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79 OCEAN AVE - BUILDING INSPECTION I r A 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 Application To Construct, Repair, Renovate Or Demolish a 413-596-2800 One- or Two-Fandly Dwelling Ext 118 This Section For Official Use Only Building Permit er. Date Applied: Signature: va.0 Building Commissi r/Inspector of Buildings Date SECTION 1:SITE INFORMATION - 1.1 Property Adgsl 1.2 Assessors Map& Parcel Numbers I.1a Is this an accepted street?yes no Map Number Parcei Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(It) 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❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Own t ecord: Name(Pant) � Address for Service: Signature --"'T Telephone - SECTION 3: DESCRIPTION OF PROPOSED WORK'(check al that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑ [Brief emolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ j3q-7 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: $ F4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ j' 0 paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name of CSL- Holder List CSL Type(see below) Address Type Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted 1&2 FamilyDwelling Signature . . M Masonry Only RC Residential Roofing Covering Telephone I WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered e-Im r vent nt£S trac r(HIC) HIC Compan ,ynae e e i tran amer /�^r Registr on Nu e Address l.� p fl Expiration at Signature Te SECTI 6: WORKERS'COMPENSATION INSURA E AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance the building permit. Signed Affidavit Attached? Yes .......... V No .._....... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTO 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. Signature of Owner Date SECTI N 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, 111 ,as Owner or Authorized Agent hereby declare that the statements and inform tion on the foregoing application are true and accurate, to the best of my knowledge and behalf. _ Print Na e — 4,1 A J;A S&Lphrre o Owne or Authorize Agent Date (Signed u er the pains and penalties ofperjury) 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 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 IO.R6 and 110.115, 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" i CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT construction Debris Disposal Affidavit (required for all demolition :utd renovation work) In accordance �%ith Ilse sixth edition of the State Building Code, 7SO CbIR section 111.5 Debris, and the provisions of NIGL c 40, S 54: Building Permit it 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 111, S 150A. The debris will be transported by: (uame of hauler) The debris will \beAddiisposed of in (twinc ul facility) � A 9`I/Ir p►�� (addre" ul IaCII11V) aenam c of p:nnn apllhcam ,gate The Commonwealth of Massachusetts Department of Industrial Accidents , Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lealbly Name-(Business/Organization/Individual): Address: 24 ftHCity/State/Zip: Phone#:_ Are yo an employer?Check the appropriate box: Type of project(required): 4. ❑I am a general contractor and I 1.IV,am a employer with�� 6, New construction' employees(full and/or part-time)." have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I p a sole proprietor partner- These sub-contractors have g..[]Demolition ship and have io emploo yees working employees and have workers' ng for me in any capacity. 9. [3 Building addition [No workers' comp.insurance comp.i*c„rance X 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 12. Roo a insurance required]t myself. [No workers'comp. c. 152, §1(4),and we have no employees. [No workers'• 13 Q i 5 comp.insurance required.] Any applicant that checks box#1 rust also fill out the section below showing their workers'compensation policy infonnstion. - . t Homeowners who subrndt this affidavit indicating they are doing all work and then him outside contractors.