70 ORNE ST - BUILDING INSPECTION The Coin mumveaIth of Massachusetts
�. Board of Building Regulations and Standards CfCY OF
Massachusetts State Building Code, 730 CMR ELM
SAX
Revised Mnr i"I201/
!\� Building Permit Application To Construct, Repair, Renovate Or Demolish a
}\v\ One-or Two Family Dwelling
1 Chis Sectton For Official Use Only
Building Permit Nurrberr D'te A lied.^;
uilding Official(Print Name) ign D
SECTION 1:SITE INFORMATION
1.1 Property Add�� 1.2 Assessors Map& Parcel Numbers
1.1a 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(it)
1.5 Building Setbacks(It)
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❑
SECTION2:, PROPERTY'OWNERSHIPL
2.1 OwnP ' Itecor� /'�
���y) Vsi /ti
r �d7 IPh, T
Name(Print) City,State,ZIP
No. and Street Telliphone Email Address
SECTION 3: DESCRIPTION OF.PROPOSEDWORW'(checkall tapply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 111 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory.Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Item Estimated Costs: Official Use Only,,
Labor and Materials)
L Building $ I. Building Permit Fee:S Indicate how fee is determined:.
Standard.City/Town Application Fee
2. Flectrical S 3
❑'total Project Cost (Item b)s multiplier x
J. Plumbing S 1 2- Other Fees: S
1. Mechanical (IIVAC) S List:
i. Medvutical (Fire $
Sep uessitm) _ Total All Fees: .S_
Check No. .--Check Amount _ _Cash \muuut: _
6 I'MA Project Cuit S L ]Q�r D P ml in Pall — Cl Outst:rndm" Il tlrtna Dll
sr,cru)N �. CONSTRUCTION SF,RVICFS
-•5.1 Construction rvisor Li CSL)
OL License Number E.e ir. rat ate
Name of CSSL Holder List CSL rype(see below)
j—tqJ�� �z '� Type Description
No. and Sireel
Unrestricted BltddI' s u to Ji,000 w. ft.
^ IG,
R Restricted 13e2 F,unil Dwellin
City/rown,Slate,ZIP NI Nlasonr
RC Roofin Covcrin
1VS Window and Sidin,
SF Solid Fuel Burning Appliances
Insulation
l'ele hone Email address U I Demolition
5.2 Registered Home
cl—mp o_veme tCoo/ntract r(IIIC)
Registrulon Nwnbar Ex rat n to
IIICCoi 0 11 Regis!Regis!j,N e
No. and a Entail address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be connRW15d.and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance a building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property, hereby authorize �M7
to act on my behalf, in all matters relative to work authorized by this-building permit application.
Print Owner's Name(Electronic Signature) a e
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby atte undc the pains and penalties of perjury that all of the information
contan this cation is true and a curate t he b t of my knowledge and understanding.
Print ow'ner's or Autlwrirod:\;ear's Name(Lie
ruote Si n, urn U•'
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or:in 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 timd under M.O.L. c. l 2A. Other important information on the HIC Program can be found at
www juasS tuiv/oca Information on the Construction Supervisor License can be round at www.utass.eu�rdp_a,
F2. W'hen substantial work is planned,provide the information below:
al t)uorarea ; . lt. including garage, tinislted basement/atticS, decks or porch)
s; living area(sy. It) Ribitablc room count
n bar of turpl.lccs "----- Number of bctkoams
mber of bathrooms _— Number of halbbalhs— — — —Icpe of heating.Sy;lent _ ..- - ---...—_ Number of dccks/ porches
I)Petit'cooling, ay;tcm Eaeloscd (tpcn
1. I tlal I'r„ject �yu ,ra I n,rt Ike' ni.ty be 'iih;titer. I t,l I iujcet C,ta"
CITY OF S'U.E.tit, Aus m afusETTs
,l tt i�;. � `�,� QIaLDLYG DEP.IR'I�IEVT
120 V(I"JI VGT0N STREET J`ft
TFL (978) 745-9595 ao2
F.+x(978) 7•W-934,5
I<lJCOE4L.EY D(LISC0[1.
