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35 NICHOLS ST - BUILDING INSPECTION (2) / The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY M 1�( Massachusetts State Building Code, 780 CNIR SdMar Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section.For`Official Use Only Building Permit Number: Date Applied , Building Official(Print Name) Signat Datt� SECTI N 1: SITE INFORiMATION. 1.1 Property Add_ — A 1 1 1.2 Assessors Map& Parcel Numbers Lid Is this an accepted street? yes no Nfap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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: Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION2( PROPERTYOWNERSHIPl' 2.1 Ow r'ofRecord: �� (�I vl� rr. 4 ©0-71) Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check aJkhat apply) , New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTEVIATED CONSTRUCTION COSTS" Estimated Costs: Item Official Use Only, Labor and Materials I. Building 'S 1. Building Permit Fee. S .A 7 Indic die how fee is determined: Electrical S ❑ Standard City/Pown•Applicatioa Fee 2. ❑Total Project Ccst .(Item.6)x multiplier x 3. Plumbing S 2- Other Fees:'S \ ,1. Mechanical (HVAC) S List: L/br`�-- S. Mechanical (Fire Su ressian Total All Fees: .S_ Check No. Check Amount: _Cash AmOLHI 6 1'otal Project Cost: S ❑Paul in Pull 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Superviissorr Liicce'�nse(CSI.) w— J �1. — License Number Gepinti n D e Name of CSL f[o der 1QC-JI" List CSL Type(see below) Type Description No. and Strz U Unrestricted(BUildings up to 35,000 cu. ft.) R Restricted 13e2 Family Dwellin City/Gown, Statz, ZIP - bI tk4asonr RC Roofing Covering WS Window and Siding SF uzl Solidula F Burning Appliances Jn 1 G� �( 7J [ Instion Tce Email address D I Demolition 5.2 Registered Home{ mproveeJgtent Contractor((MC) t -mot _ l 1 CU n7J) HIC Registration Number Erpi tti Da HIC Cot n a or -I ' R• ame No, a a At �— Email address City/Town,State, ZIP If Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. M. § 25C(6)) Workers Compensation Insurance affidavit must be complete ,and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance o uilding permit. Signed Affidavit Attached? Yes .......... No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property, hereby authorize 42� C ate f to act on my behalf, in all matters relative to work authorized by this building permit application. a Print Owner's Name(Electronic Signature) I .to SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest ad the pains and penalties of perjury that all of the information contame m r application is true and ac urat to th bes fray knowledge and understanding. (-G[ - a, Print Owner's r r\uthontzd Agcnt's Name( -feet, nit Signa uro) Dxte 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 Hone Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the MC Program can be found at wWw.utass.,-mvdoca Information on the Construction Supervisor License can be found at www nmss.eovrdL 2. When substantial work is planned, provide the information below: Total flour area(sq. ft.) _(including garage, finished basement/attics, decks or porch) Gross living area(sq. ft) Habitable room count Number offireplaees_ Numberofbedrooms ___-- Number of bathrooms Number of half/baths _ rype of heating system _--_- --- Number of decks/ porches — — I'ypeofcoolingsysiem -). Total Project Sgwue Footage„ may be substitulcd t;x.,Total Project Cost" -- ------ ---------- ------------------- L 12/07/2012 20:54 17818940331 TODD RIDEMAN PAGE 01 ' HOME IMPROVEMENT CONTRACT PLEASE READ THIS 1�1�// h `y / Sold,Fum FTed�Installed by: Branch Name: Boston Date; f(i/f f I�' THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(800)657-5182;Fax(508)845.6017 Branch Number:31 Federal ID#75-2698460;ME Lie#C'02439;RI Cont.Lie#16427 e,� CT Li i/�_C.05�65522;MA Home Improvement Contra/c�torgReg.