18 NAPLES RD - BUILDING INSPECTION • - ...rMMKillj4yuy9r.Y.....
INSPECTIONAL SERVICES .
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The Commonwealth of Nlassachusetts QL!4 OCT 24 A CBFY
IW
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR
i. b g Revised Alar_011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OlTciul Use Only '
Building Permit Number: Date App ied:'
d /
Building Official(Print Nmne). Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Addre s 1.2 Assessors Map& Parcel Numbers
I.1 a 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 It) Frontage(If)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:( 1.C.L c.40,§54) t.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal [3 On site disposal system ❑
Public❑ Private❑ Check ifyes❑
SECTION2: PROPERTY OWNERSHIPt
2.1 Owner of •ord'
thine(Print) City,State,ZIP
rc�.�2�
Wes/
No. mid Street It Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteralion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of.Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(item 6)x multiplier x
3. Plumbing $ P Qtlter Fees: .5
4.Slech:mical (FIVAC) S List:
5. Mechanical (Fire S Total All Pees:S
Suppression)
Check No. Check a\mount: Cash Amount:
6. Total Project Gist: S ❑ Paid in Full ❑Outstnndiu� Bal:mce Due:
,�3Jr '� TN1p I�12�
( ? •11a3 SECTION 5: CONSTRUCTION SERVICES
5.1 C'uilstruSu'' ucere(CSL)
License um cr E.epimti to
Name of CSL Holder List CSL Type(see below)
ma Vu �r'h�' Type - Description
No. ;md Street
�7 11 U Unrestricted(Buildings up to 35,000 cu. 11.)
R Restricted 1&2 Family Dwelling
Cityffow� M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
I cle hone Email address D I Demolition
5.2 Registered Home Impr vement Contractor(HIC) }a�
HIC Registration Number F..e iru on at
HIC Cu ran oV
o" Nm
.17
No.an Strce Email address
Ci /Town,S ate ZIP Tele hone
SECTION 6:WORKERS'.COMPENSATION INSU NCE AFFIDAVIT(M.G,L.e. 152. 9 25C(6)),
Workers Compensation Insurance affidavit must be c eted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Wuan 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'
1,as Owner of the subject property,hereby authonze��G�
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering y n, a below, I ereby attest under the pains and penalties of perjury that all of the information
contained i t this a plica n i rue and accurate to the best of my knowledge and understanding.
Print Owne 's or A uhnrizeJ Agent's :one(C•Iccuonic Signature) Date
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 not have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A. Other important information on the HIC Program can be found at
www.mass. vL y�Information on the Construction Supervisor License can be found at AAAAIas.��ov'J_ �_Lts
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) 'r ,(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces dumber of bedrooms
Number of bathrooms Number of halt baths
Type of heating system Number of decks/porches
Type ofcooling system Enclosed Open_
1. "Total Project Square Footage"may be substituted for"rota) Project Cost"
i 4
i'v72'v5 Yll^lIL
c.�ard o £zi{ain=a r=�uiais�ns an''.Si nrJards
" r_•aa,trucnon Supcn isrr'Speci�lr:
a.
commissioner
• r
k. -
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Ilrnished and Installed by:
Branch Namc:Bmtun North&South DatiVO b/LVI-i THD AI-Hinnc Services.Inc.
d/b/a The home Depot AI-Home Scrdicws
L Branch Number:31 and 33 908 Bossism Tumpike,Unit.1.Shrewsbury.MA 01545
Toll Free 877-903-3708
Federtd ID p 75-2698460:ME Lac s C 02439:RI Cum,Lill 16427
-I CT Lac 4N•HIC�.0565522:MA Home Improvement Contractor Reg.so126893
n
Installation Address: _,�8Aao\gn 1'J .�CAem U 019-70
City State Tp
Purclumer(s): Work Phone: Home)-tal Cell Phone:
l 190$?24-02391 f 1
r ] 1 [ ] It
Hotnc Address:
(If different from Installation Address) City State Zip
Eauall Address(I,,rcaoivc pniject cornmunicalinns and Hume Depot updates): . . ..
