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70 ORNE ST - BUILDING INSPECTION (2) �� � I'he C'omnomceahh of M:usachuseus Iloard of Iluilding Regulations and Standards CI"I'Y OF , Massachusetts State Building Code, 730 CNIR S.\ui\I e, .. Iluilding Permit Application To Construct, Repair. Renuvate Or Demolish a One- or Tuv-f'umily Dt •llinsr This Section Fur flicial Use Only Building Permit Number. Date Applied: _ Building uliicial(Print Mune) Signature Date SECTION 1:SITE INFORIIIATION 1.1 Property Address ,5-- 1.2 Assessurs blap St Parcel Number — 1.In Is this an accepted street?yes no Map Numher Turco] Number her Zoning Inrormatlon: 1.4 Property Dimensions: Zoning District Ilropuscd UW Lot Arco lsy It Frontage(It) 1.5 Building Setbacks(fl) Front Yard Side Yards Rear Yard Required Provided Requited Provided Required Provided < t 1.6 Water Supply:IM.G.I.c. 40.§Sq) 1.7 Flood Zone Information: .1.3 Sewage Disposal System: 1§tblic❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposal ssstem ❑ Check if 0 SECTION2. PROPERTY OWNERSHIP' 2.1 Owpav!of Reco �Il d rrlyv ; Wunc(Print City tote,!. P No.and Street re cp une Emuil Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all: apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(sj' Alterations) ❑ I Addition ❑ Demolition ❑ Accessory Bldg.❑ I Number of Units_ y0 , ❑ .Spccily: Brief Description of Proposed Work*: \ SECTION J: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: I N. ,. 011)clul Use Only I Labur and ..\hmerialsl I. Building I. Building Permit Fee: S Indicate how fee is determined: O Standard City+Tu+sn Application Fee 2. lilectrical S t ❑Total Project Coil'(Item 6)..1 multiplier s l 1. I'lunihing S 2. Other Fees: S ' a. \Icch.11lical ill\ 1C1 S List: - 1u.vciiionl ChccA \o. _( heck Amo a t: C'•tih \mount: h 1'u1al 1'roject Cost: S ❑ P.iid in Full 0 thust:mding Ital,ulcc Due: SECHON S: CONSI'RIIC'r101y SF.RVI('F.S 5.1 Construe upenisu .' tse(C'SI.) ---� ice�-t4 u ---- I nse,'uul cr I's 1 a1i t Un e Nat nc ol'l'S I. ikii'lo I let l'SL I')pa lie,he luwl.--. N.I. ,nd�trcet 1'�pe Deirnptiun lInreslrLov IItoildin gs tillto 15,000 cu. It.) __� y.�.. . .-- It Re.IriecJ IR? I'.unil Diw1holl Cil�i loon,.'Ltle.LII' \I I Masollry RC Rmllina Onerin ..._. W'S - Window mcl idiolt S Sulid Fucl Burning:\ppliances I Iniuomion fele bona Pmail aJJresy D Demolition 5.2 Registered Ilome I n w men,- ulor(H IIIC I cglstr lion Nunitwr I( tiro uu Uwe IIICC' a el I Nu. fe unJ ✓� Email uJJrca'I Ci boon, State ZIP 4rele hone SECTION 61 WORKERS'COMPENSATION IINSVMNCE AFFIDAVIT(M.G.L It. 152.1 25C(6)) Workers Compensation Insurance affidavit must be C-01,101cled and submitted with this application. Failure to provide this affidavit will result in the denial of the Issugedorthe building permit. Signed Affidavit Attached? Yes .......... O No...........❑ SECTION 7e:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR4111.1 ILDING 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 Nurne(Electronic.Signuture) 9iltis SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below. I hereby)ttestvts er the pains and penalties of perjury that all of the information contained in this application is true a b accurat the stokmy knowledge and understanding. Prim Dwner's ar \uthuriieJ,\yent's N:w e I I:I. trunlc.tii n:uure) ma vo'res: ' 1 .Nn Owner who obtains a building permit to do his.her uwn work,or an owner who hires an unregistered contractor not registered in the Hunte Improvement Contractor(HIC) Program),will nu have access to the arbitration program or guaranty lund under M.G.L.c. I12A. Other important information on the HIC Program can be found at Ilww airs. % " I Information an the Construction Supervisor License can be found at 1,IN, nl.n+ g.,t ,Ip+ 1. \%'lien substantial pork is planned,pros ide the information below: rota) Flour area(N. Il.) _ I including garage, finished basement Mmics,decks or porch) T Cross lising .Irealsy. It.l - flabitable room count Numberol'lireplaces _ _... . \'umher Ill'hedruoms \umber m hmhrwms . . - . -- Number III hall,hauls . . . . I\pc athe.nutg i)%acln N'umhcr oI Jccks, porches Ispc, I'coolIItgi\Aelll 1,1101 +ed (ll,an ( "I,n.d II/IlieCl 1,IIItlrY F,llll,lga Ilt;l\ ha •IIhiIII11ICJ IUf"I JL11 I'fPjeCl CP,1" BOB DANGELO 9785157766 p.1 HOME IMPROVEMENT CONTRACT ' r /_f/\� PLEASE READ THIS —1 �9 (ICJ Sold,Furnished and Installed by: Branch Name: Boston Date: SvwC 51� a 01 Z THD e Services,Inc. d/b/a The Home Depolr At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(900)657-5182;Fax(508)845-6017 Branch Number:31 Federal ID#75-2698460,ME Lie#C 02439;RI Cont.Lie#16427 CT Lic#H1C.0565522;MA Home Improvement Contractor Reg.