#126893 Installation Address: s 5"i Lr�n'1 AI n el 1 City Statc Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: [ l [ l [ 7 Home Address: _ (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates), _ ❑I DO NOT wish to receive any marketing entails from The Home Depot Proieet Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and 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"): i Job#: tw.aa adorertl Products: Spec Sbeet s #: Protect Amount n ❑Roofing ❑Siding ❑Windows Insulation ❑Goners/Covers ❑Entry Doom ❑ 6 Uv Roofing ElSiding El Windows Insulation ❑Gutters/Covers ❑Entry Doers ❑ $ Roofing LlSiding 0 Windows ❑Insulation $ ❑Gutters/Covers ❑Entry Doors❑ ❑Roofing ❑Siding ❑Windows ❑Insulation $ ❑Gutters/Covers ❑Entry Doors _ Minimum 25 Deposit ofCantrectAmoum aue ttpoo ezawtiao ofmie contracL Total Contract Amount Maine Purchasers may trot deposit more than one third of the Contrast AnroauL 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 bejointly and severally obligated and liable hereunder. 'rho Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its discretion,it'The Home Depot or its authorized service provider determines than it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint, other salzty concerns,pricing errors or because work required to complete thejob was not included in the Contract acntract. t_// Pavmen�mmarv: The Payment Summary #. b 8 b /U O . included as part of this Contract, sets limh 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 you 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 r is complete. in the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,tabor,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: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot will)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 assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement- Accept y: Submitted//!�CX. /l7 (7u6t er's Signature Dat - / Sales Ccasultant's Signature Dale X Telephone No-—_ Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS ros annusenml �' 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. NOTICE:ADDITIONAL.TRRMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 01s,110-12 Wbite-(Ranch Fae Yellow-Cuslorner � M �sac �a�e#ts ` eartrne #raf Public Safet �. s:�rtr � � 13aa d Bu" �d�'ng�Re g'.u' r s�r� .� a r °wy�,n 'u � k Q 9,9871, pit ON �:<UJR, 1�"��, ';`�■/�'�■:IA$��ryyi�s+� "(�(k^7� +i` � i T ti; O lkt fk 1.4� Si P xW" .f* Pwh� $�^�S{� p���- R�' b...'/ p I t�4#ilo � �y: 'r� h� `�E�t v 5n- n*,��' ✓✓ �,S Y � + �'�A 8'� `�'e" 61.291201_�� r � ��� ( pp♦♦ � �� ry� e{may a _ ' .y aks s iF l aZr r L i ' 1 � i9 d C.1'I"F t?°i i1t 7T1'�} nn. � ls,.i 5'.��-tY 7t ��s^✓�', o.. s,r(.1.� ^ ,...:or/?.ud.vid..n.): Ad d yl>ne Are yo employer?Check the appropriate box: Type of project(required): I am a general contractor and I I. I an.a employer with 4. ❑ 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. Q Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp..insurance 1 5. ❑ We are a corporation and its ME] Electrical repairs or additions, required.] 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.Q Roo pairs insurance required.]t c. 152,§1(4),and we have no 13. ther n3 li lln, employees. [No workers' comp.insurance required.] Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this af�tdavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. _ tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below Is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: I t-7 Expiration Date: Job Site Address: L N)arils ZJ City/State/Zip:�IPrvt Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required trader 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 fort 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi u der he ins and penalties of perjury that the information provided abo a is tr and correct. Si afore: Date: Phone#: ON Dg� Official use only. Do not write in this area,to be completed by city or town offt ciaL . City or Town: Permit/Liceuse# Issuing Authorjty(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: ,., CITY OF S'kL.ENI, NLksSACHUSE-nS Bu DING DEPAR"I'%t&NT 3 120 WASHINGTON STREET, 3� FLOOR T EL (978) 745-9595 FA..c(978) 740-9846 KIJiBERI,EY DRISCOLL i"VfAYOR T1io.