77 ORCHARD ST - BUILDING INSPECTION _ 2 9 - ' 313
1 31 J 203 2
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FO&
Massachusetts State Building Code,780 CMR,7"edition MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January
One-or Two-Family Dwelling 1,2008
This Section For Official Use Only
Building Permit Num Date Applied: —3C�"
Signature: �U
Building Com spec of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Add��A,44 fE 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.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'
Owne of ecord Name(Print) r
A �efr sKrvy ce ",
!See G14641L
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION C04TS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ dicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(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 Construction Supervisor Lie use(CSL)
EkLicense umber Expt tion D e
Name of CSL Holder ' �)
List CSL Type(see below)
No.and Street 1 Type Description
IPA
U Unrestricted(Buildings up to 35,000 cu.ft.
City/I'o tate,�ZIP R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
/ SF Solid Fuel Burning Appliances
9 r� 1 Insulation
Tele Ine Email address D Demolition
5.2 Registered Rome It raven e t Contras HIC)
HIC egistration umber E n Vale
HIC y e ant Jame
d
No.and III Email address
rot
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be co eted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest un he pains an penalties of perjury that all of the information
contain in this annli' ti n is true and ac th est o y wledge and understanding. /
111C��
Print OwAoVs or Authorize Agent's Name is Sign D e
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 can be found at
Information on the Construction Supervisor License can be found at
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1r 600 Washington Street
e's.
Boston, MA 02111
{r��..f--r'ici
_ems:;'' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblti
Narne (Business/Organzatiomgndividual):
Address: t�wlly PYs�r
City/State/Zip: hone #:
Are you an employer?Check the appropriate box: - Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. El 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
p '. :ees
These sub-contractors have v 7 llgmnlition
workingfor me in•an capacity. employees and nave workers'
Y P tY 9. ❑Building addition
[No workers' comp. insurance ! comp. insurances
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plyt>'nbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. oof repair
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other_
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing thew workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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 eu4.1loyer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information,
Insurance Company Name: �—
Policy#or Self-ins.Lic.#: 14 Expiration Date:
Job Site Address: City/State/Zip:— IS.
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 IA for insurance coverage verification.
I do hereby eerti an r pai and nalties ofperjury that the Information provided ab veils true and correct.
Signature: Date:
Phone 4:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitfLicense#
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#:
THIS CERTIFICATE IS ISSUED AS A M4I TER OF INFORMATION ONfl Y AND CO ar' P tic mc-H73 UPOiN 7HEP G. R !C"i HOLDER. T 1
I CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR AlTER THE CEVEVGE Ari " AEU a'- -+ POLICIES- I
B:LDVI. THIS CERTIFICATE OF iNCUF,AtiCE DOES NOT CONSTITUTE A CON RA_T BETWEEN' THE ISSUING IN4J�Et.t51: Ai7fHOftZEIJ I
R_FRESENTATWE OR PRODUCER,AND THE CERTIFICATE HOLDER. -
=---- -
1 INIPOnTANT; If the certiticaia Felder is an ADDITIONAL INSURED,the po!icy(ies)to psi ce En dOrsed. h SU5ROGATION 1S WAIVED,subje:ci!c� ' I
Le i=_Tms and e0ndi`iena of the Policy,certain policies oirw require or;F;;, =_=_mer,Z. A eEaiemer!!0!:Urz cedrlcat0 doe:na:conf=r rinhta to the i
r,
cemFicote holder 11 lieu of such encorsement(s),_" —
I'FCOLCFR CDh ACr
HARSH USA,INC. NAME'
TWO ALLIANCE CENTER PHONE -- - - FAX
,i.TK IsNOX ROAD,SUITE 2900 E4
4vL — —
ATLANT,4 CA 30325 ADDRESS __-
j INSUR R{ JAr OROOJv CO ERn N:1:0.
i !SUS?HD'ne0.CAW-11'; INSURER A.o,aadfast lnSura ce C ,po ny.
