55 ORD ST - BUILDING INSPECTION (3) - ---
�, The Commonwealth of Massachusetts --
i� Board of Building Regulations and Standards CITY OF
)•i;, Massachusetts State Building Code, 730 C'MR SALLM
L•,•• lleriseJ.l bu•'rlll
Building Permit Application To Construct. Repair, Renovate Or Demolish a
(Are-or Tnu-Fumilr Duvellin,ur
�\ This Section For Official Use Only
Building Permit Moolter: Date Applied: _
Mtgj, C LT—fizz, .wSicF
Building Official(Print Mane) Si lure Date
SECTION I:SITE INFOR IATION
I.I Property Ad �i 1.2 assessors flap& Parcel Numbers
1.la Is this an accepted street?yes no Map Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dlmenslons:
Zoning District l'mp..ed(Jsc Lot Area IN II) Fronlage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.1.c. 40,§Sa) 1.7 Flood Zone Inrormatlon: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone? ,y)unici al❑ On site dis
Check if .—, P Wsal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl eF-Record:
Nanic(Print) �� `— City,State.ZIP '4. 06:h
No.aud Street �. relcphone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all at apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory.Bldg.❑ I NumberofUnits_ they ❑ .Specify:
Brief Description of Proposed Work-:
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
I Labor and \Imerials) Orllcial Use Only
1. Building S 1 I. Building Permit Fee:S Indicate how fee is determined:
2. Llcc(ricai g ❑Standard City/Town Application Fee
❑Total Project Cosl'(Item 6)x multiplier — _ x
1. I'lunhing S 2. Other Fees: S — -
J. \loch;mical ill\'.\('1 S List:
. :. .\Icchanieal (Fire - ----- -------- ------. . . .
tit I treision I S Total \11 Fees: S
t ('luck No. _ _('heck Am tount: lash \moun _
. Total Project Cast: S ❑ Pnid in Full 0 Outstanding Bulwice Due:
+ •
SECI'ION5: CONSI'RIicrIONSERVICES
5.1 Construction Supervisor License(USIA
_--------��--�/°/���—.__--.------ i.ieense N�t mihcr -- F�piru au ;ue
N;unc u(C'SI. I lolder 111---KKK---- ll •�
list CSI. I)PC(,'cc l+clout
-._ -u��=-.+-r� -1''1--__----- -...-------- 'I)pe Ikscriplion
Na. .md Street
(I PC
(IIuilJin i up to 35,0110 cu. ItI
R Re tricled I&2 Tamil) MwIlin
Civil' + .Slate .IP N) klaiAmry
KC Rooting 'overinit
-.-- W'S W'indow and Sidin
SF Solid fuel Burning Appliances
!� I Inxdution
I'cic hone S�u`JL� h:mail address D Demolition
5.2 Registered Ilun a Improvement Contractor(HIC)
I IIC I cgistnaion Numhcr Fa{Tali n Iota
IIC Coln a Nei I IIC Regis mri Na
No.;red S c �� Email address
Ci /Town.State,ZIPhone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 Issu of the building permit.
Signed Affidavit Attached? Yes ..... e..O No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
APAPPLIES
SFFOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize G 'F`c -�tt"i/�
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print O+mer's-Name(Electronic Signature) ate
SECTION 7b:OWNER- OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accu to th es f my knowledge and understanding.
Print Qener'sor:\udnrtircd,\gcnt's Name(Elect nnc. gnu ucl ate
,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 Hone Improvement Cuntraclur i HIC) Program).will no have access to the arbitration
program or guaranty t'und under M.G.L.c. 142A.Other important information on the HIC Program can be found at
wo ni.r•. + s,t Information on the Construction Supervisor License can be found at m%%% vies; �_ I{+,
2. When substantial work is planned•provide the information below:
Total flour area liy. R.) _ ncluding garage. finished basement attics.decks or porch)
Cirois liv ing area(iy. Il.l ._._ , Habitable roost count
Number of fireplaces.__. Number of bedrooms .. .. .. . .
