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11 MOUNT VERNON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, T°edition OF SALEM Revised Junaury 1 Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008 One-or Two-Fumdr Dwelling This Section For Official Use Only Building Permit Number: �i�,. Date Applied: Signature: �'✓ 4 '"s 9/it1/�f Ruilding Commissioner/InspeciorW Buildings 13ate SECTION 1:SITE INFORMATION 1.1 Property Ado Iss:0± I0',n ot,�31� 1.2 Assessors Map& Parcel Numbers t-'c— I.I a Is this an accepted street. yeses no Map Number Parcel Number IJ Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use La Am(sq 11) Frontage(11) 1.5 Building Setbacks(R) Fmnt Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 OwnertofRec L Name(Print) Address for Service: Signaure Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alterations) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ goter ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: 011lclal Use Only Labor and Materials I. building S 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee ?. Electrical S ❑Total Project Cost'(Item 6)x multiplier x ). Plumbing S 2. Other Fees: S h 4. Mechanical (NVAC) S List: 5. Mechanical (Fire S Suppression) Total All fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S = 0 Paid in Full 11 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES e. 5.1 Llcens Cons ructlon ' ervlsor(CSL) rya, �� I.1c�cnssee Number 12.api lion )ale Name of 'SI fill er 1 ist C'SL type(see below) l Description :Wdres U Unrestricled u to 33,000 Cu.Ft. R Restricted Id2 Famil UwelRn Signa M M Only �� RC Residential RoofingCovering fclephme WS Residential Window and Sidi SF Residential Solid Fuel Bumin D Residential Demolition 5.2 Registered Ho pro a ant cloy HIC) 1�i Re istrwton N IIIC urf IC istran Registration A �f �� � Expiration ate Si 'telephone S ION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. y 2SC(6)) Workers Compensation Insurance affidavit must be pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issu of the building permit. Signed Affidavit Attached? Yes .......... No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIE 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. - siloudurc orowner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1 ,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 behalf. Print N e Si owner or Nut orized gent Date Si un r the sins and nalties of 'u 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 W have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I l0.R6 and 1 10.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basemenVattics,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" 09/01/2010 10:28 15087568623 THD AT HOME SERVICES PAGE 01/08 HOME IMPROVEMENT CONTRACT ' PLEASE READ THIS e Sold.Furnished and Installed by: Branch Names Boston Daft: .92/-71 1 o - THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street.Unit 2,Worcester,MA 01607 Branch Number:31 Toll Free(800)657-5182; Fax(508)7564823 Federal M#75-2698460:ME Lic#C 0243%RI Coma.Uc#16427 CT Llc#565522;MA,,Ho`roc lmptovanen[Contractor Reg.#126893 installation Address: 1 l f 'r`( j�� �`� r�I'�1 Q-rh /4` Q (9-7 6 City State Zip Purehiews): workPloouz Home Phone: CellPhwa: r. ] [ J [g7gJ3t7 Spy Herne Address: (If different from Installation Address) City State Zip i_ '7 E-mail Address(to restive project communications and Home Depot updatcv): �fi"2rJ 914 0 /••C.� -('O�"tvt44+L• GUIP, vC ❑I DO NOT wish to receive any marketing emails from The Homes Depot Prsi t_Infornmtion: Undersigned("Cnslomer"),the owners of the property located at the above installaHnn address,agrees to buy. and A' D AIt-Home Services,Inc.C 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 arc incorporated into this Contract bT this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Ordets(collectively, "Contract"): Job#- ^m'drm'mal 5 , #: Project Amount �7 Roofing Siding endows ❑Insulation 3 a ,�/ 5 0 t S-7� ❑Gtdkn/Covers ❑&ntry Doors ❑ �[4 y $ 6 ❑Roofing LISidin L3 Windows 0 Insulation $ ❑Gurtets/Covers ❑Entry Oosni ❑ Roofing ❑Siding ❑Windows ❑Insulation ❑Gutters/Covers ❑Entry Doors❑ $ Roofmg OSiding E3 Windows ❑Insulation $ ❑GutRn rs ❑/CoveEntry Door, ❑ M®wn25%Drpah of Contract Amend due opera nonunion of this control Total Contract Alnomut $ S6 �.