%tAs ST.PIERRS DtRHCTOR OF PLBLIC PROPERTY/BCILDNG CML,11SSIONER 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 1 11.5 Debris, and the provisions of MGL c 40, S 54; Building Pen-nit # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal 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-� —_ ad Tess of facility) 4,1;knaru ofpermttapplicant Pate dcBn>�ITdu a 1 •� ply � eair� andess Regulation • . ,� . - a Office of Consuls I i 10 Parlc Plaza - Suite 5.170 7i oston sach-asetts:02116' 41 A�©ineLimprove . '. ontractor•RegistiAtiOii Replatratlon: 126093 .... h Fib Type: Suppiernent Cao . i — r_ r F�lplraUon:' a/312W The Home Depot At-Home Servim }' _ RICHARD .FALLON.E 2690 CUMBERLAND PARKWAY ATLANTA, GA 30339 � — >c'o^A sq.. Update Address arid retuin card.murk rensonfor.cI, . Address RcncwaP .n Bmployment f� LostCnrd e toanwreoaw�e .e✓r d°`fi tlon valid for individul use only r' T registration• License or r g Office of Consumer Artnirs ReHusmnss Regvinhvq. before the expiration date. If found rclurn'.to:' •• i UME IMPR EWTXNTRACTOF q(tiee of Consumer Affairs and Business Regulation �.� I�.�_ � Reglstratlo��a268cJ3 • - ' :Typo: 10 PerkYlozn-Smtq 5120 . ` Explra(Iti ;y,'B(3 1'4 Supplement Card Boston,MA02116 ' . `1'he Homo Dep01r}A7= MeienlF�es .. ,;} a Vs� � 1J i I U��tD FALLtSN .-I l ..4n"ture - . [,�D c,UMDCRLA�IO of vnlyd witlit ',`�U."TrA: -A 30339•r"..., Undersecretnr� .. . .� .. . .. ... - w CERTIFICATE OF LIABILITY INSURANCE DAiE(MMIDD Mr) 11/is/Iola 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. U 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). PRODUCER 1-866-966-4664 CONTACT NAME: Marsh USA Inc. PHONE FAX WC,No Eatil A/C No homedepot.certrequest0marsh.com E-MAIL s: Two Alliance Center, 3560 Lenox Road, Suite 2400 ADDRE Atlanta, GA 30326 INSURERS AFFORDING COVERAGE MAIDR Fax (212) 948-0902 INSURER A: Steadfast Ins CD 26387 INSURED INSURER 8: Zurich American Ins Co 16535 The Home Depot, Inc. Home Depot U.S.A., Ind. INSURER C: New Hampshire IIIS Co 23841 2455 Paces Perry Road NW INSURER D: Illinois Natl Ins Co 23817 Building C-20 NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER E: INSURER F: Illinois Union Ins CO 27960 COVERAGES CERTIFICATE NUMBER: 30289573 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 LTq TYPE OF INSURANCE ADOL SUBR POLICY NUMBER PMIDDYEFF POLICMMMDYEXP LIMITS A GENERAL LIABILITY CL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 y' D A O D COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 1,000,000 CLAIMS-MADE �1 OCCUR MED EXP(Any one person) $ EXCLUDRD X LIMITS OF POLICY XS PERSONAL B ADV INJURY $ 910001000 X OP SIR: $IN PER OCC GENERAL AGGREGATE $ 9,000,000 GEN,AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 9,000,000 X POLICY PRO LOD $ B AUTOMOBILE LIABILITY BAP 2938863-09 03 01/13COMBINED SINGLE LIMIT 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROAUTOS PERTY DAMAGE $ HIREDAUTOS AUTOS Per accident X SELF INSURED PHY DMG - $ UMBRELLA LIAR OCCUR _ EACH OCCURRENCE $ EXCESS DAB CLAIMS-MADE AGGREGATE $ DELI I I RETENTION$ $ C WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 X TOCSTAMTU- OTH- ANDEMPLOYERS'LIABILITY � D ANY PROPRIETOPoPARTNERIEXECUTIVE NIA WC019736917 (FL) 03/Ol/1 E.L.EL 03/Ol/13 EACH ACCIDENT $ 1,000,000 OFFICERNEMBER EXCLUDED? N E (Mandatory In NH) WC019736916 (CA) 03/Ol/1 03/01/13 EL DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe undo DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Workers Compensation NC1192494 (QSI) 03/01/1 03/01/13 SIR (AOS)/SIR (GA) 1M/750,000 C Workers Compensation NCO19736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/lM DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD HIT,Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. HOME DEPOT U.S.A., INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 USA 0 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Jthornton_hd - 30289573