Number of hmhrooms Number ot'half haths i
1'�peofhcatings)stem _ _ Numherofdecks, porches. -
i
I')pe ofcooling s)iteta fncloied _ _ . Open
1. "foul Project Square Footage-m;l) he substituted for"Total Projact Cost"
12/13/2011 17:37 15087568823 THD AT HOME SERVICES PAGE 01/07
1 HOME IMPROVEMENT CONTRACT
PLEASE RIlkD THIS
Sold,Furnished and Installed by:
Branch Name: Boston Date: /� �- / ( THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
345A Greenwood Street,Unit 2,Worcester,MA 01607
Toll Free(800)657-5192;Fax(508)756-8823
Branch Number:31 Federal ID#75-2698W;ME Lie#C 02439;RI Cont.Lid#16427
Cr Lie#HIC.056.5522;MA Hone Impmvement Conte Reg#126993
Installation Address: �� /h2Zi ST- �,'/ll...r �y� af97o
(Sty State Zip
Purcbaser(s)- Work Pha= Roue PhD= Cell Phone:
Home Address: c
(If different from Irsallabon Address) City State Zip
- E-Mfl Address(10 receive project#xfr##munirations and Home Depot updates):
I DO NOT wish to receive any marketing entails from The Home Depot
Project Information: Undersigned("Custome ).the owners of the property located at the above installation address,agrees to buy,
and THD At-Horne Services,Inc.(-Fhe Home Depot'')agrees to furnish,deliver and arrange for the installation("Installation")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 Slate Supplement and Payment Smm�tary attached herein and any Change Orders(collectively,
-Contract"): �loD,
Job#-. wsemcRrodarts: Spec Sh s #: Pro ect Amount
❑Roofing ❑Siring Windows ❑]nmlatron
❑Guaers/Covers ❑Entry Dor os ❑ $
Roofing id-mg ❑Wutdows ❑I.Ia ma
❑tittles/Covers ❑Entry Doors ❑ $ D
BLtG
Roofing 13sidmg Lj Windows ❑Insulation
❑Gut Ws/Covers ❑Retry toms 11
❑Roofing Siding ElWindows Inada[ioo $
❑Gunners/Covers ❑Fntryl)oors ❑
Nt dnmm 25%r Depend ofCantradAuo vi din upon execution ofthematrad, $
Mah:Nurbasersmay not deposit mare flmmel�defthe ContraRAuont Total Contract Atrount
Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate
(one for each Pmducl 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.
The Home Depot mssetves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot m its amhorirrd 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 concerts,pricing errors or because
work required to complete the job was net included in the Contract
Payment Summary: The Payment Summary# 5/ /�.f`7 7 . included as part of this Contract, sets forth the total
Contact amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely[flied-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is are Complettan Certificate for each Bated Product as defined by individual Spec Sheds)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 Authmivation: Customer agrees and understands that this Agreement is the entire agreement 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,rebating to said Products and Installation.This Agreement 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 Aunt
=7)0 1Z. 7. x
C mo er s Sigaamm Date Sal n nt's Signature Datc
x Telephone No. ��-S-9Y- 6 7 /
Customer's Signature Date
Sales Consultant Iirense No_
CANCELLATION: CUSTOMER MAY CANCEL THIS #ss wp8®bk)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE MCI 6 dy�
STATE SUPPLEMENT ATTACHED HERETO gg11�I
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE
NO'1'IC&AI DDIONAL TERMS AND CONDITIONS ARR STAT®ON TILE REVERSE SIDE AND ARE PART OFTHIS CONTRACT
07-13-11 CSC White-Iandh File Yellos-Customer
'�I:U`atiItU•CtI• - UCI;:�I'I SIP:u. .n .w.u•
}3uai,1 n( timidim_ Re,ul.itnnn, ,lnd �nu+d;u ds
:enstruction Super;i:;or Spec,aity License
License: CS SL 99364
estricted to: WS
AERTE TORRES
6 FELTOM STREET
AARLBOROUGH, MA 01752
E:<piration: 31612012 //� tf—i(✓ 1 ��'
----�J Tr4: 99364 Iy� Y V
Restricted to: WS i
IA.= Masonry only
RF Roof Covering i
WS-Windows and Siding '
SF- Solid Fuel Burning Devices
DM-Demolition only
Failure to possess a current edition of the
Massachusetts State Building Code
Is cause for revocation of this license.
