Licensed Construction Supervisor(CSL)
�1��
C L(t rcev , License Number Expiration ate
Name of CSL-Holder
16 �� �( j�ac��s rr�l ry o2t�f List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone INS Residential Window and Siding
SF Residential Solid Fuel Burninp Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
L_r-e-er -t—,);-s\A I"b-1 /o ;2 15 7
HIC Company Name or HIC Registrant Name Registration Number
0 gs,. s \D-- J>\e fad AMA o-r s— 7 /3 �lZ
Ad � �( 7 - �y 2--''I �9 Ezpirauon Date
Sign=attuuree 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 .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, K e k' ) WAY�4^G\ as Owner of the subject property hereby
authorize_�� C,�L to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the statements and inf rmation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name ( //o
Sigiffirbre of wner or Authorized Agent Date
(Signed under the pains and penalties of a du
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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 halffbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
40
Boston,MA 02111
wwwanass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): . RortalA (—r¢tr�•-C
Address: j o lZ A 'or.
City/State/Zip: me d-�Orc tMk 07lSs Phone.#: 617— 5/Z — o
[2.
you an employer?Check the appropriate box:
\Iam a employer with to4- � I am a general contractor and I Type of project(required):
ve to ee « ha 6.
mp y s full and/or arttime . ve hired the subs ❑New constmction
( ontrac
P ) tors I ant a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling,
ship and have no employees These subcontractors have g, E Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp. insurance.l 9- ❑Building addition
required.] 5. E We are a corporation and its 10.EElectrical repairs or additions
3.E I am a homeowner doing all work officers have exercised their I I E3 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.]t C. 152, §1(4),and we have no 12.E Roof repairs
employees.[No workers' 13.E Other
comp.insurance required.]
"arty 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 contactors must submit a new affidavit indicating such.
tCootractors that check this box must attached an additional sheet showing the name of the subcont ictors and state whether or riot those entities have
employces. of the sub-oontractors have emptoy=,they must provide their workers'w
rrp.policy number.
_ _.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
injorma[ion.
Insurance Company Name: I�IQ J G`n9`rti✓1� o- _r k tnt evtu/
Policy#or Self-ins. Lie.#: 4 5 l'>a//l 3 Expiration Dater l f
Job Site Address:_ 0 T c�1fa` Free S City/State/Zip: `xkVern , MA
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 criminyl,penalties of a
fine tip 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 under the pains and pentrUies of perjury that the information provided above.is true and correct.
Signature:
Si (_
� ��� Date: d' 3//O
Phone#: 269- l .
Off[cial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Liceuse#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
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�.This rsonly equole'ior me merchandise andserv,ces.prmtegbelow Thls becomes an agreementuportpayment Upon paymenq the g�tlre agreement,including ihespecihcally completed pages of this4 t- ..,
tlocyroent,the Terms antl'Condtrori5inclutletl wikB this tlocument anCany other atlCEhtla erW attachments hereto shallbe,reterred to 6e[eln as thlg"Cont[act Y +' 1T .
PLEASE READ ALL TERMS AND OONDITIONS ON THE,REVERSE;SIDE OP TRI3PAGE AND FOLtQWiNG PAGES BEFORE SIGNING Y}' JF F,* 4�y +a4k .
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NOTICE TO CUSTOMERS';Federal law repwres Lovie's to provide you with the pamphlet Renovate Right•Important Lead Hazard Information for
• ' .. . .Families:Child Care Pr6Videf5 and Schools By signing this Contract Customer acknowledges"having received a copy of this pamphlet before work
J - began informing Customer of.the potential nsk"of the lead hazard exposure from renovation actnrity�to be performed in Cus d tomer's welhrig linrt
Work is to commence.upon reasonable availability of Contractor and/or availability of any special order o'r custom made Goods which is'anticipated
to.:be § �: ��" w •.[fiII in date] ,,Estimated completion`date is - � } " [fill In date]
Said eshm;jfbd•substantlafcomplebon,date Is not of the essencei Contmgencles that may materlally.:change said,estimated substantial completion datefollow. . `
✓.. .'J +.`.. _ t ,.z kw NxT ES
`--(If applicable insert a statement of such contingencies).
