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1A HART WAY - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of SA Massachusetts State Building Code, 780 CMR, T°edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Family DivelGng / T_bisiSection For Official Use, nly Building Permit Number: Date A ied: Signature: 16Z&VI ! Building CotrimissloKed Ins of dFildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers . 1 A !WZ f� jj41e/, MA 01g1 I.1a 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(R) 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? Municipal ❑ On site disposal system ❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Re ord: `ZZ fi t-k —C�ct /( 0.n L- O f tt a ) / A (�R�+ wg f S' IeM A4 vt910 Name(Print) Address for Service: i ure Telephone SEC+,[O 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief DT�ggcription of Proposed Work: d" , 11 O N/p YJ-rjc Fv1,c ChAn7eS bt Don Rt Pl<}Ce wont S�ro�A odor SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount: . 6.Total Project Cost: $�$ , 8,�� 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction I/ j Supervisor(CSL) Z ao "11,4 N I ' -,n License Number Expixpiration=Date N.me f CS -A HRI er ✓1 Sf O&NVCS ► A. List CSL Type(sec below) b to A s �—� T Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted 1&2 Faimily Dwelling a O M Masonry Only Q _ RC Residential Roofing Covering Telephone - — WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5 is 2 Registered Home Improvement Contractor(HIC) `�O 6,Sy HICK pt a e or H�Rgist t Name { 1 ' Registration Number ` )7 Q A r ss a V- 0 Expiration Date eleon 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 I, -T e cvn L e Parke.e TmtQ -L u c. as Owner of the subject property hereby authorize �PRA 6 A I i)/I to act on my behalf,in all matters relative to work authorized by this b ' to it application. i relof Ownue Iate SEC ION 7b: OW Rt OR AUTHORIZED AGENT DECLARATION MA 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 T- /11 -el AraS�-5-/K 60 ner or Authorized Agent Date Si ned under the ains and penalties of perjury) NOTES: 1. 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.RG and I IO.R5, 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" JOHN WALSH INSURANCE Fax:9787459557 Apr 26 2011 12:29 P. 01 OP 10:JM PATE niwooff" ) CERTIFICATE OF LIABILITY INSURANCE Barran+ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AOLDER,THIS NTEND D CONFERS NO RTHE IGHTS N THEO ISSUING N THE ENSURER$)RTIFI HAUTNOR ZED CERTIFICATE THIS DOES CERTIFICATE AFFIRMATIVELY NSURANCE DOES NOT CONSTITUTE NEGATIVELY AME TUTE A GONOTRACY BRETWEE COVERAGE AFFORDED BY THE POLICIES REPRESENTATNE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT: If the ceftlficete holder M an ADDITIONAL INSURED,the pOliey(ie5)must ba endorsed. 