Refer to: WWW.Mass.Gov/DPS
t
✓/ee iJonvnxa�wi�ea�i a�./�aaaac/u�deltt
� Office of Consumer Affairs&Business it -I hon_
OMEIMPROVEMENTCONTRACTOR -
RegistraBon f26893 TYP
Expiration 8l312012 , Supplement
The Home Depol rAt kofne.S en!ices "
(\
i RICHARD FALLOyE
n' 2690 CUMBERLANt)PWWAYS -��---
XKM GA 30339 Undersecretary.
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r-MCR 'iu PEKE ORlMArrroOEE WINCL
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f FaCar-0 Caxfc!xnmGa^•anda.de:nergia solar
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ADDITIONAL PER. 1ANCE RATINGS
-EVALUACION SUPLEMENYARlAOERENDIMIENTO
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CERTIFICATE OF LIABILITY INSURANCE 02/21/2011 j
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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ios) must be endorsed. If SUBROGATION IS WAIVED, subject t0
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 1-404-995-3000 CONTACT
NAME
Marsh USA, I.C. PHONE
FA.(
INC Na Ext)_ . ...__—_ ---11A&N1
homede ot.certre ueat(Nmarsh.com EMAIL
P 4 ADDRESS:
Two Alliance Center, 3560 Lenox Road, Suite 2400
Atlanta, GA 30326 __ INSURER(S)AFFORDING COVERAGE_____ NATO d_
Fax (212) 948-0902 INSURERA: Steadfast Ins Cc 26387 ..
INSURED - INSURERS: Zurich American Ins Cc 16535
The Home Depot, Inc.
Home Depot U.S.A., Inc. INSURERC: New Hampshire Ins Co 23841
2455 Paces Ferry Road NW INSURERD: Illinois Hatt Ina Co _ 23817
Building C-20
INSURERS: NATIONAL UNION FIRE INS CO OF PITTS 19445
Atlanta, GA 30339 - '— ---'
INSURER F: Illinois Union Ins CO 27960 27960
COVERAGES CERTIFICATE NUMBER: 19834682 REVISION NUMBER:
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 I TYPEOFINSURANCE AODL SUER POLICY NUMBER MMIDPOLIOYYYV MMLDOMYY LIMITS
LTRIm AM
A GENERAL LIABILITY CL04887714-01 03/01/1 03/01/12 EACH OCCURRENCE $ 9,000,000
X DAMAGETOR NTED 1,000,000
COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $
CLAIMB-MADE OCCUR MEDEXP(Anyonepemon) $EXCLUDED
X LIMITS OF POLICY XS PERSONAL B ADV INJURY S 91000,000
X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S 9.000,000
X POLICY PRO LOC I $
B AUTOMOBILE LIABILITY BAP 2938863-08 03 1 1 0 1 12 COMBINED SINGLE LIMIT 11000,000
Ea acddent)
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AUTO$ BODILY INJURY(Per accident) 8
N EO PROPERTY DAMAGE $
HIRED AUTO$ AUTOS
Per accident
X SIR AUTO P Y $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEO I I RETENTION$ - $
C WORKERS COMPENSATION WC061967352 (ADS) 03/01/1 03/01/12 X WCSTATU- OTH-
AND EMPLOYERS'LIABILITY ----
D ANY PROPRIETORIPARTNERIEXECUTIVE YIN NIA WC061967354 (FL) 03/01/1 03/01/12 E.L.EACH ACCIDENT $ 1,000,000
OFFICEAMMBEIS (MandaoryEn NH)EXCLUDED7 WC061967353 (CA) 03/Ol/1 03/01/12 E.L.DISEASE-EA EMPLOYEE S1,000,000
IIy s.describe under
DESCRIPTION OF OPERATIONS below I E.L.DISEASE POLICY LIMIT g 1,000,000
.0 Mockers Compensation WC061967355(XY,MO,NY,WI, W0310111 03/01/12
F TX Employers XS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/1M
E Workers Compensation WC1192378 (QSI) 03/01/1 03/01/12 SIR 1M
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Alison ACORD 101,Additional Remarks Schedule,it more space is required)
RE: EVIDENCE OF COVERAGE .
