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15 R NORTHEY ST - BUILDING INSPECTION ZZ. The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of Massachusetts State Building Code, 780 CMR, 7'" edition Wilbraham Building Dept Building Permit Ap ' anon To Co struct, Repair, Renovate Or Demolish a 413-596-2800 One-or Tw -Famil_y Dwelling Ext 1 18 This Se Lion For Official Use Only Building Permit Nu ber. A Date Applied: Signature: Buildmg Commissi er/ for Buildings' Date _ VV ACTION 1: SITE INFORMATION 1.1.Property,Add 1.2 Assessors Map& Parcel Numbers I.1a Is this an accepted street?yes n Map 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 O On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert comer- i� _ Name(Print) Add &&coHjW- — Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check al at apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Sp cify: Brief Description of Proposed Work': �^ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ lrid 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ - ' 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) C ' . License Number Expuation D, Name if CI -Holder List CSL Type(see below) Addr s 0 /v(,0 Type Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted 1&2 Family Dwelling Signatu a �—T M Masonry Only J��� / �J� RC Residential Ruofing Cn_�in Telephone WSP Residential Window and Sidine, SF Residential Solid Fuel BurningAppliance Installation D Residential Demolition 5.2 Registers ' ne Ipypro e e ontr or(HIC) HIC ne or HI egist m Registration Number m tt Expiration ate Signa a Te SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provioe this affidavit will result in the denial of the Issuance the building pemit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRAC 'OR APPLIES FOR BUILDING PERMIT I, P _rL�(J. _ , 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: OWNEW OR AUTHORIZED AGENT DECLARATION I, ,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. � 1 � 1w' �'—'a--, -- Prins a ,rr t Si are wner of Authorized Agent Date �f Si ned un r the pains and penalties of perjury) NOTES: 1. 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 M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.R5, respectively. 2. 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 heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" XicenVc Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Pubiioc$afety Department of Public Safety Licensee.Complaints License Type construction_Supervisor License # 74722 Restriction 00 Name Kostaniinos S Vaitis City, State, Zip Saugus, MA, 01906 Expiration Date 7/5/2009 Status Current No complaints found for this Licensee. Back To Search r http://db.state.ma.us/dps/licdetails.asp?txtSearchLN=CSL74722 6/17/2008 68-5LP-28 12:46Pti FRONrHpme Depot 2636 87fi7401417 T-453 P.001/005 F-004 t HOME IMPROVF.NIENT CONTRACT r.._ PLEASE READ THIS Sold,Furnished and Tnstalled by: THD At-home Services,Inc. Branch Name: Boston Date: d/h/e The Home Depot A[-Home Services 345A Creeawood Street,Unit 2,Wr.rcester,MA 01607 Branch Number! �[ Toll Free(800)657-5192; Fax(508)756-9823 (JrNorth 33 []South 31 Federal rD#75-2698460;ME Lie#C 02439;RI Cant.Lic#16427 A �/1 Cr Lic#565522;MA Horne Improvammt Contractor Reg.#126893 )M-13 Installation Address: �fJ' i� N(�Y lhlN �a' `'`� � ���" City State Zip Purchmer(s): work Phone: Home Phone: Cell Phone• Homo Addt,?S ' City State Zip (If different from insmllation Address) Ems- rail Address(to receive project communications and Home Depot updates): hA I DO NOT wish to receive any marketing smells from The Hame Depot Proieer.