1f SUBROGATION IS WAIVED,sub c o the terms and conditions of the polity,certain Policies may roquire an endorsement A statement on this certificate does not confer rights t0 the certificate holder In lieu Of such ertdorsemen 5. Ni T 978-7463300 NA e SLODUCER NA ohn J Walsh Iris Aganiy,Inc 978-745.9557 P4m O Box 4407 ADDRESS: :alem,MAG197B-8407 Uu IO .9MALK01 John J.Walsh Ins.Agcy.,Inc NAR:B INSURERS AFFORDING COVERAGE WSUReO MALKIN 8:SONS INsunERA:Nautlfus Insurance Com IRA MALKIN INSURER 9:Travelers 180 DAYTON STREET INSURER C: DANVERS,MA 01923 INSURER o: INSURER E: INSURER F: . REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: THIS IS 70 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE IR THEREO NAMED ABOVE FOR THE POLICY PER IOD CEINDIRTIFICATE NM YNBE SSUED OR MAY POERITa N. HE INSURANCE AFFORDED BY THE pONT TERM OR CONul 1 ION OF ANY UGES DU. SCRIBED HEREN IS SUBJ ECT T O ALL THE WHICH TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REOUCEO BY PAID CLAIMS. POUOY NUMBER IUD uMtTs IIUD DIT Parr M YY'r 1100010 IN TYPE Di INSURANCE EACH OCCURRENCE 6 GENERAL LIABILITY 101071`10 403111 ,PR nce i 550,00 A X COMMFACUA GENERAL LIABILITY Y MED EXP MY MB pe(aM) f 5,01) CLAMSHADE ❑X OCCUR .PERSONAL a ADU IWURY 6 � GENERAL AGGREGATE f 2,000.0o TRODUCTS-COMPIOP All i 2,000, GENT AGGREGATE LIMIT APPLIES PER i ICY PROS LOC OOMaINED SINGLE LIMIT f POL AUI NUNDLE LuumUrY BODILY INJURY(Per Pe, ) i ANY AUTO BODILY INJURY(PW P=r A) f ALLOWNEDAUTOS %PROPERTYOAMAOE S SCHEDULED AUTOS (Per awde,dl i HIRED AUTOS NONowNEonuros . s " EACH OCCURRENCE f UMBRELLA UAS OCCUR AGGREGATE 6 QCC'bi DAB CLAN16-MADE e pFDUCTLBLE i IiErENnON f X WC STAMU- oYYi- WORERSCOMPEVnINT10N 0913tfl0 08131111 E.LEACHACCIDENT 4 100,00 AND EMPLOYERS'UjAR LITY 7PJUB-203X968-2-10 100,00 B ANYPROPRIETORIPAR7NEWFXECU'TNE Y❑ N/A E,L DISEASE-EA EMPLOYE f OFFIMANEMBER EXQ U)EU? - 500.00 (MRRdatayIn win I,L D'ERi E•POLICY LIMIT f R��BBa.0 under pEgCRI PTIONPTION OF OPERATIONS btlpw DeSCMPTWNOFOPENATIONSILOCAnONSIVEHI0LE3 (PI�cA ACORO 101,AddtllPnal RaRudm SCNadnlA Rmare apace ialpnl+ddl CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ASOVE'OESCRU8EDPtiLICIES 8E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN JEAN LEPOUTRE ACCORDANCE WITH THE POLICY PROVISIONSsH' ,UP�GE AGENGY,INC- 1A HEART WAY SALEM,MA 01970 AUTHORIZED REPRESENTATIVE �a.� John J.Walsh Ins.AgCy., InC, 16 ®1988-2009 ACORD ORPORATIO his reserved. ACORD 25(2009109) The ACORD name and logo are m9istared marks_of ACORD �< Pagel of 6 No. 2686-218761 Ey SPECStore IAL SERVICES CUSTOMER INVOICMA Phone: E 741-9299 z �. . 