126 MARLBOROUGH RD - BUILDING INSPECTION 1
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The Commonwealth of Massachu etf�pr 2. "
, datt!§ L a6rfV t z, CITY OF
Board of Building Regulations and Stat<n
Massachusetts State Building Code, 780 CMR SALEM
lk dg O Q C, 'evised Mar 2011 .
Building Permit Application To Construct, Repair,Re t r emo is
a
One- or Two-Family Dwelling
( This Section For Official Use Only
Building Permit Number: Date pplied:
f
BuildingOfficial Print Name Signature D t
( ) � a
ION 1:SITE INFORMATION
1.1 erty Address: 1.2 Assessors Map&Parcel Numbers
1 Ix 1,6�
1.1a Is this an accepted street?ye 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'
2.1 O er'of,lRecorrdd: / C ,M q
'�v41A -1D41J�il-rrdn'f'C- JC1 '�171 f'r/t O147o
Name(Prin�—� City,State,ZIP'
y M(;-r) 61-771- IA
No.and Street J Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ip I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other 6 Specify:
Brief Description of Proposed Work':
L j
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item - Labor and Materials) Official Use Only
1.Building $ �ja 5 _ `1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ i ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ i List: 6 (fez
5. Mechanical (Fire $
Suppression) Total All Fees: $
�7 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ d.i �jrj— ❑Paid in Full ❑ Outstanding Balance Due:
» Y1/\t 1.i:E0 14/ (P I 1 5
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
AA 1(,,h(,L!� ( d V ll I Io License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
G0.1`Q.r'1 (n t�nI 7 (�'1 7Q U Unrestricted(Buildings u to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
C'ty/T IP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Cf�9- 5-30-717`( I Insulation
Telephone Email address D Demolition
5.2 Registered Ho a Improvement Contractor(HIC) LI pp v 1u 1
w� e Ck n4�M HIC Registration Number xp rratio Date
jqC ompany Name pr HIC R strant Name
II ((�v i U�'/�t71V2.Q t-i�hari�• rl�alehp S+yrP.
N .and S eet Email a dress
- ou h ,;Su</�. d1)/'�-01-77� 6i7-3-sy may,
City/Town,State,ZIP 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
I,as Owner of the subject property,hereby authorize �[ (�at I��D
to act on my behalf,in all matters/relative to work authorized by this building permit application.
Print er'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
conta' ys apj lic to s true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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
m2ny mass.eov/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'
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5 BMSTOL. ST
SA,LEM MA 01970
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Office of Consumer Affairs d Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
... F Registration: 148688
tr Type: Supplement Card
LOWE'S HOMES CENTERS LLC. t ` " ' Expiration: 10/18/2017
RICHARD CHALONE i - w -- - ----------------- ---A--
136 TURNPIKE RD. SUITE 100 - —
SOUTHBOROUGH, MA 01772
Update Address and return card.Mark reason for change.
sCA i o 2OM-OW11 Address ❑ Renewal -Ji Employment Lost Card
�I4' 1�.NJIIIJfiIiIJHYJIII l�n'/IIGUOC�g3t'7J
°x ice of Consumer Affairs&Business Regulation License or registration valid for individul use only
SME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
:-..- Office of Consumer Affairs and Business Regulation
0M17 ®Registration: 1gg5gg Type: 10 Park Plaza-Suite 5170
'' Expiration: 10/182017 Supplement Card Boston,MA 02116
LOWE'S HOMES CENTERS LLC.
RICHARD CHALONE
--
1000 LOWES BLVDVD
MOORESVILLE;NC 28117
Undersecretary Not valid with, t signature
60I0 10 RR Donwlley=13.All ngNs reserved.—0667
2TV It
Yell
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CONTRACT# 00 f 1
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L;*+ LOWE'S AUTHORIZED REPRESENTATIVE NUMBER $r CUSTOMER ^e�"
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' STORE NO. ,; STR TADDRESS �^ STREET ADDRESS
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CITY ". STATE ZIP > CITY STATE ZIP
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TELEPHONE " TELEPHONE
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DATE LOWS S HOME CENTERS,LLC'S MA HIC NO.: 14668a s �`H BrWK Lcc 't rt FEIN:58-0740356 ;� y�,rT• •.. CMD CHARGE
INSTALLATION STREET ADDRESS CITY STATE ZIP
Owe PA\%a s
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W(mot} c�" QIJI 4 Full S rrn a : l ve
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 measuredsquare 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 are performed.
6� Contract Total
Are permits required for this installation?: [)o Yes [ ] NO *applicable tax included �r S 00
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 induded 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 t c4ram ��ye upon reasonable availability of Contractor and/or any special order orpustor(1�r made Good(s)which Is anticipated to be
�/ /(o [fill in date]. Estimated completion date is 7 �/2���/ [fill in date].
Said estimated substantial completion date/' not of the essence.A statement of any contingencies that would materially change said estimated substantial
completion date is as.follows: it) d/r
(if applicable, insert a statement of such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full
QqMPLETE 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 afterthis 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
[ ]Depositmy/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.
NQ710E REGARDING ARBRRATION AGREEMENT FOR CLAIMS COYERED'BY M.G.L.c 142A--
not be refunded once the Installation Services are performed.
