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4 MOULTON AVE - BUILDING INSPECTION I'Ite Co III 11101me IIII of b)assachuscIts C'I'I'1' OF • /� � y; ,;�� Board ul Building Rcgulatiuns ;utJ Standards 1V s Massachusetts State Building Cute. 780 CNIR SALE•M flevis"'I Building Permit \ppiication 'ro ConsirucL Repair. Renovate Or Demolish a One-or rwo-kamd. Dive/I nti Phis Section For Olfciul U•e Only Building Permit Number Date A lied: Building 011icial(Print Nmne) Signature Dute SECTION I:SITE INFORNIATIIPN I.I Property Add es ��L /� 1.2 Assessors M2 reel Number I.In Is this an aceerr—I d ssireet° es�nno Map Numhcr I'urcel Nwnbcr 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed tlse Lot Ana(sq 11) Frontage(11) 1.5 Building Setbacks(II) Front Yard Side Yards Roar Yurd Required Provided Required Pruvidcd Required Provided 1.6 Water Supply:(M.G.1.c. 40.154) 1.7 Flood Zone Information- 1.3 Stwngt Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal s)stem ❑ Check if u30 SECTION2: PROPERTY OWNERSHIP' 2.1 Ownar'o e ord: Mune(Print) City.Sluts LIP Nu.and.tree relephune Emuil Address SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ I Addition ❑ Denwlition ❑ Accessory Bldg. ❑ Number of Units_ J Other ❑ .Specily: Brief Description of Proposed Work*: r r * SECTION a: ESTIMATED CONSTRVCTION C STS Estintated Costs: Item Olnciul Use Only I Lahur:md..\Luerialsl I Building S I. Building Permit Fee: S Indicate hove fee is determined: '. Ifkclrieal ❑Standard Cir Town Application Fee S ❑Total Project C'oit,(hem 6)x multiplier 1. I'Iumhing S '. Other Fees: S � /' 1. \kchanical tll\ \(') i List:__ " � S -- C.V. . . �upncssionl fetal \II Fres: S_.,___—___ Che" \o' ('heck :\nu l'nurt: .uh \m.nuu: I. fatal Project Co%v i ❑ P.tid in Full ❑Outstanding Haf.tnce Due: J SECTIONS: ( ONSFRUCTIONSERVI( ES 5.1 b- -C I No. mid Sircet t I I Itirv,itrioci t fluild ..Its lip to 15 555'11 it I J 1&2 F.1111il) M%ellilig Stale, 11 q11 i I RC' lt,x,ting Cmering P Windmi aid Sidinit SF Solid Fuel litiming Appliances N I c I It L"I I I Pe lice Id ..Its I Vomit addrc.sli L Dgnxllitiun 11.2 Registered ![vai4mlitru ,enlent Iclor Npirilioll Me IC I Name r rc e Wo-. WWI — - - Email address hone City/Town, 5 %i I SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6)) Workers Compensation Insurance affldavit must be conipjoed�and submitted with this application. Failure to provide this atYIdavit will result in the denial of the Issuance building permit. Signed Affidavit Attached? Yes .........Al' No...........C! SECTION 7a. OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. 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. Print Umier's Nwile(ElcorunicSignuture) I DP SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest un3"t pains and penalties of perjury that all of the information contained in this application is true and occur e to cat iy knowledge and understanding. .." `E/A NOTES: I. An Owner who obtains a building permit to do his her own %sork,or an owner who hires an unregistered contractor I not registered in the Howe Improvement Contractor I HIC) Program). will LU) have access to the arbitration program or guar.inly lbod under M.G.L. v. 142.A. Other important information on the HIC Program can be found at \%\%,% IM111 �,O% "t I Information an the Construction Supervisor License can be found at „ it,1,; 2, \%lien substantial l%ork is planned, provide the hillurmation below: rotai (lour area I sq. IV) I including garage. finished basement attics. decks or porch) Gross IN ing .irea 114. it.I Ilabiiabli:roum count N till I her ol,llrelllncci \umherol hedrooms I Ile it lic.1tilig S)swill porilicli I I,e i,l �ooliilg ),Mll 1:110o,cd Ppeli T foial VrojvYt Stlwiry Fooi-ice- IIIa1 be gIhU11111CJ I'tir llrojcct Co,[- BOB DANGELO 9785157765 p.1 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold, Furnished and Installed by: Branch Name: Boston Date: J�Ad`-r_- THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street, Unit 2,Worcester, MA 01607 Toll Free(800)657-5182: Fax (508)756-8923 Branch Number:31 FLdeml ID#75 2698460;ME Lic#C 02439;RI Cont.Lic# 16427 /) CT Lic#HIC.0565522;(MA Home Improvement Contractor Rea.