50 TRADERS WAY Salesperson:JRG1776 SALEM, MA 01970 Reviewer. Ptrne Nara PPme • LEPOUTRE JEAN (975)744-1237 REPRINT ' lA HART WAY WedP"'" (9711)968-B794 cm¢anr rams • Gh SALEM mhor9 (nm 4/13 NRTS PAT10 DOOR QUOTE F :2011-04-2613:31 SMAM MA ZD 0 19 70-271 9 G"""t' ESSEX INSTALLER DELIVERY #1 MERCHANDISE AND SERVICE SUMMARY widcustomers Ltolmitt equan das of me than Gse N REF# 101 STOCK MERCHANDISETO BE DELIVERED: REF fr SKU OTY UM DESCRIPTION PV PR EXTENSION R02 966-471 1.00 EA 9X33.3 WINDOW&DOOR SEALING TAPE o $19.29 19.29 R03 163-613 1.00 EA 1X8.8 PT APPEAR WEATHERSHIELD $6.97 $6.97 R04 715-499 3.00 RL E/0 2'X16"X48-MIP INSUL RL S.33SOF r $3.94 11.82 R05 702-678 2.00 EA 1X8X16 PRIMED FJ PINE $32.18 64.36 R06 617-334 7.00 LF 1 X6 R/L RED OAK S4S $'3.18 22.28 R07 464-567 24.00 LF STOP WM917 PINE 3/8X1.114 .82 19.68 ROB 489 467 3.00 EA 1X8X8 DBTA S4S WHITE PINE Y 18.98 56.94 R09 746-322 3.00 EA 1 5116X42'MILL FlNISH ALUM DRIP CAP Y $1.29 $3.87 SIO-INDSETO BE DELIVERED: REF ESTIMATED ARRIVAL DATE: 06/08/2011 P.O.086585739 REF# SKU• OTY UM IPTION . TAX PRICE EACH EXTENSION V S7101 606-440 1-00 EA NLGD 6'6'X 6'/c>6' 'X ,R.O.6' 5 3/4' X/NLGD 6'6"X 6' 10'[>tl)o Y $400.71 $400.71' m NLGD 6'6'X 6' 194MAWE, ALUMINUM SILL WHITE/CLEAR PINE o CONVINUED ON NEXT PAGE`*` m s O O - o rc Check your current order status online at Hwww.homedepoLmroforderstatus ' Indicates item markdown = Page-1 of NO. 2686-218761 Customer Copy SPECIAL SERVICES CUSTOMER INVOICE- Continued Last Name: LEPOUTRE Page 2 of 6 No. 2686-218761 INSTALLER DELIVERY #1 ' (Continued) REF fH01 S 1102 606440 1.00 EA NA/UNIT-NLGD 3'3 3/8' X 6'6 21/32",STATI/-ATT TO[#1)'NLGD 3'3 3/8'X 6'6 Y $402.03 $402.03' 21132',STATIONARY PANEL,WHITE/CLEAR PINE, LOW E SMARTSUN TEMPERED GLASS 0 S1103 606A40 1.00 EA NA/UNIT-NLGD 3'3 316'X 6 6 21132",OPERA/-ATT TO(91)'NLGD 3'3 318' X 6' Y $402.03 $402.03; 6 21/32%OPERATING PANEL,WHITEICLEAR PINE, LOW E SMARiSUN TEMPERED GLASS S1104 6064" 1.00 EA NA I HARDWARE-HARDWARE TRIM SET,GD,2 PANEL,/'ATT TO Y $34.99 $34.99' #1 `HARDWARE TRIM SET GD 2 PANEL,TRIBECA-WHITE 2565694 S1105 606-440 1.00 EA NA/HARDWARE-LOCK,AUXILIARY,GD, WHITE 19971'ATT TO (01)'LOCK Y $13.20 $13.20' AUXILIARY GD WHITE 1997301 S1106 606-440 1.00 EA NA/HARDWARE-LOCK,GD, LH, EXTERIOR KEYED,TI-ATT TO(#I)-LOCK, GD, Y $30.37 $30.37' LH,EXTERIOR KEYED TRIBECA-WHITE 2573068 N S1107 606.440 1.00 EA NA/SCREEN S-PD T 3 WS'X 6 6 21/32'. INSE I'ATT TO [#1I'PD 3'3 318' X 6' 6 Y $131.30 $131.30' 21/32' INSECT SCREEN GLIDING,WHITE ti S1108 606-440 1.00 EA NA/THRESHOLD-8, THRESHOLD,MAPLE W/SCREWS 1 I'ATTTO(#1)-8, Y $24.03 $24.03' THRESHOLD, MAPLE W/SCREWS 1207060 S1109 606-440 1.00 EA NA/SILLSUPPORT-POSO, SUPPORT, SILL,ALUMINU I'ATT TO[91)'PD80, Y $18.49 $18.49' SUPPORT SILL,ALUMINUM NEUTRAL GRAY 1997058 VENDOR-SPECIAL INSTRUCTIONS: 15.0.1:: S/O-MDSE TO BE DELIVERED: REF# S12 ESTIMATED ARRIVAL DATE: 05/06/2011 P.O.