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10 HEMENWAY RD - BUILDING INSPECTION -rb . "7 -7 `r0 10 3 S a The Commonwealth of Massachusetts l Board of Building Regulations and Standards n REC:E{�J .� CIT OF� Massachusetts State Building Code, 780 CMR INSPECTIONAL SERV$ 1 =' ReviseY ar 2011 Building Permit Application To Construct, Repair, Renovate Or Derr fi a8 A � ZO One- or Two-Family Dwelling n�a A ' This Section For Official Only EBuildiing Permit Number: Date pplied: alp nig Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Propert r "Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?y s_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tt) 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? Check if yesO Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' wne 2. r of Recor � r �i � es� rrr-� ern Name Pnnt) City,State,ZIP /11�1�tR� �� No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work2: 4TotaSECTION 4:ESTIMATED CONSTRUCTION COSTS l 4Cost: Estimated Costs: abor and Materials Official Use Only g I. Building Permit Fee: $ Indicate how fee is determined: cal ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x ing 2. Other Fees: $ nical List: nical on Total All Fees: $ Proj Check No. Check Amount: Cash Amount: (p ❑Paid in Full ❑Outstanding Balance Due: S TO 1;A. n, �( t3 SECTION 5: CONSTRUCTION SERVICES t truction Supervisor License(CSL) � oe ns ly2yr�3 i/ License Number Expiration Date Name o CSL Holda.• List CSL Type(see below) No. and Street. e1 /� Type Description 0/(LTU� {nf4� ©� N-7 U Unrestricted uildin s u to 35 000 cu.R. City/Town,State,Z:e R Restricted 1$2 Famil Dweilin M Masan RC Roofs Coverin WS Window and Sidin SF Solid Fuel Burning Appliances 1� —fL I Insulation Tele hone Email address D Demolition 5.2 Regis ered E s elm rovement Contractor C) /L � tycL �l/�Az /.Jas77 HIC Compaq, an ,qr HICRegistr [sine HIC Registration Number xpiration Date No. and Street �,� tz &Aq �) mil a� �s�� 2 /it Email address I State..ZIP Telephone Uw TION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M G.L.a 152.1 25C(6)) omper:.ation Insurance affidavit must be complete bmitted with this application. Failure to provide it will •esult in the denial of the Issuance of uilding permit. idavit f Wached7 Yes .......... No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN I)WNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT of th.: subject property,hereby authorize beh iIf,in all matters relative to work authorized by this building permit application. Print ��resNaw—m;,t-7VIactronic Signature) Date SECTION 7b:OWNER'OR AUTHORI=of ATION By entering my r.sine below,I hereby attest under the pains and ll of the informationcontained in this.application true and accurate to the best mnding. ALI Print Owner's or f uthonzed Agents Name(Electronic Signature) Date NOTES: I. An Owner c:ho obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not register iA in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration program or :.uaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at Information on the Construction Supervisor License can be found at a«v.jl,tss, )% ;.L_,_: 2. When subst Intial work is planned,provide the information below: Total Floor area tq. ft.) (including garage,finished basementlattics,decks or porch) Gross living are (sq. ft.) Habitable room count Number of firep.aces Number of bedrooms Number of bathr;roms. Number of half/baths Type of heating:system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Projoat Square Footage"maybe substituted for"Total Project Cost" COASTAL. ROOFING CONTRACT ��> c qMa-z ,n/usanslmnscuoarzs a n p evV N��WJ / LYI yyyyl�M DATE Gr '? kflaio Ilq Glmmings Cantec5uite 23fiH•eevmly,A.