29 1ST ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Ulf
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CNK 7`"edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
a� One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numb r: Date Applied: ( O
Signature: 11, I Gj t f J
Building issioner/nKpector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Proper Address: 1.2 Assessors Map&Parcel Numbers
1.1a Is thisan 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(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'
2.1 Owner`of Record:
1orsto< Z9 �$+
Nay} (Pint) Address for Service:
I75-71y—v7ly
Sigo re Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz: reMy-d I MP6Ae plus Sl of nn
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ �1 Z-.so. 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ 1
Suppression) Total All Fees: $ lt/JI
Check No. Check Amount: Cash Amount: ��
6. Total Project Cost: $ 11 230, 2.1 ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ga 9 lq S 10 11
IC ad 3)e I ct IC License Number Expiration Date
Name of CSL-Holder
�/S�etsl.k S+ So4e 9rr% MA 01 7o List CSL Type(see below)
q— %,F'T —�� Type DescriptionFt
U Unrestricted u to 35,000 Cu.Ft.
Signature - R Restricted 1&2 FamilyDwelling
M Masonry Only
f7a-74S—53 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 I�eg�ste{rgd Home��trprovement Contractor(HIC) 1`
/'� tXM ( r�, l�
HIC Compan Name or HIC Registrant Name Registration Number
Adds L�—_I •� . 54em a�A d476 I [6[11
�E—]�$— Expiration Date
Si ature ' 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 CONTRA1C(T`OR�APPLIES FOR BUILDING PERMIT
I, SiW iG C c , as Owner of the subject property hereby
authorize MI ha-C) !='!�Cllillc to act on my behalf, in all matters
re l e o work authorized-by this building permit application.
Si ture of Own Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, oM (f1Ct'e I L)ej"�(6 ,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.
rl
PrintN _ `(/i�//O
Signature o caner or Authorized Agent Dale
—(Signed under the pains and penalties of perjury)
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 I I0.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 halfibaths
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"
STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO VALIDATION
DOOR
LOWE'S OF DANVERS, MA., STORE # 1091 STORE PHONE: (978)646-9099
153 ANDOVER STREET SALESPERSON: EDWIN VELAZQUEZ
DANVERS, MA 01923 SALESPERSON ID: 794346
Document Print Date : 11/12/2010
This is only a Quote for the merchandise and services printed below. This becomes an agreement upon payment and
an endorsement by a Lowe's register validation. Upon such payment and endorsement, the entire agreement, including
the specifically completed pages of this document,the Terms and Conditions included with this document and any other
addenda or attachments hereto, shall be referred to herein as this"Contract."
PLEASE READ THIS ENTIRE DOCUMENT, INCLUDING THE "TERMS AND CONDITIONS." BEFORE SIGNING.
Lowe's Registration or Contractor License Number/Lowe's Contractor Name
Lowe's Home Centers, Inc.'s MA HIC NO.: 148688 Lowe's Home Centers, Inc.'s FEIN:
56-0748358
Customer Name Home Phone
S JANICE TEDFORD 978-740-0714
O Customer Address Other Phone
29 1 ST ST, UNIT C
L City State/Province Zip/Postal Code
D SALEM MA 01970
Installation Address
T 29 1 ST ST UNIT C
Installation City Installation State/Province Installation Zip/Postal
O Code
SALEM MA 01970
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
1161 : 1161 : STK : 1X8X8' SELECT PINE : 1X8X8' SELECT PINE : PRECISION LUMBER - QTY 1
18302 : STK : PNE CASE 351 2-1/2X1 1/16X8' : PNE CASE 351 2-1/2X1 1/16X8' - QTY 3
+`80456 80456 : STK : 32" RB MINI-BLIND 2 PANEL RH UT : 32" RB MINI-BLIND 2 PANEL RH UT : AMERICAN BUILDING SUPPLY, INC. - QTY 1
131207 : 131207 : STK : 1 X8X16 PRIMED FINGER JOINT : 1 X8X16 PRIMED FINGER JOINT : IRVING FOREST PRODUCTS (MAINE) - QTY 2
220619 : 34680031 : STK : 32" TRADEWINDS MV WHT-BRASS : 32" TRADEWINDS MV WHT-BRASS : LARSON COMPANY - QTY 1
Store 1094 Project No. 311782112 for JANICE TEDFORD Page 1 of 7
STORE COPY
Materials Price $ 587.29
INSTALLATION DESCRIPTION
Stock or SOS : Stock Door Type : Exterior
Select Location : Back Door Select New Door : Single Pre-hung
Number of Doors to Install : 1 Side Lights or Transoms : No
Hardwood (Mahogany or Oak) Door : No Hidden Damage Description : None
Number of additional holes bored for accessories : None Install Specialized Mortise Hardware : No
Install Storm Door : Install new storm door Select Storm Door : Storm Door
Lead Safety Practices : No Total Linear Feet of Custom Trim to be Installed : 0
Deliver Door : Yes Customer Understands Scope of the Project : Yes
Permit Required : No Additional Miles Traveled over 20 : 0
Bring Up To Code Description : None Local Disposal Fee : Yes
Describe Other Work Needed : build out of jamb on entry door and caseing for Other Work Charge : Yes
storm install
Comments : tradewinds bevel for storm. ?entry
Labor Charges $ 578.00
Detail Deduction $ 35.00
Additional Specifications:
Notation: Lowe's will not make structural modifications, paint or stain or remove/reinstall security system equipment. Customer is responsible to advise if prop-
erty is governed by Historic District Regulations.
Additional Specifications: The Environmental Protection Agency (EPA) has requested that Lowe's notify installation customers that a lead based paint hazard
may exist in dwellings built prior to 1978. See pamphlet EPA 747-K-99-001 for details.
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES "where applicable labor is taxable,check local tax restrictions.
