2 GRAND TURK WAY - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Town of
Regulations and Standards
µ�{ g g
4 Gy( i Massachusetts State Building Code, 780 CMR, Th edition Wilbraham
I Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two-Fan ' t yelling Ext 118
This Sect' For fft ial Use Only
Building Permit Numb to pplied:
Signature:
Building ommissione nspecto of Buildi lz
Date
S TION TE INFORMATION
1.1 Prop=ress: 1.2 Assessors Map& Parcel Numbers
I.la 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 R) 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 f9' Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 O t f Reford: C Z 6t4k,'D TbfRK &Jft
Name(Print) ' Address for Service: '
/o17-Gov-G<3�/
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': lZi✓)SN WIAf )
nAXWM,t .96-215m 1 Rk .SPET'0'/— 7)C? A&P CAflnt 6 1`1. a sN rrr '7'50�,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ U 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ Z. Other Fees: $ '\
4. Mechanical (HVAC) $ List: ����/ U
5. Mechanical (Fire $
Suppression) Total All Fees: $
l ,/ Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �J'w' ❑ Paid in Full ❑Outstanding Balance Due:
�"o'ea�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �Sl!_ 7
License Number Expiration Date
aofSL- er List CSL Type(see below)
Wn—'ew ,oeo_ T Descn lion
U Unrestricted(u to 35,000 Cu. Ft.)
R Restricted 1&2 Famil Dwellin y)/ `�"� M Masonry Only
RC Residential Roofing Coverin!
Telephone _WS Residentiai Window and Siding
SF Residential Solid Fuel Eumin•Appliance Installation
D Residential Demolition
5.2 R tered Hoe Improve ent Contract (HIC) 13 7 9t-
G/ C O2,u� k 5C
HIC omp y Name or HIC gis[rant me Registration Number
Addres
O Lliyi'l Expiration Dale
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 lssuancSpf 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 building permit application.
Signature of Owner Date
SECTION/7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, y/Bn* d-�L . l-fQ��a.�i ,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.
Pri ame
g a o Owner r Authorized Agent Date
(Signed under the pains and penalties of edu
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 :he HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I 10.115, 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 half/baths
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"
•y
CITY OF SALEM
Y
�s
PUBLIC PROPRERTY
DEPARTMENT
\I . n , . i I.. \1 „il: .:. .".1:±Ilr ♦ \\II \L \I\„�: .. 1 . . .11 -
III, y•Y.'J 9.
construction Debris Disposal Affidavit
(reliuired lbr all demolition and icno\ation \\'ork)
In accordance I111 the si\th edition of tlic State Building Code, 7S0 C NIR section I 1-1.5
Debris, and the provisions of\vIGL e 40, S 54;
is issued with the condition that the debris resulting front
Building Permit t
this work shall he disposed of in a properly licensed waste disposal lacility as defined by V1CiL c
l 11. S 150A.
The debris will be transported by:
I tome of hauler)
I he debris will be disposed of in
t ualne ul InJny) ,.
60
luddress of IAlllll Vl
.4 Q?.)Z/
,ICne1mC :1 p:nnrt .yiphcunt
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I\lV;M:I'\ :,Milt t-t l
\I git 12C WA1tlj.s.G l os.S I:ILL I' • SA F.M. MANS%1.nl it i is O)07-^
fc1:978-715.9545 0 1:tx 978-7.4C 7s46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
1 fiicant Information Please Print Le iC hlv
V 81Tld IOuuucssi t�rganv:uioNlnJry ulual t: VIU�S ��AJt�a �����S
Address:
City,State,Zip: MA
Are \o an employer:' Check the appropriate box: "Type of project(required):
I. I :un a employer with� 4. ❑ I am a general contractor and 1 6. ❑ new construction
cm iloyces
(full and/or p art-ante).• have hired the soh-contractors
1 listed oil the attached sheet. 7• emodeling
2.❑ 1 a a a sole proprietor or partner-
ship and have no empioyces These sub-contractors have 8. ❑ Demolition
working, Inc me in any capacity. workers' comp. Insurance. q, ❑ Building addition
Ko workers' cum insurance 5. ❑ We arc a corporation and its
I p� 10.❑ Electrical repairs or additions
required.] Officers have exercised their
}.❑ i om it homeowner doing all work S exemption
right of per IM m
GL I LE] Ptubing repairs or additions
Pon P'
myself. (Ko workers' comp. c. 152, ¢1(4), and we have no 12.❑ Roof repairs
insurance required.) f unployccs. LKo workers' 13.0 Other
comp. insurance required.]
