148 LORING AVE - BUILDING INSPECTION (2) K4+:- , o mn5eDe
GK lbtl5
\ } The Commonwealth of Massachusetts
Board of Building Regulations and Standards l �gI�EM
Massachusetts State Building Code, 780 CMR,; . \ ' !Revised Mar 2011
BuildirigiFermit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
G" z
3 Building Permit Number, Date Applied:
rn
1 Building Official(Pint Name) Signature. _ Data—
SECTION 1:SITE INFORMATION r' rM
' 1.1 Proper ,A d s • 1.2 Assessors Map&Parcel Numbers
' is` q Ma Number Parcel Number
1.laIs'this'an cepted street. yes. no P �,, i i.
L1.3 Zoning Information: 1.4 Property Dimensions
II
Zoning District Proposed Use ��, ,,� Lot Area'(sq ft) V Fro tnages ' -
1.5 Building Setbacks(ft) = .q 1 " '" '
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 Ownert cord•
e�loi�r A�r vl1
Name(Print) City,State,
JLIC-u_
No.and Street e ephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other q ify:
Brief Description of Proposed Work-2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ ^ 1. Building Permit Pee:$ ISHI�$how fee is determined:
2.Electrical g ❑Standard City/fovvn App ration Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing - $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:.
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ OeM
0 1 ❑Paid in Full ❑Outstanding Balance Due:
Pa-oJtO�wC_�. (Ct 02q(D'zg
r
� ; .rt; [ram � � _ • i��' \ {..
> �4 It • o. + 1 ... i
SECTION 5: CONSTRUCTION:SERVICE_ S
5.1 Constructi upe\ �Jor License(CSL)
�in /J� � License umber Exp' ati n Date
Name of CSL Hold •sue 111
I r C. y� Lis[CSL Type(see below)
lti n,
No.and 9tieet _Type , .':Description,,`
U Unrestricted(Buildings up to 35,000 ca.ft. .,
R Restricted I&2 Family Dwelling
[. City/Town,StatE,ZIP M Masonry
g-ram
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
t� I Insulation
Tele ton - Email address I D I Demolition
5.2 Registered H r e ImprAxamej t Contractor(HIC)
HIC Re istration Number Epfratyh DFe
t e
No.Ein'ORN Email address
City/Town, State, Te] hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.1-c.
Workers Compensation Insurance affidavit must be,o6mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issup6e of the building permit.
Signed Affidavit Attached? Yes ..........❑ No........... ❑
SECTION Tat OWNER AUTHORIZATION TO BE'COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES.FOR BUH,DING PERMIT"
I,as Owner of the subject property,berkby authorize
to act on my behalf,in all matters Telative to wo k'authdrized by this buildtng`pe pit application 's" .:
o tt
Print Owner's Name(Electronic Signature) I - Date
SECTION 7b:bWNERr OR AUTHORIZED AGENT DECLARATION
By entering name below,I hereby attest under the pains and penalties of perjury that all of the information
contained!. i appf atio is o
ands accurate,_to the best of my knowledge and understan g.
li—
Print ONKGN uthonze am s Name(Electronic Signature) - Date
NOTES: `
1. An Owner who obtains abuilding 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
wnvw.mass. oa v.,oca Information on the Construction Supervisor License cari lie found at www.mass.eov/dam
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenUattics,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". a. F,
OTYOFSALEIK MASSAa-REETPS
DEumicDaPA$n&w
120 VA90MMMERTs3APROCR
7UL(978)745-9595.
$DABERLEYDRiSODLL
FAx(978)740.9846
MAYOR 1)JOKASSTMUM
DmEcrcat cFPURUCPFJ3PWY/BUMDMCCMAWCMM
Construction Debris Disposo/Afdovit
(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 coo,S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly lensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Si nature of applicant
ate
The Commonwealth ofHassachusetts
Department of lndush'ialAccidents
I Congress Street, Suite 100
Boston, MA 0 2 11 4-2 01 7
www.mass.gov/dia
` V.,vgkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED tN ITH THE PERhIITTLNG AUTHORITY.