[nformation: Undersigned("Customer'7,tiro owners of the propperty located a[due shove installation address,agrees to buy, and TI-Q)At-Home Services,Tnc.("The Home Depof")agretPto furnnsb, liver of wli h are 0ncoorporated ltalmtrothis IContnctr by on") all maerals described an dte below and on the referenced Flynt Sheet(s), refervaee,along with any applicahle State Supplement and PaNneot Summary attached hereto and any Change Orden(collectively, "Coritrntt"): Job#: a--, 0 ums:t.A.••a> Sea Shaets #: Pm'eet Amount Routing Siding Wmdo ❑Insulation $ Mg 5 q ❑Gutters/Covers ❑En vent ❑ Roofing LISiefing ❑W-ln4ews hlsuladvv $ ❑Guttea/Covers ❑Enhynoort El- Routing Siding []Windows Insulation $ [:]Gutters/Coves ❑entry Doors � Roofing Siding VTndOws❑,_Insulation $ ❑turret/Covers ❑Entry Doon ❑ Ammum25M DepositofContrad Amount due upon execution ofthis conft c Tom[Contract Amount 5; 8 Mulue pumboots may nor deposit more than one4hirdofthe CoawetAmavnt U Customer agrees that,immediately upon completion of the work for.eaeh Product,Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheol)and Pay any balance due. As applicable, ea<:h Trainmen tinder[his Contract agrees to be jointly and severally obligated and liable bemrrnder. The Home Depot reserves the right to issue a Change Order or terminate this Contract cr any individual Pmducls(s)included heroin,at is discmrion,if The Home Depot or its authorized service provider determines that it cant perform its obligations due to a structutal problem with the home,environmental hazards such as mold,Asbestos or lead paint,other safety contends,pLicing errors or because Work required to complete the job was not included in the Contract. payment Summary: The Payment Summary# © �I , included as part of this Comracr sots 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 you sign. Do not sign a CampleDOR Certificate(note: there is one Completion Certificate for each listed Product m defined by individual Spec Shects)before work on that Product is cumplem in the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses e Depot or Authorized and services provided by The Mom 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 Wr rHHOLD AMOUNTS OWED TO THIN HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENVi MADE, WITHOUT LIMITTNG THE HOME DEPOT'S OTFIER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceornnce and Authorization: Qtstomer agrees and rmderstande that this Agreement is the cadre agrcernent between Customer and The Home Depot wdb mgerd to the Products and Installation services rind supersedes all pier discussion s and agreements,either oral or written,relating to said Ptodut•Is and installation.This ement cannot be asstg¢ed or emended ex,:ept by a writing signed by Customer and The Home Depot.Customer acknowledges end agmc8 tact(,lstomer has rend,understands,voluntarily accepts the terms of and bee received a copy of this Agreement. A�pgQted by: Sabmitte h Z Dafe Sales nsulmat's Si�attw e Cusmmer's Signature 7 X Telephone No. I.+1�•�5t�9 �q 1 - Cusfotner's Signature Date Sales Consultant License No. L - (.is appliaWtc) CAN('E_- Li LA7•HON: CUSTOMER MAY CANCEL THiS AGREEMENT WITHOUT PENALTY OR OBLIGATION By DELIVERING WRITTEN NOTICE TO TIM 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 TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF PHIS CONTRACT 8.0548 C-SC Whae-Branch Flle yellow-Customer Pink-Seise Commilent The Commonwealth ofpfIzssachusetts Department of Industrial Accidents Office of Investygations 600 Washin'on Street Boston, MA 02111 , www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/El P ease Print Legibly Ant) ic ant info rmation ou/indrndual) U Name (gusmess/Organtzart /��/ FIh1/ 1 r•I� IF I Address: \\\\ City/State/Zip: laki � _ Phone.