5 LAUREL ST - BUILDING INSPECTION (3) 30
2 S l -1-7UTT�( c r t7o 4 y
The Commonwealth of Massachusetts N' 3
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALEM
p 17t�1}iblYStl ' Reyisf . 2011
Building Permit Application To Construct,Repair,Renovate Or a H
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date icd..
i� Building Official(Print Name) Signature WB
Dale
{-- SECTION,I.-SITE INFORMATION
1.1 Prop e dress: r 1.2 Assessors Map &Parcel Numbers
L I a 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 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?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2:' PROPERTY OWNERSHIP'
2.1 Owner-1 r
�J" f
Name(Print) City,Stat6,
No.and Street Te � r — —
eP Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK 2{check 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 :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) - y
1.Building $ 1. Building Permit Fee: $ ,-indicate how.fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
13 Total Project Cosrt(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (f AC) $ List:
5. Mechanical (Fire -
Suppression) $ Total All Fees:
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES .
5.1 Construction Supervisor License(CSL)
—}�
License Nu er Ex Date
Name of CSL Ho der
List CSL Type(see below)
No.and�r�e�et :Type _ 'Description
U Unrestricted Buitdin nDwellin
Clty—/Town,Stttaate-,ZIIPPI"i—J—F R Restricted 1&2Famil M Masonry
RC Roofm CoverinWS Window and SidinSF Solid Fuel Burning App
CF6`14'�� I Insulation
clep one Email address D Demolition
5.2 Registered Ho aW
Ionr(HIC) _
HIC Co N or HIC Re s wr Ex ra' n ate
No.an t
Email address
City/Town, State, IP ele hone
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 .......... ❑ ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
C (,t
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERr.OR AUTHORIZED•AGENTDECLARATION
By entering my name below,I hereby attest under the pains and penalties ofpetjury that all of the information
contained in this application is true and accurate to b edge and understanding.
Print Owner's or Authorized Agent's at
- NOTES: - ..
1. An Owner who obtains a 1ng permi 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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 haWbaths
Type of heating system Number of decks/porches
Type of cooling system dk Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SMXINI, 2IASSACHUSETTS
BUILDING DEPARTMENT
ax
130 WASHIINGTON STREET, 3' FLOOR
TEL. (978) 745-9595
KIatBERI EY DRISCOLL FAX(978) 740-9846
MAYOR THortw ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDIING COSMRSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will
be transported by:
The debris will be disposed of in :
name of( facility)
(address of facility)
e ermit applicant
da e
a�bd„ir.ak
e ,
Window World of Boston LLC MA HIC Registration
t�wy Offices & Showrooms' Number,
❑15A Cummings Park ❑295 Old Oak Street 166025
WH/6J(i/ Woburn, MA 01801 Pembroke, MA 02359 Federal ID #
(781) 932-4805 (781) 826-6281 27-1481665
"Simply the Best for Less" i www.WindowWorldofBoston.com
Customer: id N,&, Phone (h)
Install Address: Phone (w)
city:5, . State: MA Zip ate qTO E-mail
WINDOW WORLD GLASS OPTIONS
_1000 Series Single-hung All-Weld $189 /—SolarZone Elite $99
2000 Series DH Mech/Welded Sash $195 Triple Glazed TG2x $175
i1:4000 Series DH All-Weld $205, (*Series 6000 Only)
6000 Series DH All-Weld $240 - WINDOW OPTIONS
2 Lite Slider $334 Glass Breakage Warranty $15 INCLUDED