# 126893 Installation Address: _J / 'Oct/�D� hrU� t�3�t'M NH 6 /`j 76 City State Zip Parchaser(s): Work Phone. Home Phone: Cell Phone: .v Co h /,.v [ l K74 ?79 scram [ Home Address: (If different From Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): PJ I DO NOT wish to receive any marketing emails from The Home Depot Pmiect Information: Undersigned ("Customer").the owners of the property located at the above installation address,agrees to buy, anti THD At-Home Services, Inc. ("The Home Depot") agrees to furnish,deliver and arrange for the installation ("installation")of 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#: ("..t s A Products: Spec Sheet(s) Pro'ed Amount ❑Roofing ❑Siding ®Windows ❑ Insulation `♦ GO"3 O CC) ❑Gutters/Covets ❑Entry Doors ElS! 3 9 7 3 tC []Roofing ❑Siding ❑Windows ❑ Insulation ❑Gutters/Covers ❑Entry Doors ❑ $ ❑Roofing ❑Siding ❑Windows ❑ Insulation ❑Gutter%/Coven ❑Entry Doors❑ ❑Roofing ❑Siding ❑Windows ❑ Insulation ❑Gullers/Ckwers ❑Entry Doom ❑ Minimum 25%Deposit of Contract Atrmnt due upon execution of this contract Maine Puntmserc may not deposit more than oocahird of the Contact Amount Total Contract Amount c1� 6 — 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 Ham Depot or its authorized service provider determines that it cannot perform its obligations due Lou 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 the job was not included in the Contract. Payment Summary: The Payment Summary nq`j , 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 TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time von sign. Do not sign a 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, labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT-S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acccmmnce and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written, relating to said Products and Installation_This Agreement cannot be assigned or amended except by a writing signed by Customer and The Hoar: Depot. Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the terms of and has received a y of this Ao-eement Acce t b Submit by: Cti tomer's Si- ture date Sales Consultant's Signature Date :1b � WINDOW SPECIE{CATION SHEET - Spec.Sheet B: ,� 73 sneer of Customer:S�sntCl GyJt //,y lob tl:y�[_G'v,Jv�s=n Consultant: (s�' Date: h,CIA/Le ✓[ �U NewWlndm auming Wmdnw Labor Hinge Locations Measurements Gilds Product Options Options From autslde, V Lehto Rl ht .CL Bays,Bows, Location Color Rough Opening Aof bars tlot bars Csmnts,s w, use L Ror5 Glass Misc Items NHardware Cade Fordoorsuse 33 e 5owns "Sr=stationary or { style Wra Mull ')('=operatlnp ETk. ,., Coda yM St y1r,Code Series Code a W 5 F 333p ° i T 1 �H N BI-E (c+oo W1+ 1014 $G ;2 6n I/ a' sc a tinIn � 1Y 3� ay 6�4 4 q v a 1 84 hJ i31� 6+oa 3G �y 60 1 SH N 64 6100 3(, 95 rot a 1 .B11 N d)+ . (.+ov' 36 34( 60 -- -- - { n) Q H 6+ c6 36 V 60 _ a I a I O u J LLJ SpECIALCON51DE0.ATON5: Bayor Bewwlndow: m SCamoard MtlMel'Mnylenlyelt[h or Oat? -, Bay Prolnhon Male In'.,as Bay FkaaerTyq(OH,W.IC[met) Tapof wilMaww w(fit(Jech,s) _ Iftled tesalht[olerof wlntmandal rhavercvlewedantla newhhallthan miamabwa ard1h! Comau[r Aaol ryes or No) ' ,pedal Terma antl edRWaF Gckpf N! IIaw lCmromeO mpy Garden Wlndewa tumwrd MarerNl(Wnyl onlyWhirc plonhe,Blrchor0ald � [ �� WallThkknas gPdw C emm naturea) ,..._. _ Add'glamlBhelf(Yaam Na) I.RrnnueuMttuamM.vaaq'nMImaIP 19nerotr. ...............o wnae.Tsn Hmeaoepa vBllaw.gammw nro-lra e nastrsaan ,vnt s ' t.S,E:,.