4 LANGDON ST - BUILDING INSPECTION (2) r T z-3R Lz
The Commonwealth of Massachusetts CITY OF
�x Board of Building Regulations and Standards RE El SALEM
Massachusetts State BuildingCode, 780 CMR INSP EI F
ECTIONA( ' ��dMar20/1
Building Permit Application To Construct, Repair, Renovate O Demolish a CES
One-or Two-Family Dwelling fU�S JUL
This Section For Offici .Use Only lb
( Building Permit Number: Date &plied:
t Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
U 1 12 OrW4 Jon*
I.la Is this ccepte strH eet?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
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 Owner'of Rggcord: ' n
nA,t^IdT��✓�d k �el,Om . oty7D
Name(Print City.State./lP�
y �a�u d on E-7 4a
No. ,IdNo. Street Tc hon ---r Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ElExisting Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other 10 Specilj:
Brief Description of Proposed Work':
8
SECTION 4: ESTIMA ED CONSTRUCTION OSTS
Item Estimated Costs:AOfficial Use Only
(La or and Materials)
I. Building $ Q 0 I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g / ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ J
4. Mechanical (FIVAC) $ l List: � 'S
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: ❑ Paid in Full ❑ Outstanding Balance Due:
L4
y
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructio Supervisor Lice nse(CSL)
License Ela '
e Number xpira wn3 �ate
Name of CST Holder
51 rfi List CSL Type(see below)
No. and Street Type Description
Splft (xt{'�D U Unrestricted(Buildings u to 35.000 Co. It.)
( m" R Restricted 1&2 Family Dwelling
Ciq•/fore . � �_ M Mason
/
RC Routine Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1'N I Insulation
telephone Email address D Demolition
5.2 *me Home Improvement Contractor(HIC) i j�� �0
Lem "e c4n4a HIC Registmti, Number spiration Date
I-IIC C mpan •Name r HIC istrant Name
C�4ortge k)
0 and St4�t �1 q Email address
Cn town, State,ZIP I 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 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
1,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
(1 ,rIQS da-limnn'�- -7- ,��• �T
Print O%Mncr's Nan�lectronic Signature) Dole
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
co in ' lies true and accurate to the best of my knowledge and understanding.
r 0At _ 7 si -I s
Prmt Owner s or Authorized vin's Name(Electronic Signature) Date
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.go�,oca Information on the Construction Supervisor License can be found at www.mass.aov LIPS
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"
i
' .�.-� me �.uniarun weuun u� lvr ussucnuseus 1_ ._ -
Department oflndustrial Accidents
d
Office of Investigations
1 Congress Street, Suite100
Boston, MA 02114-2017
sl1�,�i� www.muss.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Levibly
Name (Business/Organization/Individual): / ►ie hael T_)e mik ! _
Address: Jt' $(jS+o)
City/State/Zip: (} 0W70 Phone #: I 1-7V' 530-717Y
Are you an emplover? Check the appropriate box: Type of project (required):
I.❑ 1 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
❑
2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
shipand have no employees These sub-contractors halve
" l 8. ❑ Demolition
workin • for me in any capacity. employees and have workers'
b 7 P b' $ I 4. ❑ Building addition
[No workers' comp, insurance camp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. No workers' com right of exemption per MGL
[ R 1 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers I
comp. insurance required.]
'Any applicant that checks box 9.1 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outsidelconlractors must submit a new affidavit indicating such.
+Contmctors 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. It the sub-contractors have employees.they must provide their workers'comp.policy number.
I am an emplgver that is providing workers'compensation insurance for m}=employees. Below is the policy and job site
information.
nsurance Company Name:
Pol icy:=or Self_ins. Lic. #: l Expiration Date:______`
Job Site Address: N Lu•ngton I City/State/Zip: 5^4mt cl170
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
tine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this staff ement may be forwarded to the Office off'
Investigations of the DIA for insurance coverage verification.
I do hereby certify under lite pains and enatties o er"u that the in ormaliion prorided above is true and correct.
Signature: q p Date
Phone ',: / 7p-530 '7ny
Official use only. Do not write in this area, to be completed by city or town offtciaL
City or Town: Permit/License N _
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
C'rntart Persan: Phnrc a•
ffica of Can so mar Affairs A Itusiness RMul2Iion License it reektration valid for individul use ,nlv
:.A-+SHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return tor.
:; Office of Consumer Affairs and Business Re;;ulmion
-.„!— Registration: 148688 Type 10 Park Plaza-Suite 51?0
Expiration: 1 0/1 8120 1 5 Supplement aid Boston.NIA 02116
LOWE'S HOMES CENTERS INC
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CERTIFICATE OF LIABILITY INSURANCE °ATT n1rr'
na/2c)/2z�liao,4
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON DIE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING iNSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT Hihe cortlRcalo holder Is an ADDITIONAL INSURED,the 110110Y(Iosl must be endorsed.If SUBROGATION 15 WAIVED, subjoct to the
tonns and conditions of the Policy,codaln pollclos may roqulro an ondorGomont.A statement on Nils certificate does not confer rights to the
cortlBcato holdor In Ilou of such endorsom nt s .
