7 MAPLE AVE - BUILDING INSPECTION (4) z-7gG5 25�,
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CNIR SALEM
Revised.L/ur_7
Ol 1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:'
zl 3
Building Offlicial(Print Name). Sik t e- Date
SECTION l:SITE INFORMATION
1.1 Property Ali t(ie@g:� r 1.2 Assessors Map& Parcel Numbers
I.1 a Is this an accepted Ilstlriet?yeas' no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required ProvidedRequired Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p p Y
SECTION 2: PROPERTY OWNERSHIP`.'
slime(Print) City,�Stale,Zl
No.and Street �lr7 {�� Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check.1 that apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
ItemEstimated Costs: Official Use Only
Labor and Materials)
I. Building S c I. Building Permit Fee:S In Icate how fee is determined:
❑Standard City/Town'Application Fee
2. Electrical ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) $ List:
5. Nlechanird (Fire S
Suppression) Cotal:\II Pces:3
Check No._Check Amount: Cash Amount:_
6. Tutai Project Cost: S ❑ Paid in Full 11 Oulsmnding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
cam,nni�� Yfe'p'2 License Number E.epira on ate
Name o t— C r r f n ---"iii
'-L.11� yv'(n�Iy1l List CSL Type(see below)�r��
4 I
No.and SU., Type y)`;- Description .
U Unrestricted
(Buildings u cu. R.)
R Restricted 1&2 Family Dwelling
Gtyltown,State,ZIP M Misonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Tee lone Email address D Demolition
5.2 Registered Homl, Improveme t Contractor 11[C)
HIC Regis tnber E, uati Date
11CCCms n• II R is
No.and lr a Email address
Cit /Town, ate,ZIP 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, 152.§ 25C(6))
Workers Compensation Insurance affidavit must be comflIe ed and submitted with this application. Failure to provide
this aRfdavit will result in the denial of the Issuance he building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES-EQR BUILD NG.PERMIT'
1,as Owner of the subject property,hereby authorize
t9 act on my behalf, in all matters relative to work authorized by this building permit appltcat on.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR.AkTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under he pn' s and p hies of perjury that all of the information
coutaine n his:1pp ' n i true and accurate the es f m Howl dee and understanding.
Print Owner's ur Aulhoi zc Agun's Name(Electronic Siquuure) Date
NOTES:
I. An Owner who obtains a building permit to d6 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 NI.G.L.c. 142A.Other important information on the HIC Program can be found at
mww.nwss.¢ov:oca Information on the Construction Supervisor License can be found at wsvw.nmss.uov lM.
�. When substantial work is planned,provide the information below:
'total floor area(sq. RJ (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 ofcooling system Enclosed Open
3. "I'otal Project Square Footage"may be substinited for"Total Project Cost"
!° CITY OF SM-EM, NL-�SSACHUSETTS
Bi:i DL,,G DEPARTMEINT
120 WASHIINGTON STREET, 3w FLOOR.
"ids.. (978) 7.45-9595
F.kX(9 7 8) 7.0-99 46
KINfBFRi EY DRISCOLL
AkYOR THOMAS ST.PIE AE
DIRECTOR OF PUBLIC PROPERTY/BCILDL\G CO$XMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t ilicant Information Please Print Le ib1
Nit ITIC (13usiness Organizariuwlndivi(lual):
Address: _
City/State/Zip: �tre !<: �. �I ram' O
Are yi n employer?Check t e propriate box: 'rype of project(required):
1. I am a employer with 4. ❑ I am a general contractor and 1 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.t 7• El Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
(No workers'comp. insurance S. ❑ We are a corporation mid its
required.) - officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbing repairs or additions
myself. (No workers' sump, c. 152, §1(4),and we have no 12.0 Ro its
insurance required.]t employees. [No workers' 13 thee
comp. insurance required.)
-Any applicant that checks hose#1 most aisu Fill out the section below showing their worker'compensation policy ioliumation.