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS.
2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE
BUILDING C-20
ATLANTA, GA 30339
USA
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Jfiero led �1 _
19834682 Y�1
1
Department oflndustrialAceidents
Off"ice oflnvesdgations
600 Washington Street
Boston,MA 02111
www,mass gov/dia
Workers' Compensation Insurance Afi3davit: BuUders/Contractors/ElectricianslPlumbers
Awlicant Information Please Print Letdbly
Name(Busincsslorgwi"donnndividual):
Address: 'Qligo
Citylstate/Zip: L7`. Fl Phone#: l-)
Are yo an employer? Check the appropriate box: Type of project(required):
I. I sm a employer with 90 4. ❑ I am a general contractor and I 6. ❑New construction
employs(full andlor part-time).* have hired the sub-contractors 7. ❑Remodeling
2,❑ 1 an a sole proprietor or partner- listed on the attached sheet I
ship and have no employees These sub-contactors have 8. ❑Demolition
working for me in any rapacity, workers' comp.insurance, g, ❑Building addition
[No workers' comp.insurance 5. ❑ We an a corporation and its 10.❑Electrical repahs or additions
mod] officers have exercised their
3.El an a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
myself.[No workers' comp. c, 152,§1(4),and we have no 12.0 Roof repairs
insurance required}t employees.[No workers' 13.❑Otber
comp.insurance required.]
'Any applicant that rhech box B I must also fill out the section below Aawiog thd rwon r d 'campeasatian policy information
t Honoeowuc s wba tulmit this afndav$Mezrag d1ey ana doing dl wade and thm him oatside oantutoe must mhmit anew afnda it mEmil" such
tContraeton that nccrA this box most sthrbed as additional shct showing the tu=of the sub-coatroom and tha wort m'camp.policy V6tmstioa.
I cart an employer that isprovidutg workers'comgemagon insurance for my employees, Below is the polity mud job site
inforntaitan. �—
Insurance Company Name:
Policy#or Self-ins.Lie,M. 'Expiration Date:
Job Site Address: J�j S�i�/��i f City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and eiplmtioa date).
Failure to sectre coverage as required under Section 25A of MGL e, 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 andlor one-year imprisonmeot,as well as civil penalties in the form of a STOP WORK ORDERand a fine
of up to S250.00 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 certfy u er a ins penalties of perjury that the information provided above true d soccer
' Si hse Dom'
Phone t<:
OfJralai use only. Do not write in this area]to be completed by city or town eu*L
City or Town: Permlt/License Y
Issuing Authority(circle one):'
1. Board of Health 2.BuUdmgDepartment 3.Cityrf own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
. _ Ph nne
CITY OF S.VZNf, >. USACHUSETTS
9Ltt.DLNG DEP.1RTtF.VT
120 W.UHLYGTON STIm", S'O Rccit
Ttt. (978) l�S-959S
KIMBERF Y ORLSCOLL F.IX(978) 740-9946
MAYOR ITTo.V,►s ST.Ptr•..
DIRECTOR OP PL BL1C PROPERTY/at:MD NG CO\p11SSfONEII
Construction Debris Disposal AtfIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I
Debris, and the provisions of MOL a 40, S 54• I.S
Building Permit If '
this work shell be disposed of in a ro erl is issued
waste disposal fac li the dccis resulting from
111. S 1 SOA. p p y p ryas dcfincd by,b1OL c
The debris will be transportcd by:
Nune of haular)
The debris will be disposed of in :
r (nama of(�cility)
(Jddrea of FJc�pty)
nJmw-e o Pcrmrt Jpphunt
' hn vl(dti