• 1 +•-'- '' . .e• canal .: ' e oRMANOCRAT1NOS ENERGY PEFIF VALUACWelotsgsNciMtECROEHScIa Heat Gain Coefficient . valor Cataden;e:4}a*ct a ergia War . FaElar•U ' .� i`? . ' '.' roshvl aacutcaRO�, - ADDITIONAL ®Aaf n?10E IU iNGS V�LUAVisi6leTransmittance _ Tonsmldan delucVlAll Ci _ 4q Re s DnUeNFRCpmcrdurstudetera +:q'whcle praduct peRennance.wduR - I ManulatWrer sUPulaxidsatNeteraVngl wntardsta aGP• rronmen r any specse use.Wcsult n:'uhctire;s fteralse t:r aMet Pw�nDeRarmanee na9n9s va detennlrted tar cased Belot enulmnmental canAVans tnxl s sdeCGcf'�dud siu.NfHC doesno2 wcemmend arc(p and daesnotwanantd+esulta0pay al any pioducV01 Intarma�ian.wew.ntsc.crgA—�— ,,. Erie hadcante esUP.--ull e —valorescumPten ccntot praced!mlentrs aPac,ti,s de tal del NfFCPx�adttesmtnar el rendmienloloucto ueta no9>'sntlnque elpmducb Bra edicuada Paaun usoespecdlco.Wnsurk eon el pmduda.lns Mares asadosparNnlCaondalemilnados por un<on(ur.W 6io de wodicunes smtiwWesyurilamana de Dmdueto" ` especako.NfaC narecamiendsnln9un prod Y twetodeI rats'csnV Pan et use apmGleaa Ee esta Pr�Eudo wwrancc.crg L 4w„,qu Ali L Loa 'Eor: LV tiiia G1 A.l .� RP ' y.. [bS'Lki1t7)E NOttbotnr 4a fh .. �J' 4n}t 31. 5.�tletl (;9n—t Rt. '-n• <e„at", N T.A asni�•r1 rnl,ifLr>t parr Inl^) R,hs 19 ', 'Kuteac:ancea lv'�uc Canecaiv . ,e r ,aCrN i.C2S • •- L'9�: pain I:Qi u,la.: 1%5,. [eu.,al .� TaataS 8i.a: ritd" :c EU a� • • yJD: Iso�wzao pp jtJi::eiu 9.13 tseDl rT' ,� , r Tasas+ra Pcohado: 123.9 L'm x 2U].2 om .. �- CITY OF S,tL&Ni, AkSS'kCfiUSETTS JULLONG CEPAim%wiT I 'O 'V.UHNGTON STAEBT, Jw FZOOIt r)!L k973) 143.9S9S U%c3pm Y OUXOLL F•�x(91� 11471N6 .MAYOR Mosw ST.Pil11i 01RUTOL OP K atic PROPIttTY/at:MDNC cmcrosstOs Eft Construction Debris Disposal At'ltdavit (required for all demolition and renovation work) fn accordance with the sixth edition otthe State Building Code, 790 C,IiR section I I I.1 Debris, and the provisions of MGL o 40, S 14; Building Permit At is issued with the condition that the debris resulting fro 1 11, S 110A. ns work shall be 1 11 disposed of in'a pro m Potty licensed waste disposal facility as do8ncd by ,b1GL e The debris will be transported by: (name urhoular) The debris will be disposed of in S klq �yI— I,ddra„ ar n„I„y) 4(;;;ti'11190wint ,,a q A5 .. ..._'..�� ,', ✓lze -Piomnxoycurea/,!� o�./�amaclu�aelYa ��;«a g Office of Consumer Affairs&Business Regulati on. OME IMPROVF�,MENT CONTRACTOR C II d +� i Registration- - TypE i - Explratton-W,372032 � Supplement r The Home Depot�Af_kiome Seeva6€s - r � F RICHARD FALLCSN�;2��� ����� � c i - . 2690 CUMBERLAND,AM AY.S 3 GA 30339° Undersecretary a � bp DATE(MMIDD/YYYY) A CERTIFICATE OF LIABILITY INSURANCE 02/27/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT 1-866-966-4664 PRODUCER NAME: — Marsh USA Inc. PHONE FAX C N AC No: —E-MA q IL homedepot.certreuest®marsh.com ADDRESS: --- Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURERS AFFORDING COVERAGE NAIC# Atlanta, GA 30326 Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURER B: Zurich American Ins CO 16535 The Home Depot, Inc. INSURERC: New Hampshire Ins Cc 23841 Home Depot U.S.A., Inc. 