# bux: 7sub Type of piolect(required): p1e y an employer. Check the appropriate4 ❑ I am a gener I 6 ❑New construction 1. I am a employer with (Z a have hired thsemployees( and/orpart-time). 7. Remodeling � listed on the- ❑2.❑ Iama bold pfoprietor or partner- These sub-c8. ❑ Demolition ship and h}ve no employees employees and have workers' 9. ❑Building addition working ffor mein nay capacity ctm:p.insurance.t 10.❑Electrical repairs or additions o workers'comp.insurance (N 5, ❑ We are a corporation its airs or additions required-1 officers have exercised their 11.❑Plumbing rep 3,❑ I am a homeowner doing all work right of exemption per MGL 12.❑Ro repairs myself. [No workers' comp. a 152;§1(4),and we have no 13. ther insurance required-1 t employees.[No workers' comp.insurance required-] •Any applicant that checks box#1 must alro fill out the section below rhowiag Blur wmi=S'ootrtpm idea policy mformadw- .. t-HnmMwners who submit this affidavit indicating they�doing ad work and dun him outaide eonapcmm nwst submit a new not those indicating such. tCoouzetn a hunt check this box must attached an additional shed showing the name of the sub-contrsctora and sate whether or not those enntim have.. have("Mloyces,Buy must Pam&dteir worlmrt•,crop.pokey number. . err�loY� Turkic sub-conuacros . that Lr providing workers compensation insurance for my employees Below is the pottcy ana�ou a..a I ant an employer . information,1\_ ) ✓a�.no NSc r .� - insurance Company Name: Expiration Date / Policy#or Self-ins.Lic.#:�� City/StateiMp Job Site Address: poach a copy of the workers' compensation poll !station page(show[ng 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 is civil penalties in the fora 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 Invesd bons of the for Mace covers a verification. I do hereby certi p s d penes of perjury that the information provided abovq is d correct Date: i attue• hone# O icia use on y. o not write tis area, to a comp ete by c or town offictaL Permit/License# ------- City or Town Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other — Phone#: Contact Person OATE(MWODIYYYY) R? ACOD, CERTIFICATE OF LIABILITY INSURANCE 02/26/09. 1-404-995-3aOO THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION PRODUCER - ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE marsh USA, I nc _ - HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Icmedepot.caquast(Pmarsh.coo - ALTER.THE COVERAGE AFFORDED BY THE. POLICIES BELOW. 3475 Piedmod N5, Suite 1200 - At:anta, GA - INSURERS AFFORDING COVERAGE INAIC0 (Z13199a2 iNSuRER A:S teadE is' Ina Co 3616A i_'.cma :),OctO U.S.A.. Inc. � INSURER 9:Zurich Adler:can ISO G � :SiJS Ta same Oepcc, Inc. Z455 Paces Ferry Road �INSUaER C:I11inoLa f9Ae ' Ina,�--'- 23817R'�' 9ui ldirg C-B INSURERO:Amarican Home Aasur Cc 19386 Atlanta, GA 30339 f INSURER Ie New Hampshire Ins Cc 23841 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED T(J 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 CONOITIONS OF SUCH, POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - IN 0 POUCYNUMBBR POLICY EFPECTNB pDAM IRA EXPIRATION LIMITS A GENERALLIABUJIT IPA 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE Is4,000.600 - X COMMERCMLGENE LVIBILITY 6INIT9 OF POLICY ARE XRC SS PR M n 31,000,000 DLAIMSMADE OCCUR -OF SIR: $1,000,000 PER CCa MEDEXP An "penael SEXCLUDED :e i1 PERSIONALLADVINJURY $4,000,000 ' Y - GENERALAGGREGATE S4,000,000 - RO . PRODUCTS-COMP/OPAGG f4,000,000 