PRODUCER
art
rick,A Kelle• °ONTO T _ ntUl Cozzolino
'<,ir�• (4011431-9863 FA 4u:J431-9e.69
450 Veterans Memorial Parkway oBR sus 'rJ t
Building 5 WcndacfilcOkelloY.crxn
PRODUCLI<�. 163601
East Providence R( 02514 G16ER �.. --...._.__,__ _........
IY.OURF.O
N!O ConstructionINSURERA: Atlantic C06Ually Ins CO 42d46
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Salem IAA 01970 wsuncRE:
W SURER r:
COVERAGES CERTIFICATE NUMBER: NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HPME BEEN ISSUED TO THE VJ5URF,O NAMED ABOVE FOR'IHE POLICY PERIOD
INDICATED.NOTV'ATHSTApDING ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOMIC'H THIS
CERIIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCEAf FORDED BY THE POLICIES DESCRIDEO HEREIN IS SUBJECT TOALL THE TERMS.
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It is undeletncxl❑mf agraed that Lo'we's Com Paimn Inr,anti it's se6si'lintil•.are Iistesl as an Additional lnjurni.
Galnrob y CootractUr.
CERTFICATE HOLDER CANCELLATION
Lme's Companies SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
PO BOX. 1 ill ltanC In (` ACCORDANCE WITH E POLICY PROVt SIONS.
_
TH
NORh VVilkeSborb
N(: B65B Katherine M. Kelley, AAI, CiC
ACORD 25(2009109) The ACORD name and logo ore m9istarad madrs�of ACORD
ACORD CORPORATION.All rights rosorved.
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8010290169 RR Donnalley D2013.AY dghh re red.-0667
CONTRACT# U O O 4 U b
R T .� a 4 �'�q {¢,� ,i r•'L�°..'�6,9tr�- 1�3 5F`s may+ ,Fy.
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LOWE'S AUTHORIZED REPRESENTATIVE , NUMBER ; CUSTOy6ER / =
STORE NO. S EET ADDRESS .:., {. STREET ADDRES —
an o
CITY a STATE ZIP x GlT STATE ZIP
TELEPHONE - re TELEPHONE >
DATE LOWSS HOME CENTERS LLCSMA HIC NO 146668 n CnGH BANK LCC 4'6' REG ��,3�r � f#'
FEIN 56-074 58 i r CnRD CHMGE xi F 4
a �b wme a qg, t.; n s mracra caaKr,.yN 'peroR �r °,"✓n�'2mte,'nQ -
„s 'YCooIIrtmnk°r� eresan �lnrSuLefi'w�,OrnlaaoamaeM. 2ny derid'aa fits Tle�toshap i» x _ .sS,K.q,y.'e- `r'c0'w T':J
F�LxEAE'Lid.fi AND CON E„RETI4PA AND F4$4VWING PAGES'8E O�I 'hs F
4 •�i:'_Ihm��..;iv.: ..,. _,_`S`�'.� ...axe ..w,w.u*r+tr+�;,r °>~s �.' :h:^ .tea.. __. �.,�^wHv
INSTALLATION STREET AD DRESS CITY STATE ZIP <
y
2 O f r d VA III W i"(.J F
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S ] e-r 0 F vs � / r incl�{r 42 i
11 ,. /
A- t/rqi hnor»d� T �• o CY , -, f
NOTICE TO CUSTOMER—PRICE CALCULATIONS: In order to properly perform the installation of certain Goods,the Contract Price may include more
Goods than actually will be installed based on the measured square footage of the Project Area.As a result,the parties agree that the lump-sum Price
stated in this Contract is calculated upon both the value of estimated Goods required to fulfill the Contract(including waste),which may exceed the actual
square footage of the Project Area,and the labor which may be estimated based on the amount of Goods required to fulfill the Contract(including waste).
By signing this Contract below,Customer acknowledges receipt of this notice and agrees and understands that the Price includes these costs which may
not be refunded once the Installation Services am performed. )yF
1' Contract Total
o�
Are permits required for this installation?: W_Yes [ ] No *applicable tax included 5
7'0 y,0
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
NOTE: If rotted wood is discovered during installation additional charges will apply. You will be given a quote and a change order
must be completed and signed by the customer for any additional charges. Customer must initial.
*Any work or material not specified is not included in this contract.Any changes or additions will be at an additional charge for the material and labor.
PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where
Installation Services will be performed and all work performed at the Premises related to this Contract,and irrevocably grants to Lowe's all right,title and
interest in and to the photographs for use in all markets and media,worldwide,in perpetuity. Customer authorizes Lowe's to copyright,use and publish the
photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including, but not limited to,marketing,
advertising, publicity, illustration,training and Web content. By initialing here,Customer agrees to the foregoing. [Customer to initial to the left].
Work is to 9mmepce upon reasonable availability of Contractor and/or any special ordevgdr customer made Good(s)which is anticipated to be
,/�� J; [fill in date]: Estimated completion date is 9 [fill in date].
Said estimated substantial completion date is not of t(hhee essence.A statement of any contingencies that would materially change said estimated substantial -
completion date is as follows: 6.I°G.:f/ts�
(if applicable, insert a statement of such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:
Customer to Pay in Full; OR [ ]Customer to use the following payment schedule:
(1 Deposit $ to be paid upon signing 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 card 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 parties'satisfaction.
NOTICE REGARDING ARBITRATION AGREEMENT FOR C AIM COVERED BY M.G.L. 11
--- - _� o cow ........y
- - ��� nn n Meiuev ucro e installation
services are performed. - � � -- "
75E
k, Contract Total
Are permits required for this installation?: W Yes [ ] No *applicable tax included
Soya
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.
NOTE: If rotted wood is discovered during installation additional charges will apply. You will be given a quote and a change order
must be completed and signed by the customer for any additional charges. Customer must initial.
Any work or material not specified is not included in this contract.Any changes or additions will be at an additional charge for the material and labor.
PHOTO RELEASE:Customer grants to Lowe's and Lowe's employees and independent contractors the right to take photographs of the Premises where
Installation Services will be performed and all work performed at the Premises.related to this Contract, and irrevocably grants to Lowe's all right, bile and
interest in and to the photographs for use in all markets and media,worldwide,in perpetuity.Customer authorizes Lowe's to copyright, use and publish the
Photographs in print and/or electronically,and agrees that Lowe's may use such photographs for any lawful purpose,including,but not limited to, marketing, '
advertising,publicity,illustration,training and Web content.By initialing here, Customer agrees to the foregoing.
9 eg g. [Customer to initial to the left].
Work is toc�cymme/a ce_upon,reasonable availability of Contractor and/or any special order pp&�cyrt6§tomer made Good(s)which is anticipated to be
2/�r � [fill in date].Estimated completion date is 5/ il/5 [fill in date].
Said estimated substantial completion date is not of the essence:A statement of any contingencies that would materially change said estimated substantial
completion date is as follows: G � - t.rr"
(if applicable, insert a statement of such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full.
COMPLETE THIS SECTION ONLY WHEN THE CONTRACT TOTAL EXCEEDS$1,000.00:
L
mer to Pay in Full; OR [ ]Customer to use the following payment schedule:
sit $ to be paid upon signing contract. Deposit should be 1/3 the total contract price;and
ent of$ to be paid anytime after this Contract is signed and before commencement of installation,I/We authorize Lowe's
of the following(check appropriate box below):
e my/our credit card for the amount of the payment indicated above anytime after the date this Contract is signed;
orsit my/our check for the amount of the payment indicated above anytime after the date this Contract is signed; and
ayment of$100.00 to be paid upon completion of the installation and both parties'satisfaction.
REGARDING AR13 Tenu A-GREEMENT FOR CI AIMS COVERED BY M r•L 142A
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 SUBMITP
SPUT TO A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED BY THE SECRETARY OF THE EXECUT-
IVE OFRGE6F-Cf�1SFA1 AND BUSINESS REGULATIONS AND THE N)<R�A LL BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
BS.PZR.QV_IDE,D IN M.� !//
r y' Date: /ro /Lowe's How Cent
Date:
Owner Signature - -
THE SIGNATURES OF THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED
BY LOWE'S PURSUANT TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE
SECTIOFCONTRACT.
E IS NOT SEPARATELY SIGNED BY THE PARTIES.
GN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU.HAVE READ THE TERMS AND
S CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.
BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE
D CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS
.YOU ARE-ENTITLED TO A COPY OF THIS CONTR/ACT AT THE TIME OF SIGNATURE.HAND( NQISEAL(S)BELOW THIS /O ' DAYOF�!I!isweome nt LLC
•Lowes.Ewtfiorized Re re five ,- r
Owner / Co-owner or Wetness Customer acknowledge receipt of a true copy of this contract which was completely filled in prior to Customer's execution hereof.You the
cancellation 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 o
form for an explanation of this right.
55102 REV. 12/13 FILE COPY o 2ooa by Lowe•s.®Lowe's and the gable design
are registered trademarks of LF Corporation.