Applicant Information Please Print Letribly
Nalne (Business/Organizabomindividual):
' r
Address:
City/State/Zip: Phone#:
Arc you a employeC Check the appropriate box: Type of project(required): �
1. _ I ant a employer with_� employees(full and/or part-time)." 7. New construction
1❑[am a sole proprietor or pannerdnip and have no employees working For me in $. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.Q 1 am a homeowmerdoing all work myself.[No workers'comp.insurance required.)'
10 Q Building addition
J. I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I I I.[]Electrical repairs or additions
proprietors with no employees. 1 12.Q plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.��Cepatls
These sub-contractors have employees and have workers'comp.insurances j j
Id. Other "
F. ❑We are a corporation and its officers have exercised their right of exemption per hlGL e. t �
152,§l(l),and we have no employees.[No workers'comp.insurance required] j
"Any applicant that checks box 41 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 outside contras ron must submit anew affidavit indicative such.
,COPtractors that check this box must attached an�iditional sheet showing the name of the sub-contractors and state whether or not those entitie§have
conotlyees. if the sub-contractors have employees'tlley most provide their workers'comp.polio)dumber.
1 am an eriiplayer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information. �^
Insurance Company Name:
Policy#or Self-ins.Lic.n: A t• 1 I L 1`l I b `/ Expiration Date:
Job Site Address: � � ��� City/State/Zip:
Attach a copy of the workers'compensation polic•d claration page(showing the policy number an a piratioo date).
Failure to secure coverage as required under Iv1GL c. 152,§25A is a criminal violation punishable by 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 up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance
coverage verification.
1 do hereby certify and the ' s a pe 1 ' ojperjury that the information provided a ove is rue and correct.
Si nature: Date:
Phone 4:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
DL ELFK- L-,LZ
70
Boy---)
Homes
P,--givrauon: 125893
TYPE: SUPPIOMe"t Car",
Expiration: 813/2
3 016
THD AT HOME— SEP410ES, INC-
Pi-CHARD FALLONE
2690 CUI\ABERLAND PAjF'Kl,',lAY
ATLANTA, GA 30339
Mark reason for chafl,ie-
7;
Address Renews( Lost Card Lvdat- kddr- s and return card.
Employment Renews(
liner before :he ,,e jr registraum, valid gDr indillidul u3e onlY
'aj BU3jn,3j a��IJUIG% Uca 'on datm. g found return to:
-
ad B'Sil' S
Type paricPlama-5urta 5170
:
m -a:H 33ston.M—kO!U�
;HARD FALLONEE
IQ CUMBERLAND PARK` -1-ky 5 of valid without sfa.hature
GA 30339 U.ndersecrttau
Finassacnusetts Department of Public Safety
Board of Building Regulations and Standards
License: CSSL-099699
Construction Supervisor specialty
ROBERT POCZOBUT
- 172 WHALERS LANE ' N._ ,
SALEM MA 01970
Comm!ss;cner 02/0812018 -
. : HOMEIAtPROVIUADITCONTRACT -PLEASE READ THE _
Sea Furnished and Installed by
Braga Name:Boon Nests&San* Date•.5- Jy��.rS��L- TRD AC-Hne o Senores.lot.
&W& The Hams Dept At-Kxm Services
Brana Ngm1 31 tad 33 908&mtoTumpi►a Unit 1.shrews".MA omi
Tall Rem s77.W3-3768
Fedm a ma 7Ss698t6O:ME 13c a C 01419:RI Cab.toic#
a f CT 13c a HIC036331.1:MA Home bnpowTorhu Cmmm RcIL6 1da91
mat.uatlemAdd/es 7yCl 1oii,r. �dl - } suite—� Cray State LP .
Psmmnal: Wort Phone: Hama Pbamr. Cen Phan:
Hans A,dmoc Q f{A&F w A �f S!a LctVrs
(if different hum blsallmioo Address) C, GP
E-ma6 Addition Ion receive pfi*O errrnmmicatims oat Home Dept*
❑1 DO NOT wish in receive my anotaiug eomils fmm The Htmr Depw
Peoleat lotartratb�: Undersigned CCbmim er).the naeen sal the properly Ineawd a the above insudloting addre,%agrees to buy.
and THD Ai-Haiti ass>¢a tnc.t"clue Hone Depm-1 apama In fami.k deliver and a.rm8e for the inadtatnm 1"InstdlaUat")of
all m oc ids described on die below aon o
the mieve nod Spec Sheens). all of which are incorpmucd into this Contact by this
reference along with my applicable Slone Sapptaaml and Payment Summary attached herein and my Choose Orders N1,11 ilvety.
