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12 HARTFORD ST - BUILDING INSPECTION (8) The Commonwealth of Massachusetts hl n?5 Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR RevisedLEM Mor 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Funnily Dwelling This Section For Official Use Only Building Permit Nut ber: Date Applied: Building Official(PrintN e) Signature Date SECTION I: SITE INFORMATION L I Property Add1�ess:��//�� ec II --II 1.2 Assessors Map& Parcel Numbers 0 YfarTPnr .7 ee4. I.I a Is this an accepted street?yes no Map Numher Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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❑ Private ❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow 'er'of Record: Ikrr Ttryey S&Lerh , 0147 Name(Print) ' ' I City. State.Z P 12 4ari�W6 n 14of 734 No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK(check all 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 2: 6 r l o SECTION 4: ESTIMATED CONSTRUCTION COST Item Estimated Costs: Labor and Materials Official Use Only 1. Building $ I. Building Permit Fee: $ Indicate how fee is determined: 21 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Costs (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ �- 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 575 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 6/-7/ 9 /o a3/5 FtlwLO License Number Expirat on Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted(Buildings tip to 35.000 cu.ft.) { (( I r! R Restricted 1&2 Famil ,Dwelling City/"I own, State/,ZIP M Masonry RC Roofing Covering /ytfLr�/'G' WS Window and Siding �7 Gi 7�-��� SF Solid Fuel Burning Appliances!" 5 9I IInsulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /r/�6� t!....bwf2.S 6 mie HIC Registration Number Expiration Date HIC Com an Name or I-I egistrant Name 1 3C el7irnPi f u No.gnd Son r et a�6 m& O/-77a ` ,��q 6 email address Ci '/Tovdn.State I �j 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 Issu Xce of the building permit. Signed Affidavit Attached? Yes .......... No ........... ❑ SECTION 7a: OWNER UTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property, hereby authorize d&kl� C"(ON to act on my behalf, in all matters relative o w k authorized by this building permit application. � Br ! Print Owners Name(Ele tropic Si ate SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. C,�&� �i „I N," 6 if Ig Print Owners or Authorized Agents ame)(Electronic Signature) _ _ _ ate 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 the HIC Program can be found at www.mass eov/oca Information on the Construction Supervisor License can be found at www.mass.Lov/dps 2. When substantial work is planned,provide the information below: Total Floor 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" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Pnnt Legrbl Name (Business/Organization/Individual): &63A ��t�t.tf1Q Address: 16 $ '[jam }, City/State/Zip: Fvtrei+ 4113 Ozt4g Phone#• 61-7'5ri2 Are you an employer?Check the appropriate box: 1. 1 am an employer with 4. _1 I am a general contractor and 1 F-IRcmodeling ct(required): employees(full and/or part time).' have hired the sub-contractors struction 2. 1 am a sole proprietor or partner- listed on the attached sheet.ship and have no employees These sub-contractors haveworking for me in an ca aci onY P tY employees and have workers'[No workers' comp. insurance comp. insurance. $ addition required] 5.-1 We are a corporation and its 3. � 1 am a homeowner doingall work IU. Electrical repairs or additions myself officers have exercised their y [No workers' comp. right of exemption perm MGL 11. -1 Plumbing repairs or additions insurance required]t c. 152,§ 1(4),and we have no 12. Roof repairs employees. [no workers' comp. insurance required.] 