^,A01915 r (C Y" l H[PPESFMAPVf ,__ 9y8-'Ay "•80E4012-1783-FOa 07(3-3Ua-1928 :vww.mycoasmhNnd-ws.roe CR/MR____SALES REP.___ GENERAL CONTRACTOR'S AGREEMENT l"W"the o"a"Y'l of she premises described beks thereby authorize you as Contractor to furnish all necessary mateeiats,labor and workmanship to install,mry stud and plane the improvements described herein according to the fallowing specifications,terms and tondidons on the premises described below. ram" NN CaLp1Y AppAES� f 1 _— �+ CrtY STgE nP i{d f2iS,nVCTrar,Sl,i ---5[NE N ---- ..a$_-----t'ro.AYIrTIq__�_ maureaAlk erlpnE Ne, "lee SHINGLE COLOR QUANTITY DULGRAM OF HOME TIMBERLINENDTIMBERLINE ULTRAHDYIFT CAMELOTO CAMELOT ULTRA _ y TRUE SLATE —� --- 1 't"V(%�✓t •i�i3�'t- tSl f t {. srcvuetrzs -' �-.— ty WORKTO BE DONE: - COASTAL WINDOWS&EXTERIORS IS NOTRESPONSIBLE FOR DEBRIS IN ATTIC � REQUIRED ROOFING MATERIAL:(squares. Chimney TEAs10FF GUTTER MEAS:LF=__,_ ' ' _Ends+—___:__ REPLACE SHEATHING IFDRY BUT Is PRESENT Skylights:2s2_-_ JsO_7i_'Custom___.___ A Setelli[e Dish?�)j„_, -pumpster Acrnss?_i_ate_ USE W WEArHERSTOPPERSYSTE M(ACCESSORIES pol'rve Accesz? ry _ �'F�____.__ 7 e�X — INBTALLLIFE9MESHNGLES Vents Type�yL�-_,_,How Many Vent;_�� __ CumentR ottypu:Camp f tlar Tile Other! �U- -REMOVE ALL10tl RELATED DCBfliS _ ' ' PiRure.Y&/fWaQ Ra: ,}V3 JOBSKdJINYARD Wurk reyuesl , Rqla-�nI_e _Pct?6enhlnstall New Skyliyhb/Replan Old Skylights eig RE-RASH CHIMNEY Rafsize__L La c.oFRofin9 I Stoies t��y3/n —ADDITIONALCONSTRUCTION(SEE ADDENDUM) coarFis, _ React, ,Nasshm EST,STARTOATE ESTCOM.DATE: SECURITYINTERE5T YESCI NOD PRICE S %) OEPOSR WITH onOEa S Payment Method��u SALESTAX BAU aMBEPAW 5 l— CASH ON C)MPUCTION $ TOTAL DUE "(r) BmAnCEiO eE Fwaxcc0• 9 FlnanamdBY— •Thisvgreement hnatrint to Bnneingi-bich you must secumwriantbbty DN deysahet like dateafthb Agreement Iffiwndngacmplablta Crude Windows&Exteriorsis not abtainMwlthin30 days.dtis M cement mnybefancellMbyeisnerpary. Allhomelmpmsement contractors andsubcontmcters must berquatred by the Oriel Ad Arnistrarorofthe Massachusetts Fraedoftluldir,g ReguWrmeted Standards Any inquires About acon,rattw ersubcantmRarela6ng loa reybnalionshwld bedlratedl-:D'vectprof Home Improvement Cantrac[Orflegls,mdnq One AshMmnnplace,Mom 1301,8os,on,MA 11]180,161)f 7274598. IneComranorshaliobtae and pay for In,building permitmM other p.mits and governmental fees,literac,.Tliatecomer necessary for pmper IncoulOn and fomplmker sidle Work. It the Ovncr acres to obtain the foregoing permits or 0 deal Mira unregistered mnmecton.the Owner will be extluded from the guaranty prmfrsi-ns of M.G.L.c.142A.The Ormw shall -"lain and 11 for allmher necessary c1se—ls.SOrments imcn incia,aM fhal ueContmapriessa omeovmer h.e"ymamllyagree inpdvamelbar intneerenttheConvaawhyrsn uhmrcemTpthsGrosen.rle Comrattarmaywbmit ihezuc"mhitmtion pmviesan Mra sMs mplal ebymutwltyaWee _ !! �,Lf nattpamraumn _—_ v'a NOOCF:Thesigrwtwe ultlN paniesabatmappNonlyto the Convacmi tbepartiez toaltamativedisWte di spum resol,nio%inillned yNeConvanos thehomeovmel mayiiateaherna,ive ms N utiun even where this section b nw sepamtory signM by me paides Na vror4shailbeginpriortoshesigning o(Ois