"Contraer):
job#: „e, lindamH: S Slhra x)a: Pro Amnand
Ifs Siding N'htdhwhx aWlatiao ! (�—([]/
g253,513 OGWwDI(-' OF"myDmas a
Ralinp IS.,bow U wSadhars Imulahm S n f
O(lune n/Covvs OEran Doou ❑ a/)
Rooting Sidng.U N91100ss UInshmlatim S
OcAmvs/Caen OFmry Doorn❑
Rodthg Siding U winduas U tnWlnaM
$
OGmutn/Comes OFihay'Dom. O 'f z0'Jg1(O —Y.
ASdaam134 Dqm&dC000naAmomtdmeupmewNW)MdIDbamRtt Total Contract Amount
Mmaera omm+mamdtPa!settmmaaetltddthr Caa+aaAmn1
Customer aim that.immediately upon completing Of the week far each Pntduct.Cuslmrev will tyetme a Completion Ccnihcme
(me fat each Product a.Wined by an individual Spar Shoe)and Pay my balance dine. As applicable.each Cu,romer under this
Contract ago to be jointly and severally obligated and liahle hereunder.
iM Home Depot msenes the right W issue a Change Order ur laminae dos Contrast or any mdisidngl Producttsl included herein,in
as,dicretim.if The time Depot um its made rimd service pwrmder detemlincs that it cannot paftrm its obhgmium dire to a structural
pimblem aith the home.msimomenlal tarred,such as nahhl,adaVua or lead paint..other safety caw^eral pricing crux'or because
atrk mquVedd to complete The job was not included in the Com id,
Payment SumumrT:. The payment Summary a . included as pat of this Cmlraer. sets forth the teal
Contract ammmt and paymmis niquired for the deposits and final payments by PtWu t las applicable).
NOTICE TO CUSTOMER
Yo are enfitled to aeemmpletdy trinuUo copy of the Contract at lbe dim,you sign. Do rot sign a Completing Certificate(note:
then Is me Completing CoWkate far eats listed Product as denned by individual Spm Sheets)before work on that Product
It emplete
In the egad of termination of this Contract,Customer age"to pay The Hone Depot the costs of materials,labor%eVeam
aced Services prmri4d by Tte Hume Depot or Authorized Service Provider through the date of terminat oo.plan am'other
a OOMa art loch Ia this Agreement or albived under applicable law. THE HOME DEPOT MAY WITHHOLD A11,16EWTS
OWED TO THE HOME DEPOT FROM THE: DF.IIOSIT PAYMENT OR OTHER PAYMENTS MADE. WITHOUT
LIMITING THE HOME DI?KYrS OTHER REMEDIOS FOR RECOVERY OF SUCH AMOUNT'&
AM?g anal&AMhg4Utlan: Customer apvcs and understands that this Agmettain is the entire agreement betweca Cusu mer
iuo ram ruome mxpa win resod to the FVmkic'ts and Installation serviccs and supersedes all prior disansims and agm ements.enter
oral or wrino.miming W said Products and Inaonutim.This.Agmemrem cannot be assigned mr amended ecsep by a writing signed
by Customer and The Name Depot.Cu.tontor m nuwtedgcx and agfen that Customer has read.understands.solunwily roe\`pU the
teems of and has mocived a copy of this Agreement.
A _ Submi by:
51'?ZZ x .�aS TIly ,
Cu') amer's Si um Date Sales Consuli:ml's Signature Die
OL Telephone Net M 3417 3.5G7 -
Custrhmrr's Signature Date Sales Consultant Lieeme No. A.,/A
CANCELLATION: CUSTOMER MAY CANCEL THIS is,a'ybnbleh
AGREMENT WITHOUT PENALTY OR OBLIGATION
BY DEUVERM WRITTEN NOTICE TO THE HOME -
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
hTATF. SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE E ONE 1S
SPECIFICALLY PRESCRIBED BY LAW IN .
CTIX17OMERN STATE
144"WE;Aanl'I MAI.TY.RMS A1DVOmgTI(M ARE STAYPD ON THE agyTiW RDL AND ASH eAa r cw 7Rt11'DYraAIT -
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