19 GREEN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
UlfDepartment of Public Safety
DMassachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Phis Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION (Please indicate Block#and Lot#for locations for which a street address is not available)
No,and.Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of AMA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ Addition❑ Demo
❑ (Please fill out and submit Appendix 1)
Y
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: _
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ -
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work
a»ktr0 nan I.n A�
tCrntvvc l�r�("I cr- -f 1om7a
SECTION 3,COMPLETE THIS SECTION IF EXISTING BUILDING UNDER OING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investi ation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): 7 Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of'Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area.(sq.ft_)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable) - -
A: Assembly A'1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ Ei Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4,0 H-5❑
1: Institutional 1-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:'
- SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Conunission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: !
Does'the building contain an Sprinkler System?: Special Stipulations:
• I
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner ,
.tYan YMAC4—► n S+•#a- Salk ern o I q7b
Name(Print) No.and Street City/Town Zip
' r
Property Owner Contact Information:
gqq- 31?o
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
l�lctIdA I6114— 136 MI4- 0f_7Z;
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Lol,rer vh �n (,17-359-09�6 / yP6�
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Name(Registrant) Telepho e No. a-mail address LDLJQJ.(R@gYstration Number
rh e 1`�l � dUf (n[� 0 1-7-7ld ��
Street Address I City/Town State Zip Discipline Expira on Date
10.2 General Contractor
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Company Name'
nj- V 'nw qQ 176
Name of, erson esponstble or Construction License No. and Type if Applicable
I Alsburh Gu4 SaLffus MN 0147d6
Street Addr s City/Td vn State Zip
Tele hone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial o th 'ssuance of the building permit.
Is a signed Affidavit submitted with this application? Ye No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 41 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ / appropriate municipal factor)_$
3.Plumbirig $
4.Mechanical (HVAC) $ i Note:Minimum fee=$ (contact municipality)
5.Mechanical -Other $ Enclose check payable to l-GS1`
6.Total Cost $ b (contact municipality)and write check num er here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT j
By entering my name below,I hereby attest under pains and penalties of perjury that all of the information contained in this
application is true and accurate to a 'st of y kn wl ge and understanding.
Please print and sigripame Teleph� Date
Street Address City/Town State Zip
MunicipalInspector to fill out this section upon application approval:
Name
CONDOMINIUM PERMISSION FORM
FOR BUILDING PERMIT
We, `� care S�- ado "pitof 1q 6ree'�-, S`�, ✓ ��
Name of condo association of management company address
/VffRo ' /
being the drily authorized representatives of S�
Name of condo association
have reviewed the plans and specifications for improvements to Oren SF
Address and number of condo unit
owned by svu '� 1�7
Name of condo owners w)
The condo association or management company agree that the above owners have permission to
seek permits and to carry out the proposed work.
Signatu e of condo association representative and tit Date
Print Name �/a tiOV��J
(In lieu of this form, a letter, stating the same purpose as above, on the condominium or
management company stationary, may be submitted.)
Rev,,,l J; 11.2010
f-:\ISD\}ORMS\IP+ilJingK:nndo Pcm+isxim+Furn+.Jac000
Sf-ict code enforcement snakes the city.safer
Btfore Guying, renting or leasing check zoning
The Commonwealth of Massachusetts FRipt Form
Department of Industrial Accidents
i Office of Investigations
1�1 � I Congress Street, Suite 100
t Boston, MA 02I I4-2017
,4ssy www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please PrfiA Legibly
Name (13usinoss/Oroanitntion/Individual):
City/Stale/ZIP: 5 6 OI D Phone #: 78I- 233-G 17D
Are you an employer` Chee le appropriate boz.