L AGGREGATE UMITAPPLIES PER: PNOY P LOC B .AUTOMOBIL9LIABILITY BAP 2938863-05 03/01/00 03/01/09 COMBINED SINGLE LIMIT S1,000,000 (Eaacddwo - X ANYAUTO ALLOWNEDAUTOS BOOILYINJURY S IPv perwn) SCHEDULEOAUTOS HIRED AUTOS - BODILYINJURY . - (Pv soadem) 3 NON-OWNEOAUTGS - X SELF ISURED AUTO PROPERTY DAMAGE S . IPv soatem) PHYSICAL DAMAGE AUTO ONLY-EAACCIDENT S GARAGE LIABILITY - EA ACC f . ' ARVAUTO OTHER THAN AUTO ONLY: - AOG i ' A EXClsmuMBRELLA LIABILITY IPA 3757 609.02 03/01/08 03/01/09 EACHOCCURRENCE f 5,000,000 X OCCUR CLUMSMAOE - AGGREGATE SS,000.000 S S OEOUCTBLE . f RETENTION f WC STATU• I OTH- C WORKERS COMPENSATKIN AND 1928757 (FL) 03/01/03 03/01/09 XLIMITS D EMPLOYSRS'UABILITY 1928756 (CA) 03/01/00 03/01/09 E.L.EACHACCIDENT 31,000,000 ANY PROPRIETORAPARTNERIEXECUTIVE X OFFICENMEMSER EXCLUDE07 1928755(AOS) 03/01/01 _ 03/01/09 EL DISEASE•EA EMPLOYEE $1,000,000 4deaaTRr wafer EL.DISEASE-POLICY LIMIT 11,000,000 E PROVISIONS W-W OTHER 0]/01/OB 03/01/09 ccurramee/SIR 25X/2N F TX Employers Xxcase TNS-C45197967 (TX) 03/01/00 03/O1/09 D Workers Compensation 1928739 (931) E Workers Compensation 11928758 (KY. No, NY, wil 03/01/08 03/01/09 IESCRIPDON OF OPEBATIONOILOOATION3I VEHICLES I EXCLWIONS ADDED BY ENDORSEMENTI SPECIALPROV131DWS FOR EVIDENCE ONLY - - :ERTIFICATE HOLDER ' CANCELLATION SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 330 DAYS WRITTEN HE NONE DEPOT, INC. NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LER,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS UR, 455 PACES FERRY RD.), N.N. BUILDING C-8 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE TLANTA, CA 303I9 USA LCORD 25(2001108)datkinson- ®A :ORD CORPORATION 1988 021321S i G63-A-G79 a3-a3 D8 Vinyi I .Yiniio 61G0 P=oduct - Doubla-bung I Vaatana da dobla 9u1114tina - Argon/Pro9olar I ArgbnJP=o9olar - , - NetlanelFeneetratlon 3/32" Class 1 2.39 sm Yidrio No Lasinatad Class 13ia vid=io laminado ® No Crids I SLa =ajillas monomm ENERGY PERFORMANCE RATINGS EVALUaaoNofRlarog IENTOaNERGEnco U-Factor Solar Heat GainCoeffic(ent .FaCorU - CodkloneeGmumdzdo BwglaSnlar 0 . 32 1 . 8 0 . 29 ADDITIONAL PERFORMANCE RATINGS EVALUACION SUPLBNENTARIA DE RENDIMUEN fO VlsibleTransmittance - W=nW ndeU2Vldble 0 . 52 - NemdemaeratlprDatma�nmm mWgomdarmmappamNe NRtcpxadammrdaemrwdno aemle podrdpmmnnance.lffN: - ratings ma datmmawdfw a(tlad woof wNkmmmnl mommne and aspeft pod ddat.NECdom not romwool mryPodet . madmamtwermmNe mthhBgrafmrYlaoduetmrmVapealb r®aC•»mtltnmo�Aaa301are0asfir60�pradstpadammrrce - mmmim.wwwnfromg - FSWUFlmrrlaeftbquememvlmm=VMrcnmeM=mb Mmappvdhede NRICpmadaWm*welmndrni*MWdd izedcb lm wbus rmtlmpor NFWsonagounkadmporoampadol(ode nod*=an 000fty an Wm do podrm0o - sspecMMNMCrommmleoderdrpmrPodrmfovmguxftgmdpmdribmpademmdopaaunueompecm=Comuwsmnd . pmeto�I[emmmroBpemeluou'WophlodemhptatiftwWwIft mg _ Unit gaaLiSias for ENERGY STAR - ragLon(a) : Northara, North - Cantaai, South Cont.al, IIouthavn. La ualdad caLillea para LAW SNE86f STAR - =agi6n(ws) RNERGY STAR: Norte, Norte Cantral, Sur Canteal, Sur. - •" IND: Rain GG/Class 3/32"/R-R43 . - Tastad Sizae 36" a; 93" IND: Raiuorzo a0/Vidrio 2.38 M/N-R43 DP " +45/-45 Tamatto grobado: 91./ om z 160 can fifi9fi�9fif�l. eG��3 RS Hoffman 2951120. Kmp d o lidol for parable EN RU STAR"mhaleLTo lean non uhHwwwAgystmgDv 6ulade esm diquam pm pau3les moludim ENEW SW plan mnotefmds alarm de am,vbb wwmmegp1milmt A IM \- Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registr�g) r,>t 126893 � E�Q,Iiatfafi�,) O10 _ -e•T U� ement Card The Home Depots;A^ wick RICHARD FALLONE= 3200 COBB GAL LEF;)1..,}1N1�#20 ATLANTA, GA30339�'—yam Administrator