=at submit a new affidavit indicating such. m tContractors that check this box must attached en additional sheet showing the name of the sub-contractors and state whether or those entities have , employees. If the subcontractors have enrployces,they must provide their workers,.comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and Job site information A 1 n �� /L Insurance Company Name: '\ 1 t n t ^I )T22 � — Policy#or Self-ins.Lic.#:_ Expiration Date: Job Site Address: City/StatelZip: ':�7b 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 staternerif may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify Iserre p 'ns and penalties of perjury and that the information provided abov is tr correct St nature: Date: Phone#: official use only. Do not write in this area,to be completed by city or town of ciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector &Plumbing Inspector 6:Other Contact Person: Phone#: t` y� ,✓�e la' om�a%G4'a�.�aaaar��aeld 4L'9' Board of Building Regulations and Standards {r License or registration valid for individul use only HOME IMPROVEdEN,T CCINTRACTOR is before the expiration date. If found return to: - Regietra,[18. 126893 Board of Building Regulations and Standards EX ipn— /21110 One Ashburton Place Rm 1301 �yemeM CArd Boston,Mal 02108 I . The Home DepoQ i RICHARD FALLO -- 3200 COBB GALL fit 1" Z0 �TLANTA, GA.3Q339 --'' j Administrator Not v li• without signature ACORfla 02/2 CERTIFICATE OF LIABILITY INSURANCE M/00/YYYY, 2/26/08 PRODUCER 1-4.C4-995-3000 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequestOmarsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# INSURED - INSURER A.Steadfast Ina CO 26387 Home Depot U.S.A., Inc. The Home Depot, Inc. INSURERB:Zurich Af.e`rican 'I?is Co 16535 2455 Paces Ferry Road INSURER C.Illinois,iPkti Ins,,,Co 23817 Building C-8 Atlanta, C- 30339 INSURER D:'Amerioan Home Assur Co 19380 �4.1-' wSURER E:New Hampshire Ins Co 23891 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEUPTO 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOI POLICY NUMBER POLTCYEFFECTIVE POLICY EXPIRATION LIMITS TR TYPEOFINSURANCE A GENERALLIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE 54,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS PREMISES Ea occurance f 1,000,000 CLAIMSMADE OOCCUR "OF SIR: $1,000,000 PER CC" MEG EXP(Anyone person) $EXCLUDED PERSONAL&AOV INJURY $4.000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OPAGG S4,000,.000 X POLICY PRO- LOG JEC B AUTOMOBILE LIABILITY BAP 2938863-05 03/01/08 03/01/09 COMBINED SINGLE LIMIT X ANYAUTO (Ea acdde.J $1,000,000 ALL OWNED AUTOS BODILY INJURY SCHEOULEDAUTOS (Parparson) $ HIRED AUTOS BODILY INJURY NON-OWNEDAUTOS (Peraccidenl) S X ISELP INSURED AUTO PROPERTY DAMAGE ,$ PHYSICAL DAMAGE (Peraecidenl) GARAGEUABILRY AUTO ONLY-EAACCIDENT $ ANYAUTO OTHERTHAN EAACC S AUTO ONLY: AUG $ A EXCESSIUMSRELLA LIABILITY IPA 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $5,000,000 X OCCUR 1-1 CLAIMS MADE AGGREGATE S5,000,000 S DEDUCTIBLE S RETENTION $ S C WORKERS COMPENSATION AND 1928757 (FL) 03/01/08 03/01/09 X WC STATU- OTH- D EMPLOYERS'LIABILITY 1928756 (CA) 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETCRNARTNERIEXECUTIVE E OF FICERIMEMBER EXCLUDED? 1928755(AOS) 03/01/08 03/01/09 E.L.DISEASE.EA EMPLOYEE $1,000,000 oyyes.des«lea under SPECIALPROVISIONS EeIow E.L.DISEASE-POLICY LIMIT 51, 00,000 OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 Occurrence/SIR 25M/2M D Workers Compensation 1928759 (OSI) 03/01/08 03/01/09 E Workers Compensation 1928758 (KY, MO, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS -FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DES CRUISED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL 2455 PACES FERRY RD., N.W. BUILDING C-8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)datkinson ©ACORD CORPORATION 1988 8213215 Sep 17 08 09: 36a Michael Bedard 1-401 -246-2868 p.2 SEP-17-2008 08:520 FWTID MWATION 505-756-2B5Y T-W5 P.001/501 F-159 . ••••••,••PLEASE READ 71M �a C Sold.Fmoisbed and handledby-. Date: r 11L_ THD A1,RWc Services,lom jamel,Nmar Bu ro --y- dlbra The Race Dapor At-Hoax:SC1310e= 345AC3 wood Street•lkal Z+w'm=m.