"t-ky0R T11os4AS ST.PtEAM
DRECTOR OF PUBUC PROPERTY/SLMDLNG COSL%ttSSIONER
Construction Debris Disposai Affidavit
(required for all demolition and renuvation work)
In accordance with the sixth edition of the State Building Coda, 790 Cl fR section t l I.S
Debris, and the provisions of tb(GL e 40, S 54;
Building Permit h, 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 tNIGL c
I11, S ISOA.
The debris will be transported by;
:' L r
(nantc ut'haulw)
The tkbris will be disposed of in :
�_— (norms of facility
---_—(.tddres.t ur'raailit/)
3o;rn ra ufprrntit applicant
,it
I
r Massachusetts-Department of Public Safety
' Board of Building Regulations and Standards
ye�Y�fati..p 'y lrq ^..r i"�+Cti iaj4a !.7t .,
License CSSL-099699 `�-
r
ROBERT POC76BIIT�.
172 WHALEN5 LANEa
Salem MA 01970 �g
it,
%� — J136rgq-
Expiration
Commissioner - 02/08/2014
H
'eye
y#J■ryJ
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Inves4ations
IV 600 Washington Street
Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/EI bers
please Print m ibl
Ayplicant Information
Name(Businessiorgenirsation/Individual): .
Address: a
City/Sfate/Zip: Phone.#:
Are you an employer?Check the appropriate b Type of pioject(required):
4. I am a general comracWr and I 6: El New construction
1.❑ I am a employer with s have hired the sub-contractors
employees(full and/or part-time)•
listed on the-attached sheet. 7. ❑Remodeling
2.❑ I am a sole proprietor or partner- These sub-contractors have g. []Demolition
slip and have no employees to es and have workers'
wonting forme is any capacity. t� 9. ❑Building addition
[No workers'comp.insurance comp.insurance t 10.❑Electrical repairs or additions
required.) 5. ❑ We ari a�orporation and its
3.❑ I am a homeowner doing all work
officers have exercised their 11.❑Plumbing repairs m additions
right df exemption per MGL � 12. R ass
myself[No workers'crimp• c. 152,§1(4).and we have no 13
� ° ] employees.[No workers'
comp.insurance required.]
Hearn that checks box#1 must atso 8g out the section below showhng thee'wodma'coml��tla'l+ogcyinfmmation. (f
'My a#P k
t FIoirn:oaners who subiidt this a6davit indicating Poet aR doing erg wodc and then hire outside eonhacmrs���wttether or not those rntitl�'evheve� .
tConbaemra that check this box nest attsehed an additional shoes showing Re name of the aug n��.
employees if the subcontracmrs bast mmieyas.Poey must provide gnu workers'c(mp.po cy
I am an employer that is providing workers'conpensodon Insurance for my amployees. Below is the policy and,job site
information ki cam'
Insurance Company Name:
Expiration Date:
Policy#or Self-ins.Lie.#: �y3�^ �4�-� ------ p
Job Site Address �, j'( I- viaLaratioo:;Pa�gesho
City/StatdZip:Attach a copy of the workers'compensation policy dec ng the policy numbeir and expiration date),
d under Section 25A of MGL c. 152 can lead to the imposition of criminal Penalties of e
Failure,to secure coverage as requite 1
fine up to$1,500.00 and/or one-year;mprisonmeny as well as civil penalties is the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
7nvesti ati ns of r insunance covers a verification.
I do hereby cettr under e d p hies ofperjuiy that the information provided abut .is brie and correct
—
Si
fjtejai use only. Do not write in is area,tb be completed city or town offulal
PermiMcense
City or Town:
#
Issuing Authority(circle one): q
1.Board of Health 2.Building Department 3.Cit r/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Si
6.Other
Contact Person:
Phone#:
OMet 0 consd :er Affairs j�S=m n 9s Rcgdlst un •.; 'La can or registration valid for•ittc4tv:slu]rue•�:rfy -
OME ifilPRb�EWT CDtdTF .0 , before the Ep.. ....ov$nte if fauttti reFurn te:.
y Re Istrotiga t ;, £Zfiici:t5SC4n�urderAffarrsxmtt�usinessRz�ttS� :�n t
9 Q93' fuPe 10Ryaticplai,2 a;te5170
Expl{i�-at}s ( : Suppt�nent and ysos+on,lwiAtltii6
The Holt E DapOtT wig{
/ 'RIChL4P,D Fr1�L
P�YA GA3(133. -;s. _ Undefsccretary - `dif r1i1 :iEttautsignaYut•e ' •.
