40 HOWARD ST - BUILDING INSPECTION If
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The Commonwealth of Massachusetts CEIVEU (�y OF
Board of Building Regulations and Stand �ECjFNj�f< $ V�-SALEM
Massachusetts State Building Code, 780 C Revised a/ur 2011
oa
Building Permit Application To Construct, Repair, Renovatq"6�o" a
_ One-or Two-Family Dwelling 1
4 This Section For Official Use Only
Building Permit Number: Date Ap edr
ty Building Otticial(Print Mme). Signature Date
J SECTION 1:SITE INFORtNIATION
I.1 Pro ert Addr s: 1.2 Assessors blip& Parcel Numbers
� Y � 5� ��. /�
l7 �L.l7 LL//.Yf✓J
I.1 a Is this an accepted street?yes no Map Number Parcel Number y
1.3 "Zoning Information: 1.4 Property Dimensions: n f
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
CID
1.5 Building Setbacks(ft)
Front Yard Side YanLs Rear Yard 4 -
Required Provided Required Provided Required Provid-+
CD
1.6 Water Supply:(M,O.L 440,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION2: PROPERTY OWNERSHIP'
2.1 O, rvpert of Recotti�)0— 1 . , �pn L
)me(Priny f�`iW City,State,ZIP
LIC bD�W )"l 4 79 7'6 - 25 0),`1
No.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
`I New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessary Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $l('J � I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard CitylTovyn Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S P Qther Fees: .S
4. 'lechmlical (1-IVAQ S List:
5. Nlechnnical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6. Tutai Project Cost: S/p Cl Paid in Full ❑Outstanding Balance Due:
ti
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor.License(CSL) - l00-Yv3 _1
G--- License Number Expiration Date
Nam/eofCSL`tfolJer"'t List CSL'rype(see below)
/ ,57
'type - � Description
No. and Street
U Unrestricted(Buildings u to 35,000 cu. I1.)•L1 �//'`/ / Ol 7S R Restricted 1&2 Family Dwelling
Cityffovn,State,ZIP NI Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Bruning Appliances
I Insulation
Tale hone Email address D Demolition
5.2:Rc istpre m/��J_((m� ovemen�(,'on top^(HI[C /)�
M,�,{61 //__, // ( LJ' U es HIC Registration Number Expiration Date
HIC Cumr Nn IlCC Re w one /`r r� ,
No. :ur ce /1- O/'7S> Email address
City/Town, State ZIP Teletilione
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)),.
Workers Compensation Insurance affidavit must be complet submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance o e building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT`
1, as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to[work or d by this building permit application.
Print Owner's Nmne(Electronic Signature) Dale
SECTION 7b: OWNERI OR AUTHOR/ZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this np ication is true and accurate t st o kit ledge and understanding.
Not Owner's or Authorized Agent's Name(Electronic. 'mature) Date
NOTES:
I. An Owner who obtains a building permit to do Iris/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 1I.G.L.c. I42A. Other important information on the HIC Program can be found at
xNww.mass.cov'oca Information on the Construction Supervisor License can be found at www.mass.uov'Jns
2. When substantial work is planned,provide the information below•.
Total floor area(sq. R.) '!i .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) 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"
ROOFING CONTRACT
COY{yyy�.aq',W YT j�i A,o,:a[Iru,_\\s Llrn:,"a liNi+b
WINDOWS DATE � 1 , f Jar, clL/7C.,
EXTERIORS, INC.
'.� REPRESENTATIVE_(.•H f�N l'-.
100CummLr95-EBE5dle M3- eevaq,ma1028
9]e d0a4wW w m,A,o,-2203�Fax.9iB-3Da-192A SOURCE
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GENERAL CONTRACTOR'S AGREEMENT
Uwe,the owners)of the premises described below,hereby authorize you as contmcterto finish all necessary material;labor and workmanship to innall,can-
uruct and place the improvements described herein according to the Willing specifications,terms and Conditions on the premises described below.
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SHINGLE COLOR QUANTITY DIAGRAM OF HOME
TIMBERLINE HD
TIMDEPUNE ULTRA HD
CAMELOT If �...—
CAMELOTULTRA 1
-
INUESLATE
SKYLIGHTS Yx'vhjil NE — f(���r
._ __ �'Gf'vr�t..,•sx ""'%�1 r`�7'��dy:a ,4"•^ B.CLa45 ..
WORKTO BE DONE: ROOF TAKE OFF
REQUIRED ROOFING MAI EPIAL:squares-----_ ___)Chimney
Ej///P'EAROFF GUTTER MEAS.LF= Ends, g0'.= DS=___,. _
C�'iEfBACE SHEA4INGIF ORY ROTIS PRFSENT SLyellite n'll—
SaiNlile puh?, Dumtszser Aceesz?