•411%applicant Ibut checks box art musl also fill out the secuml Iwluw showing their wurkuu'cunitscmation pulicy iatinitr ii.n.
't lumcuu'm:n who submit this afridavii indicating they.me doing all work andIhcn hire outside conmxton must suhnil a new affidavit indicting sucA.
-famra aors that Jwck this box most attached an additional slwrot+hawing the name of the tub.eontra,aom and Ihelr surlwls'comp policy mformamm,
/run mn eu+p(uyrr t/+ut ix pruviJiaq rvurkers'c•uu+prnemtinn in.curuucc•fur cry entployecs. Below is the pulicy and job rife,
information.
Insurance C umpuny Name: ---
Policv +l or Self-ins. Lic. ft: �"�C'� a3 !�, Z7 . .. Expiration Date: 5ZLl O
/Jy�_^y
Job SiteAddress: � / ,er _ City;SlateiZipa /?4 0/ig
Attach It copy of the workers' compensation policy declaration page (showing; the policy nmuber and expiration date).
I'ailutc to secure coverage as required uodcr Section 25A ul'.NIGL c. 152 call lead to the imposition of criminal penalties of a
time up eo S1.500.00 and/or one-year imprisanincnt, as %%ell as civil penalties in the turn of a STOP WORK ORDER and a fine
of up to S250.00 a day againsl [he violator. lie advised that a copy of this statement may be lurwarded to the Office of
Ion rmugannns of the DIA :or io,urar.cc coverage \eriticat;on. _
7,dlu reby c • fifk•under lie tin'u .pera/ticx of per that the infurinuNan provided above is true and correct.
I'h��ce l• /(1t 6A��V 'a
Ofliciul use only. Do tint Irrite its dti.s area, to be completed by city or town official.
Ciro or Fawn: ---- Permit/License At.. _
Issuing; Aulhurify (circle one):
I. IA,arJ of llc,ath 2. Building Department .1. ('it)"foon Clerk 4. Electrical Inspector 5• Plumbing; lospeclor
6. Other -.
Contact I'cnou: -._ -- Phone it:
Information and Instructions
>I assaclluselts General Laws chapter I i2 requires all employers to provide workers' compensation for their employees.
Pursu:ult to Ihis statute, an rmplorre is defined as "...every person in file service of another under any contract of hire,
express or implied. oral or written."
An employer is defined as"an individual, partnership, association, corporation or tither legal entity, or any two or more
of the h,revoing engaged in a joint cnterprse, and including the legal representatives of a deceased employer,or the
receiver or trustee ol':m individual,parnnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling horse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the.,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.IGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
-applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes;that apply to your situation and,if
necessary, supply sub-contractor(s) name(s), address(es)and phone nunnber(s)along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other(ban the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this of davit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or"town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennit/license number which will be used as a reference number. in addition,an applicant 1(
that must submit multiple permit/licensc applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid 'affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen Is obtaining a license or permit not related to any business or commercial venture
(i.e. a dug license or permit to burn leaves ctc.)said person is NOT required to complete this affidavit.
I ll. I)I lice of Investigations would line to thank you in advance fur your cooperation and Should you lla\c :my questions,
please do nut hesitate to give us a call.
fhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
;fa:.cd -'o-u5 www.mass.gov/dia
CONTRACT TO INSTALL OWENS CORNING BASEMENT WALL FINISHING SYSTEM
Owens Corning Basement Finishing Division(the contractor)hereby submits this proposal to sell and install the Owens Corning Basement
Wall Finishing System and related items as described herein at the residential premises set forth below.This proposal shall not become a
binding commitment unless and until it has been signed by the Contractor and the Customer.
Contractor.
