4 PETER RD - BUILDING INSPECTION (2) ss C-1< I Ll -7 o f
The Commonwealth of Massachusetts
�� 5 nT►O NLL SERVICES
a- Board of Building Regulations and Stand i s V CITY OF
4 Massachusetts State Building Code, 780 CMR ,,''11 SALEM
O �g ��Ol . } P )a'sed Mar 2011
Building Permit Application To Construct,Repair, Renov e r emolish a
1 One-or Two-Family Dwelling
t lV This Section-For Official Use Only
9 Building Permit Number: Date -plied: '
Building Official(Punt Name) Signature Date
SECTIONY: SITE INFORMATION
1.1 Property Addrels: � 1.2 Assessors Map&Parcel Numbers
1.1 a 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(ft)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2c"PROPERTY OWNERSHIP'
2.1 Owner'o or �y�
�tkem
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) W1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Oth r ❑ Specify:
Brief Description of Proposed Work2:
S
:'SECTION 4-ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined-
La Electrical $ ❑Standard'Ciry Town Application Fee,
❑Total Project Costa(Item 6)x multiplier:: xr
3.Plumbing $ 2. 'OtherFees: $ '
4.Mechanical (HVAC) $ List: -
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check'No Check Amount ''Cush-Am-
ount
6.Total Project Cost: $ ❑Paid in Full ." - ❑ Outstanding Balance Due:
SECTION 5:'CONSTRUCTIONSERVICES_
5.1 Construction Superviso ense( SL)
"CA eLQ Lic nse Number Expir ti Da[e
Name of CSL Hold
� �� . r1 `�/, List CSL Type(see below)
1 1�(G�
No.and Street Type ' W Description
-
1p�, U Unrestricted(Buildings u to 35,000 cu.ft.
4'�,,f,-{^may 1' R Restricted 1&2 FamilyDwelling
City/Poiat"e,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
(— SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Illmne Improvement C ntractor(HIC)
egistran�. *Emt;,
Date
a o stra Name
No. Street Email address
Ci /Town,` State,ZIP Tele hone
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 Issu of the building permit.
Signed Affidavit Attached? Yes .......... E5 No...........❑
SECTION 7a: OWNER AUTHORIZATION TO:BE COMPLETED WHEN "
OWNER'S AGENT OR CONTRACTOR APPLIES` /FOR BUI LDING'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 a application.
Print Owner's Name(Electronic Date
' SECTION 7b:OYMRt-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 accurate to the best of my knowledge and understanding
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at yA mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.R.) (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 half/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"
CITY OF SiU.&M. NL-kSSACHUSEITS
' BUILDING DEP.sRT%[&NT
a� 130 W.%sHLNGTON STREET,3BO FLOOR
TEI- (978) 745-9595
FAX(978) 740-9846
KLNBERLEY DRISCOLL
MAYOR THoN sST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUMDMG CONMSSIONER
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 hauler
The debris will be disposed of in
(name of ac
(address of facility)
4s4ignaepermit applicant
J
date
debriw,r.d4w
/
- \
/
� f
——-------- - ------- �{
Oflaco Consumer &f�%n aUBesRegulab£ {
\ m 10 Park Pla - S i! 5170 \
Boston, Massachusetts 02116 $
Home Improvement ContractorR b !o \
THD A HOME SERVICES, we . \ —
mc#RD FALLONE \ —
Sm cUeBE RLANDPARKWAY SUITE 6e .
ATLANTA, GA 3033
. Lpdmmress e -Mark Change.
— ter 2 _e Gplovrnentyi c,
The Coraswaosweaddda of m=acdaaasela?s
Depaposead of&d=MdAcc1den&
690 WashhWom Sfreet
Boston,MA 02111
tow .maass,govldaa
Workers' Commpemsmdiolm duaaaam®ee Affidaavit )��HtHecsl�m�>la mc2en>rs/H;Heeclte ns®aseas/�H�beBs
AISIaHieant Inffornadion PHeattte Print Leg2!h
Name,(Business/Organization/individual): t' 0mie- � � f!m-e—
Address: Rog 6 o j-�vt.) r�0&
City/State/Zip: S u . i915Y,5- Phone #: SO 9Y�2—
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ® I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hived the sub-contractors
2.0 I am a sole proprietor or partner-
listed on the attached sheet Y 7. Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
requited.] officers have exercised their t0.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12_El Royrrepairs
insurance required.]t employees.[No workers' 13, er
comp.insurance required.]
*Any applicant Viet Checks box If must also fill out the section below showing their workers'compensation policy Womtetiom
t Homeowners who submit this affidavit indicating they are doing all work and then hire outsift wntmaoss must submit a dew affidavit indicating such.
tContmetors that obeek this box must almrLbd an additiaml sheet slmwmg the mane of the sutrewtruser;and dusk workers'comp.policy mfotrmtiou.
®am an employer fleaf is providing workers'conWemsamora interlace for way employees. Belary is the pollg and jab sine
informrodom. /►
Insurance Company Name: r#441 f 6�rr'e' 7-+ 7"5 . (i0
Policy#or Self-ins.Lic.#: c o / / d J Expiration Date: 3
Job Site Address: City/State/Zip: —
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 to4he 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 eet3lf+am er has ofperjery tbaf Me baformadoo provided Mhosteandcorrssat
Si azure:
Phone#: � - cb 10 7
Fula]use only. Do not Write in dais area,to be completed by city or town offrelai
City or Town: Permit/Lieense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
' (� i Sold.Famished and Installed by:
Branch Name:New England Date:JJ— THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
Branch Number:31 908 Boston Turnpike.Unit 1.Shrewsbury.MA 01545
-roll Free 877-903-3768
Federal ID 4 75-2698460;ME Uc it C 02439:RI Cont.Licit 16427
CT.Lie d HI��C,..0,,,56�5522;MA�H�om/e�Improvement Contractor
Reg.
