41 FRANKLIN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards O MUNICIPALITY
Massachusetts State Building Code, 780 CMR, 7°i edition S11 USE
j� Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Jruumn'
�1
One- or Two-Family Dwelling 7, 2008
This Section For Offici n
Building Permit Number: Dat Applied:
Signature: ULA._ -
BuildingCommissioner/Inspector (Buildings ate
SECTION 1: SITEINfORMATION
1.1 Property Addres : - 1.2 Assessors Map& Parcel Numbers
4 ! �tael�h �.
I.1 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 It) 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'?Check if yes[] Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Re or
AUit Re y! I;ri Sf .
Name( Hilt) Address for Service:
Signature/ Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
.0 e,r for us new
cOe
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Ts—tinm—iatedCost-s-77 Department sign offs
(Labor and Materials)
I. Building $M�07A ,�. ElectricalBoard of Health
3. Plumbing $ Tax Office
4. Mechanical (HVAC) $ Fire Dept
5. Mechanical (FireConservation
Su ression) Public Works
6. Total Project Cost: $ For notice purposes only. Signature does not constitute approval.
-4 ' SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) lgaIq 3
—A
rc
/'\t De&& License Number Expiration Date
Name o7f�CSL- H Ider �t
r. !7rl.Z Yf��fj��Jl�jt7/jf/F b 1 q 70 List CSL Type(see below)
Addregsy �'� �' Ee Descrition
Unresu-icted(u to I5 1100 Cu. FtSignatpure�j Restricted l&2 Famil Dwllin-
1 �0 —7({s--Sj�(r MasonOyTelephone TT siential RoofinResidential iow aSdiResidential Solid Fuel Burning A Hance Installation
Residential Demolition
5.2 Registereoome Im ovement Contr ctor(HIC) `q
HIC Coin any N:me o 1 $ isttant tm Registration umber
5�,�e��s ,,faro fl a17-7a
jAddr,, 60 �O l"
6(7-36g agy6 Expirati)nDate
Signature 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, 6& ( 6 U+ —, as Owner of the subject property hereby
authorize Qlr—__c�JpylQ
to act on my behalf, in all matters
relative to work authorized by this building permit application.
SmiaLiAeo ' wnor Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, A" Cite IDII'2 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.
Rr rdt cha�o►,�
Print me
-- ic
Si,nature of Owner or Authorized d Agent Date
(Sieved under the pairs 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 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 I IO.R6 and I I O.RS,respectively.
The Commonwealth ofMassachusetls
Department oflnduslrialAccidents
Office of Investigations
VJ 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Af.davit: Builders/Contractors/Electricians/Plumbers
Applicant Information p� " -Dper_ h Please Print Lelribly
Name (Business/Organization/Individual): t-ijJ-A�el cmd1
Address: 57"6rfS4J
City/State/Zip: Phone 4: `(719 '714 s IS 3Ly
Are you an employer? Check the appropriate boa: Type of project(required):
i.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insurance? 9. ❑ Building addition
required.] S. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c.152, §1(4), and we have no
employees. [No workers' 13.❑Other
comp.;ncnrarce required.]
°Any 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 hive outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for my employeez Below is the policy and job site
information
Insurance Company Name: �Qit $
Policy#or Self-ins.Lic. #:. 2&j Expiration Date: d 1Zl it
Job Site Address: 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$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$250.00 a day against the violator. Be.advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerd
fy under Jhe paing and Denaftles ofperjug that the Information provided above is true and correct
Signature- Date
Phone#:
FOther
ly. Do not write in this area,to be completed by city or town official
Town: Permit/License#
ty(circle one):
alth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
R,m)d trl limi.lin ita pulanun Snd >t txraFartls
C�.1 CxJrtG2rllCCSV�tS �SaCrf'rytc� . ; irpj(i5�
linense: CS 82193 -
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MICHAEL7 DEMILLE
S BRISSTOL ST
SALEM, MA 0197p
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Offira o6Coimm sirs- &Bufi egee'e License or registration valid for individal use only
:HOME BMPROVENIENT CONTRACTOR before the ezpiratiou date. If found return to:
ak � :ry Registration: .762722 Type: 04Ticeof Consnuner Affairs and Business Regulation .
r✓Eupiratiorc 4/62013 Individual HO Park?lays-Babe SH70
Boston,MA 02116
MI FaEL THOMAS QEhQLLE... .
MICHAEL DEMILLE
5 BRISTOL ST a �'
SALEM,MA 01970 Hind
rcAa7 Not valid without signature
.lily
�A ✓T 'C70�ivH2ONlI/¢¢[I/L o��/K¢�ar/w4eQ�d .
a�\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only '
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: n
. Office of Consumer Affairs and Business Regulation
Registration" iA�Q 88 Type: 10 Park Plaza-Suite 5170 \�
Expira,- pp
� 13 Supplement Card Boston,MA 02116
LOWE'S HOME$>C€IRS.NC
RICHARD CHALt>rllr7 F
136 TURNPIKE RCY,;,Si1fiY1rT00 - � - , _
SOUTH BOROUGH, 01772 Undersecretary 14i valid without signature .