Owens Corning Basement Finishing Systems
a division of Bay State Basement Systems,LLC
60 Shawmut Road,Canton,MA 02021
Telephone a(781)821-0060
s Facsimile k(781)821-8552
• Federal Tax ID N 14-1855297
II`` Mass.HorrmAe Improvement Contractor Reg.n 137943
Date V _I_I ,
Customer: -
Customer Name
Street Address fl
City,State,Zip "/C1..1v� /Vy
Telephone( `( 11 0
This is a contract between the Contractor and the above named Customer to sell and install the Owens Corning Basement Wall Finishing
System and related items specified herein at the Customer's residential premises identified below:
Installation Premises:
Street Address
City,State,Zip }-
ScopealWork: ,,:. :z.._.. :.._..-u � '� G�lr�1 c.l 1iI /JhU�I
Are Sketches and/or specification sheets attached? ❑No
'el avacnmema era mco,poretm into era Ixc. a pan m tno-rives II ppII
Description of Wmk/Specifications: `C z fln aU Q. r 'I�Q$
T4 C t CI vl FL
N',n N 7 Cf t 1/1 S n t S ,
l 1 / _c C
� e�z� ow��-t,�n S �lC t�S cc� k/i� G✓/ l,mnw � t.r.a y Sw/
ei-H. 5-C i Lq I pal et liru.F�+^
Work Schedule": ( +SM JLe
Approximate Commencement Date:
Approximate Completion Date: l ) C J u
"The proposed work Schedule is approximate and subject to change
Contract Price:
Total Contract Price: $ h,_✓ts�L�V
Deposit with order: $ 1 II /11 U U 1 ❑ Cash 0Cf'eck It I ls!
Balance Due: // $
Terms: mash ❑Finance
(Cash terms are 10%%deposit,50%/on\commencement,40%on completion)
$ 1 , 1 � V� Due on Commencement „
S �Q 1� V Due on Completion
DO NOT SIGN THIS CONTRACT UNTIL ALL APPLICABLE BLANKS ARE COMPLETELY FILLED IN AND UNTIL YOU FIRST READ
AND UNDERSTAND THE ENTIRE CONTRACT,INCLUDING ANY ADDENDUM ATTACHED HERETO,AS WELL AS ANY ATTACHED
SKETCHES,MATERIAL LISTS OR THE LIKE;'ANDTHE,TEPMSANO CONDITIONS ON THE BACK OF THIS CONTRACT DOCUMENT.
YOU ARE ENTITLED TO A COMPLETE,FULLY EXECUTED COPY OF THIS CONTRACT AT THE TIME OF EXECUTION.
Witness our hand(s)and seals)below on this I n day of 0 C
Bay State Basemen stems,LLC/Auffir, tl ReR Live:
C/ l G
Signature arigA11. �Lk c /
S " aMllnL,
Print Name
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Gusto
Cp{ipmer 9lgn tp �
rrI5
Print Name
Customer Signature
Print Name
Contractor may have certain lien rights in the premises until the price is paid In full.You have the right to cancel this contract,without any -
penalty or obligation,at any time prior to midnight of the third business day after the date you signed this contract See the notice of cancellation
below for an explanation of this right.
"'Customer acknowledges receipt of a true copy of this Contract which was complately filled in prior to cuslmi s execution hereof.
NOTICE OF CANCELLATION
",e"xn... T cf e t Customer Signature
I. SKETCH Contract Date C q Sales Representative Signature f i ✓—�.
ATTACHMENT customer Phone fot'1 °
Contract Pdce
z z x e e r e e to a u is m n n ie is m e, u n u a m m m a a v u m s m m n m m w a u w s w a w w m m u m m m m ez m �u m
z
alls Lau ry
S1D�e5 —;-
ie I� Pudl
i to
,�/ C,,(urn NT I _ _
r
J . 1 L I
lip L
r I j
� I
v�ak� V'a��; 4 ao
1
m I
et
m •—'
m w0 -
NOTES: (� t' Each box equals one fool unless be olherwl9e noted.This sketch Is a good leilh
F.
of the work to be done,it is understood that all dimensions
dedved from this Sketch are approximate,and that all locations of outlets,light
fixtures,plugs,Jacks anNor a ob,a are subject to change If necessary.
"I"' 1'"'n r `"1 e t Customer Signature C —^�
SKETCH Contract Date_ C q Sales Representative Signature
ATTACHMENT Customer Phone (Dn (e46b. (0 ?q- Contract Price .
z x . s a z e e 10 a Ix I. Is u n n Iv so xl zx n w xe a nb 'q a vl L y w e3 m s1 y a U .I q 9 .e .e n x n w sl w w w es w 9 w "w w
s cum. we ' LaH J
to
\,
� uPl' ir
I
xl
- i
al
I
a val 0 i1
xx - 1
xl II
w
NOTES: (� j� Q 411,14FEachbo x equals one tool unless othernise notetl.Thie sketch is a good faith
sentation of the work to be done,II Is understood that all dimensionsd Imm this sketch are epproxlmale.and that ell locations of outlets,light
s,plugs,lacks and/or switches are sublect to change If necessary.