3 Lite Slider n13,1/3,1/3) n/4,v2,1/4) $525 / 1/2Screens "INCLUDED
_Picture/Fixed Lite $334 —Foam Insulation on Jambs and Head $11 INCLUDED
_Awning $260 l Double Strength Glass $15 INCLUDED
_Casement $290 Double Locks (> 26") $5 INCLUDED
2 Lite Casement $575 Full Screens $22
_3 Lite Casement (its. Aim (1/4,1/2,1/4) $860 Colonial Grids (Contoured/Flat) $45
Basement Hopper $334 Prairie Grids $51
_Bay Window,S Diamond Grids $69offit Mount/INS Seat $2660 Simulated Divided Lite $182
Bow Window-Soffit Mount/INS Seat$2785 Tempered DH Sash (BSO) (TSO) $65
_Garden Window $1880 Obscure Glass (BSO) (TSO) $35
Specialty Window $ Oriel Style (40/60 or 60140) $30
Beige/Almond $40 Foam Enhanced Frame $35
_Wood Grain Interior(Series 40W 16000 only) $100 PRE 1978 BUILT HOMES (Federal Lead Containment Law)
(Light Oakl Dark Oakl Cherry/ Fox Wood Lead Safe Practices Required $25 -
Rich Maple)
_Brown Exterior(Arch,Bronze/American Terra)$100 MY HOME WAS BUILT IN THE YEAR Z 9P Initial 0
Designer Color Exterior $155 MISCELLANEOUS
ii Custom Exterior Aluminum Cladding
Window Color LA-A'\4r-- ( L ❑Facing Color Textured$75 ❑Smooth G-8 $75 $
Inside outside Metal Window Removal $50
NON CUSTOM DOORS New Construction Vinyl Removal $175
_Vinyl Rolling Patio Door 5ft.or 6ft. $995 Specialty Window Exterior Trim $
_Vinyl Rolling Patio Door aft. $1095 Mull to Form Multi Unit $30
_Add to base price for Custom Rolling Patio Door $1150 Install Interiorii'Exterlor Stops $50
French Rail Sliding Patio Door 5ft.or Oft. $1295 Install Interior Casing Starts At $95
French Rail Sliding Patio Door 8ft $1395 Insulate Weight Boxes $20�
_French Rail Sliding Patio Door 9tt $1495 Roof for Bay/Bow Windows $500
_Custom Exterior.Cladding $150 Existing New Const. Ext, Ratio Fit $150
_SolarZone Elite or ETC Glass $175 Removal of Existing Bay/Bow $250
_Grids Patio Door $129 Repair Sill, Jamb or replace sill nosing $50
_Woodgrain Interiors $295 Full Sub-Sill (Single) replacement $150
_Exterior Designer Colors $395 Mullion Removal $30
_Interior Casing 21/2 3112 $175
_Handleset Options $ Bay/Bow Conversion Ext. Retro Fit' $350
$ (New Siding Will Not Match)
Building Permit $150 �P
Door Color / Vft
Inside Outside rlIR1d�p 1 ¢ft
W'
St.Jude CNlrrea's Research RpSpII $emu
tr
Customer declines exterior wrap and understands_painting and/or repair fray bee ired Initlaf
Customer declines grids one windows/doors Initial
DISCLAIMER:.Customer is responsible for the following in connection with this contract Painting,Staining,Alarm System(11sc@eWrecomect Building Permit as in
excess of$25.60,Homeovmar and or Condo Association Approval,Historic District Approval.City of Boston parking&sidewalk Permit fees in connection will installation.
NO EXTRA WORK IF NOT IN WRITING! Customer agrees to the terms of payment as follows:
Extra Labor&Materials $ Z " 4
Site Set Up, Disposal &Delivery Fee $ $195.00
Total Amount $ -44 6 C/
Custom Order Deposit 50% $,29QL Ck#
Balance Paid to Installer upon Completion $ R0 sl L
Amount Financed $
Window.Wond of Boston anticipates starting this work on — L,- and being substantially completed inL-2,days.Security Interest:Yes No
Any deposit required in advance of the start of the work SHALL NOT exceed 331/3%of the total contract price or the actual cost of any material or equipmerd of a
special order or custom made nature,which must be ordered in advance of the start of the workto assure thatthe project will proceed on schedule.No final payment
shall be demanded until the contract is completed to the satisfaction of both parties.
Ali home Improvement contactors and subcontractors shall be registered and that any inquires about a contract or subcontractor relating to a registration should be
directed to:Office of Consumer Affairs and Business Regulation,Ten Ptark Plaza,Suite 5170 Boston,MA 02116.Phone:(617)973.8700
No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract
Window Waritl of Boston under provision of Chapter 142A of the general laws is required to apply for and obtain all construction-related permits.Window World of
Boston shall not be deemed responsible for delays in the work described in this agreement caused by regulatory,permit granting agencies,authorities or individuals.
Notice:If the.PURCHASER(3)obtains-hisawnconstruction related permits.for the work described under this.agreement or deals with unregistered contractors,
the PURCHASER(S)is hereby advised that,in,the event of a disputeJudgement and nonpayment,the PURCHASER(S)will not be entitled to make a eialm or
collection from the guaranty fund established by chapter 142A,M.G.L.
You the buyer may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.
Notice of cancellation must be in writing postmarked no later than midnight of the following third business day.
FOR RESALEI
This Window Worlds Franchise is Independently owned and operated Window World of Boston LLC.under license from Window Word Inc.
,O ,✓9 Q Own :D not sign If there are any blank spaces. ata r
CC�1i1 gll�
salesman:Do not sign if there are any blank spaces. Date Owner:Do noYsign if there are any Wank spaces. Date
eonon g7as White Copy-Original Yellow Copy-File Pink Copy-Customer Hay.Printing 888E87-1116
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston, 11IA 02111
;r H*M massgov/dia
GVorkers' Compensation insurance Affidavit: Builders/Contractors/Electriciaas/Plumbers
Applicant Information Please Print Legibly
Name (Business/Or;dnization/individual):
1
Address:
tt Phone #:
City/State/Zip: ��L) t'�(�'Y�
Are yo employer? Check the appropriate box: Type of project (required):
I r .lam a employer with _��7 4. ❑ I am a general contractor and I 6 ❑ New construction
employees (full and/or part-time).* have hired the sub-contractor; Renrode'wIg
listed on the attached sheet t ❑
2.El am a sole Proprietor or partner- Demolition
ship and have no employees These sub-contractors have 8- ❑
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5- ❑ We area corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
t exemption per MGL 11.0 Plumbing repairs or additions
riP>h of
3.❑ I am a homeowner doing all work mP p
myself. [No workers' comp- C. 152, §1(4), and we have no 12-❑ RR of repainrs
insurance required.] t employees. [No workers' 13.E Other tN
comp- insurance required.]
'Any applicant that checks box#1 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 hue outside contractors must submit a new affidavit indicating such
tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers comp.policy information-
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.mP �� I� E�
Insurance Co any Name: �/ I C
Policy#or Self-ins. Lic.#: a2 lL e 1 Expiration Date:
Job Site Address: 1 a�P� 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 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 fie
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify under pa• nd p Ides of perjury that the information provided above is true and correct
Si ature: / Date- L
Phone#`.-
official use only. Do not write in this area,to be completed by city or town offrciaL
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#:
! assacn usztts De�artmznt of Public Safety
3oard of 3uilding Ragufatians and Standards
_icensz: CS-072772
JEFF C STEELE 2-
24 SHERW000 AVE
DANVERS MA 01923
i� A Expiration: _
Commissioner OM07/2018
---Office of Coacomer Affairs&Rusiuess Rcgu/ahun
- -'HOME IMPROVEMENT CONTRACTOR
Registration: 166045 Type:
Expiration: 41121201a LLC
WINDOW WORLD OF BOSTON,[LC.
JEFF STEELE
24 CUMMINGS PARK SUITE 15•A!
WOBURN;MA 01601
Undersecretary
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- Li registration valid for in ivtdual use only
befo expiration date. If foun return to:
of Consumer Affairs and Bupmess Regulation
Plaza-Suite 5170
Boston,MA 02116
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dNot valid without signature
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