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53 ORD ST - BUILDING INSPECTION e°Lz�zs The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM 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) t3awr SECTION 1:SITE INFORMATION 1.1 Property Ad r��� 1.2 Assessors Map&Parcel Numbers a � 1.1 a Is this an accepted street?yes _ no Map Number Parcel Number 1.3 Zoning Information: 1.4 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.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 Owner'of R ord: �,,/� � ts►� � " q1 01 Name(Print) City,St ,ZIP�No.and Strcertt Te1e Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check 3JI that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Erl Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work 2. n SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ L Building Permit Fee:$ 0 In icate 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 (RVAC) $ 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 Construed u er�\�se1r/�License(CSL rLicense EWra1 n ate Name of CSL Hold / �`�, l )) List CSL Type(see below) No.and Street 1�/IIr4rlFd-tyG� Type Description r U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,Z M Masonry RC Roofing Coveting WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone " Email address D Demolition 5.2 Registered Home hi provem of Con ctor(HI� HIC Registration Numr ion ate HIC Company Name or HIC Regista-dritNaine Email address Ci /Tow State,ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be compjpted and submitted with this application. Failure to provide this affidavit will result in the denial of the 1ssuancSpk1fe building 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) 9 to SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby atte nd the pains penalties of perjury that all of the information com7 in this a 'cation is true and a to e b st y knowledge and understanding. Print Owner's or Authohzed Agent's Name(EI nic Si ure) ate 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.fL) 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" Ht)AtF:IMPROVEMENT CONTRACT Sold,Famished and Installed by: PLEASE REAL?THIS C'ON't RACY THD At-Honic Services,Inc. d1bla The home Depot At-Home Services 908 Boston Turnpike Unit I,Shrewsbury,MA 1545 Branch Name: Boston North Date:12117f2013 'roll Free 8779033768;Fax 8009863610ME Lie#C 02439 RI Cont.Gc#16427 Branch No: 33 CT Lie#HIC0565522 MA Home Improvement Contractor Reg.# 126893 Federal ID# _ 75-2698460 Installation Address: 55 Ord Street. Salem MA 01970 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: Ms.Jean Monahan (617)834-9269 978 3544041 Home Address: 55 Ord Street. Salem MA 01970 (If different from Installation Address) City State Zip E—mail Address (to receive project communications and Home Depot updates): 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 buy,and THD At-Home Services, hrc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installati on")of all materials described on the below and on the referenced Spec Shect(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'): Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount 7273254 Windows 7273254 $3,211.78 Minimum 25% Deposit of Contract Amount due upon execution of this contract Total Contract Amount $3,2'I 1.78 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 be jointly and severally obligated and liable hereunder. Pavment Sununarv: The Payment Summary# 7273254 ,included as part of this Contract,sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). GENERAL TERMS AND 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 permits and provide permit numbers. Customer: will identify any property lines,easements,covenants,underground or overhead utility lines,pre-existing physical or nrJau-sa Np 1 o1 15 HOME IMPRO'i, EMENT CONTRACT PLEASE