• .. _ .. • , •• •, • O •• s ICI
DATE(MMIDOIrM
ACCOM CERTIFICATE OF LIABILITY INSURAANCE 02�7�013
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:. 1f the certificate holder Is an ADDITIONAL ITJSURED,the policy{iesj must be endorsed. If SUBROGATION IS WANED,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 endorsements). c N ACT
NAME:
PRODUCERMARSH USA,INC. PHONE
Y7 _ aC Na:
TWO ALLIANCE CENTER _ E.0 IL-
35W LENOX ROAD,SUITE 2400 ADDRESS' -- '-
ATLANTA,GA 30326 INSURERS AFFORDING COVERAGE NAIC p
Steadiael InsumnCe Company 28387
100492.HomeD.GAW-13-14 _ INSURER A: 16535
INSURED - INSURER B:Zurich ARlenGan ln5uf311S CO
THE HOME DEPOT,INC. NEW Hampshire Ins Co 23841
HOME DEPOT USA,INC.- IxsuRER c: 23017
2455 PACES FERRY ROAD,NW INsuaea D:Illino&Nadanal Ins Co
BUILDING C-20 INSURERS
ATLANTA,GA-30339 - -
- INSURER F:
COVERAGES CERTIFICATE NUMBER:- AT4003159545434 REVISION NUMBER:?
TH
RT
ED
OVE F1
INDICATED.CERTIFY
STANDING ANY5i: HAVE BEEN ISSUED TO THE INSURED REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCCUMENT BWITH RESPECT TOCY
LWHIPO
CIi RTNJS
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.: LIMITS
1 SR TYPE OF INSURANCE POLICY NUMBER MMIOD MM100WYYYY 9000�0
LTH GLO4887714-03 10310112013 0310112014 EACH OCCURRENCE s
A eENERAL LIABILRY - p N EO 1,000,OW
PREMI ES E cocume, S EXCLUDED
X I C)MMERCIAL 3E14ERAL UABIUTY
CLAIMS-MADE OCCUR LIMITS OF PO XS ME An one Person) 3 %utau'000
OF SIR:$1M PER ER OCC PERSONAL
AL a ADV INJURY S
— -�-- I GENERAL AGGREGATE S
PRODUCTS- OMPIOP AGG S —_ 9,000,000
GEN'LAGGREGATE LIMIT APPLIESPER. - - S
X- POLICY PftO- LOC - COMBINED SIN IT 1,000,000
BAP 2939%310 - 03N712013 03'0112014 Ea a 'dem S
B AUTOMOBILE LIABILITY -I BODILY INJURY(Per person! S
,...X ANY AUTO
ALL OWNED SCHEDULED 'SELF INSURED AUTO PHY DMG BODILYPROPS TYDANJURY(Per accident) S
AUTOS AUTOS PROPERTY DAMAGE S
NON-0NMED Pera dent
HIRED AUTOS AUTOS S
EACH OCCURRENCE S -
UMBRELLA AS OCCUR
AGGREGATE S
EXCESS DAB CLAIMSM1tADE
S
DED RETENTIONS WC033575314(ADS) 0310112013 �0 0112014 % WC STATU- OTH-
CWORKERSCOMPENSATION ( j
I AND EMPLOYERS'LIABILITY YIN WC033575315(AK.AZ) 030112013 031O1f2014 E.L.EACH ACCIDENT S 1'��'�
ANY PROPMETORIPARTNEIVEXECUnVE 51 1,000,000
D OFFICERIMEMBER EXCLUOEDt NIA WC033575316(FL) 03N1R013 03101R014 E.L.DISEASE-Ea EMPLOYE S
(Mandatory In NH) 1,000,000
Uyea,describe under E.L DISEASE•POLICY LIMBS
DESCRIPTION OF OPERATIONS ealox 1,000,000
C WORKERS COMPENSATION WC033575317(KY,NC,NH,VI) 03J0112013 0310112014 I(EL)UMIT
C WC033575318(NJ) 0310112013 03101/2014
DESCRIPnON OF OPERATIONS I LOCATIONS I VEHICLES ptaach ACORD 101,Additional Remarks Schedule,Ir more apace is mqulredl
EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
THE ELLED BEFORE
HOME ME DEPOT
POT USA,INC. SHOTHEULD ANY OF THE EXPIRATION DATE THEREOF,DESCRIBED POLICIES
WILL CBE CDELIVERED IN
H55 PAGES FERRY
IN -
2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS.