#865%740 REF# SKU OTY UM DESCRIPTION ITAXI PRICE-EACH I EXTENSION S1201 692-802 1.00 F11 21950 1 0 36'W X SO'H -D,R.O. NIA/21950[#1)0 4FVB-36WH,SPECIAL Y $279.00 $279.00 ORDER ONLY,STORM DOOR,ANDERSEN,FULLVIEW,4000 FULLVIEW WITH BRASS HARD WARE 36' X 80',WHITE 21950 VENDOR-SPECIAL INSTRUCTIONS: 11.0.3:: _MERCHANDISE $1941.34 r DELIVERY INFORMATION: DELIVERY DATE:INSTALLER WILL SCHEDULE INSTALLER WILL DELIVER MDSE TO: SITE OF INSTALLATION#101 AT TIME OF INSTALLATION. NOTE:UPON RECEIPT OF ALL SID MERCHANDISE-INSTALLER WILL CALL CUSTOMER TO SCHEDULE INSTALL DATE. 0 x 0 LL 6 O - f0 N Q 2 " Indicates item markdown Page 2 of 6 NO. 2686-218761 Customer Copy SPECIAL SERVICES CUSTOMER INVOICE -Continued Last Name: LEPOUTRE Page 3 of 6 No. 2686-218761 INSTALLATION #1 REF# 101 0 ESTIMATED INSTALL BEGIN DATE: 04/22/2011 ESTIMATED INSTALL END DATE: 05/22/2011 MERCHANDISE TO BE INSTALLED: d REF 4 SKU OTY UM DESCRIPTION R02 966-471 1.00 EA 9X33.3 WINDOW&DOOR SEALING TAPE m R03 163-613 1.00 EA 1X8-SPTAPPEAR WEATHERSHIELD R04 715-499 3.00 RL E/O20XI6°X48' WP INSUL RL 5.33SOFT R05 702.678 2.00 EA 1XIIX16 PRIMED FJ PINE R06 617-334 7.00 LF 1 X6 R/L RED OAK S4S 807 464-567 24.00 LF STOP WM917 PINE 31SX1-1/4 0 ROB 489.467 3.00 EAl 1X8X8 DBTR S4S WHITE PINE 0 R09 746-322 3.00 EA 1 6/16X42'MILL FINISH ALUM DRIP CAP m S1101 606.440 1.00 EA <>6'6'X V 10'-0 R.O.6'6 314' X S1102 606.440 1.00 EA UNIT-NLGD 3'3 3/8' X 6'6 21132'.STATI S1103 606-440 1.00 EA UNIT-NLGD T 3 3/8' X V 6 21/32',OPERA S1104 606-440 1.00 EA HARDWARE-HARDWARE TRIM SET,GD 2 PANEL S1105 606-440 1.00 EA HARDWARE-LOCK AUXILIARY GD WHITE 1997 51106 606-440 1.00 EA HARDWARE-LOCK GD,LH, EXTERIOR KEYED T S1107 606-440 1.00 EA SCREENS-PD T 3 3/8'X 6'6 21132' INSE S1108 606-440 1.00 EA THRESHOLDS THRESHOLD,MAPLE W/SCREWS 1 S1109 606-440 1.00 EA SILLSUPPORT-PD80 SUPPORT SILL,ALUMINU S 1201 692-802 1.00 EA o 36'W X 60' H -D R.O. NIA BASIC INSTALLATION LABOR: SKU DESCRIPTION I OTY I UM .ITAXI PRICE EACH I EXTENSION N 235-045 ]/SLIDING PATIO OR UP TO 72 X 80 1 1.001 EAJ N 1 $469.1)01 $469.00 0 o OPTIONAL LABOR SELECTED INCLUDES: 0 OPTION DESCRIPTION OTY UM ITAXI PRICE EACH IXTENSION E ._. . O _ O-' LL 6 N O - f� N K L 6 = Page 3 of 6 No. 2686-218761 Customer Copy SPECIAL SERVICES CUSTOMER INVOICE-Continued Last Name: LEPOUTRE Page 5 of 6 No. 2686-21 8761 INSTALLATION #1 (Continued) REF#101 o .ANSTALL FIXED ARCHED TRANSOM LITE IN EXIS11NO OPENING ...REINSTALL EXISTING CASING OR BRICKMOLD REPAIR CARPENTRYTO