type of project(required):
1.❑ I am a employer ith 4. i�� tam algcncral contractor and I I
6: j❑ New construction
employees (Cull apd/ui parkl * have hired the sub contractors
2. 1 am a sole proprietor on pattncr- listed on the attached sheet ❑ Remodeling
Thcse sub-contractors have
ship and have no Iemployeett I I I ; 3, '❑ Demolition
working lot- me m any cape city. employees and have workei s' 6 I. - -
! 1 y. '❑ Buddingaddition
com -insurance.-
INoworkers' comp. insurar ee � ! P , !
required.] 5. ❑ We are a corporation and its 0,'❑ Electrical repairs or additions
3.ElI am a honicown I-doing'!a] work icers have exercised their 1 I i❑ Plumbing repairs,ur,additions
myself. INo workers' c({ sight of exe nplion per MGL
12 ❑ R col repairs
insurance icquu,cid.l cl 152' §k4i, and we have no I _
employees. (,No workers' 13!❑ Other
,epmp.;insurance requircd.J
f' Any applicant{hat checks hot v i must'als r till out the section helow shnwin-their wnrkees•'compensation policy in loon t[i nn.
ILnnenw nos who suhmil this afBdacirt of icadng they are Jelin Irll work anJ their outside con«'actnts must submit r niw affidavit m1 .du nmg:auch
'Cnn[rnctou that cheek this b�Ix mu�"L anacl}ed an additional shleet shoe in'g the name of the sub-eontractols and state:whether or nor those c ut!ncs have unploJav 11 the sub-contras Initi haucm�ln}ecs they must provide their workers'comp.Policy number. I.
I am an employer that is,pro vi,Uni, workers'coin pl easatioh insurance for my employees,. Below is the policy and job site.
information.
Insurance Company Name:
Policy#sir Self-ins Lrc.#: I { Expuatiol Date:
Job Site Address: �f( CK t S t , 2 City/Slate/Zip: I oYl/I OI `I745
$! Attach a ropy of tht workers �o npensation policy declaration page(showing tht policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the'nPositionlof criminal penalties of a
fine up to$1,500.00 and%or ono-yelp r imprisomnent,Jti well as civil penalties in the Ibrm of a STOP WORK ORDER and a fine
of up to 5250.00 a clay against the violato . Be advised that a copy of this statement may tic furwardlcd to the Office of
Investigations of the DI/� Cur insurance coverage verification.
t ]do hereby certify under the pRin and penalties of perjury that the information provided above i5'true and correct.
Sienauire:
Date:
I
Phone#: 33 dt
!
Official use , ly. Do not write in this area, tq be completed by city or town official.
City or 1 own i Permit/License It
Issuing Authority (cercicloni)
➢. Board o➢'�lealt� �i B aldmg Department 8. City/1 own Clerk 4. Electrical Inspector 5.I11Iumbing Inspector
6.'Oth(r 1 i
Contact Perm."o i Phone#:
!
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011 � �umZet Of Ie of Con Cons Affairs and usiness'Regulation
t 1140 Park Plaza -:Suite 5170
Boston, Massaqtlusetts 02116
j Home Improueent Ctr,a,�,tor Registration
Registration: 163105
f Type: Private Corporation
_ WINDOWICHO#CES INC ;I, I IE�iratton: 5/11/2613 "---Tr# 211575
VlNCENT KILROW
1 AUBURN CT.L i — — —
SAUGUS, MAI011906 — — - ---
Update Address and return card_Mark reason for change.
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—.. I. : L __ mp7oyment Lost Card
�? Office of i^oasumer _ airs $ '`ness y License or registration valid for individpl use only
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NOPAE IAflPROVEME NT CQIN'fRACTOR '� before theea pi ration date. fffound return ta:Regtstratron :1s3105 TYpe: , Office of Cousu€ner Affairs andBusiness Re lotion
' Experahon: 5�1if1013 Private Corporatton 10 Park Plaza-Suite Sf70i- "� - j Boston,),fA02116
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1 AUBURN COURT
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EApiration. 12/27/2012
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*I CERTIFICATE HOLDER ) I '
CANCELLATION
LOW%'3 COMPANIES INC.