PARENTE INSURANCE Fax:9785315587 Nov d 2010 10:09 P.01
AC®: . CERTIFICATE OF LIABILITY INSURANCE ^�*�
10/27/2010
RAC M - rm 70 ISSUED A NIw (W N TTON li
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ANY REQUIREWENT, TERM OR CONDITION OF ANY CONTRACT OR O7TIER DOCUOENT WITH ABOVE MR THE POT.ICy PERIOD INDICATED: ZMTH(jPANmNO
WAY-PERI"AIN- THE ROURANBE AFFpR0E0•EM•THE P9ti&F9.0E8F.RIOTH REROC IS•8UB7EC{TOE-PE T7 TO HE VOOCH TIUS CERTIFICATE MAY BE ISSUED OR
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STORE COPY
INSTALLATION SERVICES CUSTOMER CONTRACT- MWORK- INT/EXT/PATIO DOOR
LOWE'S OF DANVERS, MA., STORE If 1094 STORE PHONE: (978)646-9099
153 ANDOVER STREET SALESPERSON: EDWIN VELAZQUEZ
DANVERS, MA 01923 SALESPERSON ID: 794346
Document Print Date : 10/17/2011
This is only a Quote for the merchandise and services printed below.This becomes an agreement upon payment and issuance of a Lowe's receipt, upon which the entire agree-
ment, including the specifically completed pages of this document, the Terms and Conditions included with this document, the applicable portion(s) of Lowe's receipt, 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 GAYLE STOUT 585-335-2949
O Customer Address Other Phone
41 FRANKLIN ST
L City State/Province Zip/Postal Code
p SALEM MA 01970
Installation Address
T 41 FRANKLIN ST
O Installation City Installation State/Province Installation Zip/Postal Code
SALEM MA 01970
MERCHANDISE AND INSTALLATION SUMMARY
MERCHANDISE SUMMARY
1046 : 87544 : STK : 1X4X4 RED OAK BOARD : 1X4X4 RED OAK BOARD : BABCOCK LUMBER - QTY 2
1161 : 1161 : STK : 1X8X8' SELECT PINE : 1X8X8' SELECT PINE : PRECISION LUMBER - QTY 1
18302 : STK : PNE CASE 351 2-1/2X11/16X8' : PINE CASE 351 2-1/2X11/16X8' - QTY 6
101566 : 34682031 : STK : 32" TRADEWINDS MV WHT-BRSHD NKL : 32" TRADEWINDS MV WHT-BRSHD NKL : LARSON COMPANY - QTY 2
131207 : 131207 : STK : 1X8X16 PRIMED FINGER JOINT : 1X8X16 PRIMED FINGER JOINT : IRVING FOREST PRODUCTS (MAINE) -QTY 4
234942 : 234942 : STK : 32" RB MINIBLIND W/GRILLES LH : 32" RB MINIBLIND W/GRILLES LH : AMERICAN BUILDING SUPPLY, INC. - QTY 1
327948 : L0327948 : STK : 32" RB 9 LITE LO E RH : 32" RB 9 LITE LO E RH : AMERICAN BUILDING SUPPLY, INC. - QTY 1
Materials Price $ 1258.62
Store 1094 Project No. 338268431 for GAYLE STOUT Page 1 of 8
STORE COPY
INSTALLATION DESCRIPTION
Stock or SOS : SOS Door Type : Exterior
Select Location : Front 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 Safe Practices : No Stock or SOS : Stock
Door Type : Exterior Select Location : Front Door
Select New Door : Single Pre-hung Number of Doors to Install : 0
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 Safe 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 : Buid out for storm door and cover tirm with alu-
minum for both doors
Other Work Charge : Yes Comments : No Comment
Labor Charges $ 851.00
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:Federal law requires Lowe's to provide you with the pamphlet Renovate Right: Important Lead Hazard Information for Families,
Child Care Providers and Schools. By signing this Contract, Customer acknowledges having received a copy of this pamphlet before work began informing
Customer of the potential risk of the lead hazard exposure from renovation activity to be performed in Customer's dwelling unit.
t. Store 1094 Project No. 338268431 for GAYLE STOUT Page 2 of 8
STORE COPY
TOTAL CHARGES OF ALL MERCHANDISE AND SERVICES 'where applicable
SUB-TOTAL $2074.E
*TAX $ 0.0
DELIVERY $ 0.0
ORDER TOTAL $2074.E
BALANCE DUE
Work is to commence upon reasonable availablity of Contractor which is anticipated to be [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 $1,000.00:
[_J Customer to Pay in Full; OR
[_J Customer to use the following payment schedule:
(1) Deposit$ 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):
(_J Charge my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed; or
[_J 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-
Store 1094 Project No. 338268431 for GAYLE STOUT Page 3 of 8
r
STORE COPY
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-
ARY OF THE EXECUTIVE OFFICE OF CONSUMER AFFAIRS AND BUSINESS REGULATIONS AND THE OWNER SHALL BE REQUIRED TO SUB-
MIT TO SUCH ARBITRATION AS PROVIDED IN M.G.L. c.142A.
By Date:
L s Home rs Inc.
By: Date:
Owner
By: Date:
Snouse
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 7 DAY OF_c�c ,rQpL,01 1 .
Lowe's Home Centers, Inc.
By: (Seal)
rint Nam .
(Seal)
Address Owner
, (
City State/Province Zip/Postal Code Print Name
Co-Owner or Witness (Seal)
1 Store 1094 Project No. 338268431 for GAYLE STOUT Page 4 of 8