RF,AD THIS CONTRACT NOTICE TO CUSTOMER You are entitled to a completely tilled-in copy of this Contract,signed by 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 agreement between Customer ,aid 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.This Contract cannot be assigned or amended except by a writing signed by Customer and'I'hc Home Depot Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terns 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 emailed copy,your consent applies only to this Agreement.By contacting sales office (877)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 emails and PDF(Adobe Reader Version 1.0.1..4 or later)formatted documents. .. • Your email address is correctly listed on the Home Improvement Contract Submitted by: -Sates Consultant Jason Beisiegel License Name. Ms. Jean Monahan (Dec 17, 2013, 12:42 PM) Telephone No. (8 77)903-3768-- - �� �� �0 Sales Consultant License No. (as applicable) Accepted by: JB68(Dec 17, 2013, 12:43 PM) CANCELLATION:CUS'rOMF,R MAY CANCEL THIS CONTRACT WITHOUT PENALTY OR 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. 11 aa`12-SA Pate 14 of vi is t r15 TI c-i, r nlnr ,�i 6'LEr r P ov jlt',qtl?11.1 4 , „i `v OTiiC!"S' L.O ri]3�1;Sn fill•: I3t°. Li1.11 ° Ai.11 it. '_..Ilu uuiicartlnf ,rmaLi -- — --_— # ' CIni7,IS t$iB/L7➢' �� 4--��°� hO;IC t~ Are}o n employer? Check the appropriate hex. Type of pt o)ect(re(Ju 1 ed): 1 ' l r r am a employer with_ `� 4- I ,m c g ntral m0"Im and I have 1,n d tl e uti conuacio s' emnlcFees Iluh andlor parttmc).= --� I —t list r' nn h � ar,h=.d tL t,et i V A model-ng ), j I m a c le It -T nr arm l-p .,pr.,,. p : Th s- sul trnra,.rnrc}teae &. (w�Deau1 tine shia e ra t_no employees i I working far me to any caparty. m}rlraPsz c� ' averno a �� 9. �Pulri tadt; l Coo 111S1. Il C" I I No o�]<>_!s' comp wsuralce I t�e are a cc rroranor no its i1 1(L❑ale 1 u dl ep 1 �or addmons eqm ed ] oefiL-rshar c exercised their _ L�damn nr.rep sir or additiaet S 1 am a homeowner dos-0work: n v1a[ion _ :ld of o t, Jc MG, 1_.❑ myselY [Ivo wo he-s' come. j I and insuraPCC rFOLtr..d ] i c 1;3.. 61r,. dr �h .�� nr S _1 mia� a5. NOW,",_._' cmm�.insurance regoired.l j i i I Iry appucam tam sheds 1 o k I nust.ls�Li no' th cecl or oelnw chm tl.cl 'wktrFmop <a sn onl in�o v m I i Homnnwoers whn utmi'this a- i It m dice n are Ju'n all t+t i men hirev run,, a.I.ac or 'Cni r,¢tnrs that Fe this hn must atm.nn d n a atnn she. ch win- h nc n:in tY cry racer. u d ware o nil�,hos_eni i_.,her; emn.o.ees. if tn..sao-e,^,ni a.rors na,e uanlm : n act Tin id,t9el •o kern. co r r umh... - I and an employer[tzar ia-providill worlrers'campertsariarf insurem f for nr,entpfovees: 6elnm is[he nnficl• nndjuh wire j I u;jornzaaon, Insu Fall ceComnan) Name: Poli .y �o Seti-ms Ll _ ration Date. lab Site fi Gr1 Jt11-r�;F:_. --- Z21.. Attach a copy of the workers'compensation policy declaration page islaowing the policy number and expiration date.i. Failure to secure cove-aRt as required under Sectlnn ^_5A of N G,_c. 1 - can I-ad to tht imnos tior c f C7rn mal p ra¢ies n / r tiff. fire up to S; 500.00 andror c rep, P impn5n� rle t at w 1 ll a,civil nulii t zr tint ,i rm oL a STOP jnORn ORDER and of up lo.S ih(ir! a day a r,t f,e :iulainr. P a :ao t'la aupy n hi ,statem nt ma1, he tar..ard.,o tx:r4e Orti,e o,`' 1.r�.cstie8 Ti r{.tI ALi ins]rnc '.:'n_vr n._Venice - m. ) do herehr e rri.ft` under ne ..in, lid n^na.ln-es of perjury d oim at the wformm�:on plOd aoc me is cr e uld con cn. J . pfryrinl use nnh:, Do not xri[a i.n.this area. to be conzplered!ry cin�nrtml•n official City or T own: F`ermi(1.icense k I .I Issuing Authority (circle Doer. 1.Board of Health `'.Buildin_Department 3. Citj iTown Clerk 4. Electrical inspector 5.PVu nnirg Inspector i (i. OEncr Conta^tnerSnn I'honeLr i i I (td M I CERTIFICATE OF LIABILITY