17 PATRIOT LN - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
�- Board of Building Regulations and Standards CITY
OF SALEM
Massachusetts State Building Code, 780 CMR, 7'h edition
Revised Junuary
Building Permit Application To Construct, Repair, Renovate Or Demolish a L• =008
One-or Tivo-Funnily Dwelling
This Section For Official Use Only
Building Permit N mbe • Date Applied:
Signature:
Buildi C missioner/Inspector f Bu dings Dale
ECTI IY 1: SI INFORMATION
1.1 Property d 1.2 Assessors Map& Parcel Numbers
f) / -
L la Is this an accepted street'?yes Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
I"��V11 Zoning District Proposed Use Lot Area(sq to Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
C \ 1.6 Water Supply:(M.G.L c.Jo,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
\`\�Y Public❑ Private❑ Zone: Outside Flood Zone?
Municipal❑ On site disposal system ❑
Check if yes❑
\ ' SECTION 2: PROPERTY OWNERSHIP'
2.1 Own�r'/�f Record: ��1 �,/'x
o f1 t\L -ia f Fr7 G APr 'L'a"-^"`_ 1TI
Name(Print) � Address for Service:
5.e ��rfira c ��J t�i37
Signature —T Telephone �1
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all 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':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S �
4. Mechanical (BVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licens Constr_u�ct1�'11f�)Supervisor(CSL)
�,��,,,/'� kmr'�,� I.icense un Espiml m 3ate
Name o1 C" IuIJe —� V��
List C'SL Type(see below)
-f Description
IJ 1 Unrestricted up to 35.000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
5171 nare M Masonry Only
+ 33 RC Residential Rnotin g Coverin
l-elep lone VS
Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registere mpr vemen�t foe rac IC)
111C om rn� rpe r HIC R, is 1n Regislmlton Nun r
r rA
A ress 7
Espimtion le
'fete hone i
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be c9titripleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes .......... d 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.
Signature of Owner Date ' I t
SECTTIION'7b:OOWWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements a 'nformation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print
Silmatu&ot0 vner or Aut orized Agent Dale
Si ned unJ the pains,ndpenalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to Jo 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt%baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
p. 2
• 11-MR-09 10:1 BAM FROM-Hoe Osput 2086 49TST461402 7-925 P.001/007 F-III
"UNA'•rmYrtV v CrOGIV 4 e.vp uwa..+
PLEASE READ THIS
Sold,Furnislird and'Ia vaned by:
Branch Nome: Boston Date: THD At-Home Seviecs.Irv_.
Wit& The R.Depot Ar-Home Services
345A Orrs:awood Street.Unit 2,Worcester.MA 01607
Toil Free(800)6S7-51 B2:Fat(508)7S6-8823
Brn,rh Number:31 FeAttal ID It 75-2698460;ME Lie A C 02439;RI Cont.Ligl 164'17
Lied T"R7,065522;MA Hume)mproveruent Ceninvor Reg.A r26993
Installation Address: / -/')
' City Srn¢ Zip
Purehasn N1: Work Plana[ home Plmtx: Cdl Phone:
05F` Wei
Home Address 17 2?6r".7,v O/?1_P
(If dif(eTew from TnsmOauon Address) City Soon: / Zip
R.mail Address(To receiva project communications And Home Depot updates):
❑1 DO NOT wisb to reteiv.,my marketing emails from The Homo Doper
Project Information: Undersigned("Customer-),the owners of the property letamd ac dre above insta8ntioa address,agrees to buy,
and THD At-}lame Services,Ina. ("The Home Depot")agrees m fumiah,deliver and arrange for the ins vallnlioa("Instillation")of
all mrierials described on the below and on the mfetcoced,Spec Shee[(r), all of which are incorporated into this Contract by this
reference,along veldt any applicable State Supplcmrnt and Payment Summary arambcd he=and any Change Orders(co0ccu,¢ly,
"Contra.vT
Job#: S.Shsatrn)p: proke,Amount
R„ofag sing indowe- fnnilatioa' �J - m
S [ [ �G ttert/Coves 08 ay Doors❑ -7 3 f U $ S-3
Roofag Siding 0 Winticvn insulation g
OCnnnw/.Govern OEnuy Doors
Roofiaf Sluing ❑iMndotrs Insalatlon ,
E]Qomw/Covers.OPntrl J)w.❑ $
Roating Clihctmc Wimlows LTInsuianor, - $
00.nan 7 Covem DCave Doors ❑
htaimnm 75%Dmauaar(bKmd Amnanr doenpmumoion afd+[s tarltraR Total ConhactAmount $ rn
hhtinr Pusviaters may na[drpose e1ara than orathW nfda ConmtAArrrount �� '
Qrstorner ,ogrccti!liar,imineffiately uptineom)m lim ol-mc wdrf:for taeb Product rusbrmcr va0'citheSre a 14166:oh C'enifl.a.