INSURED
HONE DEPOT,INC. INSURER 0 z Zurich American Irsuarca Co IE a5
HOME DEPOT U.S.A.,INC. - INSURER C;New Hampshire ins CD 93841
2455 PACES FERRY-ROAD,-NW- IMOCIS Nahond in;Co "
BUILD NO C-20' INsuaea a ,23817
Al IANTA,GA 30339 INSURER E:
INSURER.Fc
COVERAGES CERTIFICATE'NUMBER: ATLZ3159545-04 REVISION NUMBER:-I
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW!HAVE BEEN 18SUEO TO THE INSURED NAMED A80VE 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 Or SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -
INSR -
LTR TYPE OFINSORA MO—M SUBR NCE POLICY NUMBER POLICY EFF POLICY EXP --_—'—---
__ IMMNDMYYYI MMIDDYYYYY LIMITS
A ceNERA!:uaelim GL04037714-03 0300112013 WjD1 014 EACH gccuRRENCE 5 9•W0,00D
X COMMERCIALGENERALUABUTY - DAMA TORENrEO- 1,000,OOO
-PREMISES fEa S _
CIPJMSmMADE . OCCUR LIMITS.OFPOUCYX$ - MED EKP(ANY Erie arson) S EXCLUDED
Of SIR$IMPEROCC - 9pW;00�PERSONAL A a V`INJURY - 5
. - - GENERALAGGREGATE_ 5 9,000,000
GEML AGGREGATE LI,NI(TAPPUES FER; . PRODUCTS-COMPIOP AGG--S .9,OW,000
' X POUCY .. . PRDT. LOQ.`. $ -
B aurDrvIDBILE uae!Lin. - BAP293BRT10 . . 031012013 0310112N4 COMBINE SINGLE[!MIT ?5-1;000,000
ANYADTD DODILY INJURY(Per person} $
AUTOWNED, scNEouLED SELF INSURED AUTO P.HY DMG AU705. AUTOS - BDOILY.INJURY(Peracatl t}NON OWNED
S
' HIREDAW05 .. .y_: ' :.'_� ' � PROPERTY DAMAGE
ALR05 $
- Per acdtlent
5
.UMBRELLA LIAR OCCUR
' EACH OCCURRENCE $
.EXC[55 UAB CMMS-MADE - AGGREGATE_ 5
DED RCfENrIDNE _
C WORKERS COMPENSATION W'C0;3575319(DOS) " U3N72013 U31D1l2U74 X v+c sl Aru, �DT4+ —
nNo EJ>,PLorERs unalLrty _
C ANY PROPRIETORIPARTNEWEXECUnVE YIN =33575315[AK,AZ) 03/01/2013 03V12014 1,(100,000
D OFFILEwryIII NNI)EXCLUDED'1 ,�- NIA ELEACHACC!DENT 5
(Maoaamry In NH7 WC0 3 3 57 5 316 AFL) 0310112013 0310IM14 EJ_DISEASE-EAEMPLOYE S 1,D00,000
tt rS;,dgOe under' 1,000,U00
DE SCRIPTION OEOPERATIONS belov EL DISEASE POLICY LIMB. 5
C. WORKERS COMPENSATION EL
NQ,.NIL VT) 03N72D13 0310112014 (EL)LIMIT 1,000,000
C WC03357531R-(NJ) 03AJ120.13 - 0310112014
DESCRIPTION OF OPERATIONS(LOCATIONS I VENICLES IAIIach hCORD inl,Atldllional Remarks 5inednle.Il me,e space is required) J^�
EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION '
THE HOME DEPOT TIN - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
H55 PACES FERRY
INC. THE EXPIRATION DATE THEREOF,-NOTICE WILL BE DELIVERED IN
BULL PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS..
BUILDING G20
ATLANTA.CA 30339 --.
._ AUTHORIZED REPRESENTATIVE
Qf M=h-USA,Inc. ; -
Manaihi Mukheljee 31tla.0 kZ INOOL QUNI -. L
0 19 6 8-2010 ACORD.CORPORATION. All rights.reserved.
ACORD 25(2010105) -- 'The AQORD name and logo are registered marks'of ACORD ..
.'. .. N
1?Po�vr�wruueasG6a O�✓1.��N^�Y.�Ci ; -. '.; -'.
- �� OI(iceotCgns�m�e4A,tCairsFi�usmessRegUlat.on 'Lrceri5 CrregistYattonralidforindly'tiju}ice o*t1y ,
DME Ih1PFbYMF�N7 C0{JTPACTOR bzCo,a the eYj irgtaon dnte; if sonndretutn to
Uffice of Consumxt Affalrt�t d 13usines nc�uth;ion ,
Regktratlon'6,93 t TYPe; k0.1 arY'P1nza L Suite 5170
Ex I6ra� ' Supplznertt erd Eo'on,ttt 02110 '
The homeDep;'o
RICHARD TALL
2690 C.WMBERIA " 5 Cam. sv7Er 4 ,r 4
GA;3033'9 o �, `otvalidxithautsignatni•e'
CITY OF SM-.& i, �LaSS.�CHL'SETTS
Bt:li=NG DEPAEM E,VT
• b� 120 WASHINGTON STREET, r 1'LOOR
TEL (978)745-9595
F.Ax(978) 740-9846
ICINfBERI-EY DRISCOLL
MAYOR THmus ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNIG COMNOSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(nameofh uler)
The debris will be disposed of in
(name of facility) \ `
(address of facility)
ignature f permit applicant
are
•IcbriulCJm
3
a
,r.