#126893 Installation Address: 70 D RN F s'F SQ(Pm P't P 619`76 City State Zip Purchaser(s): Work Phone: Home Phone; Cell Phone: 5cxutJ 4��eor✓ �o5oty ] (47F1]`/75'17ei.2 ET3019b� Soy Home Address: (If different from histallation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ®.I DO NOT wish to receive any marketing entails 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-Norte Services, Inc. ("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installatioo')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, "Contracf7: Job#: a-�na -o Products: Spec Sheet(s)#. Project Amount p Roofing inSiding [A Windows 0 Imulation ,97384-7 $ to 36.3 / ❑Gutters/Covers ❑Entry mots El573BS 73r. Roofing Siding 0 Windows ❑Insulation ❑Gutters/Covers [-]Entry Doors ❑ $ Roofing ❑Siding ❑Windows ❑Insulation $ ❑Gutters/Covers ❑Entry Doors r1 Roofing OSiding Windows ❑Insulation $ ❑Gutters/Covers ❑Entry Doors 1-1 Minimum 2W.De"Wof Contract Amoumdue upon esentdoo ofd&eonlract - Total Contract Amount $ 73 � 7 Maim Purchasers may not deposit more than one-third of theCootractAmmmt 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. The Home Depot reserves 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 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 Contact. Payment Summarv: The Payment Summary # Co F I <1l a , 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). NOTICE TO CUSTOMER You are entitled to a completely filled4n copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each Bs"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 the 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 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 Agreement. Accejt4 by. ,`/�� Submi bY- Cust ees,Signature Date Sales Consultant's Signature Date rr The Commonwealth ofMassaehtrsetts Department of Ltdustrial Accidents Office of Investigations 600 Washington Street Boston,AL4 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ConiractorsiElectricians/Plumbers Applicant Information .{— Please Print Let?ibly Name (Business/Organization/lndividual): Address: City/State/Zip: , i. 9�Phone.M nj _ Are yo employer? Check the appropriate box: L7R project(required): 1: I an a employer with 'o`�f2 4. ❑ I am a general contractor and I employees(full and/or part-time). e have hued the sub-contractorsew construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. modeling ship and have no employees These sub-contractors have molition working for me in any capacity. employees and have workers'co insurance.t ilding addition ilYo workers' comp. insurance n'P•required.] 5. ❑ We are�torporafion and its ctrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their mbing repairs or additions m self. o workers'co right of exemption per MGLy c. 152, 1 4 ,and we have no repa rs insurance requ red.]t § O er_ employees. [No workers' comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tCon tractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: 1 Policy#or Self-ins. Lic.M Expiration Date: Job Site Address: eolne 1 City/State/Zip: m �� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverageas required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a foe 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations Lf4he DIA for insurance coverage verification. _ I do hereby c rtify i n r th pains nd penalties ofperjury that the information provided above sirue arrd correct. Si nature: Date: `J 1 / ' Phone #: Ojficlal use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I-Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: - i CITY OF SALEms Aus.,CHUSETTS OLLEnctc CEP.11tnt8\r I _'0 �IiHNCTON SrXW, }u Ftaa)t KJ1CIFFIF Sy OUXOLL FAX(978) 14&9844 MAYOA Mosw ST.PMAU OIRFGTOII OP PL avc PROPIRTY/el'QnGYO cotamstm eit Construction Debris DISPOS31 Affidavit (required for 4 demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 Q�tR Debris, and the provisions o(,btdL a 40, S J4; section I 11.J Building Permit,$ is issued with the condition that the debris resulting from (his work shell be disposed o(in a properly licensed III, $ IJOA. waste disposal facility as defined byxICL c The debris will be transported by; (name ul hauler) The debris will be disposed of in (nam•or racilily) (,ddreas - +4 amre of ermif � PP icrnf _ DATE(MPBIDCI•ri•!