(one for oacb product"dcfwcd*by an individual Spec Sheet)And pay say balance due. As applicable,each Cusumutr undar this
Comma agars to be jointly and severally obligated and liable hermader.
The F{omc]kpm nsmves me right to issue a Change Order or teltninase[tun Conran or any iodsvi0ual Prodact(t)incuded)w+cin,m
its discredott,if Tba Home Depot or its authorised service provider determaties that it cannot pertorm its o6hpriona due to a snucnnal
problem with the home•environmcntnl bumdR such as meld,asbestos or lead paint.other sorcry concerns,pricing errors or becuum
work rcquitcd to compJt[ethe job Was rat included in he Conu'ac[.
PAvment Summ9ry, The Payment Summary (t 5'-_,1- included as part of'mis Contract wK 1bnb rbe.ropl
Contract amount And payments required for the depositsand final paymmits by Pratt=(as applicable).
NOTiCt TO CUSTOMER
You are entitled tD a con Netely fRled-in copy oribe Contract at the time you sign. Do not sign a Completion Carfirirnrc(srote:
there i9 one Completion rULleate Ior each listed Product M defined by individual Sam Sheers)before work on that Pruduct
is complete.
In do evert of trrminatioo oC this Contract,Customer agroca to pay The Home Depot the costs of materials,labor,evpmse;
and Services provided by The Homc Depos or Autlmriad Service Provider through the dale of t<rmaralton,plus coy other
amounts set forth in this Agracurcnt or allowed umler applicable law.'1TiE HOME DL•T'OT M1IAY WPIHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM TIDi DEPOSIT PAYbIENI' OR OTHER PAYMENTS MADE, W[l•FIQUT
LBWTING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OE SUCH AMOUNTS.
' Armntanre And Aumoriaatlan: Customer aLrrreas and understands that this Agreement is the entire agree-mere berwcen Customer
and The Home Deltot with regard to the Prodilm and Installation services and supersedes all prior discu.sioos wirl agreements-cidtcr
aN or wriaen•rdming to said Products and Installation.This Agrr<maat ea be assigned or attended except by a writing signed
by Customer and The Home Depot, Ctu1omoroeknowlcd9):S and agrees that C• Omer h ad,eadersmnds,vulunumly accepts the
terms of And ha^,remivcd A copy of this Agreement.
Aeaepted by: Sub itttd h .
x /�
L'a�trstnm i marura Dote Sal Cormvtfant's Signalute Date
X Na. !91)$ Zq 3 73yL
Customer's Signature Dam Sales Consultant License No. '
CANCELLATION: CUSTOMER MAY CANCEL THIS tax apAtiembl
AGREFrMEfv`p WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WnITTiEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THr THIRD BUSINESS -
DAY AWrER SIGNING THIS AGREEMENT. 7'FIE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A rORM TO USE IP ONR IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE:ADDUMNAL VIMMS AND CONIXT1ON5 ARE WATM)ON THE RF_RSE Star AND ARM PART Of'fIBS CONTRACT
tale-IaC-sc When-Uraneh Tea venaW-Ca910mef
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R081cco INC
f oeir-- -rc�"O�wry CyU?
17 2,FAieT'I
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,ems T a i ftti[irc [S n �rxar 4Lf3ir w Sri±nc,slit 1:94s,u
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f3r1 u d«rt Suildim: Re ul aril.and [and n ds
License:: OS SL 99699 --
Restricted:0: WS. - - -
ROBERT POCZOBUr
17 BEACH ROAD APT. 45 l
LYNN, MA01902
'Expiration. 2182012 -
t'numio.i.nFt' -
- 7r—"—".59694 -
Tlfe Commonwealth ofMassachusens
Department of Industrial Accidents
Office of Investigations
kq�F7�vl 600 Washington Street
Boston, 3M 02111
www.ntass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
Narrie (Business/Organization;lndividuall: Ho
iif- -��
Address: r2 ,5� -t /d�l
City/State/Zip:_ �i V1' !Ey Phone #4:_
E, full
n employer?Check the appropriate box:
a etn to er with } q_ TS'Pe of project (required):P y ❑ 1 am a general contractor and I 6. New construction
loyees(ful!and/or part-time).• have hired the sub-contractorsa sole propr etor or partner- listed on the attached sheet. ❑ Remodelingand have no employees These sub-contractors have 8. Demolitioning for me in any capacity. workers' comp, insurance. 9• Building additionorkers' comp. insurance 5. ❑ We are a corporation and its
red.] officers have exercised.their ME] Electrical repairs or additions
a homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions
lf. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof epairs
ance required:] r employees. [No workers'
comp. insurance required.] 13. ther
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy infomtation.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -
_ [Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'come policy informal on
I am an employer that is providlog workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: LD
Policy#or Self-ins. Lic. #: Expiration Date: _
Job Site Address: City/State/Zip: p
Attach a copy of the workers' c of 11 i�/J ar t'on howing the policy number and expiration date).