13. -1 Other tAny applicant That checkox fnomcowners s b #1 most also fill out the section below showing their workers'compensation policy information. who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. the sub-contractors have em to ees,th must Contactors that check this box must attach an additional sheet showing the name of the suntractors and state whether or not those entities have employees. If t rovide their workers' bco Iic number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. A J /"1 Insurance Company Name:_ RT /10ml = :wtg,w ca. Policy#or Self-ins. Lic. #: A W C- 400-7026S 19- A°13/} Expiration Date: #yAy( Job Site Address:— City/State/Zip: 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 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification I do herby e pains and penalties of perjury that the-information provided above is true and correct t iQnature7 =;� — Date Print Name.7 7: DNO . Phone# !',17 59� 309 [Issuing icial use only Do not write in this area to be completed by city or town official or Town: Permit/license#: Authority(circle one): ard of Heath 2. Building Department 3.City/Town Clerk4.Electrical Inspector 5. Plumbing Inspector ther Contact person: Phone#• Office of Consumr� ��""a�� 7 �V�aaac Affairs&Business Regulation IMPROVEMEN7CONTRACTOR 1OME Registration:o,U8666 - .. Expira{foty;' 91i8/ 013 Type LOWE'S HOMES CE S fNC,c 3uPPlement RICHARD CHALptaE.:;; _. �. 136 TURNPIKE Rd StfjTe ppg. SOUTH BOROUGH,`MA-oj-772 Undersecretary n r ( \I:n•achu.crt� - Dcpnrtnwnt nt Puhlic �atct• I! Bn;n d fit Buildin- Rc-ulatwn. ;ind Ntmidard, p Construction Supervisor License t One- and Two- Family Dwellings License CS 61719 RONALD A GREENE 10 RITA DRIVE MEDFORD, MA 02155 �L f Expiration. 10/27/2013 t ........ "i....... Tr- 5✓199 ..---. .. -: .--.'- ��� ps uxnfrr<•:rr,�(�nf.T�L�aJJaclifkML�J Office of Cuasu_yar 4ffalrs&Busiden Regutatioa ME IMPROVEMENT CONTRACTOR egistratlon: 102957 Type: XPlration, 71312/114 Private Corporatlai; GREENE 1NSTALLATtoN Go.,INC. Ronald Greene 165 Bow Street Everett,MA 02149 Uudcnecretary y ra < oCrver 5/9/'L013 9:40 : 45 AM PAGE 2/002 Fax Server GREEINS-01 BSULLIVAN CERTIFICATE OF LIABILITY INSURANCE DaT5/9120r3 Sl9/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSYTTLITE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,ANDTHE CERTIFICATE HOLDER. IMPORTANT: If the certifcate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed If SUBROGATION IS WAIVED,subject to the terns and Conditions of the policy,certain policies may require an endorsement A statement on this certificate don not confer rights to the certificate holder in Ileu of such endomement(s). PRODUCER CNANEACT Salem Five Insurance Services,LLC PHONE Fax 445 Main Street IA ,No Eul(781)933-3100 5595 ac xe:(781)933-9048 Woburn,MA 01801 ADOgE EArAIL 55: INSURER(SI AFFORDING COVERAGE NAIC# _ INSURERA:Safetylnsuranee:Com any 39454 INSURED INSURERB:Safety Indemnity Ills.CO.____ 33618 Greene Installation Co.Inc.165 Bow Street INSURER CLAIM Mutual Insurance Co. 0913 165 Bow Street INSURERD' Everett,MA 02149 INSUflEfl E _INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BFFN ISSUEDTOTHE INSURED NAMED ABOVEFORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBIECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WSRADDC -_. ...._____...-. ..-...— ._. . LTR TYPE Op IxaURANCE POLICY EfF POLICY E%P LTR "---'-'—'—""' INS POUJYNUMBER MIDDMYY MNWD LIMITS GENERAL LIABILITY EACH DccLIRRErvcE T 1,000,00 A X_ COMMERMI-GENERALLIABILITY BMA0008519 5/812013 51812014 CLNMSMN]E OCCUR MED EXP(An,u2 peFl—) ¢ 10,000 PERSONAL&ADVINJURY a 1,000,00 -- GENERAL AGGREGATE $ 2,000,00 GENLACGREGATELIMRAPPLIESPER: PROOJCTS-COMWWAGG $ 2,000,00 POLICY1�1 MT J T p LOC. $ AUTOMOBILE UABRJTY 0IEa1A 4 SINGLELIMIT ¢ 1,000,00 B NNY ALITo 6208932 1/30/2013 1/30/2014 aOMYWJURY(Perpwr n) $ —. ALLOWNED ISO ICDL-ILED _._ AUTOS X ACrgc BODILY INJURY(Pcr n.ziEat31 ¢ X HIREDAUTOS X AIOG VIED FgOP MACE ¢ PIA AGGNENT UMBRELLALIAB OCCUR EACH OCGJiRENGE $ EXCESS LIAR CLAtMGMPDE AGGREGATE $ DED RETENTION _ $ WORKERS COMPENSATION W G GrATI1 OrK AND EMPLOVERS'LIABILnY X TCRYLIMdG ER C A,V'f FROPRIETORNAgTNERIE%ECI-RIVE YIN WC-400-7025594.2013A 314/2013 314/2014 EL.EacH AGCIL%:NI $ 500,00 =OFFICERAAEMBER E%CLI-OEDP L NIP dNary In NH) L.L.UEEASE-EA EMPLOYE $ 500,00 RyAs,eescdee vnda uLJCHrvrICN DF OPERArroN:oauw _ F.A.