❑1 1X)NOT wish to rccrivc tray marketing emnds from The Home Depot
Project infarmalion: Undersibmed("Cistumer"),the owners of the property located at the abt,ve in.viallaliim address.agrees to buy.
mad THD AL-Huma Services, (tic. ("I'he Hume Depot")agrees to furnish,deliver slid arrange for the installation("Installation")of
all materials deteribed on the below and ion the rcfcrenced Spec Shew(s), all of which are incorporated into this Contract by Lhis
reference,alimg with any applicable Suite Supplement and Payment Summary attached hereto and any Change Orders(wicelivOy,
"Cunlract"):
dob#: 0-Lou Spec Sheet(s)k: Project Amount
Ruufms wls Windows Insulation r r - $ -3�
Z836430 ❑Gutreix/Covey ❑ISnry IN.. ❑ 3�p I 7 �J h
❑RustingLjSiding LJ Windows U Insulation
❑GUnCrs/Covers ❑Entry Doors ❑ I 'S](osifing LISiding EJ Windows ❑InAinnion R
❑Cutters/(rovers ❑Enhy Doors❑ _
~— LJRtsfing LJSidnui Ll Windows 0 Inmintioa
j ❑CtuLrerx/[:rners ❑Entry IN"s ❑ $
Minhmim25%,Deposit of Uminat A=wd due upmexmAim Mtlds contract
Memel'unhwmnmynMdccpmtin thanune4hh'duf#*CAmtmeAm nt. Total Contract Amount .fi
Cwtomer agrees that. immediately upon cumpictitm of the work for each Product.Customer will excri le a Completion Certificate.
(one for each Preluct as defined by an individual Spec Shot)and pay tmy balance due. As applicable,each Customer under this
Contract agrees to be jatnty and sevrxally oblignted and liable hereunder.
The Home Depot reserves the right lit issue a Change Order car terminate this Cmuract or any individual Products)included herein.at
its discretion,if The Monte Depot nor its authinivlxl service provider detcrnlines that it cannot perform its obligations due to a structural
problem with the home,environnicnLal hazards such as mold,asbestos it lead(mint,other safety concerns,pricing errors or because
work required to complete die jab was not included in the Contract.
Payment Summary: The Payment Sunlinary o-0g89779 , included as part of this Coral sets forth the total
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE'IT)CUSTOMER
Yvan are entitled to a coca otely filled-in copy of the Contruct at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion C'erlificate for curb listed Product at defined by individual Spec Sheets)before work on that Product
is complete.
In the event of termination of this Contract,Customer agrees to pa T'he Home,Depot the costs of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Pravider 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 HOMU' DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUa'
LIMITING THE HOME DEPOT'S OTHER REMF:DIKS FOR RECOVERY OF SUCH AMOUNTS.
Accepoloong PIW Autherizallrm: Customer agrees and undersmnds that this Agreement is the entire agreement between Cusuamor
MCI [he Home Mpor with regard to the Products slid Ins allalirm services and supersedes all prior discussions and agreements,either
oral or written,relating to said Products and Installation.'this Agreement cannot be aesibmet in amended excupt by it writing signal
by Customer and The Home Depot. Customer acknowledges and agrees that Cuslornur has read,understands, voluntarily accepts the
terms of and has reecimol a copy of this Agreement.
Acce led by: I Submitted h :
x 1 + I s l�
usiomcr's Si tore. Oate 15a s Cimsuluh Signamrr `� llatc
)( _ Telephone No. 1 27- 9117�
Customer's Signature Date 1 Sales Consultant.License No. _
CANCELLATION: CUSTOMER MAY CANCEL '['HIS [n apprgibla)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME I
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AF FER SIGNING THIS AGREEMENI'. THE
STATE SUPPLEMENT ATTACHED HERETOI
CONTAINS A FORM TO USE Ir ONE IS
SPECIFICALLY PRE.SCRHIED BY LAW IN
CUSTOMER'S STATE.'
NOTICE:ADDITIONAL TERM$AND CONDITIONS ARE S7ATED ON'1'HR REVERSE SMF..AND AttE PART Or"I'HIS CONTRACT
08.07.14 Willa-Branch File ynla,w-C�etmmry
nn � nuv •nAnn noinu -� ,iun�-,n,� • iannn-, n�•nn nn n, un-,
QTY OF SALEM, MASSACHUSEM
a
BUILDING DEPARTMENT
120 WASHNGTONSTREET,3' FLooR
TEL. (978) 745-9595
F
KIMBERLEY DRISCOIS. FAX(978)740-9846
MAYOR THomAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
l�1-)6al
(address of facility)
Signa ure of applicant
ae
L
B�,5!o;2 M 024
C
7
Name i9uzirl—
Add-ess:__
A if
city/state"Zip: 111TA 4
If Are anemp foyer? Check the apjr X: Type ol'project (required):
4, ❑ 1 am a gencial contractor and F,--! N-v, ,-m-ruction
I. I am a emplo�er with—go
have hired the sub-conti
— -acuurs employees (full and/or part-time).* listed on the attached sheet. T7 Remodeling
2. [ am a sole proprietor or partner- These sub-contractors have g. 0 Demolition
ship and have no employees employees and have worker` ti. E Buildirn, addition
apacity I
working for me in any c trip. insurance.+
[No workers' comp. insurance co t t),E] Electrical repturs or additions
required.] 5. 0 We are a corporation and its
3.0 1 am a homeowner doing all work officers have exercised their 11.0 plul-f-ibing repairs or 2
myself. [No workers' comp right of exemption Per IVIGL 12.[] Ro o �pairs
c. 152, §10), and we have no
insurance required.] employees. [No v,of kers'
comp. insurance required.]
