HomeMy WebLinkAboutBuilding Permit #843 - 29 EDMANDS ROAD 6/28/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: 6FV-3
Date Issued: G / Q71/v
Date Received
IMPORTANT: Applicant must complete all items on this pate
LOCATION 3 [2-D
Print --D
Print
PROPERTY OWNER CZC)c,-J,)
Print /
MAP 210 PARCEL: ZONING DISTRICT: Historic District yes ` n
Machine 'Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One fa
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
eme
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: w 4.2 Phone:
Address:
CONTRACTOR Name: 0 ,nn DI, e— ' C U Phone:
Address:RS)
Supervisor's Construction License: / o 3 9 Exp. 'Date: zl—klz�
Home Improvement License: I/ ') r)
Date: 11116 //0
ARCHITECT/ENGINEER Phone:
i -
Address: Reg. No
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �, C �) U G o FEE: $ S -/—
Check No.:�D 7 Receipt No.: .11-123 0-700*'
NOTE: Persons con0ae%ing c do not have access to the guaranty fund
,---
ignature of Agent/Owner Signature of contractor
Location
No. FV 3 Date
AO*Th
TOWN OF NORTH ANDOVER
Of 4
Certificate of Occupancy
$
CMU
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # 00( 7
2 3 0 %41 8 Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit /0/
DPW Town Engineer: Signature:
t_ocateo s64 Us ood Street
FIRE DEPARTMENT - Temp Dumpster onside' " es no
Located .at 124 Main Street
Fire Department signature/date le
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be. obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
.Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Building Permit Revised 2008
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THOMAS DEFUSCQ I I r
DBA -Tom DeFusco - General Contracting
23 Dutton Rd. Pelham, NH 03076
H.I. Reg. #117756 - Constr. Lie. #071037
PROPOSAL SUBMITTED TO:
HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR:
Page No. I of I Pages
DESCRIPTION OF JOB
DATE OF S
a
7_1P ytfL.
DATE / If
MU v�TCA
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q, r
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WAA p S b:a r 4,7- c
(�)eMave --4 2_e® Gic . % S
�E•..µ�Tis�
N j� LC
Co l2�lZe � 313 � ?,,,Pr"
We hereby propose to furnish material and labor, complete in accordance with above specifications, for the N
p a G /�` C e
sum of_"e1e'Z add n 011k tJ�a�� h -- dollars (5 ®�� 7
f
with payment to be made as follows: ?Gp CY t 1.4.-2 C a�
G?d` 0o -
All material is guaranteed to be as specified. All work is to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from specifications Authorized
involving extra costs will be executed upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. owner to carry fire, tornado and other necessary Note: This proposal
insurance. Our workers are fully covered by Worker's Compensation Insurance. within_�ys.
Acceptance of Proposal - The above prices, specifications and condi-
tions are satisfactory and are hereby accepted. You are authorized to do
the work as specified. Payment will be made as outlined above.
Date of Acceptance C " O — h0 10
be withdrawn by us if not accepted
NL•usachusetts - Department of Public `afeo
Board of Building- Regulations an(l �tamlar(!s -
uonstruction Supervisor 'License
License: CS 71037
Restricted to: 00
THOMAS A DEFUSCO
23 DUTTON ROAD
PELHAM, NH 03076
Expiration: 6/18/2011
Tr;;: 17284
�. Jfie �rrn-�.v�.u�-,ate ��,��acfuuerfia .
Board of Building Regulations and Standards
1 HOME IMPROVEMENT CONTRACTOR
icy
Registration: 117756
Expiration: .11/15/2010 Tr# 277330
Type: DBA
TOM DEFUSCO GENERAL CONTRACTING
THOMAS DEFUSCO
23 DUTTON RD
PELHAM: NH 03076 Administrator
W
t
—� �j PAIE("WAAHTrtTt
AcoRD . CERTIFICATE OF LIABILITY INSUMNCE °BSRRFRI- I 08/07/09
TE m IssU® AS A MATTER OF INFORMATION
T. A. Sullivan Ins. Agcyf Inc -
344 S. Union St.
Lawrence, MA 01843
Phone:978-683-4700
JFB Vinyl Siding
Frank S James Berry
DHA/ Sona
S Son Contracting
gppinq�Ie; 30421
�
YNcoarD S No RMM UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
INSURERS AFFORDING COVERAGE MAIC Is
INSURER A, Gresham S Assns of R1 Inc.
INSURER B: Msss . Workers . Assi ed
IIISURER C:
INSURER D:
COVERAGES
THE
POLICIES
_ INSURED _
WHICH CER IRI ABOIVE FOR THE POLICY PERIOD ATM MAY BE OR NOTWITHSTANDING
of INSURANCE LISTED MOW-TOISSUED THE
�
Y
TERM OR CONDITION CONTRACT OR DOCUMENT wrtN RESPECT
TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
MAY
M
PERTAIN.
PERTAIN.
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED SIN IS s
THE I
POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS.
TYPE OF IISURAMCE NUMBS
L>MT8
�� EACH OCCT>RRENCE
$1000000
Raw LTR
GENERAL LIABILITY
X COMIMERCIALGENERALLIABRM 3DB5940
04/23/09 04/23/10 PREMISES (ED e�en�)
$
A
MED EXP (AM am Pw�)
$
CLAMS MADE ®OCCUR
PERSONAL & ADV INJURY
$ 1000000
R Owner/Cont Prot.
GENERALAGGREGATE
s2000000
PRODUCTS -COMPIOPASG
s2000000
GENL AGGREGATE LIMIT APPLIES PER
POLICY JEC7 LOC
AUTOMOBILE LIAINLRY
)SRI(A E LMTf
$
ANY AUTO
ALL OWNED AUTOS
ODDLY P)
$
SCHEDULED AUTOS
BODILY
Bert)
s
HIRED AUTOS
(Per eaident)
NON -OWNED AUTOS
PROPERTY DAMAGE
(Per
$
LIABILITY
AUTO ONLY - EA ACCIDENT
s
GARAGE
EA ACC
$ _
ANY AUTO
OTHER
ONI�Y: AGG
i
BICCESBIUNIBiiBJ.ALLABILITY
OCCUR FICLAMS MADE
EACH OCCURRENCE
s
AGGREGATE
$
s
s
DEDUCTIBLE
$
RETENTION $
WORIaM COMPENISATION AND
EMPL0YERS'LIABLITM
WC 446-95-91
07/22/09
07/22/10
is TORY LMrrs ER
ELEACHACCDExr
$100000
E.L. DISEASE -EA EMPLOYEE
$100000
B
ANY PROPRIETORIP�
OFFICERNMEMBER EXCLUDED?
E.L. DISEASE -POUCYLVMT
$ 500000
Iyes. describe undw
SPECIALPROVISIONS Oefow
OTHER
A
Commercial Applica
3DB5940
04/23/09
04/23/10
DESCRWMNOFOPERAMMILOCATD IV rMMLUMMADDEDBYEIWWALPRUVMM
S
vinyl siding installation, minor carpentry, residential
home painting and roofing
CERTIFICATE HOLDER
CANCELLATION
]
ANY OF TTI£ ABOVE D POuaES BE CANCELLEDBEFORE TME EIIPRIATIO
DATE7MMW.TMMSUWGVMMMVdLLENMVORTOMM
10 DAYS WRITTEN
Tom DeFUSCO
NONCE TD THE TERTIFlCATE HOLDER NAA TO THE LEFT, BUT FAILURE TO DO SO SMALL
General Contractor, LIC
Orr NOODUGATIDN OR UABILTTY OF ANY K= UPON TMINSUREK US AGENTS OR
22 Dutton Road
a
Pelham NH 03076
., e,nrE VT
.
The Commonwealth of Massachusetts
Department o f rndustrW Accidents
Office 011nvesd adons
600 EVashina on Street
BOStorn, .1124 62.111 '
www -mass -g ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors
!2451/Eleciricians/Piumbers
nt Information
Name (Business/Organiza6on/Indi,6dual):
Address:
J
City/State/Zip:_ t:�, C ?'C Phone #:
—X90?C3C3,d
Are you an employer? Check the appropriate bo
1. ❑ I am a employer with 4. ffl am a general contractor and I
2. ❑employees (full and/or part-time).* have hired the sub -contractors
I am a sole proprietor or partner_ listed on the attached sheet I
ship and have no employees These sub- contractors have
working for me in any capacity.
[No workers' comp: insurance
re
quired_j
3. [:].1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
workers' comp. insurance.
5. ❑ We, are a -corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § I (4), and we have no
employees. [No workers'
comp. insuzan
Type of project (required): .
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
.11.❑ Plumbing repairs or additions
12- oofrepairs
ce required ] I 13 ❑Other
_11='Miran± that che. box -M! mn t �o a Q•sC Ece Be:iivn avow W ov rt
Homeowners who submit this affidavit indicating they m_ doing all wor'ri anti cir a'ori ^s' cQmYoa
�Coutra== that the '- this box must atbaea-d an additional sheet showing th� hi- outside contxzctors gtst Bait a new af*ndavii indi zting such.
the same of the subs U---Cton and their woricerc
T-
` t G"spinyer MM rs provuting workers compensation
tn-forlJt�p� insurance for my employees. Below is the polis ----- job site
'
Insurance Company Name:
Policy # or Self -ins. Lic. #
Expiration Date:
Job Site Address: 9 %J� ry " G(,
City/State/Zip-I f
Attach a copy of the workers' compensation Policy declaration pate (shovt�:�g the poky :_number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL 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 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
r.r.. r_____r
��. ��y uaaer a pacts and penalties of perjury �tt the in or
thf nmuon. provided above is true and correct
0f,
D. ffzcial use only. Do not write in this area, to be completcd
City or Town:
by citt, or toN,rt officiaL
P—,—. #
Issuing Author- (circle one):
L Board of Health 2. Building Department .3. City/Town Clerk
6. Other
Contact Person:
4. EIectrical Inspector 5. Plumbinb Inspector
Phone #-
Information an- d-In.structions
Massachusetts General Laws chapter 152 requires all -employers to provide workers' compensation for their employees.
Pursuant to this statate, an employee is defined as "...every pcf--.Tson in the service of another under any contract of hire,
express or implied, oral or written."
An emplcyer'is defined as "an individual, partnership, associ�tion, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including t3ae legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association Dg other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartnL encs and who resides therein, or the occupant of the
dwelling house ofanother who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtcnant thereto shall not be=cause of such. employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or Iu cal licensing'agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co>@pliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall'
enter into any contact for the performance of public work uric acceptable evidence of compliance with the ir,s mre
requirements of this chapter have been presented to the contracting authority.,,
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone numbe(s) along with their certificate(i) of
insurance. Limited Liability Companies (LLC) or Limited Liability partnerships (LLP) with no employees other than the
membeis or partners,. am not required to carry workers' comp =sation incnrance. If an LLC or LLP does have.
employees, a policy is required. Be. advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. .Also be rvi a to sign and date the affidavit. The, affidavit should
bCi vt =ntd to the city Or tCiRTi that theetuyuCS.`uon for the p` it or License is being requested, not t.ht D --parent of
Industrial Accidents. Should you have any questions regardirrt - the taw or if you are required to obtain a workers'
compeasationpiouc`y, please call the Department at the.numberr listed below. Self-insured companies, should enter their
self-insurance license number on the appropriate line.
Cite or Town Ofiiews
Please be suit that the affidavit is complete and printed legibly, The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a -reference number. In addition; an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under `.`Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by time city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each .
year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture
(Le. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit
The Office ofluvestigations would like to thank you in advance for your cooperation and should you have any questions,
please. do not hesitate to give us a call
The Department's address, telephone.and..faxnumbez__-.
The Con=onwm1th- ofl assachttsatts.
Department of Industrial Accidents
Office .of hVest i ativous
(500 Washington Stmt
Boston, MA 02111
Tel. ## 617-727-4900 ea. -t 406 or 1-9 77 MASSAFF
Fax # 6.17-72.7-7749
Revised 5-26-05
a�'v�'u'-mass._aovf dia.
Location
Date
No. to
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
S Z
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL (�j $ s2,—
C� 4:�Ptt9sp,10: 06 52.00 PAID Building Inspector
9312
Div. Public Works
4Z'.* -?
PERMIT NO. +
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE I I
IMAP+40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK '.PAGE
ZONE
SUB DIV. LOT NO.
f-OCATION
SID HAtAl>S.
PURPOSE OF BUILDING ,.� J,,, �2
OWNER'S NAME C 5 t.::-
NO. OF STORIES SIZE
OWNER'S ADDRESS A
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME 5 e,-,- 1=
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES
REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATERZAL OF CHIMNEY
IS BUILDING ALTERATION >lt-7;�.)
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE YL_ --7
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS I - 3
PAGE 2 FILL OUT SECTIONS I - t2
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
+�ED /0--31-9
TURC-OF OWNER OR AUTHORIZED AGENT
F E E '��2-co
PERMIT GRANTED
Lb 19 9- S-,
3 PROPERTY INFORMATION
LAND COST
EST. BLDG.,COST r7
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
v BUILDING INOPWftft
IOWNERTEL.#
CONTR. TEL. #
CONTR. LIC. #
H.I.C.# 49%
BUILDING RECORD
OCCUPANCY
12
SINGLE FAMILY
S-OlkIES
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND'DISTANCE FROM
MULTI. FAMILY
IC
[O�FFESS
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA -
APARTMENTS
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
CONCRETE
-- a
2 13
CONCRETE BL K.
PINE
BRICK OR STONE
HARDW D
PIERS
PLASTER
-'�RY WALL
UNFIN.
3 BASEMENT
AREA FULL
FIN. B M T AREA
V, 1/1 1/1
FIN. ATTIC AREA
t!O 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAP80ARDS
DROP SIDING
B
1
3
60-NCRETE
WOOD SHINGLES
EARTH
ASPHALT SIDING
HARDW D
ASBESTOS SIDING_
COMIACN
VERT. SIDING
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
ATTIC STRS. & FLOOR
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY
WIRING
STONE ON FRAME
SUPERIOR 1-1 229R
ADEQUATE ONE
5 ROOF
10 PLUMBING
GABLE
I
HIP
BATH (3 FIX.)
GAMBREL
A
MANSARD
TOILET RM. (2 FIX.)
FLAT
SHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
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TOWN of NORTH ANDOVER
AFFIDAVIT
E me Ott CaMmctcr law
judomtt tc) Fammt Aplicatim
! ct I 1 1 . 4,416 a.• .■ ovia ■• crw• IMILZ64 • w• Imaza,:11 0111011 c• 1 r.w•opulio swa
n• • ons z I I Iwo 13-1 11 • v .• . ■ w . r .t•1 w • �• • z, ■ • _ •.. *124111s,
• .• .1 a-
• - • •' I1.: - • • t - 1 • 1 w r N ■ 1 1 . .I - .t ...
• :..Y S •: = 1 tl .- to • .•J `� Z Q• .• I.•: 10 w I t .� Y.1 �•.�Iw • • 1 t • 1
.t 1 :11 -
Type of Work: c 1L_ \� v4' H (�c) z; vvk Est. Cost
Address of Work a C= �', lel A-1\, � S 2 ` .A
Owner Name: � >�� � L . w �
Date of Permit Application: 10 S 1- 9 j
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under $1,000
Building not owner -occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
J
�-•1111
OWNERS PULLING THEIR OWN PERMIT OR DFALIM WITH UNREGISTERED CONTRACTORS__
FOR APPLICABIE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRA-
TION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Seed uxier penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR:
Notwithstanding the above tice, I hereby apply for a permit as the
owner of the above propeC��
)-0--3(-9_i �—z
Date /-- Owner Name