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co 23817 Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER F: Illinois Union Ins CO 127960 COVERAGES CERTIFICATE NUMBER: 25776028 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POLICY EXP LIMITS LTq TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDDn'YYY A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACHOCCURRENCE $ 9,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea ccu ante $ 1,000,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ EXCLUDED X LIMITS OF POLICY XS PERSONAL S ADV INJURY $ 9.000,000 X OF SIR: $lM PER OCC GENERAL AGGREGATE $ 9,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 9,000,000 X POUCV PRO- LOC $ H AUTOMOBILE LIABILITY BAP 2938863-09 Ee aDINEDISINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Peraccidenl) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS gUTOS _. Per accident X SELF INSUR D PAY DMG S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ _ DED I I RETENTION$ $ WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 X WCSTATU- g- C AND EMPLOYERS'LIABILITY D ANY PROPRIETORIPARTNEMEXECUTIVE YIN N/A WC0197 3 6 917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? El E (Mandatory In NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 1,000,000 Ilyes,describe under E.L.DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS below E Workers Compensation WC1192494 (QSI) 03/Ol/1 03/01/13 SIR (AOS)/SIR (GA) 1M/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity ITNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C ^ ATLANTA, GA 30339 l/� USA ©1985,2010 ACORD CORPORATION: All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD` Jthornton hd j '7 1 1 77 I A '/V rk C 0 1,3 -S-j I-z i-c e d a i t B'ij I u'Erz.'�'o" iI ._'11'clL 12ab t rs C n 13 t 111 fo r 1 rt 2 0 u PriTA Add,-ess- FLone ri Are yollran employer" Check the, appropate bc"T: Type of prujzci L a a"cillployer With AD— 4. Ll I im a gfm ,ral contractor and 1 6. New coi employees (fulf and/or paa-iinuc).* 1 , have hired the sub-contractors ❑ 2.Ej I am 9 Sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling ship and have no employees These sub-contractors have S. F1 Demolition working for me in any'ODaCily. workers' COTTIP. illSUMFICC. 9. [j Buildiijg additlool. [NO workers' comp. insurance 5. El We are a corporation and its . required.] officers have exercised their 10 0 Electrical rep8hs or additions 3.0 1 am a homeowner doing al I I work right ofexemption per MGL 11.0 Plumbing repairs or additions myself [No worker,' comp. c. 152, §1(4),and we have no 12.E] Ro pairs insurance required.] 1 employees. [No workers' comp. insurance required.] 13.VOthel LA) l 'Any applicant thot checks box fit must also 611 oul the section tclow showing their workers'compensation policy information:, flonxowncrs who submit this affidavit bidicating they are doing oil work end then hire outside contractors mac!submit .ncw.fridavit indicating such (Contractors that cbeck this box must attached an additional shed showing the name of the sub-contractors and!heir workers'comp.policy information. I am all employer that is providing workers'.compensation insurance for trey employees. Below is the policy and job site information. Insurance Company Name: Policy ft or Self-hrs. Lie. fi: Expiration Date Job Site Address: 3 City/Stale/Zip: OA At(a.ch a copy of the workers, coinfiells,16.Oil policy declaration page (showing the policy number and expirathon date). Failure to secure coverage as required under Section 25A of MGL c. 152 call lead to the imposition,of criminal penalties Ora fine Of) 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 a rst the violator. Be advised that a copy of this statellicot may be forwarded to the Office of Investigations of th IA Fo insurance owerage verification. -1do hereby cep 7f)'Illld the ill idpei ties ofile,pjury that the information provided above is rue and correct Signature 4S> Date: Phone fl: 0j)icial,use only. Do not write in this area, to be completed by cio,or tolvil official. City or Town: Perinit/Liccuse ft Issuing Authority (circle one): 1. Board of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5..Pluiubing Inspector 6.Other Contact.Persouz Phone