-DISEASE-POI ICYLIMIr LS 500,00 DESCRIPMONOFDPERATONSILOCATONSIVEHICLES (AmM4CORD 1M,AtltlltlonN RemarNs Sctletlule,H,mro space is roqulrotll 10 day cancellation clause for non payment 3D days for all other regarding General Liability. Lows's Companies mc.and any and all subsidiaries are named as additional insured per written contract for Auto Liability purposes only. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lowe's Companies Inc IS Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O.Box 1111 ACCORDANCE WITH THE POLICY PROVISIONS. North Wilkesboro,NC 28656 AUTHORIZED REPRESENTATIVE C)1988-2010ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 'Alt CONTRACT# 00j�� „ r : INASSsACHl1SETCSX'fER1DR SOLI9TI©1�IS�INED SALESt.CONT .�' a -, g w. INSTIA�LLED 54LE/a�aPECIgI,IST NUMIBER I Mla CUST -En �F�.. ✓"G ±ci ✓C STORE uOJ aTREET ADCWSS P STREETADORESS 1 H rF jM CITY STATE 21P Ae CITY -STATE LP - lvur5ciix,� ril ifl Ui:hZ11 lala.� Sri 6157 '�:_ > ,.TELEP10NE._.-.. _. _. _. __ - c_..- -_._ -- -_._... ... ......._._._._..-. _ TELEPHONE i DATE / LOWE S NOMECENrER51NL FEIN SMAHICNO 100600 SaeT4B350 •,„ ; �D � �/ y CWWGE �� 5-R9s ,[wsy x ti-T i I S ' ks a .9r" 'ti.v' . 7`.d¢w.}c -' " " � � 'SR' "` •s �Vle'^�dle'�Isdanait.moesoN�a�uf mvngmmaasrnr�wNl��t Wvmoa-NbrEv$menCM'§ mu@Nd#�mayk°R °md n�Ri 4th aoN+h+�4are7aeP4tdcoealmCONDI NS69!uEREmja,4 ely4 �a°�4e eel oald5mwre ea'ralnamm3re�s'cn `� Y :etrass„R&w TedMsgrmGou0liid oNTtiEREVFr(sE oFgt7ls, grID upgcE5y4EFa _'T.. TIO z ST.=1i �' `P INSTgL1ATION STREF�TADDRE�S CnV STATE ZIP 1 V! Contract Total . Are permits required for this installation?:[>-Pffis [ I No -*applicable tax included p�,5-7 S NOTICE TO CUSTOMER:Federal law requires Lowe's to provide you with the pamplet Renovate Right Important Lead Named Information for Famil• ies,Child Care Providers and Schools.By signing this Contract.Customer acknowledges having recalved 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. Work is to commence upon reasonable availability of Contractor and/or availability of any speclal,order or custom made Goods which Is anticipated to be k' '- + [fill in date]. Estimated completion date Is b - I / ) [fill in date]. Said estimated substantial completion date is not of the essence. Contingencies that may materially change said estimated completion dale follow: (If applicable,insert a statement of such contingencies). IF THE CONTRACT TOTAL IS$1.000.00 OR LESS Customer must pay in full. COMP 7ETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00: [ ustomer to Pay in Full; OR [ ]Customer to use the following payment schedule: (1)Deposit $ to be paid upon 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,I/We authorize Lowe's to do one of the following(check appropriate box below): [ ]Charge my/our credit taro for the amount of the payment Indicated above anytime after the date this Contract is signed; or [ ]Deposit my/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 padies'satisfaction. NOTICE REGARDING ARBITRATION AGREEMENT FOR CLAIMS- O RE BYM - - LOWE'S AND OWNER HEREBY MUTUALLY AGREE IN ADVANCE THAT IN THE EVENT LOWE'S HAS A DISPUTE CONCERNING THIS CONTRACT,THAT LOWE'S MAY SUBMIT SUCH DISPUTE TO PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT- IVE OFFICE OF CONSUME AFFAIRS AND BUISNESS R GULATIONS AND THE OWNER SHALL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION AS PROVI?gD IN M.G.0 r,142A. 7 r.. ey: r/ i/� f % Date: JJ ' i - LPIGNATURESO BYDate:OTHE . �THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED By LOW E'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE SECTION ABOVE IS NOT SEPERATELY SIGNED BY THE PARTIES, - DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND - CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT BY SIGNING BELOW,YOU ARE ACKNOWLEDGING THAT YOU HAVE READ,UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE. WITNESS OUR HAND(S)AND SEAL(S)BELOW THIS ff DAY OF ,i�'t-, ;_ 3 Lowe's Home Centers Inc. Spedcalistor Above. Owner - Spouse Customer acknowledges receipt of a tme copy of this cQOtrae which was completely filled In prior to Customer's execution hereof.You,the buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.See the attached notice of cancellation form for an explanation of this right