`Q —) CERT ICATE OF LIABILITY INSURANCE 02,27/2012 TH9 RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CC) FE 5 q9O RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTFICATE DOES NOT AFIRMATIVELY OR BELLO9W. THIS CERTFIICATEFOF INSURANCE DOES NOT LCONSTITUTE A CO TRACT BETV`FR IEEN Y AMED, EXTEND LTOTHERSSU9NGAGE F®SURER(S)TBY AUTHOR ZIED � REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. the IMPORTANT: R A and it a COTs of thehpol policy,certain Dpolicies Amay INSURED,require an endorsthe ement. A statement on this certiles) must b. 0-0ficOate does not WAIVED, righth)to 4S certifiicate holder in lieu of such endorsemenY(0. coNTACr 1-866-966-9664 NAME: FAX RODUCER PHONE INC,No: -- arsh USA Inc. C E-t: E-MAIL -- ADDRESS: Omedepia cerCenter, 3560 Le om INSURERS AFFORDING COVERAGE NAIC# ._- wo Alliance Center, 3560 Lenox Road, Suite 2400 387 ,tlanta, GA 30326 Steadfast Ins Co 26535 INSURERA: 16535 'arc '(212) 940-0902 Zurich American Ins-Co. -- NSURED - INSURER B: - 23841 :he Rome Depot, Inc. INSURERC: New Hampshire Ins Co 23817 INSURER 0 tome ,Depot U.S.A., Inc. is Natl Ins Illin Co :455 Paces Ferry Road NW - - INSURER E: NATIONAL UNION FIRE INS CO OF PLTTS 19445 3uilding C-20 27960 4tlanta, GA 30339 INSURER F: Illinois Union Ins CO ` - REVISION NUMBER. . COVERAGES CERTIFICATE NUMBER: 21776028 TNO INDTO ICATED.CNOTWITHSTANDINGA ICIESOF INSURANCE NSU ANTE LISTED OR CONDITION OF ANY CONTRACTO R OTHER DOCUMENT WITH RE THE INSURED NAMED BOVE OSPE6T TOLWHICH PERIOD 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 REDUCE CY aBY PPo CLAIMS Limns: ADDL SUER POLICY NUMBER MMI00MrYY MMIDO/YYYY INSR TYPE OF INSURANCE I .9,000,ODO LTR GL04887714-02 03/O1/1 03/Ol/13 EACHAGE ETORRENE $ A GENERAL LIABILITY A MI ES Ea NTED $ 1,000,000 PREMISES Ea occurrence X COMMERCIAL GENERAL LIABILITY EXCLUDED - MED E%P(Anyone person) $ CLAIMS-MADE Fi-IOCCUR PERSONAL&ADV INJURY $ 9,000,000 X LIMITS OF POLICY XS GENERAL AGGREGATE S 9,000,000 X OF SIR: $lM PER OCC PRODUCTS-COMP/OPAGG $ 9-000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ PRO- 1,000,000 X POLICY LOG BAP 2938863-09 3 O1 3 1 1 fEOMxcid I51NGLE LIMIT B AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ _ X ANY AUTO BODILY INJURY(Per accident) $ ALL OWNED SCHEDULED PROPERTY DAMAGE $ AUTOS AUTOS per accitlent NON-OWNED S HIRED AUTOS AUTOS X SELF INSUR D PRY DMG EACH OCCURRENCE $ UMBRELLALIAB OCCUR AGGREGATE $ EXCESS LIAB CLAIMS-MADE $ DED RETENTIONS 03/01/13 X WC STATU� OTH- C WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/Ol/13 E.L.EACH ACCIDENT $ 1,000,000 AND EMPLOYERS'UASILITY YIN WC019736917 (FL) 03/01/1 ➢ ANY PROPRIETORIPARTNERIEXECUTIVE NIA OFFICERIMEMBER EXCLUDED? WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 1,000,00 E (Mandatory In NH) E.L.DISEASE-POLICY LIMIT $ 1,000,000 If yes,describe under 1M/750,000 DESCRIPTION OF OPERATIONS bel (4 Win. WC1192494 SI) 03/01/1 03/01/13 SIR (ADS)/BIR (GA) E Workers Compensation 03/01/1 03/0 /:1 C workers Compensation TNSC4656639 (WI) F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/O1/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is regeired) RE: EVIDENCE OF COVERAGE CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THE HOME DEPOT, INC. ACCORDANCE WITH THE POLICY PROVISIONS. HOME DEPOT U.S.A., INC. - 2455 PACES FERRY ROAD NW _ AUTHORIZED REPRESENTATIVE BUILDING C-20 / //m,_,_ ���✓T ATLANTA, GA 30339 USA l ©198Q-2010 AC.ORD CORPORATION; All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORU - c fee-�omvmo�uri°,al� o�' ukatjo lta -0ffice of Colisumer Af€aii5:g$uamess_ReglaLio4' k. F OME ImfF MENT {fN Rp:CTOR TY Registratibrf14b893 lement Expire'. Supp. s� The"Home 3y, RICHARD FALL �;,, T, 269�CUMB ER" S . s try —9 dam...:._-:. r r` i4ris n:.tvr - Gt(�:�rtm,ant or P blr. ': -•y .. .oarrl ci �ii' liry Rogul;.atinn! And CSSL-099699 'r" 'CF ROBERT POCZOBUT �rz=- 172 WHALL+NS LAND Salem MA 01970 i7oni.msrumer 02/08/2014