EXISTING OPENING(LIMITATIONS APPLY- SEESPECIAL ...DISCONNECT AND RECONNECT SECURITY SYSTEMSMIRING o NOTES) e FERRY OR BRIDGE CHARGES ...HIGH-RISE CHARGE FOR ELEVATOR ACCESS a ...STRUCTURAL WORK v ...PAINTING OR STAINING m SPECIAL NOTES: —HOW THE PROCESS OF PURCHASING AN INSTALLATION WORKS: OTHER PARTS OF THE HOME IS A NATURAL OCCURENCE AND IS THE 1.SELECT NEEDED MERCHANDISE WITH A HOME DEPOT ASSOCIATE RESPONSIBILITY OF THE CU STOMER. 2.BASED ON YOUR ESTIMATE OF THE DOOR'S DIMENSIONS,WE WILL —AFTER YOUR INSTALLATION: ESTIMATE THE TOTAL COST OF YOUR I NSTALLATION.IF ...YOU WILL HAVE TO IMMEDIATELY PAINT OR STAIN ALL DOOR AND v ACCEFTAeI._I-YOU WILL PAY A FEE FOR AN INSTALLER TO TRIM SURFACES TO MANUFACTURERS SPECIFICATIONS ON c CONDUCT A SITE INSPECTION PRIOR TO PROCESSING YOUR ORDER. UNFINISHED OR PRIMED MATERIAL ti 3.THE INSTALLER WILL SCHEDULE THE JOBSITE INSP ECTION TO ...UNFINISHED WOOD OR OTHER DOOR MATERIAL CAN SPLIT,WARP, m m VERIFY THE WORK AND MATERIAL REQUIRED.AFTER THE OR DETERIORATE IF NOT PROPERLY FINISHED.FAILURE TO DO INSPECTION,WE WILL UPDATE YOUR QUOTE NOTE THIS AMOUNT THIS CAN VOID THE PRODUCT WARRANTY AND WE CANNOT CAN CHANGE DUE TO SPECIFIC CONDITIONS WITH YOUR GUARANTEE THE INSTALLATION.REFER TO THE PRODUCT MANUAL INSTALLATION. FOR SPECIFIC WARRANTY AND MAINTENANCE INFORMATION, 4.WE WILL ORDER YOUR MATERIAL(IF IT IS SPECIALORDER) —OTHER INSTALLATION EXPECTATIONS AFTER YOU PAY THE BALANCE OF THE PRICE FOR MATERIALAND ...CANCELING APPOINTMENTS WITH INSTALLERS OR MISSING INSTALLATION.WE WILL GIVE YOU AN ESTIMATED LEAD-TIME SCHEDULED APPOINTMENTS WILL LFRD TO ADDITIONAL CHARGES THAT MAY CHANGE BASED ON THE AVAILABILITY OF TH£PRODUCT. ...IF UNFORESEEN LABOR IS NEIDEC(E.G..REPAIR DAMAGE FROM 5.ONCE THE MERCHANDISE IS AVAILABLE FOR INSTALLATION,THE WATER OR TERMITES,ELECTRICAL OR PLUMBING PROBLEMS), INSTALLER WILL CONTACT YOU WITHIN TWO WORKDAYS AND SET A THERE WILL BE EXTRA CHARGES.IN SOME CASES.THIS LABOR DATE FOR THE INSTALLATION. MAY NOT BE AVAILABLE FROM HOME DEPOT AND THE CUSTOMER —BEFORE YOUR INSTALLATION: MUST HIRE THERR OWN CONTRACTOR TO COALPLETETHE WORK. ti ...IF YOU HAVE AN ALARM SYSTEM.YOU MUST HAVE IT ...THE INSTALLER WILL PROVIDE THE MANUFACTURER'S PRODUCT o DISCONNECTED BEFORE THE INSTALLATION BEGINS.ALSO,IT MANUAL AND WARRANTY CARD TO TH E CUSTOMER.PLEASE REFER c WILL NOT BE RECONNECTED AS PART OF THIS INSTALLATION. TO THIS FOR WARRANTY REQUIREMENTS AND MAINTENANCE o ...ELECTRICITY MUST BE ACCESSIBLE TO THE WORK AREA. RECOMMENDATIONS. "- E --DURINGYOURINSTALLATION— ......... . s - "'SERVICES NOT AVAfIABLE WITHTFi1S INS'fALix PROGRAM: "*CONTINUED ON NEXT PAGE"` d O f0 6 d 6 Page 5 of 6 No. 2686-218761 Customer Copy SPECIAL