'BUILDING C-20
ATLANTA.GA 30339 AUTHORIZED REPRESENTATIVE
of Marsh USA Ina
Manashi Mukherjee �KnLKova.:
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
06/09/2013 18:53 FAX 2001
HOME IMPROVEMENT CONTRACT ��®®
PLEASE READ THIS
Sold, Furnished and Installed by:
Branch Name: Boston Date: THD At-Home Services,Inc.
J,_,_,-J_.•� dWa The Home Depul At-Horne Services
908 Boslon'rumpike,Unit 1,Shrewsbury,MA 0154.5
Tull Free IBM)657-5182; Fax(508)845-6017
Branch Number:31 Federal ID#75-2698460;Mli l.ic#C 02439:RI Cont.T.ic9 16427
CT I.ic 9 HiC.0505522;MA Home improvement Contractor Rug,# 126893
Installation Address: 7D nf/1/1P 5•'F'-..... ....... .,l7IIQ GS/ri76
City State Zip
Purchaser(s): Work hhnne: llome Phone: Cell Photte:
Home Address:
(Itdifferent from installation Address) City State Zip
E-mail Address(to receive project conuuuuicutious and Haute r&-pin updates):
i DO NOT wish to receive any marketing emails from The Home Depot
Pnrtet4,oforrtmt a: Undersigned("Customer'). (he owticn of the property located at the above installation address. %paves to bay.
and THD At-Htime Services- Inc. (''The home Depot") agrees to runtish. deliver and arrange for the installation(-Installation") of
all materials described tin the below and on the referenced Spec Sheet(s), all or which ure incorporated into this Contract by this
reference, along with any applicable State Supplement and Payment Summary attached hereto cold any Change Orders (collectively,
"Contract"):
Jab#: amemal arkrena•' _ Products: Spec Sheet(s)#: Project Anoint
rrYY
t�Rooling Siding D2 Windows ❑Insulation
9S�Zra 9"( - ❑Guvers/Covers ❑Frnry Duers ❑._—.—
❑Rooting MSiding Windows ❑insulation $
❑Gutters/Crivers ❑Entry Thurcs ❑r.y
ItoNinF ❑ ❑Wi Siding edovs tJ Insultalon� $
❑Guuers/Covers 013rtry Doors❑_ ._
. .......I....---..- .ng g ❑ s ❑Rooh Srdin Windom Insulation
❑GutterslCnvcrs ❑Rnlry boos ❑.-
Mnhaurn25%Depositt of Contract Anitivat thrc upon vw•cttlion of this txxtlna4 Total Contract Amount $ V .1 �
Nirane Patr>taxrs Mkv ma deposit ame tlmn one4ldr'd of tbe CmllrmtAumurrl. W CAS
Customer agrees that. immediately upon completion or the work for each Product. Customer will execute a Completion Certificate
(one for each Product as defined by ins individual Spec Sheet) and filly tiny Intancc due. As applicable, each Customer under IhiN
Contract agrees to be jointly and severally obligated and liable hereunder.
The Horne Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,irThe Horne 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 salty concerns, pricing errors or because
work required to complete the joh was not included in the Contract.
Payment Summary: The Payment Summary #3'*� S'l Z , 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 filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is(me 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 Deport the rnsis or materials,labor, expenses
and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any tither
amounts set forth in this Agreement or allowed under applicable law. 'rim HOME:DE:PO'r MAY WI'rHIfOLD AMOUNTS
OWED TO THE HOME DEPOT FROM '11110 DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WiTifOUT
LIMITING THE.HOME DEPOT'S UfIfER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Accentanee attd Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
ant)T'hu dome I'>epot with regard to the Products and Installation services and supctsedes all prior discussions and agmenn:nts,either
oral or written,relating to said Pro duct%and Installation. This Agreement cannot bo 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
tern%of and has received a copy of this Agreement.