'I hnncuwm"who submit this off davit indicating thcy art doing oil work and then hire outside contractors most submit a new affdavil indicating such.
$Coa aura thus chivk this box must anached an additional shut showing the na ne of the subaonlnctore and their workers'comp.policy information.
I am an employer that is providing workers'c•orripeas i insurance fort my employers. Below is the policy and fob site
information.
I nsurance Company Name: _-._—
Policy A or Sclf-ins. Lic, b: 1l1! �t� / / ., Expiration Date:
Job Site Address: oe City/State/Zip:
Attach a copy of the workers'compensa on 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 ofcriminal penalties of a -
fine 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 S25o.00 a 'ainst tire violator. Ile advised that a copy of this statement may be forwarded to die Office of
Investigut ions oi' Ile DI for insurance coverage verification.
l do hereby ce i y w er tl pah and jollies of perfury that the infurinat un provided abAte td correct.
Sit, Ittre: A Date:
Phone d:
Officiul use wily. Do not write in this area,to be completed by city or town offlchtL _
City nr'l'uivn: .,___ Prrmit/Llccnxe# _.,_ .
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cily(fuwn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6:Other ..__..—
Contact Person: Phone#:
(
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A:e�w fi4�i.C4 ! 5, 7k` t' 5.15 FT•T� i!•.}
CSSL-099840
JAMES MOON
40 AI E R
=;,tr its ttiraFz 0312312014
-f
1137 Park East Drive ■ R.I.Reg#:12259 (Moon Assoclates Inc.)
Woonsocket,Rhode Island 02895 n�p�#rnawro Conn.HIC.0562725(Moon Associates Inc.)
(800)975-6666 1 1 / Mass.HI#119535(Moon Associates Inc.)
Purchaser(s)Name: QrL1 Slr cpI'
Installation Address: 7 MAp) ji 104, 6!97 D
Mailing Address: n
Home Phone fnL!). 3!., O�7 Cell Phone: E-mail:
Year Home Built:_9)9 ZI) _Customer Initial s� _ Taxes Paid in Town of:
I/We,the above purchaser(s)("Purchaser(s)")and the owner(s)of the property located at the above installation address,hereby jointly and severally agree
to contract with Moon Associates, Inc. ("Moonworks")to furnish, deliver,and Install of all materials as described in this agreement("Agreement'),the
attached Spec Sheet(s)and diagrams)which are Incorporated herein by reference and made a part hereof.A Completion Certificate will be executed for all
jobs at the end of the Instal Ilation.
Order Number: Order Number: Order Number:
Project Type: 1't ;t d"Lr Project Type: Project Type:
Agreement Amou nt $ 12-S-0 Agreement Amount $ Agreement Amount $
Less Deposit# $ L— L)I,) Less Deposit# $ Less Deposit# $
Balance Due On Completion $ �33-7 Balance Due On Completion $ Balance Due On Completion $
*Minimum 33%of Agreement Amount due upon execution. *Minimum 33%of Agreement Amount due upon execution. *Minimum 33%of Agreement Amount due upon execution.
Indicate Payment Method For Balance Indicate Payment Method For Balance Indicate Payment Method For Balance
Due at Time of Installation: Due at Time of Installation: Due at Time of Installation:
Est.Start Date: Est.Completion Date: Est.Start Date: Est.Completion Date: Est.Start Date: Est.Completion Date:
V-b taC --L1
DEPOSIT/PAYMENT 0 IONS (Subject to fund verification and/or credit approval)
1.Check,Cashier's Check or Money Order Ck# it 3.Financing
(Made payable to Moonworks) Acct# Approval Code
2.Credit Card'(circle) Visa MasterCard Discover Acct# Approval Code
'I/we agree to allow Moonworks to charge the referenced credit card for the deposit amount
ACtt# E%p Date_Security Code_ indicated.Balance to be charged to credit Ord upon completion of installation if noted above.
