14 GRANT RD - BUILDING INSPECTION (3) -I&tA lS1WWT19EfiLE� APPROVED BY T+IE
,LWZCTD.R PR.IDR TD A.PEBM T B,FING GRANTED
j CITY OF SALEM
yNo. ,�• •�. � Date
s:
Is Property Located In ' / Location of
the Historic District? Yes No-4 / Building
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) f, Install Siding, Constr t Deck, Shed Pool
epaidReplace, ther: if? N -, Ltd I( 10
PLEASE FILL OUT LEGIBLY &COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name
Address
esa&Phone It/
t/ ra-n i �\ C
6= aW- Name I JG-
2 J o\
Address & Phone ISM (7C.a�k� 15� 1 �Fc od L
Mechanics Name
Address & Phone
What Is the purpose of building?
Materiel of building? /A )O,n If a dwelling, for how many families?
Will building conform to law?77-7 Asbestos? I C,`
Estimated cost 4�S� CBy License t NIA Slate Li k 16� 1
Bo.e l q I�6 ��
/ yy,�
Lie. l�
t Si na ure of Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
G
0�
MAIL PERMIT TO:
.t.
F � '
No. �j
APPLICATION FOR
n
PERMIT TO
LOCATI
PERMIT GRANTED
i
2b� ,
APPROVFD(n5/
ECTOR OF OUILDINGS
4 '
F'
•r
1
o CITY OF SALEM9 MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01970
- f TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition
- - - of Building Permit# L-------,-all-debris-resulting-€rom-the-construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S150A//..�
The debris will be disposed of at: I3
\ Location of Facility
Signature of Permit Applicant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
1 D 1 1 In �z� I S^
N rune o Permit Applicant
First Name, if any
wart M d
Address, City & State
The above statute requires that debris from the demolition,renovation,rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cM, S 150A, and the building permits or licenses are to
indicate the location of the facility.
(( - \ The Commonwealth of Massachusetts
Department of Industrial Accidents
of#olIfiWSU eUoMS
600 Washington Street, ;'"'Floor
Boston,Mass. 02111
t'
Workers' Com ensation Insurance Affidavit: Buildin lumbin lectrieni Contractors
name
address:
city state, zip, phone#
work site location(full address)
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ 1 ;m-a sole proprietor and have no one working in any capacity. ❑Building Addition
-I-am anFetnployoFprovtdgtgg-workers' mpensatron- r my emptoyees working on this job — ----—
fiT
k
add ; k115 hCt },
s o-
n � a c x+rtf�(sb .4. «. V a s k�s
city: f/�-� (7cc� , Mt c `s, = enelh € n �
�zw;�° F'e'if a ?'z�
2.
� per+ . 1A` �7 / k' f
insurance 1`�t�lil.� o'` >Q PmilcvM 'V\ / � /.
a 'A RAsISII cz _ _ _ _ —
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
cumpanv name'
r
address:
City: nllpnE� a > if-
W th
msu n :"
company Rome: v <a .. *pro'' tea', X.,<:,,�, : >. _ t+
address:
+ +, x .E ?Sa i •r° Sa '- rmF '4?`*";t 'l ' x1.' vs `Y " 7
t
ti
Failure to secure coverage ea required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or
one years'imprimoment as well as civil penalties in the form ors STOP WORK ORDER and a Ilne of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OMce of Investigation of the DIA for coverage verification.
l do hereby certify alrder the p ins and penalties of perjury that the information provided above is true and correct.
Signature Date d— — _(
Print name \ Phone# O 6
Official use only do not write in this area to be completed by city or town omcial 1
city or town: permit/license#
_[]Building Department
❑check if immediate response is required ❑Licensing Board
❑Selectmen's Office
contact person: hone#; ❑Health Department
n<„W srn.Ev)n P ❑Other
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their "
employees. As quoted from the"law",an employee is defined as every person in the service of another under any
contracrof hire,express or implied, oral or written.
An employer is defined as an individual,partnership,association,corporation or other legal entity, or any two or more of
the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the receiver
or trustee of an individual, partnership, 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 house of
another-who employs persons to do maintenance,construction or repair work on such.dwelling house or on the grounds
or building appurtenant thereto shall not because of such'employment be deemed to be an employer.- - •- ,.
MGL chapter l52 section 25 also states that every state or locaflicensifi agency s'hairwithkold-theissuance or -— --
renewal ofa.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,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 fill in the workers' compensation affidavit completely,by checking the box that applies,to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as`all affidavits 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.
