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1 PERSHING RD - BUILDING INSPECTION
c(< I ()5o ICS 4 TheCommomvealthoftlassachki CTIONALSERVIC S CITYOF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 7(UI PA1 ) U A 2 Rev1 eJ,l/ur?0ll `u'J x' Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only ' Building Permit Number: Date A ed: � Building Official(Print Name). Signature Date (n SECTION 1:SITE INFORMATION' L1 Property Address: ` 1.2 Assessors blap&Parcel Numbers IRrsh oo, 'ed 1.1 a Is this an accepted street?yes csC, no Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: IZuning District Proposed Use Lot Area(sq Il) Frontage(Il) 1.5 Building Setbacks(ft) Front Yard Side Yams 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: Zone: Outside Flood Zone? Municipal❑ On site disposal system C3Public 13 Private❑ — Check if es❑ p p y SECTIONZ: PROPERTY OWNERSHIP! 2.1 p)XQ^er)'or ecarRd}� 'So1 e m M h 0 bo tme((JPrint l City,State,ZIP ��rShihG �1 791- -7)8- 0$-91 No,mid Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 13 Existing Building C3Owner-Occupied C3Repairs(s) Alterations) 13Addition 13 Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work=: SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S 9 j 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S P f2ther Fees: S 4. Mechanical (I-IVAQ S List: 5. :\lechanical (Fire S Total All Fees:S Sup ression) /J Cheek No._Checke\mount: CashAmowit: 6.Totai Project Cost: S I%, 9�" 0 Paid in Full 0 Outstanding Balance Due: t , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) j� � chaef D� r�I� p G e , Y i License Number Expiration Date y Nmnegl"CIL Huller ` w ,Iry/6 List CSL'fype(see below) TypeDescription No. and Street -- ,\�� C J �M Q D / U Unrestricted But ldin s in)-to 35A1111 cu. It.) _ J v l �P R Restricted 1&2 Family Dwelling Cityll'uwn,State,ZIP hI Masonry RC Roofing Covering WS Window and Siding II(( n SF Solid Fuel Burning Appliances - Y J 1 Insulation Telephone Email address D Demolition 5.2 Registered 11OTF Improvement Contractor(HIC) r a 6 V bk '! P HlC Registration Number Expiration Date H r� npasN, -Or tIIC gy�tstm�d70�'rt741 •7 yrAv(/I�k Email address Cit crown,State ZIP Telephone 1. SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§25C(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 Isivance of the building permit. Signed Affidavit Attached? Yes ........ No...........❑ SECTION 7a:OWNER AU THO.RIZATION:TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT` I,as Owner of the subject property,hereby authorize 4uf' i r t9 act on my behalf,in all matters relative to work authorized by this building permit application. 5 � E con-*PC-61- J/ -- /5 Print Owner's Name(Electronic Signature) Dale SECTION 7b:OWNERI ORAUTHORIZED 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 accurate to the best of my knowledge and understanding. moe �adr� 5—_ i/ S Print Owner's or Aw lzed r\gei ' nn,e(C•Iecuonie Siymt re) Date 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 Home Improvement Contractor(HIC) Program),will rrof have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at Nvww.mass.eov'oca Information on the Construction Supervisor License can be found at w,aw.nmis.,ov!dLLi 2. When substantial work is plumed,provide the information below: 'rota) floor area(sq. ft.) '- ,,(including garage, finished basementlattics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number ofhalflbaths rype of heating system Number of decks/porches Type of cooling system Enclosed Open i. "roml Project Square Footage'may be substituted for"'rutal Project Cost" c. CITY OF SALEM MASSAa iUSE M BLIIIAINGDEFARTMENT 120 WASHINGTONSTREEr,3IDFLOOR TEL(978)745,9595 KIMBERLEYDRISQpLL FAX(978)740-9846 