� Mahn Pn�sessmad,am deposit am than une(h'ud ufthe CtmnadAauoot. Customer agrees that,immediately upon completion of the work'for each Ptoduct Customer wi11'exetme a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay arty balance due. As applicable, each Customer under this Contract agrees to he jointly and severally obligated and liable hereunder. The Horne Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(,)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing emus or because work required to complete the job was not included to Contract.'r Payment Summary: The Payment Summary# o� 7 , included as pan of this Contract sets forth me mist Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a co tdy RBed-in copy of the Contract at the time you sign. Do not slips a Completion Certificate(note: there is one Completion Oil to 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 agoras to pa 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. Acceptance and Authorization, Casmmer agrees and understands that this Agreement is the entire agreement between Customer and Th¢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 he a.0 ed nr amended except by a writing signal by CustumugsuLThe Home Depot. Customer acknowledges and agrees that C nsmmer h read,understands,voluntarily accepts the terms of eived are of this Agreement A=Pt Submitted by: / ', X CuslonneNZgn Date Salca Consultant's Sig^afore u Date X _ _ Telephone No. Customer',Signature Date Salsa Consultant License NO. CANCELLATION: CUSTOMER MAY CANCEL THIS tas appiicaMe) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE. THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE. IF ONE IS SPECIFICALLY PRESCRIBED, BY LAW IN CUSTOMER'S STATE. N(r17CR:ADDITIONAL TERMS AND CONDITIONS ARE,TATED ON THE REVERSE SmE AND ARE PART OF TMS CONTRACT rW.10 CSC Whho-Branch Fae vwnw-rhstn , The Commonwealth ofMassachusetts Department oflndustrial Accidents - Office oflnvestigat, ns 600 Washington Street Boston, ,•114 01111 _ www.ntassgov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl na v Name (Business.Oreaniutionrandividu al). -- Address: City/State/Zip:... Phone #: A ren employer?Check the appropriate box: Type of project (required): a employer with 4. ❑ 1 am a general contractor and 1loyees(full and/or part-time).• have hired the sub contractors6. New construction a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling and have no employees These sub-contractors have 8. ❑ Demolitioning for me in any capacity. workers' comp. insurance. 9. Building addition orkers' comp. insurance 5. ❑ We are a corporation and its red.] officers have exercised their10•❑ Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions lf. [No workers' comp. c. 152, §](4),and we have no12,� repairsance required:] * employees. [No workers' 13. Other comp. insurance required.] �q *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. i Homeo%%ncn who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractom that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. ,ram an employer that is providurg workers'compensation tnsurance for my employees. Below is the policy and job site information. Insurance Company Name: �� Policy # or Self-ins. Lic. #:_ Expiration Date: Job Site Address:_ , tAh0_2,ts [ (l. 1 City/State/Zip: Attach a copy of the workers' compensation 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 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. I do lrerebl cerN •u der!I s and penalties ofperluq•that the information provided above is true and correct. Si nature: I ' Date: Phone#• Official use only. Do not tivritet in+this=area,to be completed by c!n•or town official. City or Town- Permit/License# `sluing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other r150BT569923 T-606 P.DOI/001 F-903 JW 2 2G0N ON:IIAM FROM-THD PRODUCTION i iG • I 7 F'umlly MnNe. Lacmr CS 79470 i HcShlctcJ W: co ARTHURJ PARArINOWICZ vdlur.11,pv.w .curfew c4ilio.of Ihr 4 CARL ST j Mdxwebu.ell.Sl.0 1111i1Jinµ CIWr WORCESTER.MA 0100T iv rdu.c hrt m1w-lun of Ihi.liaun.. 1lufcrlu: WWW,Mdxv.Gav10PS ,� .i . _y„_• Eqm nuuv, b15/1f01 18130 1�•um.l x•n•.r I CITY OF SALEMT J PUBLIC PROPRERTY DEPAR"I'vIENT '.I �. 'r I:` U "ni�,.., •,>t 1l.tr � l.�ii II I I.9;4i ♦ I fix: Construction Debris Disposal Affidavit (reILluired liir all demolition and renovation work) In accordance %N ill, the sixth edition of the State Building Code, 780 CNIR section I 1 1.