�USEGAFWEATHERSTOPPERSYSTEM(ACCESSOPIES Delivery Assess?__
STALL LIFETIME SHINGLES VemsTYpe __ M How any Ven[s_.
I crnemit000Ry econp Cedar Tile Other___-_-._
y PkrureFVeS/No Questlans:_ _
LJ REMOVEALL108 RELATED DEBRIS Won requesled:Replace Pool/ResheetingAnstan NmV Skylights/Replace OW Skylights
(�IOR SGNINYAM Reet,be __Roof Pitch___Layers of Roofing __
Stories I1I14
❑ AUDI RONAL CO((NsmucRoN(SEE ADDENDUM) DWn'.Mi., Major Ma'sBe
E511 START DATE i1")'(1✓ ESTCOMRDATE.: {(� �/aLJ SECURITYINTEREST: YESD NOS
PRICE 5 fiv'�/q / DEPOSIT WITH ORDER
Payment Method _-_—
SALES TAX $ BALANCE TO BE PRO �y
GSII ON CONRFPON 5 �)l✓
TOTAL DUE $ 'C) l� RAIANCE TO BE FINANCED' S Financed By
•This rear elon,upon re Raton g vJxl you rant secretwilbin Briny(301days after the daleoflhis Agreement.l(EirvmingmeryaMe to Coastal Windows&Exteriors is Trot
obtained widan 3o dll I NB Agreunmi may 4 wxeffea 1,ekKa party.
I All hone:imPtowelenlmntmctonand subcenutal mml be regiathm bythraiel AdminRmr.rofine M.1W,seps 0oord of UURdlrlg ite,flicrosand Standards.Any inquiries
aWnl a cornaug.r sub[anntua,relaonytoa reyiamtionshaultlhedrerted lo:Di.Renf MarelmProwonel Cootranar Repiannion,OEM Ashbremer place,Rmm 1301.Rosser,MA
02100.051717270590.
The Com•aaar Arallobtainand Bay for the bdldarg pennit ardother Xrm-11 and govemmental fees,Drente,and inspmions nWezzaryfot properexe[Utkart andconrpletion of the Work.
If ll eCterer Le le wobrain tbef l"cl g Lanni...m to derl with emeghtered conlra[tors,the(hvner will be,oluded from dB,ua only provisions of MG.Lc.142A The Oo a,sball
obtain ark pay kr ,a)I a Cher eacessary approval;a Penn elx amwerwns and charges.
Tr, t'mmard mel crherp....,li, ,e,radvame Uat yr rRaIom thiContrador lor adinvencancenve,lis Cantract the Cortrmtormay otheifttl well,arbitration
toJded /A3 hhh. iC, Ir ZrNp
Nsync lvtl-re 1 sepayrtan]A� mtlb y {I / /�(� The homeovnrer>re Yunulealrt
[t of te panes to ahxvie(Jerrie resduenm[l byhe Commror NOMEfl t59namr,r1, pre bar ,Uty rtcetheC mm ive
thepates
No wmkshdlbegit ptionodredgrgng RrthisCgnlrazl antltnnuninalm Br<0\merofammmfrhis Cwiraa.This mnlm[I COrrstitutes the panieS:otal agreelmnc.ThiscomneCII.,
de ammdedar suppl„tmntcvl only bVa Urine\cbangeadrrsynedlrymwrer alkwnvactw.All smplusmapeal isfeconlye COASTAL WINDOWS&EXIERIORS.Youagrrelobebound
by Nre getraral[end tiuln of the remse.ke.
The Ream,Los sea.'simple Wia—, ties that wA be hovided by COASTAL WINDOWS EXTERIORS upon ing,oalm', ❑5an\plc wananries piovidMtoOemLrc.
NO ORAL AGREEMENTS ARE ACCEPTED DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
You,the buyer,may nMN.Min tnazWion at am Bearer-to miWghtof Uc Nlyd business day apmthe dareofthis Y aetmn.Seetho Nonatof CancNtation Eatm
pmvidMmyouhemvriN kroneaplarrationof this rlBht. ,f�(
IN WITNESS WHEREOEIIre panes ha+R herewno signed Their comes this
stared
r o`°�a _-—
17L
,autn— <Muu tnrowaa rxr Nmslhrnrrx $i9n�
napD MAKE ALL CHECKS PAYABLE TO COASTAL WINO JOBS -.
.,It Nw¢Er v lnw¢ualuavw
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The Commonwealth of Massachusetts
Department oflndustrial Accidents
l; Y Office of Investigations .
606 Washington Street
` Boston,MA 02111
www.mass.gov/dia
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Workers Compensation Ins
urance Affidavit. Builders/Contractors/Electricians/Plumbers
Applicant Information , Please Print Le 'bl
Name(Business/Organization/ludividual): /�y d rQ_G/
4_1Address: IS^/ 4�Am �, "5;�
Cit /Stato/Z' t Yp/�FO�S�hone#: 77 d��.