MAYOR _ THOMAS STY ERRE DIRECTOR OF PM1JCPROPERTY/BLIILDWGOC)M ISSIOMR Construction Debris Disposa/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 c40, S 54; Building Permit# condition that the debris resulting from this work sthe hall be dispis osed of in a properly licensed e waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: 164Sfore (name of hauler) The debris will be disposed of in: 0 U21)d4eS+- /k+I. S;ae Car4m� (name of facility) N Pn dove-I (address of facility) Signat re of pplicant - lI ` IS" Date AN The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �# 4t 600 Washington Street 9�2 .F a Boston,MA 02111 www.mass. ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 0."?, � jp� �9'it1�. —e,— /fiJV/GQiJ Address: Rog 60,45,0 City/State/Zip: s v - 0/5`45- Phone #: SOF- Are O8-Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.i 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp. insurance. Y P ty• 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.E] Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.E] Roof repairs insurance required.]t employees. [No workers' 13Other V iAll( comp.insurance required.] y *Any applicant that checks box N 1 must also fill out the section below showing their workers'compensation policy information. t I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the time of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is lite policy and job site information. Insurance Company Name: t q" #x4401 rl/trgL _co / Policy#or Self-ins. /L�ic. : /�/ d ( Expiration Date: Job Site Address: { 1 4 r,5 h i `\d City/State/Zip: Soaz 41 10A 0]ry�g/0 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$1,500.00 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. I do hereby certify under the paints mud penalties of perjury that the information provided above is true and correct Signature: e^� ��`t`4/ Date: � �f Phone#: i — ( � f0 /!2-- Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitiLicense# 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#: L ACORJD CERTIFICATE OF LIABILITY INSURANCE �42k05D"YY" 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 policy(ies)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 CONTACT MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE FAX 3560 LENOX ROAD,SUITE 2400 E-MAIL No ATLANTA,GA 30326 ADDRESS INSUREM)AFFORDING COVERAGE NAR;• IOD492-HomeD GAW-16-16 INSURER A:Steadfast IlaurenW CORVarly 26367 INSURED THD AT-HOME SERVICES,INC. INSURER B:Aalch Amencen Irsuranor Cd 16535 DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hanpshre Ins Co 23841 2690 CUMBERLAND PARKWAY,SURE 30D INSURER D:Illinois National Insurance Company 23817 ATLANTA,GA 30339 INSURER E: INSURER F: - COVERAGES CERTIFICATE NUMBER: ATL-=4268509 REVISION NUMBER;7 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. INSRADM SU POUCYEFF POUCYEXP LTR TYPE OF INSURANCE MIDPOLICY NUMBER MMIDp1YYWl (MUMNYM UNITS A GENERALLIABIUTY GLO48877144D5 ON12015 O3IOI2016 EACH OCCURRENCE E 9•00D•000 X COMMERCIAL GENERAL LIABILITY PREMISES IF,aaurmnce $ 1,000,000 CLAIMS-MADE MOCCUR LIMITS OF POLICY XS MED EJ(P(Any one Person) $ EXCLUDED OF SIR:$1M PER OOC PERSONAL&ADV INJURY $ 9•000•000 GENERAL AGGREGATE S 9•000•Iw GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPMPAGG 3 9,00D,000 X POLICY PRJECO- LOC 8 B AUTOMOBILELMBILRY BAP 293666312 031012015 031012016 COM INED SINGLE LIMIT g 1060060 Fa acGdeM X ANYAUTO BODILY INJURY(Per person) E ALL OWNED SCHEDULED $SIF INSURED AUTO PHY DMG AUTOS AUTQS BODILY INJURY(Per accMeM) 3 HIREDAUTOSNON�WNED PROPERTY DAMAGE AUTOS PeracciderdS 3 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTIONS $ C WORKERSCoMPENSATION WCOI 731493 (ADS) 031072 3101 015 62016 X WCSTATII- OTN- AND