INSURANCE DATE 027272 ,CIOOlYYYY) 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. If 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 CONTACT MARSH USA,INC. NAME` TWO ALLIANCE CENTER LAIC No.PHONE xt. AIC No: 3560 LENOX ROAD,SUITE 24DO E-MAIL ATLANTA,GA 30326 ADDRESS: INSURER B AFFORDING COVERAGE NAIC p 10W92-HomeDGAW-1014 INSURER A: Steadfast Insurance Company 26387 INSURED Zurich American Insurance Co 16535 THE HOME DEPOT,INC. INSURER B: HOME DEPOT US.A.,INC. INSURER C:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD,NW INSURER D:Illinois National Ins Cc 23817 BUILDING C-20 ATLANTA,GA 30339 - - INSURERE: INSURER F: COVERAGES - CERTIFICATE NUMBER: ATL003159545-04 REVISION NUMBER:7 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 ADOL BUBR POLICY EFF POLICY EXP LIMITS f LTR TYPE OF INSURANCEHIMYU2 POLICY NUMBER MMIDDNYYY MMIDDNYYY A GENERAI LIABILITY GL04887714-03 0310112013 0310112014 EACH OCCURRENCE $ 9,000,000 X DAMAEL TOR NrEO 1,000,000 COMMERCIAL GENERAL UABIUTY PREMISES Ea occurrence $ CLAIMS-MADE aOCCUR LIMITS OF POLICY XB MED UP(My one person) $ EXCLUDED OF SIR:$1M PER OCC PERSONAL&ADV INJURY $ 9.000,000 GENERALAGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 9,000,000 X I POLICY PR0.JECT LOC $ B AUTOMOBILE LIABILITY BAP 2935863-10 0310112013 0310112014 COMBINED SINGLE LIMIT 1.000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ - ALL OWNED SCHEDULED SELF INSURED AUTO FILLY DMG - BODILY INJURY(Per accident) S AUTOS _ AUTOS NON-OWNED PROPERTY Oaccident)DAMAGE $ HIRED AUTOS AUTOS Re $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE jAGREGA $DED RETENTION$ SC WORKERS COMPENSATION WC033575314(AOS) 0310112D13 0310112014 OTH- AND EMPLOYERS'LIABILITYG ANY PROPRIETOR/PARTNERIEXECUTIVE YIN WDD33575315(AK,A2) D310112D13 D310112D14 T $ 1.DDD.DDD D OFFICEILMEMBER E%CLUDED? _ �[NIA WC033575316 FL 0310112013 0310112014 1,000,OD0 (Mandatory n any ( ) E.L.DISEASE-EA EMPLOYE $ If yes,tles«ibe under 1.000,C00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C WORKERS COMPENSATION WC033575317(KY,NC,NH,VT) 03MO13 0310112014 (EL)LIMIT 1,000,000 - C VVC033575318(NJ) 031012013 03101/2014 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) EVIDENCE OF COVERAGE CERTIFICATE HOLDER - CANCELLATION THE HOME DEPOT INC. - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING C-20 ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee J•�r.�1ADOWi Jd..al[.uA -� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) - The ACORD name and logo are registered marks of ACORD � � ✓,fie 'L�a;rs,:eoacusers�f,� are°.///�n;,:ur>�:uszte -, -' . .Office of Consumer Affairs Fr Bnsmess Re a.ian ��i- License as tcefaira3in,r�r3ad for iu divide,l use only TOME IMPROVEMENT CONTPACTOR before tIIQ eapiratrodi t3 A If found rcium tr, - Office on Consumer AfWn amd`R ,3.n.�s Rcniitatiba F Registration 126893 - T pr r �a r is�art<�laz� sn,�e�,i�i? Ex 'I g/3/2014 Supplement yard PP .. BDston,IVIA 02116 The Home Depot kt HorrPe;$e[vi4es - RICH e%AILLONE - 2690 CUAIIBERLkP1D PARKr1Uk.Y S g -7 _ 1� - Undersecretary ']oY valid N 3thoui sionadun i ' Q : ��, CITY OF SiU ENM N-WSACHUSETTS Bu=L\G DEPART1l&NT 120 W-ASHNGTON STREET, 3"0 Ft00R TFL (978) 745-9595 KENWERLEY DRISCOLL FAX(978) 7.10-9846 NL4YOR T Ho.\L{s ST.PmRn DIRECTOR OF PUBLIC PROPERTY/BUI LNG COSOIISSIONER 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 I t I.5 Debris, and the provisions of MGL c 40, S 54; Building Permit fl 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 NIGL c 111, S 150A. The debris will be transported by: (name oFltauler) The debris will be disposed or in ------ name of Facility (address of facility) si iature o permit applicant 1+ i le • _ 'Pt � Massachusetts Department,rtment of Pi h tv 30, otBudding Regulations anck a i ..r-,ense: S n8csa MA Oj970 i Cnrrisni vruner 0210612014 3