Failure to secure coverage as re utfdrider 3ecfi8tf Zo C. can lead to the imposition of criminal penalties of a
fine 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 of the DIA for insurance coverage verification.
Tdo rebr certlfr un a th a/ and ualiies ofperjurl'that the informationprovidedab vefsrue and correct.
re: Date::
FF--
Ilse onlr. Do not write in this area, to be completed by c14,or town official.
Town: Permit/License#
Authority(circle one):
d of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
r
_ n- - -
ATE
A CERTIFICATE OF LIABILITY INSURANCE D 02/21 IODIYYVY)
02/21/2011
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 policylies) 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 1-404-995-3000 CONTACT
NAME
Marsh USA, Inc. PHONE
_(AK No,EsI) . _- -._ .. IAIC Nl-_ _ __ ......
homedepot.certrequestomarsh.com n ORE55:
Two Alliance Center, 3560 Lenox Road, Suite 2400 --
Atlanta, GA 30326 INSURERS AFFORDING COVER AGE NAIC N_
Fax (212) 948-0902 INSURERA: Steadfast Ins Co 26387___
INSURED INSURERS Zurich American Ins-CO 16535-
The Home Depot, Inc.
Home Depot U.S.A., Inc. INSURER C' New Hampshire Ins Co 23841
2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co 23817
Building C-20 -_-
:NsuRER E: NATIONAL UNION FIRE INS CO OF PITTS 19445
Atlanta, GA 30339 -- 7960 _
INSURER f' Illinois Union Tn.. Co 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 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INBR ADp-SUOR ff POLICY EFF POLICY FRI LIMITS
L O TYPE OF INSURANCE S IO POLICY NUMBER MMDIYYYYJ_ MMIDOIYYYY _
A GENERAL LIABILITY Gn04887714-01 03/01/1 03/01/12 EACH OCCURRENCE $ 9 000 000
DAMAGE TO RENT D
X COMMERCIAL GENERAL LIABILITY PREMISES IT. ncel _ $ 1 000 000
CLAIMS-MADE OCCUR ME_D_E_XP(Any one person) $ EXCLUDED
X LIMITS OF POLICY XS 9,000,000
PERSONAL 8 ADV INJURY E
X OF SIR: $IN PER OCC GENERAL AGGREGATE $ 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMNOP AGG $ 9,000,000
-X POLICY PRO_jECT LOG $ -
B AUTOMOBILE LIABILITY BAP 2938863-08 03 O1 1 03 Ol 12 COIA INED SI DOLE LIMIT 1,000,000
Ea accident) _. k
NX
ANY AUTO BODILY INJURY(Per person)ALL OWNED SCHEDULED - -AUTOS - AUTOSBODILY INJURY(Perattidenl) $
NON-OWNED PeOr accidenlDAMAGE $
HIRED AUTOS AUTOSSIR AUTO P Y $
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
BED I I RETENTION$ $
C WORKERS COMPENSATION WC061967352 (AOS) 03/02/1 03/01/12 X WOR MiT OTH-
ANDEMPLOYERS'LIABILITV - — —
D ANY PROPRIETORIPARTNERIEXECUTVE YIN WC061967354 (FL) 03/01/1 03/01/12 E.L.EACH ACCIDENT $ 1,000,000_______
OFFICERIME MBER EXCLUDED' � NIA
E (Mandamryin NH) WC061967353 (CA) 03/01/1 03/01/12 E.L.DISEASE-eA EMPLOYE $ 1,000,000
DESCRIPTION yes,JescrLe under EL DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS below
C Workers Compensation WC0619673 55(KY,NO,NY,WI, ?73/O1/1 03/01/12
F TX Employers XS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/1M
IS Workers Compensation WC1192378 (pSI) 03/O1/1 03/01/12 SIR 1M
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD101,Additignal Remarks Schedule,if mgre space is regpiretl)
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 �
(((
(D 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
jfiero_hd
19834682
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�•� z Ot Ice of Cdnsumer Affairs&Business Regulation
OME IMPROVEMENT CONTRACTOR
Registration 126893 - TYPq
ExpisafioTti 8(3ISOi'a ,. -:I:SWPIemeMj <.
Thee:Home Depot,; -HpnseSs .
1u i
.�,,.
RICNARD FALLONE �
2690 CUMBERLAN. PARKWAY S ✓--��-e�— -
XTr 5'T• ,GA 30339 Lladersecretary -
CITY OF S' .E.NI, l.L-1SSACHUSE-FTS
• BI;ILDIING DEPARTMENT
120 WASHLNGTON STREET, P FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KjAtgFRr RY DR.ISCOLL
T
MAYOR 1to.+us StPtERas
DIRECTOR OF PLBLIC PROPERTY/13UMOLNG CONNISMONER
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 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# 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 MGL c
111, S 150A.
The debris will be transported by:
(name of haulm)
The debris will be disposed of in :
(name of facili )),
(address of facility)
sign re of per it applicant
1
ate