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_"NOTICE,TO CUSTOMER' " `
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All dems listed in this Contract andspeciflcabon shee(s)are to be,installed under conditions agreed upon at time of purchase and at the pnee appeanng;on this
contract form`;This assumes sound existing substructures,superstructure and points of attachments,*Extra labocor maienal inDdent to installation necessdated
by defective substructures,superstructure points of attachment,or the moving of fixtures or appliances to be billed at extra host to Caustomer
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This Contract provides that all claims by Customer or Go will will be resolved by.BINDING ARBITRATION.:Customer and Lowe s GIVE UP THE RIGHT
I TO GO TO COURT to enforce this Contract(EXCEPT for matters that may be taken to SMALL.CLAIMS COURT) Lowe s and Customer s nghts;Al be
I �deterrnmed`by a NEUTRAL ARBITRATOR and NOT a judge or fury.Lowe s and Customer are,entitled to a FAIR HEARING Buf the'ar�bitrahon3:: t
( rocetlures.are SIMPLER AND,MORE LIMITED THAN RULES APPLICABLE IN COURT Arbitrator decisions,are as enforceable as,any court order and
t� i a're subject to VERY,LIMITEO REVIf W BYIA COURT FOR MORE DETAILS Reviewahe Arbitration Agreement and Waiver of Jury Traal sectson*Af then f_a
ry C I�Terin's and Co�idrtiq�ns f this GoMract and visit"Fhe American Arbdration Association s website at www:adr org �+ a �sz , 'yddd�w�s r, � > f
DO NOT SIGN THIS CONTRACT UNTIL COMPLETE AND YOU HAVE READ THE TERMS AND CONDITIONS CONTAINED ON ALL
r .PAGES•OF-:THIS'CONTRACT.BYSIGNING,'BELOW;;YOUAREACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND
h'SvN
AND AGREE,TO THE'TERMS AND CONDITIONS:SET FORTH ON ALL PAGES OF THIS CONTRACT YOU ARE ENTITLED TO A?,
'COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE
k —WITNESS HAND(S)AND SEALS)BELOW THIS _.DAY OFsr,.facet__ i- � G')I{ - r , : F : ,.4 _®
ry DATE` ^' LOWES CONTRACTOR LICENSE NUMBER CASH yG,.. t„ BnR. „zr5 LCC REG 3 pp
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I Tnrs is only a quote for the merchandise and services printed below. This becomes an agreementupon payment,Upon payment,the:entire agreements mduding the specaBcstlycompletgp pages of this *sgp Il
l f Sdominant the Terms and Contl'i4ons mclutletl with'Uis4ocumentand any other addenda and attachments hereto,shall be let- fo herernes this"Contract- :+•'— r . ,-
LEASE REALiAa TERMSANDICONDITIONS-bNTHE,REVERSE SIDEOf`TNI$PAGEAND FOLLOWING.J'AGES BEFORE SIGNING
, .' x > 9 -e_�: .a+--,xia ._H> *w,T _,*vts .,i.,�zasv p.✓...... -r rust ,ise,;,_ -RAGES
BEFORE
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applicable'taxes.included . , ;,4
.NOTICE TO CUSTOMER n_Federallaw requires Lowe s to provide you with the pamphlet Renovate Right:Important Lead Hazard lnformadon for
t FamNres, Child Care Providers and Schools.By;signing this Contract,Customer acknowledges having received'a copy of this pamphlet Before work'
'be art informing Customer of the potential risk of the lead hazard exposure from:renovation activity to be performed'in'Customees dwelling unit.
Work is to commence upon reasonable availability of Contractor and/or.:availabilityr'of any special order orvcustom made Goods which is anticipated"
to be r -y-t LL [fill in date]':Estimated completion date is t'"[fill in date] f ", -r ! q r +- ,
k, -
Said estimate substantial completion date is not of the essence.'Contingenraes that may-matenally change said,--es atbd substaritial.coritpletion,date,follow.
(If applicable;insert a statement ofsuch contingencies) "
3
•-NOTICE TO CUSTOMERI' .«-� ,*„? ,� P• -' -° n '
All dams listed in this Contract and specifcation sheets)are.to.be installed under conditionssgreed upon at time of purch%eand at the pace appeagng'on this
'.contract form z'x s a"ssurnes sound ezisting substructures,superstructure and points of attachments. Extra labor or material iricident to,idstallation necessitated
" by defectme.substructures;superstructure,pomts'of attachment;:or the moving of frxtures'or appliances to be billed at eidra cost to Customer
:>
,This Cofitract1proyidid.g ttfat all claims by Customer' L'owe's will be resolved by'BINDING ARBITRATION.Customer and Lowe's°GIVE UP THE RIGHT
` TO GO TO'COURT to enforce this b`ontract(F_XCEPT formatters that may be taken to SMALLCLAIMS COURT)'.Lowe'S and Customer's rights;will be
.`tletermmad.fry a NEUTRAL ARBITRATOR.and NOT a ludge.orlury Lowe's and`Customer are entitled to a FAIR HEARING But the.arbitration.s
f procedures are SIMPLERAND,'MORE.LIMITED THAN RULESAPPLICABLE IN COURT Arbitrator decisionsare as enfq�ceable asany court order and
are sulilect to,VERY LIMITED REVIEW BYA COURT.FOR MORE DETAILS Review;fhe Arbitration Agreement and Waiver of Jury Trial section-of the
t+s Terms and Conditions of this Contract and visit the'A
mericn Arbitration Assoaahon s websrte at www adriorg '` , �' al
�",* n :."t•b :.-_.._ a awz'"f�.'te�9`.w��.`S#9 " '."'i::�3a'w.s:$,i":i d..�.'�3r. rR.u_ ....:`.w�. '=:.4�w ia+v-, -c' �..�.lr`s''&�d.4.�` .s.,..� .Say«. .
DO NOT SIGN THIS.CONTRACT UNTIL COMPLETE AND YOU HAVE READ THE TERMS AND:CONDITIONS CONTAINED ON ALL
PAGES.OF.THIS'CONTRACT. BY;SIGNINO BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND
AND AGREE TO THE.TERMS AND CONDITIONS SET FORTH ON ALL PAGES OF THIS CONTRACT YOU ARE ENTITLED TO A,u
COPY OF,THIS CONTRACT AT`T_HE,TIME OF SIGNATURE.
a «t
WITNESS OUR HANDS)AND SEAL(S)BELOW THIS DAY OFF
Lowe s Horne Centers Inc.:, E s r Y
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Customer acknowledges re eI of a'true copy of this contract which was completely filled in rprioP to Customers.execution hereof.-You,the buyer,may`-
`, r can this trau'sactwn at an tine prior to midnight of the third busines's day after the date of this transaction See the attached-notice of cancellation
L ° 'form for an explanation ofthrs right'