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ATTN: - z8 IHBURANCE 1 I SHOULD ANV DP TNF, D POLILIEa gF CgNCEL.lO 6EF(N1E
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4h OME IMPROVEMENT CONTRACTOR
Registration: 148688 Type !
. Expfrahon �1-0/18I2013 Supplement _
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- LOWE'S HOMES CEN?ERS INC ib.. * '
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C RICHARD CHALONE
136 TURNPIKE
^ [. SOUTH BOROUGH,`MA 017-72 Undersecretary
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CONTRACT# .ld o7+�
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RAASS�Q6FiUSETTS EXTEFtIO1 SOLUTIONS INSTrc R ' '
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ALLED'' M(0E .'CONTliAOTtR y
NUMBER +s CUSTOMER 1' /�
INS rAi LED SALES SP CIALIST .x Y� [ J — �t,4+'.
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STOR NO STREET ADDRESS8!1 - rt STREET ADDRESS 11
_. STATE ZIP t
e CITY STATE IF
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i TELEPHONE " TELEPHONE
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I DATE 'it lI O NE 6 OO 83 RENTERS,INC:S MA HIC NO 146688 HAR
Ttiis s only a qmt.for toe mem"ndise and services printed below.'Th s becomes an agreementupon payment. Upoopayment the enryre agreement;including the specifically completed pages of.thie
document ,he Terms and Conditions Included wRh this document and any other addenda and attachments hereto,shall be referred to herein as this Contract R
PLEASE READ AL—TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS PAGE AND FOLLOWING PAGES BEFORESIGNING
-71 INSTALLATION STREET ADDRESS } CITY STATE ZIP
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t Contract Total : bp'"
? Are permits required for this installation?: [yj Yes [ ] No *applicable tax included
i
NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right.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.
PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees the right to take photographs of all work performed at the Premises related to this
1I Contract,and irrevocably grants to Lowe's all fight,title and interest in and to the photographs for use in all markets.and media;worldwide,"in perpet I
i Customer authorizes Lowe's to copyright, use and publish the photographs in print and/or electronically,.and agrees tha4Lowe' ty
s may use such�,`
- photographs for any lawful purpose, including,but not limited to, marketing, advertising, publicity, illustration;,training and'1Neb content. By imtlalrng
`here,Customer agrees to the foregoing. [Customer to Initial to the left].
Work is to comme ce upon reasonable availability of Contractor and/or any special order o/f,customer made Good(s)which is an to be
1 X'�_ S rz -. [fille in date].Estimated completion date is a-f'a- t'� ' (fill in date] a
Said estimated substantial completion date is not of the essence. A statement of any contingencies that would in
change said estimated substantial
completion date is as follows:
l _
(if applicable;insert-at statment of such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full. 4
i
COMPLETE
OMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: - - -
[`Z7 Customer to Pay in.Full; OR [ ]Customer to use the following payment schedule:
(I)Deposit $ to be paid upon 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, INde authorize Lowe's
J 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 -
'f [ I Deposifmy/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.
f \OTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.L.c.142A .~. ` ' -' ^�
L.OWE'S AND OWNER HERE13 MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE S HAS A DISPUTE CONCERNING THIS CONTRACT UT T
1,. LOWE'S MAY SUBMIT SU,E1~I DYI�SPUT TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECU S
I. P✓E OFFICE-CIF-�ONSU ER AF AIR AND BUISNESS REGULATIONS AND THE OWNER SHALI/BE REQUIRED TO SUBMIT TO SUCH ARBITRATION s
i AS PPt2VID€!SIN M GSEN 4 ,F d t
_•,� Leo, ,.,� Date !J A, , farI
fsreri"�a -
. c" ?f v'e^-r:•• t> l7as; sn Yi.K 'rcs - a..x��i}kg
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Contract Total ¢(>rx ]
Are permits required for this installation?: [0 Yes [ ] No *applicable tax included
NOTICE TO CUSTOMER: Federal law requires Lowe's to provide you with the pamplet Renovate Right.By signing this Contract,Customer
E acknowledges having received a copy of this.pamphlet before work began informing Customer of the potential risk of the lead hazard exposure.