"Any applicant that checks box h I most also till out the section bolos showing;their oo I tors'compensation policy in I ollinnioll.
T F10111CONVacTS who submit this affidavit indicat in a.they are doing at I work and then hire outside contractors ,lost subin it a new I fi di'\it Illd c1ting such
+ showing the name of the suh-contractors and state whether or not those comes have
.Contractors that check this box trust attached all ditional sheet
employees. Iftile sub-contractors have employees,they Must Provide their workers'conip policy number.
e y
I am an employer that is providing workers'compensation insurance for my employees. Below is the (ndjob site I I
information.
Insurance Company Name:—
Policy 9 or Self-ins. Lie. 9: Expiration Date:
Job Site Address: City/State/Zip:���� :w
Attach a copy of the workers, compenslition polio 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 I 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 ance coverage verification.
Ido hereby certify under epa s dp alties of perjury that the information provided a ove is true and correct.
09,
Si nature: Date:
Phone 4:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License A
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#:
/1
OAR IMMieC1Y'tY!j�
CERTIFICATE OF.LIASILITY I SURANGE
' T}11g EERTiFICATE 19 139UE0 AS A MATTER OF INFORMATION ONLY AND CONFERS NO 0.1GHTS UPON THE CERTIFICABY HOLDER. THIS
E�k'RE DOER 9AF.AFFIRMA' Y OR pwATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED
BY THE POLICEQ
CON � tCE DOIES NOT CONSITTUTE A CONTRACT BETNEEN THE ISSUING INSURER(S;, AUT'ri0R;2E4
t ,01AM AND TFIE'CERTIFICATE HOLDER.
t �Brgg j4plder is an AOp}T(ONAL INSURED,the poHey(les) must lea endorsed. If SLBROGAi1CN fS'NA+YEJ,suhj=tt to
tRd, m�and EbndltiDn9 of the pcltog,aartarn p011eies may require an endorsement. A statement on this certificate does not confer rights :c the
ee aBleXotdei to Reu of sdch andarsement(sj. A
:,1.Y
PR - - - Pxr3HE IArC No
E.CENtER A'
35�LENOXROAD,SUITE 24GO Naic e
ATLAJ4JA.GA 30326 IHSURER0 company
GE— ---261A7
MBURP.R A:Slead[asl Ins+uance Company 16535
10pg92.HDm80•GAW-14.15 Zuech Amakan lnsurdncs Cc
INBBPED _. - INSII a: - 23841
' TfZkT•(i0mESWCES,INC. IxsuRER D:New .Hampsllirains Ca, ._.—..
OBA THEMOMEOEPOT At-HCQ11E SERACES - 06nas Ne0m1a11nwtanoa Comp any 23817
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•2459 PACESFE W ROAD u+suRERn
- tisdaERP BER•3
COVERAGES EER7IFICATENbfdBERi.