It is agreed by and between the parties that this Agreement constitutes the entire understanding between the parties, and there are no verbal
. understandings changing or modifying any of the terms of this Agreement.Purchaser(s)hereby acknowledges that Purchaser(s)1)has read the frontand
reverse of this Agreement and has received a completed, signed, and dated copy of this Agreement, including the two accompanying Notice a
Cancellation forms,on the date first written above and 2)was orally informed of his/her right to cancel this transaction. DO NOT SIGN THIS CONTRACT IF
THERE ARE ANY ANKSPACES.
Purchas Purchaser Moonworks
>n
Signature Signature Signature
4. (' W/i
P int Name Print Name Print Name
YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE
DATE OF THIS TRANSACTION.SEE THE NOTICE OF CANCELLATION FORM BELOW FOR AN EXPLANATION OF THIS RIGHT.
NOTICE OF CANCELLATION NOTICE OF CANCELLATION
Date of Transaction 10 1 Date of Transaction
You may cancel this transaction, without any penalty or obligation, You may cancel this transaction, without any penalty or obligation,
within three business days from the above date. If you cancel, any within three business days from the above date. If you cancel, any
property traded In,any payments made by you under the Contract or property traded in, any payments made by you under the Contract of
Sale,and any negotiable instrument executed by you will be returned Sale, and any negotiable instrument executed by you will be returned
within 10 days following receipt by the Seller of your cancellation within 10 days following receipt by the Seller of your cancellation
notice,and any security interest arising out of the transaction will be notice, and any security interest arising out of the transaction will be
canceled.If you cancel,you must make available to the Seller at your canceled. If you cancel,you must make available to the Seller at you
residence, in substantially as good condition as when received, any residence, in substantially as good condition as when received, an)
goods delivered to you under this Contract or Sale;or you may,if you goods delivered to you under this Contract or Sale;or you may, if yoL
Wish,comply with the instructions of the Seller regarding the return wish, comply with the instructions of the Seller regarding the return
shipment of the goods at the Sellers expense and risk If you do make shipment of the goods at the Sellers expense and risk If you do make
the qoods available to the Seller and the Seller does not Dick them uD the aoods available to the Seller and the Seller does not nick them ur
Office of Consumer AHIirs and Bu:,iiiess Reaulation
10 Park Plaza- Suite 5 174)
Boston. Nvkissachtisetts D'116
I 10111c Impimement Comr-actor ReListration
119535
yyop. ';vale cowmtmn
I.X911ti0o. 7'24120 15 Tr 21.24i3
MOON ASSOC INC
JAMES MOON
1137 PARK EAST DR,
WOONSOCKET. RI 02895
I p lau kdd,n,,and rcrvrn o.Id.Nl.iri, for
Lulpt......ml 1.1:4 C 3111
Ovi,,A t vn,�...... --bd ro,imimduf 11"".h
MUE iPAPRQVFrAENF CONTRACTOR hefurr the"I'vatz tvf,,nIlIl mwl"to:
RegistrIllion: i195i5 T,,c. Cllfire of Cnmuwer.tlflm;....I ffi,,ml ,5 N,0.vi
10 va,h lint-Sails 5FO
U0 NIII I L.MA 02110
R V.FAtn 1 1.1 R
ti,,t'Aid"ill"mi ;v.w,v
CITY OF S, LE.Nm 1�AsSACHUSETTS
-
i'. BUILDI\G DEPART%0NT
120 WASHINGTON STREET, 3w FYOOR
TtL. (978) 745-9595
KIIIBERL.EY DRISCOLL Rux(978) 740-9845
NL.kYOR THOSLAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BI:CLDI\G CO\LMISSIONER
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 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit t# 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 tMGL c
l 11, S 150A.
The debris will be transported by:
y �r)name ofhauler)
The debris will be disposed of in
(name of facility /
(address of facility)
Patutn fpermitapplicant
dat
Id+n,al'Jn.