18 GENEVA ST - BUILDING INSPECTION (2) c< zz-,,
The Commonwealth of Massachusetts
(; Board of Building Regulations and Standards CITY OF
Massachusetts State Building Cade, 780 CNIR SALE\I
Building Permit Application To Construct, Repair, Renovate Or Demolish a /lerise</.1/ur 20//
Otte-or Two-Family Dwelling
This Section For Official Use Only .
Building Permit Number: Date.A lied:
Il 1 N
Building Official(Print Name). uluretlDate
SECTION [:SITE INFORMATION
L1 Prope ^ i 1.2 Assessors Map&Parcel Numbers
1.In Is this an accepted-
street— 7�ye no — Map Number Parcel Number
1.3 Zoning laformationc - 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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,§Sd) 1.7 Flood Zone furor mallon: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site Disposal system ❑
Check if es❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerrotip d: S C�
�hme(Print) t) City,State,ZIP
Nu. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED\VORK'(check, 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 Work':
7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: u�e
Labor and Materials Official bb Only
I. Building ,S I. Building Permit Fee:S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. llcchanicul (I-IVAC) S List:
i. :Vechanical (Fire
Su>>rcssion) S rotal All Fees:S
Check No Check Amount: Cvh:\mount:
I'rnjcct Cult: S 0 Paid in Full 0 Outstanding Balance DOe:
SECTIONS: CONSTRUCTION SERVICES
5.1 Cunstru n Supervtsyor\J reJcase(CSL)
. Liccuse Number Expire *" It
Name of CSL Ile r (see below
List CSL'rype( )
pYPe _ Description
No. and Street
U Unrestricted�OuilJin s u to 35,000 cut Il.)
�yl R Restricted Irrc2 Funil Uwellin
Citylrown,State,ZIP M Mason
RC Roofin Covcrin
WS Window and idin5.
SF Solid Fuel Burning Appliances
I Insulation
Entail address D Demolition
5,2 Registered Home Im men Contr• r(111C _
o '
fIIC Rcgisl Wir, Dute
I ryv I me r IS a r Name
No.;aJLSCfc•' 3 Lmail address
City/Town,State,ZIP Tele hone
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 IsSuanc of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHO.RIZAI JN;TO BE COMPLETED.WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I,as Owner of the subject property,hereby authorize !!��w ( � d
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7W OWNERt O AUTHORIZED AGENT DECLARATION
Dy y name below, 1 hereby attest u er the pa' sand enalties of perjury that all of the information
con ained in lis ap true and accur to to the a of k vledge and understanding.
Print t vac 's or Aut tortzed Ageat's Mane( :Icctronic. quit titre .to
NOTES:
I. An Owner who obtains a building permit to o his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(FIIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the FIIC Program can be found at
www.omss.,,ov"oca Information on the Construction Supervisor License can be found at wvvw.ntass.eov:!dM
q ? When substantial work is planned,provide the information below:
fund fluor area(sq. R.) (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 half/batfts
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
i. 'Total i'roject Square Footage"may be substituted for"'rohd Project Cost"
Sold.Futill"lled and fiimarinl Ir\
HID Al-Ilonle SCIN•ices Inc
'418 Boston Fumpikc Unit I,Shi,n%sbmN_%IA I�41
1,111 Ice N(g)'We"1610
Branch Sams: Bosion Noith Date:v9:20l %IF Lic W-131) RI Cant. Lic= 16417
Branch No: "I CI Lie A MA Home Impimcment
Contractor Res.
FCdclal 11)
71-'608460
Installation Address: IS G L N L VA S I Salcul N4 A 01970
C i IN, State zip
Kira -
Purchaser(s): Work Phone: Home I'llolle: Cell Phone:
7
Ms. DENISE DRAGONIS (97S) (7141)246-11 3,1
R
Home Address: IS GE\EVA S I Salem MA 01970
(11 dill-clelil florn Installation Vitil"St GIN Stale zill
E-mail Address (to tece)ve project communications and lionic Depot updates):
.Marketing entails will not he sent horn I lie Home Oepol.
Project Information: Undersigned f"C'ustonovrj.tile ox%oeis of the propene located at the above installation address.agrees to
hue.and II ID A[-Home Service.,. Inc. ("file Home Depot-)agrees to fiIIIIISIL LICIiNeI and 11111111"C tot the ilisl al Lit]oll
(Oil I of all Illatellak described on the bc1o" and on the ielelcllLed SIJCC Sileel(S)_all ol N\riliCll ZjrC loCt'll)(IMICLI 11110 this('01111,10
by this letclelicc. alon'. \v ill any Z1111111COble S"LlIC SUIllflefflellt MILl I1ZI\rIIICljt SLI]IIIIIZII.%.altached licielo and anN Change Ordei
(collecti\chv. "Contract"r
.1,b#:ditto nal R,fcmico Products: Spec Sheet(s): Project Amount
71S214 Will(IoNNS S5.141.23
Minimum 257 Deposit of Contract Amount
Total Contract Amount i S 5.14 V2
due upon execution of this contract
qj
111111. ilollic(liatelv upon completion oftlie\%olk lift each Product C'uslomcr will execute a Completion
Cellificate(('lie 101 CaCII PIOLIUCI as dCI_1lIcd by an indi'MILIA Slice S11CCO 1111LI 1)a 0 N MI holance due. AN applicable,each
Customer under this Contract agrees to bee-jonith and scNeialix obligated and liable hereunder.
Payment Somman: I he PavilICIII SUrrimar\ I i J 214 included its part of this Cone act. sets fonli the total Contract
3111011111 and pavincius required foi the deposit.,and final payments b) Product (its applicable)
GENERAL'I EICNIS AND CONDI I IONS
Resuonsibili ties:
I he Houle Depot: NX ill provide the Products identified aboNc-make arrangements it)have the Authorized Sere ice Provider pcitotm
tile Instillation services in it professional and i%oiknianlike maillIC1.and ZIIIZII12C IMOIJCI insurances. Unless otllel\\ise cXpressiv
provided for herein.Authorized Service Provider\\ill obtain vCLILlited permits and provide permit numbers.
Customer: will iticiink am:property lilies.casements.CoNcnaolS. LIMIC12.10told or(WeilleAl U111M lilies. I)IC-CXiStill", ploSical (11
IInWl2.SA P.,,, I m 17
r 1
NOTICE"FO CUSTOMER
You arc entitled to a contpleteh.tilled-in cope of this Cuntract,signed by both you antl The Home Depot, at the time you
sign. Do not sign a Completion Certificate before the Installation is complete.
Acceptance and Authorization: CU.itOntel ;Ltec,and understands chat this Contract is the entire a,rerment between Cu:lomct
and I lie Home Depot with to nud to the products and installation services and supersedes all prier di,etl„I011S and a¢reements.
either oral or e�riticn. relating to said products and installation. "I"his Contract cannot be assigned of amended excclit b}a m ilia:
siencd by Customer and the Nome Depot.
Customer acknowledges and agrees that Customer has read.. understands,voluntarily accepts the terns of and has received
a cup% of this Conh"act. Customer acknuwfedges receipt of the Notice of Cancellation,and that he Home Depot has oralh
informed Customer of Customer's right to cancel. Customer's signature bolus%constitutes Customer's acceptance and
execution of each of the applicable Contract Documents. DO NOT SIGN THIS CONTRACT IF"I HERE; ARE ANY
BLANK SPACES.
You are entitled to a paper copy"of this Agreement if you choose. If coil consent to an emailed copv.your consent applies
onh to this Agreement. By contacting sales office IR77i 90;-1765 ,you ma%update your entail address,withdraw your
consent.or obtain a paper colic ill"the agreement at no charge. By signing below.you confirm the.folluwin,,: _
• You consent to receive onh'an emailed copy of this Agreement
• You hair access to a computer that can receive and open emails and PUP(Adobe Reader Version 10.1.4 or
later)formatted documents.
• Your email address is correctly listed on the Home Inaprov-e�ment Contract
Submitted b%:
- Sales Consultant lason Beisicecl
License"\ante. —
Ms. DENISE DRAGONIS (Sep 29, 2013, 3:06 PM)
Telephone No, tts77)903-3761,
Sides Consultant
.....................__._._....................
License No. (as applicable)
Accepted by: JB68 (Sep 29, 2013, 3:06 PM)
CANCELLA1ION: CUSTOMER\IA1'CANCEL THIS COSII"CI'111THOUF PENACfY Olt OBLIGATION BY
DELIVERING 1VRI'I"TEN NOTICE TO"I HE HOIME DEPO"I" BY AIIDNIGHI ON THE'I'HIRD BLSINESS DAY'AFTER
SIGNING 'FHIS CON"I"RACT'10"1"HE ADDRESS LISTED ABONL. THE S1 AFESEITLEMENTATIACHED
HERETO CONTAINS A FORK TO USE IF ONE IS SPECI FICALLI' PRIES(RI BED BY L:UI' IN CCSfO:1IER'S
s'1'A I E.
11nW12-SA Pao. 16 of 17
CITY OF S'U.am, iiNWSACHUSETTS
n ButmLNG DEPARTM&NT
120 Cq.AsHLNGTON STREET,V FLOOR
< ' TEL (978) 745-9595
F.Lx(978) 740-9846
KI.%iBERLEY DRISCOLL
,MAYOR TmwsST.Piam
DmEGTOR OF PUBLIC PROPERTY/BCIIDLNG CONptISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
F
`t In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of NIGL 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 defincd by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
the debris will be disposed of in
-------� a 4tF---
aJJress of facility)
Sign tune oFpermit applicant
t at
Icbnnall dux _