SUB-TOTAL $ 1230.2
*TAX $ 0.0
DELIVERY $ 0.0
Store 1094 Project No. 311782112 for JANICE TEDFORD Page 2 of 7
STORE COPY
ORDER TOTAL $ 1230.2
BALANCE DUE
Work is to commence upon reasonable availablity of Contractor which is anticipated to be 1 [fill in date].
Estimated completion date is [fill in date].
NOTICE TO CUSTOMER
All items listed in this contract and specification sheet(s) are to be installed under conditions agreed upon at time of purchase and at the price appearing
on this contract form. This assumes sound existing substructures, superstructure and points of attachments. Extra labor or material incident to installation
necessitated by defective substructures, superstructure, points of attachment, or the moving of fixtures or appliances to be billed at extra cost to custom-
er.
IF THE CONTRACT TOTAL IS $1.000.00 OR LESS Customer must pay in full.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS 1 000.00:
Customer to Pay in Full; OR
L] Customer to use the following payment schedule:
(1) Deposit $ to be paid upon signing contract. Deposit should be 1/3 the total contract price; and
(2) Payment of $ to be paid anytime after this Contract is signed and before commencement of installation, I/We authorize Lowe's to do
one of the following (check appropriate box below):
[_] Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or
[_] Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and
(3) Final payment of$100.00 to be paid upon completion of the installation and both parties' satisfaction.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND CONDITIONS CON-
.TAINED IN THIS CONTRACT AND WHICH FOLLOW THE SIGNATURE PAGE(s). BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU
HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH IN THIS CONTRACT. YOU ARE ENTITLED TO A COPY
OF THIS CONTRACT AT THE TIME OF SIGNATURE.
NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L. c 142A
LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CON-
TRACT, THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRET-
Store 1094 Project No. 311782112 for JANICE TEDFORD Page 3 of 7
STORE COPY
ARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
MIT T S H ARB). kATION AS PROVIDED IN M.G.L. c.142A.
s 11+�/ <_� U
By: -- -- -- Date:
Lowe's Home Centers, Inc
By � �_� ! t Date:
Owner -`' T
By: Date:
Spouse
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION
INITIATED BY LOWE'S PURSUANT TO M.G.L. c 142A THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION
EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES
WITNESS OUR HAND(S) AND SEAL(S) BELOW THIS DAY OF
Lowe's Home Centers, Inc.
By:1� (Seal)
l'L�c EC
Print Name: -----
Sit
l 1 v� �e:'� C .- ✓-f �_ P Address
Orer (Seal)1 _�
City State/Province Zip/Postal Code Print Name
Spouse (Seal)
Print Name
Customer acknowledges receipt of a true copy which was completely filled in prior to Customer's execution hereof. You the customer may cancel this transaction
at any time prior to midnight on the third business day after the date of this transaction. See the attached Notice of Right to Cancel for an explanation of
this right.
Store 1094 Project No. 311782112 for JANICE TEDFORD Page 4 of 7
o
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Bostoti. MA 02111
www.mass.g of/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
Name I Business;Organizationilnelividual):._ 1 L
_ C /
Address: i� aJriw _______
City/State/Lip:__ d dA 6d v Phone;.`•: q 7� — 721
Are you an employer!Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
I '.,'/'j'• I am a sole proprietor or panner_ listed on the attached sheet. 7. ❑ Demoliti n_e
- / ship and have no employees These sub-contractors have g• ❑ emoition
working for me in any capacity. employees and have workers"
9. ❑ Quilling addition
I No workers" comp. insurance comp.insurance.•
required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a honicowner doing all work officers have exercised their 11.0 Plumbing- repairs or additions
nivself No workers' coot right of exemption per MGI.
� P• 12.❑ Roof repair
insurance required.)" - c. 152. §](4).and we have no
employees. [No workers' 13. Other _
comp. insurance required.1
`Anc apphcant that chceks hue"I must also fill out the section below showing their.orkeri compensation rolicy inibmation.
I lotneowners a ho submit this atlidau it indicating Ihey are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors than check ihi,hat must attached an additional sheet showim-the name of the sub-contractors and stmc whether or not those entities have
emrloyees. 11 titi'sub-enntraiutts have cmplocecs.Ihav most nrnvide their workers'amlr.policy numlmr.
l am an enrptnrer that is providing workers'conipe»sation insurance(or 1Hr eneplf tees. Below is Nte poticp and joh site
information.
Insurance Company --
7/ L
Policy :' or Sell=ins. Lic.+: �( Q_y5'-t7.� L-:xpvation Date:_u 7-
Job Site Address:__Z- _ x City/State/lip: f� l eY� b/9�a, M _ --------------------___---
.Attach a copy of the workers'compensation policy declaration page(shoeing 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
tine 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.
l tit)herehv cerrrriifi•undep the " s dpenalties ojperjurlr that the information provided above is true and correct
Sig-nature: ,✓/� '7p -7 Date:
Phone
Official use anlr. Do not write in this area.to be completed br citr of torn official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
PARENTE INSURANCE Fax:9785315587 Nov A 2010 10:09 P.01
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MICHAELT DEMILLE
5 BRISTOL ST
1
SALEM, MA 01970
�i-•� may/-rye. c;uica::on: 10/U2011
r--: 8801
" - � I '{ ,;:il�)>f l!( „nC.., 4.l i I„L.ti.:Yt J✓.1
4• Ecard of Bailding RegWationi and Sisndards
HOME IMPROVEMENT CdNTRACTOR
a c .
Registration: 102M
Expirafi0n:'4jVj2011. Tr#--282585."
Type: Individual
MICHAEL THOMAS DEMILLE
.MICHAEL DEMILLE
5 BRCISTOL ST
SALEM,MA 01970 Administrator "