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55 ORD ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts J Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, T"edition Building Permit Application To Construct. Repair, R/�enovate Or Demolish at*0000"M One- or rwo-Funuls DtveUi 8 This ton For Official Ost Only Building Permit N r: Date A lied: signature: /D.�i3/g.5 Building CommissioneWInspector of Budding. Date SECTIOIk ,E INFORMATION I.1 Property Address �n .2 Assessors Map 6 Parcel Numbers 1.1 a Is this an accepted7 street?yea no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage 1 R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rev Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.a0,fSa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zorie: _ Outside Flood Zone? Municipal O On site disposal system O Public O Private O al Check if sCl P Y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: � ��i_� � rv, — 7�197r-s Name(Print) Address for Service: Signature Telephone SECTION l: DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction O Existing Building Cl Owner-Occupied O Repairs(s) Alterations) O 1 Addition O Demolition O Accessory Bldg. O I Number of Units_ I Other O Specify: Brief Description of Proposed Works: F SECTION k ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Offlelal Use Only Labor and Materials 1. Building f _ I. Building Permit Fee: f Indicate how fee is determined: O Standard City/Town Application Fee 2 Electrical f 0 Total Project Cost'(Item 6)x multiplier x J Plumbing f 2. Other Fees: f i. Mechanical IHVAC) f List: $ Mechanical (fire f Total All Fees: f Sinnrpilinnl Check No. _Check Amount: Cash Amount:_ 6 Total Project Cost f 0 Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Co1nst_ru—cttion Suuppersisor iCSL) tI-sjJQa:Z7 ,� �/'VIGfL�C�)1 •`A nL[s jCn License Numbcr Esptr ion ate NyaealiM(� �,- el List CSL Type(we tk-luw) Type I Description U Unrestricted(up to 35,000 Cu A A s R Restricted IAr2 Family Dwelling Sglnamrt %A slawnry Only RC Residential Roofing Telephone �� w'S Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation D Residential Demolilton 5.2 Register Home 1 rove eat Cy actor HIC) /n� HIC C t,or H orgtst � � Registration Nu ber ryjr- A Less Expiration a Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(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 f the building permit. Signed Affidavit Attached? Yes.......... No........... 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, C D (?V&a as Owner of the subject property hereby authorize T to set on my behalf,in all matters relative to work authorized by this building permit application. Si attueofOwner Date SECTION 7b}t://OWWNEW OR AUTHORIZED AGENT DECLARATION Yll i�YC 1, El I t,W.0— ,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. Print Name Signature of Owner Authoriz g nl Date Signed under the ins andpenalties 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 have access ro 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 I O.R6 and I IO.RS, respectively. 2 When substantial work is planned,provide the information below Total (loon 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 7vpe of cooling system Enclosed Open 1 "Total Project Square Footage"may he substituted for 'Total Projecr Cost" CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT M ,,,nc I20 WAM IIXG;(,V StN LrT♦SA1I'\1, �1.