SERVICES CUSTOMER INVOICE- Continued Last Name. LEPOUTRE Page 4 of 6 No. 2 686-2 1 8761 INSTALLATION #1 LL (Continued) REF#101 3 ...INSTALL NEW STORIWSECURITY DOOR ATSAME TIME SAME JOBSITE/ 1 1.00 EA N $97.00 $97.00 13 ...HAUL AWAY EXISTING DOOR/ 1 1.001 EAl N 1 $30.001 $30.00 CUSTOM LABOR SELECTED INCLUDES: OPTION DESCRIPTION OTY UM TAX PRICE EACH EXTENSION m 1 HAUL AWAY OF OLD STORM DOOR FRONT 100. EA N $10.00 $10.00 2 BUILD OUT OF JAMB TO 5`REAR SLIDER DOOR 1.00 lA N $69.00 $69.00 3 CUTBACK SIDING TO ALLOW FOR PROPER INSTALLATION OF REAR SLIDER[)OOR 1.00 EA N $85.00 5.00 4 DIFFICULT ACCESS THRU HOUSE.. 1.00 EA N $85.00 $85.00 INSTALLATION SITE NAME: I LEPOUTRE JEAN INSTALL LABOR CHARGE: $845.00 ADDRESS: 1A HART WAY TRIP CHARGE: $0.00 N CITY: SALEM STATE: MA ZIP: 01970-2719 CREDIT FOR DEPOSITIMEASURE: 30.00) COUNTY: ESSEX SALES TAX RATE: 6.250 TAX: Merchandise-Y LABOR- N $815.00 A ti PHONE: 978 744-1237 ALTERNATE PHONE: 976 968-8794 w BASIC INSTALLATION LABOR INCLUDES: ...PRE-INSTALLATION JOBSrrE INSPECTION ...ADJUST DOOR TO ENSURE PROPER OPERATION ...DELIVERY BY INSTALLER OF ALL JOB-RELATED MATERIALS WITHIN ...INSTALL NEW INTERIOR CASING AND EXTERIOR TRIM[BRICKMOLD 30 MILES OFSTORE (CUSTOMER PROVIDES) ...REMOVE EXISTING DOOR UNIT ...INSTALL NON-COLORED STUCCO PATCH UP TO 4'FROM JAMB,WHEN ...INSTALL NEW PATIO DOOR UNIT APPLICABLE ...INSTALLER TO PROVIDE NECESSARY FASTENERS,SHIMS,CAULKING ...JOBSITE CLEAN-UP AND INSPECTION OF FINISHED JOB WITH OAK TRANSITION(LABOR ONLY CUSTOMER PROVIDES)PRESSURE CUSTOMER TREATED SILL(IF NECESSARY)INSTALLER PROVIDES ...INSTALL STANDARD HARDWARE INCLUDING LOCKSEL(CUSTOMER PROVIDES OR WITH PATIO DOOR) ...DRILL HOLE IN JAMB FOR ALARM VAR ING IN SAME LOCATION AS o ODOR BEING REPLACED. n m UNLESS STATED ABOVE THIS INSTALLATION DOES NOT INCLUDE: m ...INSTALL PATIO DOORS OVER W IN HEIGHT OR W IN WIDTH- -- o ...PLASTER,-DRYWALL OR SIDING WORK' � — x � "'CONTINUED ON NEXT PAO E"` 0 g a m o .o a a Page 4 of 6 NO. 2686-218761 Customer Copy SPECIAL SERVICES CUSTOMER INVOICE -Continued Last Name: LEPOUTRE Page 6 of 6 No. 2686-218761 INSTALLATION #1 (Continued) REF @101 c ...AN ADULT OVER 18 YEARS OF AGE WITH THE AUTHORITY TO MAKE ...ELECT'RICALWORK DECISIONS ABOUT YOUR INSTALLATION MUST BE PRESENT DURING _PAINTING OR STAINING OF DOORS AND TRIM MOLDINGS c THE JOBSITE INSPEC ION AND INSTALLATION. ...4YORK ON SUNDAYS OR HOLIDAYS a _.CHILDREN AND PETS MUST BE KEPT AWAY FROM THE WORKAREA. ...REINSTALL EXISTING INTERIOR OR EXTERIOR FINISH MOLDINGS _.IT MAYBE NOISY DURING THE INSTALLATION OF YOUR DOORS. ...STRUCTURAL WORK-REPAIR,INCREASE OPENING SIZE,ETC. m _.THE INSTALLER WILL BROOM CLEAN THE IMMEDIATE WORK AREA BEFORE COMPLETING THE INSTALLATION.AIRBORNE DUST IN END OF INSTALL 81 TOTAL CHARGES OF ALL MERCHANDISE & SERVICES 7SAIUANCF 2 756.34 ALES TAX 121.33 TOTAL $2 877.67 DUFI $0.00 END OF ORDER No.2686-218761 m n m 0 m x 0 LL d m o m d 'age 6 of 6 No. 2686-218761 Customer Copy The Commonwealth of-Massachusetts Department of Industrial Accidents �? Office of investigations . 