xx
H�
HOME IMPROVEMENT CONTRACT Sold.Furnished and Installed bv:
PLEASE REEAD THIS CONTRACT rtiD At-Monte Services. Inc.
d/b/a The Home Depot At-lionic Services
908 Boston Turnpike Unit LShree>bury lA I i45
Branch Name: Boson North Datc:,y/;Il2013 Toll Frce 8779033768Yax 800986,610
MG Lic P. C 024 39 RI Cont.Lic# 16427
Brunch No: 33
CT Lic f Ii1C.0565522 MA[ionic Improvement
Contractor Rct_!.# 126897 Pcdcrul ID p
7i-2648460
Installation Address: 77 ORCHARD ST Salem CIA 01970
City State Zip
Purchaser(s): Work Phone: Home Phone Cell Phone:
Mr.Peter Mainville (617)426-7330 (978)740-5047 I`)7F 740-51147
Mrs.Paulina Mainville 978 740-5047
Home Address: . 77 Orchard Street Salem VIA 01970
(Ifdifferent From Installation Address) City State Zip
E-mail Address (to receive prgject communications and Home Depot updates): Mainville(id116lYorld.com
Marketing entails will not be sent from The Home Depot.
Project Information: Undersigned("Customer").the owners of the property located at the above installation address. agrees to 170,
buy,and THD At-Home Services.Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installati (pf
on")ofall materials described on the below and on the referenced Spec Shect(s),all of which are incorporated into this Contract 9 l
by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders
(collectively,"Contract"):
Job#:(lnirnml Reference) products: Spec Sheet(s): Project Amount
7015785 Rooting I 7015785 S10.467.00
Minimum 25% Deposit of Contract Amount
-due uponexecution of this.contract Total Contract Amount S 1OA67.00
Customer agrees that, immediately upon completion of the work tier each Product,Customer will execute if 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 be jointly and severally obligated and liable hereunder.
Payment Summary: The Payment Summary s 7015785 . included as part of this Contract,sets firth the total Contract
amount and payments required for the deposits and final payments by Product(as applicable).
GENERAL TERMS AIND CONDITIONS
Responsibilities:
The Home Depot: will provide the Products identified above,make arrangements to have the Authorized Service Provider perform
the Installation services in a professional and workmanlike manner,and arrange proper insurances. Unless otherwise expressly
provided for herein,Authorized Service Provider will obtain required perniiis and provide permit numbers.
Customer:will identify any property lines.easements,covenants. underground or overhead utility lines,pre-existing physical or
11laN12-SA Page t of 7
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS CONTRACT
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of this Contract,signed b7 both you and The Home Depot,at the time you
sign. Do not sign a Completion Certificate before the Installation is complete.
Acceptance and Authorization: Customer agrees and understands that this Contract is the entire a;recntent between Customer
and The 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."['his Contact cannot be 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 Contract. Customer acknowledges receipt of the Notice of Cancellation,and that The Home Depot has orally
informed Customer of Customer's right to cancel. Customer's signature below constitutes Customer's acceptance and
execution of each of the applicable Contract Documents. DO NOT SIGN THIS CONTRACT IF"THERE ARE ANY
BLANK SPACES.
You are entitled to a paper coPy of this Agreement if you choose. If you consent to an entailed copy,your consent applies
only to this Agreement. By contacting sales office t377)903-3768 ,you may update Your email address,withdraw your
consent,or obtain a paper copy of the Agreement at no charge. By signing below',you confirm the following:
• You consent to receive only an emailed copy of this Agreement
• You have access to a computer that can receive and open entails and PDF(Adobe Reader Version 10.1.4 or
later)formatted documents.
• Your email address is correctly listed on the Home Improvement Contract
Submitted by:
Sales Consultant Nicholas Paccione
License Name.
Telephone No. (877)903-3768
Sales Consultant
License No. (as applicable) .
CANCELLATION: CUSTOMER MAY CANCEL THIS CONTRACT WITHOUT PENAL-I Y Olt OBLIGATION BY
DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE-THIRD BUSINESS DAY AFTER
SIGNING THIS CONTRACT TO THE ADDRESS LISTED ABOVE. THE STATE SUPPLEMENT ATTACHED
HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S
STATE.
Mr.Peter MaintAlle(Aug 31,2013,11:40 PM) Accepted by:npaccione(Aug 31,2013,11:40 PM)
11AUV12-SA Paue 6 of 7