ConlaRandtransmithl lothe thvnRMa wpyofNiz CanlmR.Thismnnattc9nstlmes thepanie,tol'N agreement This cOolra[t may baamendMorwppkonentedmn b"%wuenchaigewdersignedbymmerandcontractoc Wlsulp!usmazerialuproperrydCOASIILLMNDONS&FXfENORS Yau agree,obebound bythelienoralneaidonofthereverseside. Thromar'hv usmn 1am1h1we-emus drat will be pmvlJM It,COWALVIINDOWS&EXIEIUORSIIpen memlauon 0],upt narantlezpres,worlmoure, NO ORAL AGREEMENTS ARE ACCEPTED DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. You,me buy.,cony fame-)'bit bamallon m nny time pder to miderifto lthcUird but.day et.,he dam of this transanim.)See nagm el Cenmtlaien fee provided to You hoonath for an oplanather of this right. _t �.•: '/ ` 7l IN WRNE_SSWNDIEO�[be panics have hereunto 4gnM the'v nameahis__"_—._7.�1 �"._,_.__Z k I mA.T, a mmmnnlnsernuve F"IM MAKE ALLCHECKS PAYABLETO COASTALtViNOMVS&EXTERIORS 1".tafn2l 'OH",Kus,aMle, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , 606 Washington Street Boston,MA 02111 . :v` r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information G Please Print Le 'bi Dame (Business/Organization/individual): / Address: Y/)A01/Z•5__hone #: 7? City/State/Z' t� t Are you employer? Check thp.appropriate box: Type of project(required): L� 4. ❑ I am a general contractor and I 1. am a employer withors 6. ❑New construction employees(full and/or part-time).* have hired the Cached sheet. listed on the attached sheet 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have g. Demolition ship and have no employees employees and have workers' working for me in any capacity. 9. ❑Building addition o workers' cam insurance comp• a corporation [N P• 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers' comp, right of exemption per MOIL 12.❑Roof repairs insurance required.] t c. 152,§1(4), and we have no 13.11 Other. employees. [No workers.' comp.insurance required.] *Any applicant that checks box 41 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 contractors must submit anew affidavit indicating such. [Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have` employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'co7A—r ensatlon insurance for my employees. Below is the policy and fob site information. /t�Q Insurance Company Name: 0 6 Policy#or Self ins.Lic.,#:- Job Site Address;_ 5 5�/r'S`�'� Expiration Date:�, J3l 46 City/Stalc/Zip:55 �) - Attach a copy of the worlters' c=pensationicy eclaration page(showing the policy number a.-_ cipiratlon tw:::,. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of It 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 certify uncle the pains andJpeennJalllies ofgerfury il&f th nform n provided ab-ve is '*tie and correct. y Si Lure: ate: _ Phone#. Official use only. Do not write in this area,to be edmpleted by city or town officiaL City or Town: Permit(License# Issuing Authority(circle one): Ins actor 1. Board of Heath 2, Building Department 3. City/Town Clerk 4.Electrical Inspector 5, plumbing p 6. Other Contact Person: Phone#: +. IIM Massachusetts -Department or Public Safety Board of Building Regulations and Stalldards- Construction Supervisor License: CS402403 W USON a VALD,EZ . . ;. 151 X40 STREET - hIILFORD b1A 61757 Commissioner 1 1120120-1 4 r-. OfOce of Coemorcr.%Rain&6uiloess Ref ala�ler .HOME IMPROVEMENT CONTRACTOR Registration: 1505, Type • Expiration: 4111 DBA MASTERROOF ;204& WILSON VALDEZ 151 MAIN 5T • MILFORD.MA 01757 l oJerurn mn -