i >rom renovation activity to be pertormed in Customer's dwelling unit ' -
PHO T O RELEASE: Customer grants to Lowe's and Lowe's employees the right to takephotographs of all work performed at F'rel related to this
Contract,and ircevocably grants to Lowe's alt right,title and interest in and to the photographs for use in all markets and media,worldwide;in perpetuity::
Customer autficrizes Lowe's to copyright, use and. publish the-photographs in print and/or electronically,- and agreesthat Lowe's may use such
photographs for any lawful purpose, includin -but not limited to,marketin i - 9• g,'advertising, publicity, illustration,,training and.Web content.`By initialing- `
' here;.Cugiomer agrees to the foregoing. [Customer to initial to the left].
I-
G'Jork is tocommedce upon reasonable availability of Contractor and/or any special order cust mer made-Good(s)which is anticipated to be
�fb a I!"'?. [fille in date].Estimated completion date is X. d [fill in date].
Said estimated suL t ntlel completion date is not of tha essence. A statement of any contingencies that would materially change said estimated'substantial k -
completion date is as follows:
(if applicable,inserta statme.nt of such contingencies).,;.:_xI
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full .-
COMPLETE THIS SECTION ONLY WHEN THE OONTRACTTOTAL EXCEEDS$1,000.00: � r
,(Oustomerto Pa to Full; OP. "' � i_ r
(N - Y [ ]Customer to use the following payment schedule ry , � _
('I)Deposi£$. to be paid upori siging 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 IM/e authorize Lowe's
It do one of the following(check appropriate box below): . . - -
[ I Charge my/our credit card forffie amount of the payment indicated above anytime after the date this Contract is signed,
f I Deposit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed;and
(3j Final payment of$100.00 to be paid upon completion of the installation and both.parties'satisfaction.-
j__- ,
if NO'➢"ICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS COVERED BY M.G.I c.142A
LOWE'S AND OWNER HERESY MUTUALLYAGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS•CONTRACT THAT..
LOWE'S MAY SUBMIT SU�,�6i DIBPUT TO A PRIVATE ARBITRATION SERVICE WHICH HAS BE APPROVED BY THE SECRETARY-C THE EXECUT
AS RWiDOFFIQF-OE.C.O vJ'S111iAEft AI- AI AND BUISNESS REGULATIONS AND THE OWNS ALI�BE REQUIRED TO SUBMIT;TO SUCH ARBITRATION
4S!?POYID€D.A1 M C >�c"'1/47 - _ r/
By._ �—0ineC ' s 4'1 V Date:
Lowe s.EltSme Centers, Inc
By
Y y n - L,,., tru e � t * ti3 ° x 7uar3 art `sue r.
Owner Signature
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THE SIGNATURES OF THE PARTIES ABOVE APPLYONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED
BY.LOWE'S PURSUANT TO M.G L c.142�A'THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WE4
SECTION ABOVE IS NOT SEPERATELPSIGNED BY THE PARTIES. F ay :.; , ,H_.
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DO.NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE:TERMS AND
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BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE,TO THE
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CONTRACT. YOU ARE ENTITLED TO A COPY OF THIS CONT CT AT�fHE TIME OF SIGNATURE t
WITNESS OUR HAND{S�-AND SE 1(S)BELOW THIS ..s DAY OF,
L®aNe s HornoGnters c.
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S ec`iart orAbove Owner — - `
�1 .Go-owner or Witness Customer acknowledges receipt of a true copy of this contract which was completely filled m.priorto Customer's execution hereof.You,the buyer m
cancel this transaction at any time prior to midnight of the third business day after the date of this_t Ea may
..See the attached notice of cancellation
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form for an explanation of this right. . . nsaction
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