\Si.0 111 a r. t9 v78-745-9j95 • FAX:978-740-9846 Construction Debris Disposal Affidavit (required I•or 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 tt _ is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be transported by: I name of hauler) The debris will be disposed of in `(n'a�me ulII acilify) laddress of facility) signature ,PI le nnttapplicant date �— 4ohn ull d•m ACORD,;, CERTIFICATE OF LIABILITY INSURANCE G02/ 0/090/09ATE2I PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION :Sarsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE. CERTINCAT'E HOLDER. THIS CERTIFICATE DOES N07 AMEND, EXTEND OR •acmedepot.certra?uestomarsh.com ALTER THE COVERAGE AFFORDED 6Y THE POLICIES BELOW. 3475 Piedmont R3 NE, Suite 1200 Atlanta, CA 30105 e'ax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIL ft t:-JHu INI IA RL:aadE tIReC 2138% Z•+rich American lr, Co A .35 ?6^.0 Cvnurerlarid Parkway, ___—. _ II:$UUEi:f._NRTIONAL UNION FIRE TNS CO OF PI1'1'S 19445 —_ ---- Atlanta , GA 30339 INSURER D:New Hampshire Ins Co 23841 INSURERE:111inois Natl Ins Co 123817 COVERAGES THEhOLICIES 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 SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSft ADDI POLICYEFFECTIVE POUCYEXPIRATION Tft POLICY NUMBER CATE(MM/DDMI DATEMMIDO LIMITS A GENERALLIABILITY IPA 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $4,000,000 X COMMERCIALGENERALWABILITY LIMITS OF POLICY ARE EXC SS PREMISES Ea NTE5cundrce) $3,000,000 CLAIMS MADE El OCCUR 'OF SIR: $1,000,000 PER CC" MEO EXP(Any one person) $EXCLUDED PERSONAL B ACV INJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $4,000,000 X I POLICY 7 PRO LOCI B AVTOMOSILELIASILITY BAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT $1,000,000 X ANY AVTO (Ea accitlenq ALLOWNEDAUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIREDAUTOS BODILY addide t) $ NON-OWNED AUTOS (Per accident) X SELF INSURED AUTO PROPERTYAGE S PHYSICAL DAMAGE (Per accident)ident) GARAGELIAOILITY AUTO ONLY-EA ACCIDENT S ANYAUTO OTHER THAN EAACC S AUTO ONLY: AGO S A NEISIUMORELI-ALIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $5,000,000 Or.CUR CLAIMS MADE - AGGREGATE $5,000,000 $ DEDUCTIBLE - S RETENTION S g C WORKERS COMPENSATION AND 3566916 (CA) 03/01/09 03/01/10 % I WC STATU.LIMITS ER 0 EMPLOYERS LIABILITY 3566915(AOS) 03/01/09 03/01/10 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETORIPARTNERIEXECUTIVE E OFFICERIMEMBER EXCLUDED? 3566917 (FL) 03/01/09 03/01/10 EL.(DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER D Workers Compensation 3566918 (KY, MO, NY, WI, ) 03/01/09 03/01/10 r. F TX Employers Excess TNSC45694422 (TX) 03/01/09 03/01/10' ccurrence/SIR 25M/2M - C Workers Compensation 4801323(OSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS I LOCATIONS[VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE - - -' - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, 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 2690 CUMBERLAND PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SUITE 300 REPRESENTATIVES. ATLANTA, CA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001108)ckomraus hd ©ACORD CORPORATION 1988 11172180 t X�Ex..{��k'a> d 1`.1 L: I I .•-, i l�1 1 -•2 i �Ay�9y+�y}q� V {J�f� r^� f� �/� �]�qq - 7 d1 BEN G 1 PERFOr� N`!E RATI "a l9S - - C�11.1b®;CFI OE RFf{CIA+7iP1T0�flG�� . " U Factef s Solar Her Gain Coefficient " .Fry - C.o¢A' C,uada da frslyia:afar ' , 0 . 32 1 . 6 - 0 : 29 sue: ADOCT10NAL PERFORMANCE RATINGS ' CVALL.aC7ON 3UvtFMFNTAAU OE AE}I(>II,UEN19 . VBibI ransmittance m,�m da(aawma 0 . 52 MffXekaav OX*�w she cer=rp ca la n o awAatf.16AC 0 +ti Ar dramt+Y'+�Pmd a AFnC - n¢Rp N yermtr+�hr a bad eel of mhwnntr araEna and a gcik�s�.NPL dme Irol nmmab a7 amct � . ed mm mt wrvrt me&an^of/n Pod'd#an V�* or"nea¢%ftrv,1 ltmn Ra ca,r{road paMrwa - Hc.