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El Plibl ri A ease Print L y Applicant Information i Name (Business/Organization/Individual): Address: 180 D 41 hm ST Ci /State/Zi V2R 0tIt 3 Phone#: .— 77 y 63PO �y p=�P Aree you an employer? Check the appropriate box: Type of project(required): P i- I am a employer with /© 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time). have hired the sub-contractors p ) 7. El Remodeling 2.L� I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. workers' comp. insurance. 9. 0 Building addition [No workers'-comp. insurance 5. ❑ We are a corporation and its • 10.0 Electrical repairs or additions required-] officers have exercised thew right of exemption per MGL 11.❑ Plumbing repairs or additions 3.Elt I am a homeowner doing all work � p p myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required"] t employees. [No workers' 13.0 Other comp.insurance required.] -Any applicant that checks box#I 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 hire outside contactors must submit a new affidavit indicating such =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Lam an employer that is providing workers'compensation insurancefor nzy employees. Below is t/te.policy andjob site _information. T �aIsurance Company Name: �7i kA•V•at ed S p "Policy#or Self-ins.Lic.c. #: ! P✓ UA - 30 3 Xq& S-d—Q$Expiration Date:/�n$" qq Job Site Address: I A (�/L ►/VY44 City/State/Zip: 041eA AA 'D1l7 v 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 cerY' ur:der Ize a sand penalties ofperjury that the injormatior:provided above is true and correct Sip_natur i'L Date- Phone#7 7 K 6 3VO Ojicial use only. Do not write in this area,to be completed by city,or town official. City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: g:- \tasachusctt< - rJcpartmcnt of Puhlic Safe" ,. Board of Rcgu!ation> and Mandar ds r Construction Supervisor License License: CS 20014 ,._� Restricted to: 00 IRA MALKIN IS- 180 DAYTOR ST DANVERS, MA 01923 '„i M11 y P_zpi.anon 2131i201,' Tom. 13037 1r7-el &Mmlgl� -' 1/ y Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 100654 Type: Individual -_ Expiration_ 6/22/2012 Tr# 298948 IRA G. MALKIN Ira Malkin 180 Dayton St Danvers, MA 01923 Update Address and return card. Mark reason for chance. -- - _ Address — Rene�ca[ — Emp!a_:rent lost Car^