EMPLOYERS LIABILITY ORY LIMITS ER C ANY PROPRIETORIPARTNER(EXECUTNE VIN WC01773UM(AK,KY,NH,NJ,VT) 031012015 03/012016 EL EACH ACCIDENT $ 1.000,OOD D OFFICERAIEM NNI EXCLUDED? NIA (Mandatory In NHl WC017731494(FL) 031012015 031012016 EL DISEASE-EA EMPLOYEE $ 1.000.000 11yes,deacnne under COlritnue0 on ADdBorlal Page ESCRIPTION OF OPERATIONS new EL.DISEASE-POLICY LIMB 3 1.006.060 DESCRIPTION OF OPERATIONS I LOCATIONS T VEHICLES(Anach ACORD 101,Additional Remarks Schedule,d mom apace is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DRA THE HOME DEPOT AT-HOME SERVICES - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 3IX339 AUTHORIZED REPRESENTATNE of Marsh USA Inc. Manashi MukherjeeAgtiYy1.: r'�"wG•e,A, ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i Office d:f� d1�Slifl73ei' �° fairS arA� Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Innprove to ontractor Registration Registration: 126893 ,: Type: Supplement Gard Expiration: 8/3/2016 THD AT HOME SERVICES, !NC. MARK NIADNA ----- _ _-- _ ----- 2690 CUMBERLAND PARKWAY ATLANTA, GA 30339 Update Address and return card. Mark reason for change. SCA 1 Li 2aM•05Itt Address 0 Renewal (] (Employment Lost Card "=�' Otfice of Consumer Affairs&Business Regulation License or registration valid for individul use only ,q -. i before the expiration date. If found return to: OME IMPROVEMENT CONTRACTOR Orrice of Consumer Affairs and Business Regulation , � � Registration: Type: IOParltPlaza-Smte5170 "tom°'r Euplratioiv;:'8/3/26,1.6.., Supplement Card Boston,MA 02116 ' THD AT HOME SFRVICES;,ING: : .. THE HOME DEPOT:AT,.,f;10NJ,E',SERVICES MARK NIADNA 2690 CUMBERLAND PwwAY S X%-'AWA,GA 30339 Onderscerctnry Rptvalid withou signature i I i ' u HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold.Furnished and Installed by Branch Name: Boston North&South Date:4/J_q,,_zo_t S THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number:31 and 33 908 Boston Turnpike, Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lic#C 02439;RI Cont.Lic# 16427 CT Lie#MC.0565522;MA Home Improvement Contractor Reg.#126893. Installation Address: ?L PE4ZS!-1w IQN <,+LI=M AAA- 0 ( 0[,J-C-) City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone; LvrNn A6-*(_A —Jr`oCAM ts 14' (-InTtg [ ] T o & 0 Ili M �41Lsm vI El Home Address: (If different from Installation Address) City pp State Zip L--willAddress(to receive project communications and Home Depot updates):_/�1�>MR n S e f `rq IM S (e�('�(L L*LDO NOT wish to receive any marketing entails from The Home Depot o CUnq Prje oct 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"): Job Products: Spec Sheets #: Project Amount Roofing ,din LJ Windows LJ insulation ❑Gutters/Covers ❑Entry Doors ❑ ( 43 $ 14-9 I s— Roofing umwng Windows LI Insulation []Gutters/Covers ❑EntryDoo ��2. $ Roofing S,d,ng Li Windows U Insulation []Gutters/Covers ❑Entry Doors❑ $ Roofing Siding Windows Insulation ❑Gutters/Covers ❑Entry Doors ❑ $ FM,,n.mum 25%Deposit of Contract Amount due upon execution of this contract.ine Purchasers may not deposit more than one-third of the ContractAmount Total Contract Amount $ j Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a LCompletion 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 bejointly 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 thejob was not included in the Contract. Payment Summary: The Payment Summary # I S�I 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 one Completion Certificate for each listed Product as definedby 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 acopy of this Agreement. Ac!ptl ! hyo Q <\ /1' n t I _ t Sub teed by:O �_ / : _. .cS-099871 j1 SPRWG ROA 0 y , = �--" ,-,DRACUTMA onez ��A L�� F •tea. ..t _ ___. .