' ATL4103212685-0t - REVISIONNUM
4HI8'I TU EER?lam THAT'THE POLICIES_Of INSURA1ICE C1�9TEEi-BELOW HAVE SEEN lSSUEO TO THE INSURED NAMED ABQVE FOR THE POLICY PER OC
)NDICATE4: ?);,10TWITHSTANOWG BE ISSUE AN'[:REOUIREMENT,TERMOR CONDITION OF ANY CONTRACT OR OTk4ER DOCUMENT WITH RESPECT TO WHICH THIS
EXCLUSI NS ANDCERTiFICAO YCONDITION OF SUCH PCiii(pE5.LIMITS RO NN MAY HA*CEVEE EEN REDUEEO CBY PAID'CLAIMS. HEREIN IS SUBJECT TO ALL THE TERMS,
PO I UMITS
O R POLICY NUMBER 4 9,W0,6W
IN R + - TYPil OF INS\1RAt10E 0310112014 03N1R015 EACH�cuRRENCE
L 6L0488TI74-04 t 1,000,000
. .A GENFAALUA8141TY EXCLUDED
X� COMMERCIALGEVERALUABIUTY MED DT one arson) T 9,000,000
OMITS OF POLICY XS
cwMsn mE occuR OF SIR:SIM PER OCC PEflsON a a uRY
aov w 5 9,000,OW
GENERALAGGREGATE 8
PRODUCT -COMPIOP AGG S
sosD,Dop
GENL AGGREGATE LIMIT APPLIES PER: S
.X POLICY PRO. LOC 031011201d 0310112015 COMBINE ANGLE MR 1,ODO,OOD
BAP 2938863.11
B AUTOMOBILE LIABILITY - BODILY INJURY(Par persrn) S
X pLIY - BOD14Y INJUAY(Par 3nridan0 S -
" .ALeawNED scHEOULEO $ELF INSURED AUTO PHY DMG P AMAGE S
AUTOS NO ON•owMED S
wr+ED Avros AUTOS
_ EACH OCCURRENCE S
UAA9(t,ELi/�tUB OCCUR AGGREGATE S
F,4CEaa. B. CLAIMS-MADE S
.RETENTIONS .. . - 101882 A06j _. 03N112014 3107 5 oix- I,W0,000
.0 woacexs.CampExsA"gDN:- 03io1@014 03IMM1 5 EL EACH ACCIDENT - s
AT46,gMPlflYPS$`AIABM1RY YIN WW49161BB4(A)CAZ,VA) - 1,0W,OD0
C pNY RPORRIhTL1r41PARTNERIIXECUOVE NIA 03101@014 DMIND16 ELDISFASE-EAEMPLOY S 1,000,000
WOED7 I '• I WC049101883(flj
D MenEatu BR I. U � � ELDISEASE-POLICY111 S
NNT .: . 1,000,W0
Ify�,aesadbe Open.
pE Cg FU . NOF OPE&1ON helve' YJC0 MO18A5(M!,NC,NH,VT) 0310112014 03101@p15 (EL)OMIT
C WOP•14ERS COMPENSATION WC049101186(NJ) - 0310112014 03N12015
OILOCATIONSIVEHIClMe (Attach ACORD101,Apdidanal Remarks Sehedule,Itmme space is required)
DESCRIPTION OF PERATN)H9
EVIDENCEOFINSURANCE
CANCELLATION
OLDER- - BEFORE
CAT E H ED
j Eu.
RTIF ANc' CE SBEC
THOAT-HOMESERVICES,INC. _ SHOULD ANY OF THE ABOVE DESCRIBED NOTICE
.peA7HEWEI;ER jjQME PICES,IHOMESERWCES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
1456 PACES FERRY ROAD
ATLANtA,.GA 30339 AUTHOR] REPRESENTATIVE
of Marsh USA In&
' - Manashl Mukher)ee Ail rights reserved.
���ie• ���ra�;�druaec� o�C>
Office of Consigner Affairs d Business Re ation
10 Pail€Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement. Contractor Registration
Registration: 126893
Type: Supplement Card i
Expiration: 813=16
THD AT HOME SERVICES, INC. '
R1CHAR [3—�--AILL_ V —_— — — --
2690 CUMBE=RLAND PARKWAY SUITE 306 -- i
ATLANTA;GA 30339 — --
_ a
Update Address and return eard.Mark reason for ebange.
' Address I Renewal Employment J Lost Card
SCA 1 0 2WA-Mll —'
:11��rn.rrrrararrr�(�r•�`^/(r.::rr:�nr//..
ffice ofComm�rr Affairs&Buiiaess ltegidatioa License or registration valid for individut use only 1
OMEIfNPR10VElAEIIrCONTRA6TOR befaretheexp'va'tiandate. It fee adrdnr¢w: - 1
_ Office of Consumer Affairs aad Business Regulation
•a` .sr'Reglsti'aUon: 126M - Type: i8liarkPl�a-suite5170
-EicpiraiionRVZIc.g 016 SupplernentCard Boston, I I&
-THD AT HOME SECES,INC ' + '
IHE.HOMEOEPCTATHOME SERVICES
RIGHmb FALL6NE
?R90 CUMBEFiIANO*PARKWAY S
A'ii5,A4'A.GA 3033E l ndersevebry at va w ■ a gaala�r<r�
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