City or Towns
Please be sure.that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event.the Office of Investigations has to contact you regarding the applicant. Please
--- - -
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office Iof Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Mod I11VoNgodom
600 Washington Stree47'" Floor
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617)727-4900 ext. 406
m.THIS CONTgAClT metle Me 9 a day o1 in 9'fhe year.20 between New England Sash,Inc.and
�Fdnl F T6NNyIFER y�NFRjL/ 78—t9s�—non�'
'(HOMEOWNERS) IHOMEPHONE) (BUSINESS PHONE)
of �y GRANY ITSAL,EM >Vlq. o19�a
(STREET) (TOWN) (STATE) (ZIP) i I
As used in this contract,the words we,us or our order to New England Sash,Inc.and the words you end your refer to the 1 ftarmd' %
We agree to furnish all labor and material necessary to install the following described windows at: SAME //$ aOISOU�
Doable H.P.
Total Units: Glass Glass Grids;Y Window ColarS ,!/il Material: 3 to/7'/
Op
Double Hung Units: ` we ro notao arypahlHgwneinma. Installation: 96,11"Illy1
We ere ref mapnnsia.or mndiik4e Is dmemetee ne
Picture Units: bevel an tomcod mcledld,cordeoaagon resulting then Total Contract: oZ 1 r
or cone te ,a Mae candinma Our limkee wdnanry 5 1
Hopper Units: berehircoryolated by reference. Sales Tax:
Sliding Units:
Awning Units: 1-liter-2-1
Casement Units: 1-Iite -4'-tile: Total
Say/Bow Units:DH/CS 3-11le-4 I't s-we Price: p
Garden Windows: 3-Iile:�A t8'� Deposit
Exterior Finish: Root SoHitt Total Projection: Knee Brackets:Y/N With Order: _
I �+
Entry Doors: Steel Fiber Style: Add Deposit n — U
Storm Doors: Alum W.Care S le: Due Date: V
SlidingGlass Doors: # Color. Balance Due y Iil
Ca pin N # (I01/A;t-a On Delivery: I rd C
Additional Notes: IV IS d agodl / S
LL60,011AW A-)' - R
coNi` , ega @ Vq /
414 6V= T Q AAIA S V- N 7-
Otor All bi 4me,,
DEPOSIT WITH ORDER ❑CASH ❑CHECK# BALANCE DUE ❑CASH ,"FINANCE
You agree to pay cash according to Me terms shown above or.if Your order Is approved,to sign a note provided by us for payment of Me amount due.You also agree to sign a .
comptetion certificate upon completion of Me work.If You left to make payments when they are tlue,then we may immediately slop work.We may choose to not.sel work .In until
You are current wlth the payments and we feel secure In obtakingihe remaining payments.If there is any stoppage idwerk due to Me precatling,such delay shall automatically in ark
the dale of substantial completion. L
Payments due and unpaid order Mis agreement shall bear mown from the data payment is dusm the annual rate of 18%or at the maximum legal rate,whichever is less.In Me event
that woincur coals or expanses In collecting such payments due and unpaid, n you shah pay such cache and expenses Including reasonable momey's fees,in addition,you understand V
)hat W falling to pay according to the study.tpto�."�..,Me seller may have a claim a9a red you which may he enforced against Your prepery In accordance Wth Me applicable)lens laws.
The installation will begin on or aboN/A--911 -no will be substantially completed on or about L �)AY4 it is untlerstood by You that the following contingencies
could matedagy change the estimated completion date stated above:customer's inability to oMae or guallty far fmareing,inclement weather,Turkey or other labor dismptidn:
eyallablliN of nationals:acts M God.
We represent Met we carry Workers'Compensation and Public Llabilll,Insurance in the amount n$100.0001,000.000.
ALL RESIDENTIAL CONTRACTORS AND SUBCONTRACTS ARE REQUIRED TO BE REGISTERED WITH THE MASSACHUSErTS BOARD OF BUILDING REGULATIONS AND
STANDARDS, UNLESS SPECIFICALLY EXEMPT FROM REGISTRATION. INQUIRIES CONCERNING REGISTRATION SHOULD BE DIRECTED TO: DIRECTOR, HOME
IMPROVEMENT CONTRACTOR REGISTRATION,ONE ASHBURTON PLACE,ROOM 1301,BOSTPN,,.MAA 02p/1�B(;7g59 q
CONTRACTOR OR SUBCONTRACTOR IS OBLIGED TO OBTAIN ME FOLLOWING PERMITS:A/f /CEO T/J T AWN' F WE DO NOT OBTAIN
THESE PERMITS,AND YOU OBTAIN THEM,OR IF WE ARE NOT REGISTERED WITH THE BOARD OF BUILDING REGULATIONS,YOU WILL NOT BE ENTITLED TO OBTAIN
ANY BENEFITS FROM THE GUARANTEE FUND ESTABLISHED UNDER MASSACHUSETTS GENERAL LAWS,CHAPTER 14PA. i
ANY DEPOSIT REQUIRED UNDER THIS AGREEMENT TO BE PAID IN ADVANCE OF THE COMMENCEMENT OF WORK SHALL NOT EXCEED THE GREATER OF ONE-THIRD
OF THE TOTAL CONTRACT PRICE OR THE ACTUAL COST OF ANY MATERIAL OR EQUIPMENT WHICH HAS TO BE SPECIAL ORDERED OR CUSTOM MADE,WHICH MUST
BE ORDERED IN ADVANCE OF THE COMMENCEMENT OF THE WORK,IN ORDER TO ASSURE ME PROJECT WILL PROCEED ON SCHEDULE.NO FINAL PAYMENT MAY
BE DEMANDED UNTIL THE AGREEMENT IS COMPLETED TO THE SATISFACTION OF BOTH OF Us,
YOU MAY CANCEL THIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY THERETO AT A PLACE OTHER THAN AN ADDRESS OF THE SELLER,
WHICH MAY BE HIS MAIN OFFICE OR BRANCH THEREOF,PROVIDED YOU NOTIFY THE SELLER IN WRITING AT HIS MAIN OFFICE OR BRANCH BY
ORDINARY MAIL POSTED,BY TELEGRAM SENT OR BY DELIVERY,NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS DAY FOLLOWING THE
SIGNING OF THIS AGREEMENT.
