207 LORING AVE - BUILDING INSPECTION (4) The Commonwealth 14EVM&Musetts
Board of BuildinN IThMA6SkR9"`ds CITY OF
Massachusetts State BuildingCode, 780 CMR SALEM
Revised r 2 1
t Ma 01
\' Building Permit Application To (NA&M,a2paiARLUte Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
( Building Official(Print Name) Signature Date
t(1 SECTION 1: SITE INFORMATION
l`J 1.1 Property Add a s: 1.2 Assessors Map&Parcel Numbers
29 1n�&
1.1 a Is this an accepted street? es 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
Name2.1 Ownert o Ju rd
City,State,ZIP
No.an Street •!�t4 _ " Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) lerAlteration(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
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
M At tx0 I N 5A5C I r2 z
SECTION 5: CONSTRUCTION SERVICES
5.1 Construe ' Supe sor License CSL) G�tp
VA License er Expi a ' n Date
Name of CSL Ider Type
(
� ��I List CSL T e see below)
)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,S e, IP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
t I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
dqfC HIC It6gistrafi—cuilfrumber ion ate
WIT Comp N eLIUC R gistrant Name
No. a �t/ i Email address
Ci ty own, State, Tele 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 f 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
(I,as Owner of the subject property,hereby authorize OAA4�
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
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
contained ' this ap ication is true and accurate to the best of my knowledge and understanding.
0- 4 ll � 0�
Print Owrer's or Authonzed Agent's Name(Electronic Signature) ate
NOTES:
1. 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
16 .mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
CITY OF SM.F.M, .NAxSSACHUSETrS
BUILDING DEPARI-M&NT
• ' 130 WASHINGTON STREET, 3� FLOOR
�"` TEL. (978) 745-9595
FAX(978) 740-9846
KI.N(BERLEY DRISCOLL
;MAYOR T HoNtAs ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
(name of hauler)
The debris will be disposed of in
(name of fa i ity)
P3 4 C.
(address of facility)
signatures of permit applicant
tc
dcbdulLdm
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
�- Sold.Furnished and Installed by;
y Branch Name:Boston North R South Datj;-5/ 5� THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
Branch Number:31 and 33 9U8 Boston Turnpike.Unit 1,Shrewsbury,MA 01545
Toll free 877-90q-3768
Federal ID#7 5-2 69114 60;ME Lic#C 02439:RI Com.Licit 16427
Cr Uc#HIC.0565522;MA Home Improvement Contractor Reg.# 126X93
Installation Address: RAJ I COP'1/v(Y AA--re n� 7 w A &L'�-7 D
City Slate Zip
Purchasens): Work Phone: Home Phone: Cell Phone: `I
Home Address:
(If different limn installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing entails from The Home Depot
Project Information: Undersigned('•Customer••),the owners of the property located at the above installation address,agrees to buy.
and THD Ar-Home Services. Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation (••Installation••)of t
all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job#'0""'�1�e`r""'•" Prat Sec Shmt(s #: Pro'ect Amount
�(9 Roofing Sidi. indows Insulation $
❑Gutters/Coven ❑Entry Doors ❑
Roofing Siding Windows Insulation $
❑Gutters/Covers ❑Envy Doors ❑
Roofing Siding Windows Insulation $
❑Gutters/Covers ❑Entry Doors❑
Roofing Siding Windows Insulation
❑Gotten/Coven ❑Envy Doors ❑ $
Minimum 25%Deposit OfCauract Amount due upon execution of this contract. Total ContractAmount $ _y.3
Maine Purchasers may not deposit more than one-third moths Contract Arrtounl C/ -
Customer agrees that, immediately upon completion of the work for each Product. Customer will execute a Completion Certificate
(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns, pricing errors or because
work required to complete thejob was not included in the Contract.
Payment Summary: The Payment Summary# /0 5-/ p , included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE
You am entitled to a completely lled-in copy of theContra tt the time CUSTOMER you sign. Do not signs Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product
is complete. .
In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,laMv,expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination, pl(s any other
amounts set forth in this Agreement or allowed tinder applicable law, THE HOME;DEPOT MAY %VITIIIJOLO AMOUN'1:5
OWED TO THE HOME DEPOT FROM THE, DEPOSIT PAYMENT OR OTHl-'R PAYMENTS MADE, Wl-fIlOU11'
LIMITING THE HOME,DEPOT'S OTHER REMF,DIFS FOR RECOVERY OF SUCH AI1)OUN'1'S.
Acceotanee and Authorization: Customer agrees and undersmnds th:u this Agreement iz the entire agreement between Customer
and The Home Depot with regard to the Products and Installation services and xupCrszdes oil prior discussions and agreements,either
oral or written,relating to said Produces and Installation.This•Agreentrm Cannot be: igned or •nd 'We Pt by
by Customer and The Home Depot. Custpmer acknowlulges and agrees Ih;u Cusw er as run un 1 stuw t6u .signs i
n a, voluntarily
terms o(and has received a copy o(this Agreement.
Accepted hy: St milled ry �
Custome�gnaludz Dale S les Consu an Signature D:dc
X
2uslomer s Signature Date Tele a No.
CANCELLATION• CUSTOMER MAY CANCEL THIS Sales Consultant License No.
\GREEA(1EN'1'WITHOUT PENALTY OR OBLIGATION
(as applicable)
)Y DELIVERING WRITTEN NOTICE TO THE HOME
)SPOT BY MIDNIGHT ON THE THIRD BUSINESS
)AY AFTER SIGNING THIS AGREEMENT. THE
PATE "'1'PI c,n- —
The Commonwealth ofMassachuseth
Deparlmenl oflndust'rial Accidents
Ogee ofinvestigadons
"0 Washirrgton Sheet
Boston,MA 02111
wttrw massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aoolicant Information Please Print Lembly
Name(Business/Organiration4nddividual): •✓ �_�1golho'� Ak W&M-e— i/Y/[Pis
Address: _Rog 605-6 Iilr�c�Pi�'e,
City/State/Zip: 41 teOA4u - v/SyS Phone #: SOS-
Are you an employer?Check the appropriate box. Type of project(required):
1.[] I am a employer with 4. 19 1 am a general contractor and I
employees(full and/or pact-time).' have hired the sub-contractors 6. New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached shut. t 7. Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. E]Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its
required.] officers have exercised their ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myself[No workers' comp. c:152,§1(4),and we have no 12.0repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13. Other
*Any applicant that checks box#]must also fill out the section below showing their workers'cmepensaums policy mfomustion.
t homeowners who submit this affidavit indicating t hey ate doing all work and they hire outside conraroms most submit a new affidavit indicating such.
k-oahaclors that check this box mart a echd an additional sheet shmwing the mane of the sob-ocubactom and their wortms'romp.policy inibro tdon.
I am an employer that Is providing workers'compensation insarancefor my employees. Below is the policy and fob site
informadom
Insurance Company Name: `ew r///r�l i e�
Policy#or Self-ins-Lic.#:_ W G O / / ( Expiration Date: 3 o?
Job Site Address: cW7 I- iLe City/Statelzip:
Attach a copy of the workers'compensation policyrafion 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 fore
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 cerdfy er penaldea ofperjary that the informadon provided above Is brie and correct
5Z
D
atc
Phone
Q chil use only. Do not write in thin area,to be completed by city or town o f7cid
City or Town: Permit/Lieense#
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#: