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162 MARLBOROUGH RD - BUILDING INSPECTION (3) ' r a The Commonwealth of Massachusetts t Board of Building Regulations and Standards CITY �(� 4 Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM 1V ll J Revised Junnrvv Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 10thY One-or Two-Family Dwelling / This Section For Qffkial Usie Only Building Permit Number: /f D to Signature: ut^ thlf2 /o Building Commissioner/Inspector of Buildings SECTION 1:SITE WokMATION 1.1 Prop P 5 Add (�II/�,n, fr. 1.2 essors Ma & Parcel Numbers 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 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: Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ — Check if es❑ p Po y SECTION 2: PROPERTY OWNERSHIP' 2.1 nert of REcord: --) 1 nn n D? ( z-1-AL t oo"If44Cl Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORKr(check al at apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Omclal Use Only Labor and Materials I. Building S 1. Building Permit Fee:S Indicate how lee is determined: ❑Standard Citylfown Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Total All Fees:S Suppression) Check No._Check Amount: Cash Amount:_ 6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: r ' SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) r�V �/`� �'��C17 License NlamhelrX7 I lixpi tiun ate N,_ 'C !! •I lot List C'SL'rype(see below) r J T� Dexri Lion 9 U l)nrestricted onto 35,000 Cu.Ft. L R Restricted I&2 Farm[ Dwellin 'gn.lure I � M Mason Onl a1ri 3 RC Residential Raotin Coverin rclephone WS Residential Window and Sidin SF Residential Solid Fuel Burning A liartee Installation D I Residential Demolition 5.2 Registered Hom 1 prove eat t tor(H I I IC t v ame or III ' egi 01 Regist uo' n Nu r Addres Expiration D e Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6)) Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issu a of the building permit. Signed Affidavit Attached? Yes .......... No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �' t2fZh�Cry� as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION I, &V 0 as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behal F to of Owne or Aut onzed Agent Date (Signed Ander the pains and penalties ofperjury) NOTES: I. 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 V(have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS,respectively. ?. When substantial work is planned,provide the information below: Total floors 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 healing system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" V L -S S_ 101227 Re St,icred to: WS 1tr RICHARD DIFRAKESCO 7 PINE BLUFF ',A.1(ENUE. MERRIMAC, MA01860" ` 111S12012- • ,ro: 101227 .. MAR-07-2010 10:35P4 FROM-HOF DEPOT +978466371T T-363 P.001/005 F-425 PLEASE READ THUS Sold,Furnished and Installed by: /7_ / d THD At-Home Services,Inc. Branch Name: Boston Date: d/b/a The Home Depot At-Home Services 345,E Greenwood Street,Unit 2,Worcester,MA 01607 Branch Number:31 Toll Free(800)657-5182; Fax(508)756-9823 Federal Ill t 75-2693460;NTE L:c kC 02,139;RI Cont.Lictt 16427 CT Uc N 56-555222;MA Home lmprovemcnt Contractor Reg.S 126891 installation Address: Giry IState Zip Purchaser(s): 'Work Phone: Hume Phone: Cell Phone: 0/L/l✓rJ/ T G t)C1 [ 7812, -0 [ 7g]7`f`tr GlTfg 0-09]`12;05-t Hume Address: P (If different from Tnsudiauon Address) city gg State ../ "Lei-per E-mail Address(to reeeiVe proleCt communications and Home Depot updates): tN�G 1 [/ "� 1N•!`�G' / — El I DO NOT wish to receive any markedpg entails from The Home Depot Protect information: Undersigned("Customer"),the owners of the property located at the above installation address•agrees to buy, an [-Home Services,btc.("The Home Depot")agrees 10 furnish,deliver and arrange for the installation("Installation")of all materials described on the below and on the relanmeeti Spec Shcct(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(cplicedccly, "Contract"): 1obk: I S 11- is A: Protect Amount �t p []P.on J fing Siding indows ❑Ireataocin '��jj a,.1.�y y'�Q / / ©� ❑Gtutcrs/Covers ❑Entry Dents ❑ p d ( i 't $) Rooting Sidmg Windows [ilnxnlation ; $ ❑Guaers(Cevvr' ❑Ecrry Doors ❑ []Roafine Siding ❑WindlIows Insula60a pGunes i Covers ❑Entry ndows —1 IRoufing Siding Q Windnw�❑lnsuladon 1 QCurtcrs/Crrvzrs ❑Entry Ik+ots ❑ OC.J ;4lirdmum 25%ficposireFCantraG m Amuudue upon exccudun or thir'mnaacc j / 3� dm Total Contract Amount $ t! Maims Purehtsers may not dufsisil rave than me-third of the CmuractAmomtt Customer agrees thus 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 Shect) and pay any balance,due. As applicable,each Customer under this Contract agrees To be jointly and severally obligated and liable hereunder. I� The Home Depot reserves the right to issue a Change Order or terminate this Coptract or any individual Product(s)included herein,at its discretion,if The Hama Depot or its authorized service provider determines that it cannot perform its obligaiuns'due to a structural problem with the home.envirc rimcnud hacuds such as mold,asbestos or lead paint, other safety concerns,pricing errors or because work required to complete the job vas not included in the --^^C1on/tract.`7 I . Pavment Summary: The Payment Summary r � rite indudcd as per, of the Contract, seta fo:vh the.total Contract amoom and payments required for the deposits and lined payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Conat ellleu Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)herora work on that Product is complete. in the event of terminatton of this Contract,Customer agrees to pay The Home Depot the frosts of comer3a s,labor,expenses and services provided by The Home Depot or Authorized Service Providek through dte dale of termination,plus any other amounts set forth in this Agreement or allowed under applicahle law. TIfE 11OA'IH DEPOT MAY WITHHOLD.AMOUNTS O4VF,D TO THE t101!?E DH.POT FRONT THE DEPOSIT PAYh1ENT1 OR OTHER PAYNTENTS MaAGE, \YA`1'!!Wr LLMCTLNG THE HOME DEPOT'S OTHER REMEDIES FOR RECOYF.'RY OF SUCH AMOUNTS. Acceptance and Authm•iratinn: Customer ag[zzs and understands that this Agrement i5 the entire agreement between Customer and The Home Depot Will)regard m ore Products and Installation ter,ices and superset S elf prior discussions and a rmamcnti,either oral or wrinen,relating M said Products and Installation.This Agreement cannot be assia,,ed or umcnded except by a writing signed by Custamar and The Home Depot,Customer acknowtedges and ages s that Customer ha-read,unde ads,voluntarily accepts[fie terms of and has received a copy of this Agreement Accepted hyr Submitted by Customer's Signantre, Date I Stiles Consultant s Sig�nat-utrree ^� Date ,j x I Telephone No. all ] J 14 Cusicon is Sigaature Date I Sales Consult Iant Liccnse No. CANCELLATION: CUSTOMER MAY CANCEL T}TIS I i� plicouk) .AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO TIM HOME i DEPOT BY ilSCDNIGHT ON THE. THIRD BUSINESS DAY AFTER SIGNING TINS AGREEMENT. THE STATE SUPPLEMENT ATTACHED OERETO CONTAINS A PORNI TO TJSE IF ONE, IS SPECIFICALLY PRESCRIRFD BY LAW TN CUSTONIER'S STATE. NOTICE:A9DITtOxaL'fERVS AND CONVFfIONS ARE STATED ON Teti REYERSE SIDE AND ARP PAR4'Of TUTS CONTIL4CT 6-10.09 GSi: VJhlte-Branch rise yGe w-Dtaeomcr The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 "Up rvrvw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �! Please Print LcZibL Name(Business/Oreanization/Individual): Address: P,�I(� VYAY2 City/State/Zip: r�' � '� D33� F Phone#: al)L)(0r Are y an employer.' Check the appropriate box: - Type of project(required): 1. I am a employer with t 4. ❑ I am a general contractor and I p . have hired the sub-contractors 6. ❑ New construction. employees(full and/or part-time). . 2.Q I am a sole proprietor or pager- listed on the attached sheet, 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or addi ors 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions right of exemption per MGL myself. [No workers' comp. 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no ,�, � r employees. [No workers' 13.L,kCJthe S comp. insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. rContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. t I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: �{ � Expiration Date: _ f, �j Job Site Address: 2 6 I-- bQ L J City/State/Zip:-----• ' �1 DJ17Q Attach a copy of the workers' compensation policy claration 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 fxie 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office or Investigations of the DIA for insurance coverage verification. I do hereby certify and r t e p 'is a penalties of perjury that the information provided above is true and correct. Signature Date: Phone# Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# 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#: A4I oo.i CERTIFICATE OF LIABILITY INSURANCE D2/1910 , `�� 0z/19/l0 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homeAllia ce center, 3560 Lenox ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE j NA_IC 9 INSURED _... The Home Depot, Inc. INSURERA.Steadfast Ina Co _26387_-_-_ Home Depot U.S.A., Inc. INSURER B.Zurich American Ins Cc 2455Pacea Ferry Road NW 15535 -------- ------------- INSURER Hampshire In. Co Building C-20 _____ 23841 Atlanta, GA 30339 INSURER D:NATIONAL UNION FIRE INS CO OF PITTS _19445 COVERAGES INSURERS Illinois Union Ins Co 27960 THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _— __ __ INSR DD'L P TOLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER CIA / ryyy T M I LIMITS A GENERAL LIABILITY GL04887719-00 03/01/10 03/01/11 EACH OCCURRENCE $ 4,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ---"— PREMISESIEacccVrrenceL $ 1,000,000 CLAIMS MADE ❑X OCCUR MED EXP(Any ono person 8 EXCLUDED _PERSONAL B ADV INJURY $ 4,000,000 GENERAL AGGREGATE $ 4,000,000 GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4 000,000 % POLICY PRO- LOC __ —__.-- __.._____.__ B AUTOMOBILE LIABILITY BAP 293SB63-07 03/01/10 03/01/11 COMBINED SINGLE LIMIT X ANY AUTO - Ea accident) $ 11000,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) _ HIRED AUTOS NON-OWNED AUTOS B .o,NJURV $ (per.accident) % SELF INSURED AUTO PHYSICAL DAMAGE PROPERTY DAMAGE $ (Per accident) GARAGELIABILITY AUTO ONLY-EA�,CCIOENT $ ANY AUTO " OTHER THAN EA ACC AUTO ONLY: AGG $ A EXCESS I UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE $ 5,000,000 X OCCUR 71 CLAIMS MADE AGGREGATE $ 5,000,000 DEDUCTIBLE g RETENTION $ $ C WORKERS COMPENSATION WCO20342355 (ADS) WCSTATU- OTH- AND EMPLOYERS'LIABILITY TNEW YIN 03/O1/30 03/O1/11 X QC STATTS_ _ -ER_D ANVPROPRIETORIPXCLUDEIEXECUTIVE WCO20342356 (CA) 03/01/10 03/01/11 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? � � _ - E (MandAmryln NH) WCO20342357 (FL) 03/01/10 03/01/11 E.L.DISEASE-EA EMPLOYEE $ 1,000,000_ If yes.describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 OTHER E TX Employers Excess TNSC46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 30M/2M D Workers Compensation WC0910566 (QSI) 0.3/01/10 03/01/11 C Workers Compensation WCO20342358(EY,MO,MY,WZ, ) 03/01/10 1 03/01/11 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN HOME DEPOT V.S.A., INC. NOTICE TO THE CERTIFICATE H OL DER NAMED TO THE L EFT,BUT FAIL URE TO 00 SO SHA LL 2455 PACES FERRY ROAD NW IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR BUILDING C-20 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA .111117 ACORD 25(2009I01)Jthorntoa_hd ©1988-2009 ACORD CORPORATION. All rights reserved, 14481889 The ACORD name and logo are registered marks of ACORD ti 1 ` 4 U-Facat SolarNel;Gain Coe.FriCie(It ' F�rU CRAc'rrc¢Cvr�m�Gada fsgrgia p(ar . rQ . 32 . . �DOmONAL PERFORr,LaNCE RAnNGS ra4&LuuQHsunemc 'Lsoeaso xa NsibleTranr.-.,Iiton(e TMa�slm da t,awm4 '' rVrp n AT 1�d ar mkm+raal v.DOra rd.L U�¢�?m.!FC��t rtmrnad+rr ama � .' cd dtm Mxar*ant Cp nuhfJltY d^i'R�.tr>R!�''a aa'°c nc mcar.�Tynla,la aR+a<v°dR. a :� . I nr$Nrim'uW dW :. p 1 '�mbk"3iw T.ti Lwo m Wem '.. pi3.ta lm�atrm F fFf'C m F. 4 .q,rp¢a,•FFC ra nmiJn'�marJam'!r°a`a'� da --U&c a; ." . .unLc q:a LLCLu Cam. LrUd an Llltca pa-� L(•) . c.?Len(.,I m+onai ]cu: uectL pot Gc CanCC1L,'Su< Can Cc al; 9� -_ IV[: ft•1n Ud/CL?u -301'!R _ IN0: 4.n f..aczo Go/YLacio 2.J1 >n/K-Rr7 DP : i 4 5 —4 5 i Ra p oc;ao: sL., ca Jca �' Hdcru� 2]JUIa _ , .�.,�.,—.-.-- ' Lip iAd kbd hipnarbh QiLiGI$UC'nFaFc.To anran hh rv+_mrryid�am- .. Grarda xto rfqu do 7Q°.9 a9blC r�mla6u DIEt6'f$ilC loiomrxurim mim ba ah.1611• r+-a naQrctoLQoc .._ ✓_�e Lov+uma�ucwa��s `�_.Maeda Board of Bmldiog Ragulattons and Standards' -� HOME IMPROVEMENT CONTRACTOR Registration 126893 Expiration 8012010 Type:_Supplement Card -� H The Home Depal:Al ome Service