�nw,wYrca7.. . -- --==-- =- ---=--= -- ------:- --... Cm hhtrA��as LM"GQ N7,L m daormF duj PT W arp*eeID,'.aia.aaEd.l on b po�raaaa N�h MAL to demrmF`r r mmnlerlm twl dr. . puAm In HCrt. Ap b o arbWolw f ui hnac h RCa9a2 eeos.T ,NAG w ramr%W'dW lkgR .Xd.=f ro gvWtl Par pvmclo Ea maim 7n on uo eepslam c"A mi.r .. ' Won ar 14 t"on a�rR4NOD d ulr PnLG1 wv,tCap ..' :' . w" L Lit fo(a)Cant.a1, aN(K.f STAACanGcal, Suc_-- ' INS: ReLn. 60/CLain 3131 !N RU,. ' `� ' tan tad, 9lae 3C' r G3 dq/YLQc to 1 .3.I a+r•l H-RaJ +45// — 45 t" AQ euoosdo: 91.4 cn .-191 Cr A 671] " HS Hof laun 2931124. Lip A,d low(or pambH DOM SUr nbatc.To lean ron'M vw.muq(tta4m.. ' Guard.ism rkgfm porn gos&6 NTT Aisu Di RGY SIX 7aa m,ucumm amlm de cle,vull v,"W, �a n p� �/ee Lomirico?u�eal�c a�./lfaooac�u�ar.Q'a i Z Board of Building Regulations and.Standards a HOME IMPROVEMENT CONTRACTOR i � Registration 126893 - Expiraiwn 66/2010 Type: Supplement Card The Home Depot-:At Home Service RICHARD FALLONE 2690 CUMBERLAND PARKWAY S A ^GA 30339 Administrator III,- commonl oalth ofmassachusetts Deoartrten 4 cf1ndusrrialAccidents. lclleliV �1 pid5t27it 1);foI_nia iop. NaTrie (13usiness/Organiution/Individual) Address: City/State/Zip: (�� yl�i. �� Phone.#: �DQ�151Q - Are yog an employer?Check the appropriate box: Type oCproject(required):, 1.kd,/I am a employer with���Z_ 4. ❑ i am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors Remodeling 2.❑ I am a sole proprietor or partner- listed on the*attached sheet. 7. ❑ ship and have no employees These sub-contractors have g. Demolition working for me employees and have workers'in any capacity. 9. ❑Building addition [No workers' comp.insurance comp. nsurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I i.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13 er LJ l prr75 employees. [No workers' comp.insurance required.] 'Any applicant that checks bo x/t]must also fill out the section below showing their workers'compensation o policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subrtu[a new affidavit indicating Such. tContractors 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 subcontractors have employees,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. r� Insurance Company Name: Policy#or Self-ins.Lic.#:. t�'��—I 1 6� _— Expiration Date: Job Site Address: City/State/Zip: 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.,5.0.0.00 and/or one-year imprisonment;as-. l � r '" r' ° T"f a e . 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 the DIA for insurance coverage verification. I do hereby certi un r e p sari penalties ofperjury that the information provided above is true and correct. Si ature Date- Phone — # �� Official use only.-Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# 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 #: SEP-20-2008 05:17AM FROM-HOMEDEPOT PLAISTOW + T-801 P.001/004 F-216' Sold,Famished and Installed by: Branch Name: Boston Date: L////___� TI-ED At-Home Services,Inc. d/b/a The Home Depot Ai-Homc Service, 345A Greenwood Street,Unit 2,Worcester,MA 01607 Branch Number:31 Toll Free(800)657-5182; Fax(508)756.9823 Federal ID Is 75-2699460:ME Iic#C 02439;111 Cont.Lic#16427 / CT Lie#565522;MA Home improvement Contractor Reg.