BY SIGNING BELOW,YOU ACKNOWLEDGE THAT YOU OWN THE ABOVE PROPERTY AND THAT YOU AGREE TO ALL OF THE TERMS OF THIS
CONTRACT.YOU ALSO ACKNOWLEDGE THAT YOU HAVE RECEIVED A FULLY COMPLETED COPY OF THIS CONTRACT AND TWO COMPLETED l&ti9`tim
COPIES OF THE NOTICE OF CANCELLATION AND THAT YOU HAVE BEEN ORALLY INFORMED OF YOUR RIGHT TO CANCEL.
00 NOT SIGN THIS CONTRACT IF THERE_ARE ANY BLANK SPACES.
7/
/ day M In the year at �LY1_S K'-
IN WITNEBS WHEREO.Me arlb/a+have M1ereunM"I use Melrnamas this 1^
Signsd f�°�/� et� SI nee
� /��J�� A�1 flKgINGp�ENTATIVE g pwNEp 't'_� r`x^
Signor
AarepleG New Englantl Sesh,1
By signed
AUMOn4Ea eleNANflE TRLE _ O NEn
NOTICE OF CANCELLATION DATE(TODAY'S)
YOU MAV CANCEL THIS TRANSACTION,WITHOUT ANV PENALTY OR OBLIGATION,WI IN THREE BUSINESS DAYS FROM THE ABOVE DATE.
IF YOU CANCEL,ANY PROPERTY TRADED IN, ANY PAYMENTS MADE BY YOU UNDER THE CONTRACT OR SALE,AND ANY NEGOTIABLE
INSTRUMENT EXECUTED BY YOU WILL BE RETURNED WITHIN 10 BUSINESS DAYS FOLLOWING RECEIPT BY THE SELLER OF YOUR
CANCELLATION NOTICE,AND ANY SECURED INTEREST ARISING OUT OF THE TRANSACTION WILL BE CANCELED.
TO CANCEL THIS TRANSACTION, MAIL OR DELIVER A SIGNED AND DATED COPY OF THIS CANCELLATION NOTICE OR ANY OTHER
WRITTEN NOTICE,OR SEND A TELEGRAM W ENGLANO SASH INC. 1331 GRAFTON STREET WORCEBTER,MA 01604 NOT LATER THAN
MIDNIGHT OF:
2
DATE(SUMMAert&HOUDAY6 EXCLUDED)
I HEREBY CANCEL THIS TRANSACTION.
L
®A a r BUILDING UGULATI®ws
L4ccne* CoNSTRUCT1014 supenVfSap
Number.:PS 674203
6 Pt V: 03l Oa6 Tr. no: 9470
Rcaetrd�tef :
MAVEN Nkut1P'sNCY
7ontwonnnrt=ALTHy � -
OHREW$B )RY, MA `0
16 49 ninlAtratcr -"
44
9`aeB�n dcma�rnuoaau�Rlatfons and�Standards
e/
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Reptatra6on: 104098
Type: Private Corporation
Expiration: 7/1 312 0 06
NEW ENCI_AND SASH, INC
Kevin Wells
1331 Grafton Street __ __.___.___...__ _ ____. _____ ._._
Worcester, MA 01604
Update Address and return earl.Mork reason for thong
�scat A saw.raon.mo+z+e Lj Address r...I Renewal I,� Employment Lost Card
-
:a.. Board of Building Regulations and staoMrds Lirense or registration valhi for individul use only
'd HOME IMPROYEMP.Nr CONTRACTOR before the expiration date. If fatrnd return tm
Roglotratlon: 104000 Board of Building Regulations and Standards
�`r_ ..� ExPleStlon::71,13/2006 OoeAsbburMn PlareRm 1301
Typo: Private Corporalian Bwun,Ma.02100
NEW ENGLAND SASH,INC
KevinWells 13
1331 Crahon Sfrae! meµ,
Worcesler.MA 01604
Adminislralor Not valid withoutslganture
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