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit H is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c V 1. S 150A. The debris will be transported by: p�— (name of hauler) he debris will be disposed of in (natnr ul lao t y try. tnddrcs.of 1'aciluy) ,iana I c of pa1111t .1131) scant dat I , a CERTIFICATE OrF LIABILITY 1NSUF,r;i-'1C> r Tc IS ISM'.. 11 .. = C 1 C;,r AND R;GH.� burs*- USA. _ ___' I^rleaa^'o _ _3ao�. F.b'•a -' - 2"=- _ - .,_ C 3-3...: .. .. -. i Hose 0eoot, .. Ware Ja?et ❑.S A. .... 2su 2455 Ps^ces Ferry Road :,^0 rV5 .. -T-Tl3 1 ?-_ I I�_�Lt'E3? _ I Sc4l3ing C-20 _ - v-p90 I Atlanta, GA 30339 INRIRER_ 1Iiir-o4a Union Ins Co - COVERAGES FOR THE POLICY PERIOD THE POLICIES OF INS URAIZETERM OR ICONOIBT ONyOF ANY CONTRACT OR OT EIR DOCUM1ENT W TH RES ECT TO WH CH THIS CE ANY REQUIREMENT, RTIFICATE MAY BE IISSUEDIOR SUCH MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS Or __ — "-- POLICY EFFECTNE POLICY E%PIRATIUN( - LIMNS POLICIES.AGGREGATE LIMITS SHOWN MIAV HAVE BEEN REDUCED BY PAID --- - --_ - POLICY NUMBER A ]IY YY t r IM /Yv v i ItTSR OD'L n T O3/O1/10 03/01/11 EACH OCCURRENCE GENERAL LIABILITY GLO4887714-00 DAM �� $ 4,000,00 ji AG OTap0enm 51,000.000 __- X COMMERCIAL GENERAL IABILITY MEDEXP(AnY 2neJW!M_ - CLAIMS MADE HI OCCUR PERSONAL 6 ADV INJURY S 4,000,000 I GENERAL AGGREGATE $ 4,000,000- PRODUCT$-COMPrOP AGG S 4,000.000 __ GENT AGGREGATE LIMIT APPLIES PER: X POLICY PRo-T LOG 03/01/11 863-07 03/Ol/30 COMBINED SINGLE LIMIT5 11000,000 B AUTOMOBILE LIABILITY HAP 2939 (Ee a=ntlanl)_ X ANY AUTO BODILY INJURY --- - i ALL OWNED AUTOS (Per person) SCHEDULEO AUTOS BOOILY WJURY S HIRED AUTOS - (Per acuden)____ NON-OWNED AUTOS PROPERTY DAMAGE 3 X SELF INSURED AUTO (Per student) PHYSICAL DAMAGE AUTO ONLY-EAACCIDENT S____._-_._. GARAGE LIABILITY O ks. EAACC S ANY AUTO AUTOUTO ONLY'.AN AGO $ GL04897714-00 03/01/10 03/01/11 EACH OCCURRENCE S S_000_000------- A EXCESS I UMBRELLA LIABILTY AGGREGATE S 5:000,000 _. X OCCUR CLAIMS MADE _- f DEDUCTIBLE - - - "' S - -- '- --- —" RETENTION '5 --- -- - 03/01/Il _X WC STATU- OTH. WORKERSOOMPENSATION VICO20342355 (ADS) 03/01/10 IV -MR—Ma - It 1,000,000 C ANOEN(PLOYERTLIABILT' YIN 03/01/11 OFFICERMEMBER EXCLUDED? ' E.L_EACH ACCIDENT 3 ____ D ANY PROPRIETOR/PAATNERTXECUTNE� WCO20342356 (CA) 03/01/10 03/Ol/11 EL DISEASE-En EMPLOYE S 1_0001 000__._„ WCO20342357 (FL) E (Mandatary In NH) E.L.OISEASE-POLICYLIMIT S1,000,000 II yes,desmlEe undo SPECIAL PROVISIONS ocImI 30M/2M OTHER THSC46242373 -'(TXY-"'- 03/01/10 03/01/11 Oeeurienee/SIR E TX Employers EXCees WC0910566 IGSI) 07/01/10 03/01/11 D Workers Compensation WCO203423581RY,M0,NY,WI, ) 07/O1/10 03/01/11 C Workers Compensation DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISION$ RE; EVIDENCE OF COVERAGE ATION CERTIFICATE HOLDER CANCELL SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN THE HOME DEPOT, INC. NOTICE TOTHECERTIFICATE HOLOERNAMEOTO THE LEFT.BUTFAILURETO DOSO SHALT. HOME DEPOT U.S.A., INC. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS D 2i55 PACES FERRY ROAD NW REPRESENTATNES. BUIL➢ING C-20 AUTHORIZED REPRESENTATIVE ATLANTA, GA 30339 USA ©1988-2009 ACORD CORPORATION. All rights reserved. 1 M VLn t VLn1LJ Day-1-'1:3 43-43 ❑N - _r3s:rT I V;A7:r.a da d62.2 T,.11:__aa Nadoral7rarRsdon 3%S3' Clan I 2.32 sm V:3rW Am" NO No Laotinatad C'-a3s I 91n vLS:=3 JLULAadJ ® No C.L1a 19/A etJ LLLas . ENERGY PERFORMANCE RATINGS vA"MAp0N DE pacwUNM 9NFAoEl7C0 U-Factor Solar Heat Gain Coefficient Fa=r-U Cm kaaa Guwda do E erO Saw .. 10t. 32 1 . 8 0 . 29 umol a:e:mw AIMMONAL PERFORMANCE RATINGS EYALUACM3N SUPL614TfTAf11A 0l REND9:�Nf0 VlsihieTransmittance tranawlan aalsevhml. 0 . 52 ►inbAsseftifor ierrm+ooao11011 10WP WW •ardrm�v p v talrondstis h itroRaAsstofownts INa.eeospefePmt*LWCd=rdnorrdE7P�f nd dos nat,svrsntUr.dNE9a��fP�tre7'#�uaW.,tn.fAm+.t�SW.ItraA.Pa�Stp.M+.syo -. 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GapftbWfarpatisEA OS9Aa Aft Tola nimtMaww.insg0MlN. kwh jkMpapsussuttwoQIEt6TsWpdamoicnam=mdsuh,stiltswassagyw*t 7 w �oowamso�s.�aalGG o�✓r/amac�(uaelA Office of Consumer Affairs&Business Regulation 1 OME IMPROVEMENT CONTRACTOR Registratt------ 6893 Typo Explratigri _} -a}2.� Supplement _.:,i, The Home Depot`iAtAdme-Services RICHARD FALLONE- , a- 2690 CUMBERLAND PARKWAY S XtUA A,GA 30339�'--"�'-" Undersecretary