.ACORD CERTIFICATE OF LIABILITY INSURANCE D7/2 00DO1
10;7 28
8
PRODUCER , Phone: 781-659-2262 Fax: 781-659-4725. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Andrew G. Gordon, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
680 Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. O. Box 299
Norwell MA 02061
INSURERS AFFORDING COVERAGE NAIC#
INSURED wsURERA:Peerless Insurance 41
Bay State Basement Systems, LLC INSURER B:Pilgrim Insurance Company1750
60 Shawmut Road
Canton MA 02021 INSURER c:Renai IS sance Marketing
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
OTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,; THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH ,POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.':
UN—SR POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION
A GENERALUABILRY CPB8512851 '9/5/2008 9/5/2009 EACH OCCURRENCE f 1 000 000
DAMAGE-TGRENTED
X COMMERCINLGENERALLIABILITY PREMISES Eaxaa . $50 000
CLAIMS MADE �OCCUR MEDEXP(Mywrep ) E 1O 000
PERSONALAADVINJURY E 1 000 000
GENERALAGGREGATE f 2 00O 000
GEN'LAGGREGATE DMITAPPLIES PER: PRODUCTS-COMPIOPAGG E2 00O 000
X POLICY PRO- LOC
B AUTOMOBILE— SUY PGC10007161409 1/17/2008 1/17/2009 COMBINED SINGLE LIMIT
ANYAUTO (Ea acdtlaat) - E 1, 000, 000
ALLOWNEDAUTOS
BODILY INJURY f
X SCHEDULED AUTOS ( )
X HIRED AUTOS BODILY INJURY
f X NON-0WNEDAUTOS
- PROPERTY DAMAGE E
(Par aodtlml)
GARAGE LIABILITY AUTOONLY-EAACCIDENT E
ANVAUTO OTHERTHAN EAACC f
AUTO ONLY: AGO f
A, EXCEESIUM8RF1-LALUU1I Y CU8511953 9/5/2008 9/5/2009 EACH OCCURRENCE f 1 000 000
X I OCCUR CLAIMS MADE AGGREGATE E 1 000 000
E
DEDUCTIBLE f
RETENTION $10,000 f
C WORKERS COMPENSATION AND C 0371527 5/24/2008 5/24/2009 WORY C LIMIT ER
EMPLOVERS'LABII E.LEACHACCIDENT E 1, 000,000
ANY PROP ICEUMEMBFR EMS RJPARTNEWEJ(ECUTNE
OFyaFs EXCLUDED? E.L.DISEASE-EA EMPLOYEE f 1 OOO OOO
If
SPECNL PROVISIONS palow E.L.DISEASE-POLICY LIMIT $ 1, 000,000
OTHER
IIE MPTIONOFOPFRAIIONSILOCATNJNSIVENICLESIEXCLUSIONSADDEDBYENDORSEAENTI.SPECIAI.PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
Bay State Basements, LLC WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
60 Shawmat Rd CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
Canton MA 02021 SHALL IMPOSE NO'OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUl1NNRMED REPRESENTATIVE
&�-
ACORD 25(2001/08) 6ACORD CORPORATION 1988
� / YP. y�. �
1 % Board of Bu>l� ng t2egulatibns and ta/ rn aids
a One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 137943
Type: Supplement Card
Expiration: 1/29/2009
OWENS CORNING BASEMENT FINISHING - - --
DANIEL WALSH
60 SHAWMUT PARK
CANTON, MA 02021 Update Address andreturn card.7Miyk1vemon toi cbingei
Address Renewal Employment Lost Card
'S CAt 0 50M 05JW-PC8490
i
90 rd of 9udding eguEefioSy p ar s
Construction Supervisor License
License: CS 79893
Birthdate: 10/5/1962
Expiration: 10/5/2009 Try 4794
Restriction: 00
DANIEL F WALSH -
488 KENDALL RD
TEWKSBURY, MA 01876 --�
Commissioner