#126993 Installation Address: City State Zip Purchaser(s)i Work Phone: Home Phone: Cell Phone: Home Address_ 2q 7� (If different from Installation Address) City - Stare Zip E-mad Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing emails 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,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"): lob#: Products: Sec Sheet(s)tl: Pro-act Amount ❑Roofing ❑Siding endows ❑Insulation Y6s26gg ❑Gatrers/covers ❑Envy,Doors ❑ ❑Reefing ❑Siding ❑Windows Insulation $ ❑Gutters/Covers ❑Entry Doors ❑ ❑Roofing ❑5iding Windows Imularion $ ❑Gutters/Covers ❑Envy Doors❑ ROodng Siding ❑Windows ❑lnsuladon $ ❑GatUrs/Cover. ❑Entry Doors ❑ Minimum 25%Deposit OfCommact Amunt doe upon execution ofthb contract. Total Contract Amount $ Matra Purchasers may not delsositmore man Om-aiirdofthe CanancrAuwwn /Z y Customer agrees that,immediately upon completion of the work for each Product, Customer will (rxecuu:a Completion Cerificate (one for each Product ns.defined by an individual Spec Sheep and pay any balance due. As applicable, each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Repot reserves the right to issue a Change Order or retminam this Contract or any individual Products)included herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home, environmental hazards such as mold,asbestos or lead paint, other safety concerns, pricing errors or because work required to complete the job was not included in the Contract Payment Summary: The Payment Summary #//?1Qy3 , included as pan of this Contract, sets forth the total Contract amount and payments required for the deposits kind 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 n Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract, Customer agrees to pay The Home Depot the costs of materials,labor,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 with regard to me Products and Installation Services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by e wilting signed by Customer and The Home Depot.Costumer acknowledges and agrees that Customer has read, undcrstunds, voluntarily accepts the terms of and has received a copy of this Agreement. Accepte �byyOA ry/ Submitted b�✓ p, Xt^^,(/w✓L--f— 9. !ql O 1 X c'!=v�—�Y" Custo ='s Signature Date Saics Consultant's Signature ate X Telephone No. -,503—t/7-T-- 1dP/ Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as appacn6le) AGREEMENT WITHOUT PENALTY OR OBLIGATION t. BY DELIYERING WRITTEN NOTICE TO THE HOME DEPOT BY MH)NIGHT 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 ARF PART OF THIS CONTRACT 3-3-09 C-SC While-Branch File Yellow-Customer Pink-SWOS Consultant �I;1.c:•rchubcrts-Dcpartmeoi oY public Safctp . ]� tel ldin-_l't-"'atilM!t Boa of Sui and$tandetll. �f ConswCtloo 5st rvisor Specialty lkense ..LiC;ASW CS SL 101727 t Resteicted to, YtINY�r:..Yr. . IIAIIG_pAl►Ot� � .. . �. 11; , Expiratin:o 11A2 0 .. .oy Ytc: 1O �Z► f'e.nw for vWul use ✓� �p,werrta ✓r ' t.taasu or icBn[rriiaw vdi II four ,aunt la�nl� WarC dtldldtwa�{p1f11swraW Stand+Ns hefere the ptpwatiuu A:. It-; and Staudyrds HOME IMPROVEmp4T CowmACTOR Ow'd of tail din9IteR Reel IMP.on- 5TT t 3 Ode AS us Place Rt>e 1:+01 Fjpim"n:;.1O13112OL19 IM �ovsii geston,ma,U=1Ua 1�I E oep RICYARO OtFRANCESCO' `Nnt valid wtn us signature 7 Pld CJ PIUFf-P.VE. �ataiw� MERWMAC.tAA 01860 nin_J ueneev nna_i epee tint enn. evnuue! 91VY1 ry nui JYnLJ lean 9nw]_b l�lll >lacvichuscttc-Department nC pyOrm Safety Board gC sulitfinn Itteui Spsn�and i an oo Construction Supervisor Specialty L'Ice^se .Lieense: CS SL 1012V 7 PME MRIUIIL`:_1OAp19fiO. .. Expiration: i1i5►1A t.�wel'Mi4wrf ulrafow valid for iodivblul use uld? -iiv aw St+nd"da I.keese or Rasraiwu d,te• If found return to; ward er n.uMna R44 before ihw eSP Board of Butldixf ReCul�onti and StandurM 7 CpN7RACTDR HOME IMPRCPJFMfiN AsAburtan irlace Rsw 1301 RggistraWn: i5771a � g E*piragon:.,1O131120LV sss Rates,pia.U-tua TYPE. DBA R.bt.D.INSTALLS RIC1'ARr) DIFRAMCESCd": witirbul yRPature 1 Pin L'PLUFf-PVE., .MERR,mAC.M bpi A O1860 ._. nin_J inn..nn-� nee_r epee nnr ene. ea�ume aan rN nu1JYnVJ eeen CnN-61-1m