Are you employer? Check thp-appropriate box: Type of project(required):
1. am a employer with * 4. ❑ I am a.general contractor and I ti Q New construction
employees(tall and/or part-time).' have hired the su$-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sbjget. 7. Q Remodeling
ship and have no employees These sub-contractors have g, Q Demolition
working for me in any capacity. employees and have workers' 9 Q Building addition
[No workers' comp. insurance comp. insurance.,
5. ❑ We are a corporation and its ME] Electrical repairs or addit
required] officers have exercised their 11.❑Plumbing repairs or addit
3.0 I am a homeowner doing all work
myself.[No workers' comp. right of exemption per have
n 12.Q Roof repairs
insurance required.] t c. ploy ees4[, o wor have no 13 ❑ Other.
employees. [No workers.'
comp.insurance required.]
*Any applicant that checks box 111 must also flit 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 a new affidavit indicating su&
tContrscton that cheek this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have'
employees. lithe sub-connacton have employees,they must provide their workers'comp.policy number.
I am an employer that Is providing workers'com ensailon insurance for my employees Below is the policy and job sth
information. g�
Insurance Company Name: ✓`� `—
^� /LPolicy#or Self-ins.Lie. #:�6 �V� Y S 5 " 5 � F�tPlradon Date:- /3l� ,,�/j,,
Job Site Address:. `�O wA�h% City/State/Zip/��� /, � O/970
Attach a copy of the woraers'compensation pbacy declaration page(showing the policy number a.-- "piration u><
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties c
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the foam of a STOP WORK ORDER and
of up to$250.00 a day against the violator: Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I der hereby certify uncle the pains a,ndlpenaltles of perjury th IS arm a provided ab^ve is ^ue and correct.
Si tore: d� r" vim' ""—2 A ate' —
Phone#: �a2�
Official use only. Do not write in this area, to be completed by city or town ofjieiaL
City or Town: Permit(License#
issuing Authority (circle one): Inspector
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector.5. Plumbing p
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CERTIFICATE OF LIABILITY INSURANCE
c THIB CERTIFICATtf fs ISSUED A$A AL41TEli OF RiWRMATION ONLY AHO CONFER$ NO R16HTg UFDN•7Hg CEA71FICiLYE
HOLDER,THIEF CBRrffICA76 DOER NDT A UOMPALveLY F1 IfEG•AYD/SLY MtE71D, OCrBNO OR ALTER THB COVF3i'ADe
_ AFFORDED BY 8UR pOL1dE9 EELOW,.TM CoMpICATU OF MEURARCB OOE3 HVr CONSTR•UT9 A CONTRAOT 9
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WPORfAND rf theeeddNeelo hDAteo ADDRICNAI.INSURE$UIePOR� Mv)muatfHlmdaeed R9U3BOOA770mi9WA1.Ym.
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If�URANCe AFSUCHV BY THB POUCIEa OEBCRIS6 1'IFAEIN IS SUEl11e;'T TO ALL T}E TERMg EXCLUSIONS AND
COjIDfiIONS OF SUCH POUGIE3•UMIIS SHOW7t MAY HAVE EE„4J REOUOED BY PAIOOLAAQ.
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THE INS UFlEO9 MA EL MA IFTE8IN STATE$OTHERTHANMOL NroOAVrH3E PA OF BENORVA N19 G1VENTOPAYCLaM9 FOR BENEFITS fN
BTATE9 OfHFA THAN MA IFTHE INBUF7E0 HIRES,OR HAB•MIRED EMPLOYE@ OIJfSIDE OF MAYHIS POLCY DOES NOT
PROYIOE COVFJTACS FCR ANY STATE QTHER 7HAN UA.
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ATTNt IS OVSURANce SHO= ANY If T1I3 'ABOVE DE9CRISLRJ POUGIEy e
POSOXTH7 - CANCELLED BEFORE THE EXPD{ApON DATE THEREOP .. . . ..
N-MLKESBORO,NO*$a% HOTb7E WU Be DaivERED IN AOCORDANE WITH 7H
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Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isor t.>
License: CS-102403 T"
WILSON R VALDO
151 MAIN STREET s
MnYORD MA 6175
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954� Expiration
Commissioner 11/20/2014
�fae tJar�nza�uuea� ��dd1�iee1���
Office of Consumer Affairs & Business Regulation
VERFHOME IMPROVEMENT CONTRACTOR Type
Registration �M50577 �.
Expiration: DBA
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OOF
jWILSON VALDEZ `�
151 MAIN ST
MILFORD, MA 01757 Undersecretary