`dA OJW7 gene nrnMr: Toll Free(900)657-5192; Fax(508)756.8823 rs r1633 [3gaBh 31 g Cj U565122:MA Ham m'ter,balt & 3CoenuerorEc 0126993 M�u 7avtaflatloa Address: Stun yF pmmmlap Wart P[mm no.vl aea• j L I f Home Addrew Zip fdrrat 6om]wW onllati Address) Clry Slate i@ K-.MffAdAtBs(m wri a luajeet conamsaican?aa®d Home Depa cpdatesY- p T Do NOT wish to r ICI say m r"c"In8 enw,b fiom7ua Have DI Inform lissimigned CCuMm r").tM owners of dteProperty messed,rbe oboes installation addrea5,ngmHAI or cs is Ar- sine SavSuc.lva(•'The Him DePtfT Ellice°m itattidt.tidier¢and epmrge for the Iosmilatioo low�C C1 this all ma¢rims d ffiy .Qable 5ffie S1rPvlr+omr and Psymrnr S the below 20 w,the refireaced Spec s'm°t¢y avaehod h¢ewP"d was any�CiroBe�r+s(calf¢VNY. reference,along with a tAmmet 301 a�aw.wa ws i 14o - Roafag�da8 odiowa lamlmm $ Qv [)OmasI Covers EMD"Deaa ` cants Limam IJ Wlodows ]awiaaaa $ [3Gamn f Corm OPmay Doan EL- II,W.—. lrmdeaso $ []Oarwn/Cwm�yDavnlT srmdaas rv>Awim $ ❑owtrA/Coto,[3aoY13eors❑ - 26aimmt LA.DcyamafmahalAmomfimaPmfllaboadHasa°vbaa- Taal Cas¢tR Antoonf S MamePmAwsae6m depwfmaeOmeoeddrd�AeCarar+rrAmemf Cuatmtt¢°Deer dI i,,, d aidy upao co ladim of the w6rk fa each PHdm�t"'� etch Correa¢under 4+a (one gar earl Prothro:as�a by ant ob rdom�e�) ml' Cootractal7ea mbeloimly and tzvaaly' Egdmd The Home Depa reserves the right to lshrucroder sueeClmge Orderorferminate this Comractm Myierdual ibrrm its obligations due tded o a structural _ s d'a¢edaa.if The Home DCPat a to author ced serviea Provides deret>maa toss u emmt 1 rm s,cem pricing armsa because problem wdb the home,enventtmmtol bastards an&as tepid.astratos a Irad pain•outer eatery tank regabed to coaplem d ajob was set inelede d in the Centraa. n4C 1'1� . mdaded as port of this Crmcl,ads fir0t the mini Paymerw summary The Paymem St-1'- t tadmd grd by . Gamines aoora¢nndpeymenrstW�rd f¢Bre dratrBits u PeoNx[(as aPPliubl°} II NOTICE TO CUSFON" Do not sign a Compktlar Cernmre(eae Yoe as,ssided an tmplttdyWedin CM of the ContrwctAtthe t Spat Sheen)bests,work w spas Psdoa [me you agu• ffi there is art Completion Cerddiesse far eaeb listed Prodect as de0aed by individual Is eomplein to rice Lem or remiemion m tb6 Contract,Container a;.ees to Pay the Home the Costs of tmrterialA Sabin.err other and acrvca Provided M'���t m Auftn=t San;ce w. TU r thr the dine d'termioalia4 pFm any other menu set(tern in IM AA�g�emmc�xt or allowed Under a�0p0p ble Ivw. 7•P61f0 DF1'OT MAY MTs MADE. AMOOKFr OWED TO T- --- IE DEPOT FROM THE DEPOSIT• PAYMENT OA OTHER PAY !VYENTS MAD¢. WI'I'ROVT LIMIFENG TOE HOME DEPOT'S OTEHH RnJEDIES FOR RECOVERY OF SUCK A--'d IId7S. pre U betwers,Cardenas m ties: Cmtum¢oEsas and tadetRand.that This s e ins t�discussions ob eat¢ aod'tke Depot widr¢(Pad td Poe hodaas and ktYaHMnn swiees and sepe oral awritten,reyBag m said Pm"m and T,,.a,natiaa This Aflo.•tmem estma be assigned or a,d a a ds,voluntarily writing signed � by Costumer mrd The 13tm Depot.Cunmr¢acknowledges and aDas ego Gamin¢has read,mW¢euads, mrrm of and has received a copy of this Aseea L 7 'r �Ip s a S m� � p Sl O — TerlamineNa-�'µ'� canaFI is a S2gmntre Dana Sala Coastdum LieeMeNo. aft k (as� aaW GNCEI.TAnON: C09TOMER MAY CANCEL T1015 AGREEMENT WTFROUT PENALTY OBLIGAIPION LI HOME BY DELIVERING WRII NOT DEPOT DY MIDNIGWI ON THE THIRD BUSINESS DAY AlITEE SIGNING TRIS AGRt MMEN7: THE STATE SUPPLEMENT ATfACRRD MUCTO CONTAINS A FORM TO USE IF ONE 19 SPECIFICALLY rmscmmsas BY LAW IN 'C•Y v. ..._V 9 CUg UMEIR'S STATE No,H=-A�rrIONAL La8M8ANDCaeOYDONSABB STATE,ON TBEEEPEeaE yOEANe AlmPwm'W'196 CDcrIBA,CT 841%=G4c WND-ataaa,Fls Yeatw-Cwelurmr Ptaa-adea CattaamA