- .. . .. ... . a,
Contract Total
Are permits required for this installation?: [ d Yes [ ] No `applicable tax included �S
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 Lowers 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 c/Amm;P{ce upon reasonable availability of Contractor and/or any special order orpustoZr made Goods)-which is anticipated to be
Ii lfc [fill in date].Estimated completion date is 7 /216 [fill in date].
Said estimated substantial completion date/' not of the essence.A statement of any contingencies that would materially change said estimated substantial
completion date is asfollows: 1.r).+ne. Uh�,r�
(if applicable, insert a statement of such contingencies).
IF THE CONTRACT TOTAL IS$1,000.00 OR LESS Customer must pay in full.
MPLETE 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; I
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 A REEMENT FOR CLAIMJ COVERED-BY M G 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 SUBMIT SUCH IsP TE O A PRIVATE ARBITRATION SERVICE WHICH HAS BEEN APPROVED.BY THE SECRETARY OF THE EXECUT-
IVE OFFICE O E FFA S ND BUSINESS REGULATIONS AND THE OWN R SH L BE REQUIRED TO SUBMIT TO SUCH ARBITRATION
AS PR �� .G .1 2A.
By: Date: g�28 �
L e' �io Ce te�Ll� t /
By: I Date: 'S/2� /6
Owner " nature. I
THE SIGNATURES THE PARTIES ABOVE APPLY ONLY TO THE AGREEMENT OF THE PARTIES TO ALTERNATIVE DISPUTE RESOLUTION INITIATED
BY LOWE'S PURSUA T TO M.G.L.c.142A.THE OWNER MAY BE PERMITTED TO INITIATE ALTERNATIVE DISPUTE RESOLUTION EVEN WHERE THE
SECTION ABOVE IS NOT SEPARATELY SIGNED BY THE PARTIES.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES AND UNTIL YOU HAVE READ THE TERMS AND
CONDITIONS CONTAINED ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS CONTRACT.
BY SIGNING BELOW, YOU ARE ACKNOWLEDGING THAT YOU HAVE READ, UNDERSTAND AND AGREE TO THE
TERMS AND CONDITIONS SET FORTH ON THE REVERSE SIDE OF THIS PAGE AND THE FOLLOWING PAGES OF THIS
CONTRACT.YOU ARE ENTITLED TO A COPY OF THIS CONTRACT AT THE TIME OF SIGNATURE.
WITNESS OURy 7(S) NO SEAL(S) BELOW THIS .V� DAx OF
L eS� e C r� rs, LLC
Lowe Authorize re en ative Otter ' Co-owner or Witness
Customer acknowledges receipt of a true copy of this contract which as completely filled i to Customr'shereof.You,the buer,
cancel this transaction at.any time prior to midnight of the third business day after the date ofth srtra sacti ne See theution attached notice of cancellati na
form for an explanation of this right.
55102 REV. 12/13- FILE COPY- 020g6by,Love's.®Lowe's and fhe game design
are registered traderoaft of LF Corporeflon.
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Department oflndustrial Accidents
1 ( Office of rnvestigadon
1 Congress Street, Suite 00
Boston, MA 02114-20 7
kv I I � www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/ ontractors/Electricians/Plumbers
Ailiplicant lnformation Please Print Le 'bl
Name (Business/Organization/Individual): ff I t•) 1 tik
Address: JA I-Firisiv I FJl
City/State/Zip: (} Dig70 Phone 630-717
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
employees(full and/or_part-time).* have hired the sub-con crors 6. ❑ New construction
2. I am a sole proprietor or partner- listed on the attached she t. ?. ❑ Remodeling
ship and have no employees These sub-contractors hit ve g. ❑ Demolition
working for me in any capacity. employees and have wor ers'
[No workers' comp. insurance comp. insurance.t 9. Building addition
required.] 5. ❑ We are a corporation an its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner� oing all work officers have exercised t icir I I.❑ Plumbing repairs or additions
myself. [No workers' comp, right of exemption per TV GL 12 ❑ Roof repairs
insurance required.' [ c. 152, §1(4),and we have no
employees. [No workers 13.�Other_
e `
comp.insurance required.]
•.4ny applicant that checks boil #II mutt also fill out the section l below showing their workers' pensation policy information.
Homeowners who submit this aiffidavit indicating,they are doing all work and then hire outside contracture must submit a new affidavit indicating s ch.
ox Contractors that check this b must attached an additional sheet showing the name of the su ntractors and state whether or not those entities have
employees. I I'the sub-wnttaetors have employees,they must provide their workers'comp.policy number.
I am an employer that isroviding workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins. LicI# Expiration Date:
Job Site Address: 0w ��b�� City/State/Zip: _ry}j 6470
Attach a copy of the workers' compensation policy declaration page(she wing the policy number anb expiration date).
Failure to secure cover age'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 fine
of up to$250.00 a day agnst the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA 'or insurance coverage verification.
I do here6,certf u M e and Penalties o er'u that the in or n provided above is true and correct.
Si ature: q Date . ..
Phone#: 1 7 —5.3 7n
Official use only. Do Aot write in this area,to be completed by city or to vn off ciaL
City or Town: Permit(Licen se#
Issuing Authority(circle one):
1.Board of Health 2.�Huilding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other I
fnntart Pprsnn: I. I i Phn e..4v