#126893
Installation Address: � � �� Sct(gn& �- �1 ` l�1
City State Zip
Pure r(s): Work Phone: Ho.Phone: Cell Phanet
Home Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1.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-Home Services.Inc.("The Home Depot")agrees to famish,deliver and arrange for the installation("Installation")of
all materials described on the below and on the referenced Spec Sheel(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.
"Contrail'):
3obd: tdu,.arann.ni oduct- :TotaIctA.r.t
Fit
❑Roofing Si Windows Insulation
❑Cutters I Covers
Roofioa; Sidlag Windows Insulation
,p ❑Gmren/Covers ❑Entry Doors ❑Roofing Siding Windows insulation❑Gutters/Covers ❑Entry Doors❑Roofing Siding ❑Windows ❑Insulation❑Gutters./Covers ❑Entry Doors ❑
Mmft mn25%DepadtofCo hWArroontdmeuponexeeutionofth(scanuacL%lain¢Pn rsmaymidepositrmreibmw AhirdeftheCuntraeAnnmt
Customer agrees that, immediately upon completion of the work for each Product,Cusmmer will execute a Completion Certificate 3
(one for each Product as defined by an individual Spec Shect)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 i e�Co(n�tract.
Payment Summarv: The Payment Summary'q '� T7 , 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 home:
there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)beforework on that Product
is complete.
In the event of termination or this Contract,Customer agrees to pay The Home Depot the emits 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
1-I311TING THE.HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Aceemtance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and'I he Home Depot wah 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 Depol.Customer acknowledges and agrees that Customer has read,understand nmarily accepts the
terms of and has receive acop t this Agreement.
Acce y: r S mi Ay:
me
S'go.me Dale / / Sa +Consul am' .liigna i c p, ate
X Telephone
Customer's Signature ate Sales Consultant IJ .c No.
CANCELLATION: CUSTOMER MAY CANCEL THIS tu+applicobm)
AGRFF.MENT WITHOUT PENALTY OR OBLIGATION (yt/(Juj
BY DELIVERING WRITTEN NOTICE TO THE HOMI? " 1{�Nlbb LY�Cr r�s�,cr �•�„�
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS � 7
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORMTO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE:ADDITIONAL TERMS AND CONDMONS ARE STATEDON THE REVERSE SIDE AND ARE PART OFTHIS CONTRACT
10.0645 Wma,-Branch Flie Yellow-Customer
CERTIFICATE OF LIABILITY INSURANCEQW72412014201 DADDMIW)
V 5
• 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 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 endomement(s).
PRODUCER CONTACT
MARSH USA,INC. pN p E ppA
TWOAWANCECENTER oExit IAJC
No:
3560 LENOX ROAD,SURE 2400 MIL
ATLANTA,GA 30326 ADDRESS:
INSURER(5)AFFORDING COVERAGE NAIC0
100492-H=&D-GAW-15-16 INSURER A:Slealgasl Ilawance CalAany 26387
INSURED INSURER B:ZMidl Amaiban Instrindi a Co 16535
THD AT-HOME SERVICES,INC.
DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:Nave Hampshire Ins Co 23841
2590 CUMBERLAND PARKWAY,SUITE 390 1 INSURER D:Illinds National Insi tance Company 23817
ATLANTA,GA 30M
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-M4266509 REVISION NUMBER-7
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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.
I R TYPE OF INSURANCE O S BR POLICY NUMBER POLICY
� N�MIDID EiP
LT LIMITS
LTfl
A GENERALLWeILITY GLO4887714A5 031012015 0310112016 EACH OCCURRENCE s 9,000,000
-X DAMAJISETORENTED
COMMERCIALGENERALLIABILDY PREMISES(Ea occurrence $ 1'600,000
CLAIMS-MADE OCCUR UNIITSOFPOUCYXS NED EXP{Any one person) $ EXCLUDED
OF SIR$1M PER OCC PERSONAL&ADVINJURY $ 9.00D'ODO
GENERALAGGREGATE $ 3,' 'Ot0
GENt AGGREGATE LIMIT APPLIES PER PRODUCTS-GOMPIOPAGG 8 9,OWODO
X POLICY JET LOC S
B AUTOMOBILE LIABILITY BAP 2938863-12 03N12015 D31012016 COMBINED SINGLE LIMIT 1,000,000
6 acciderd S
IANY AUTO BODILY INJURY(Par person) S
ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $
AUTOS AUTOS
HIRED AUTOS AUTOS S� PerPc�DAMAGE $
UMBRELLA LUk OCCUR EACH OCCURRENCE $
EXCESS LIAR ClAIM3-MADE AGGREGATE $
DED RETENTIONS I $
C WORKERSCOMPEN51i WC017731493 (ADS) 03/0112015 03/012016 X WC STATU- oTH-
AND EMPLOYERS'LABILITY TO MI B
C ANY PROPRIETOR/PARTNERIEXECVTNE YIN WON7731495(At(,KY,NH,NJ,VT) 03MI/2015 03MI12DI6 EL PACHACCIDENT $ 1,UI0,OD0
D OFFlLERIMEMBER EXCLUDED?- � NIA WCOIT731494 FL 03101/2015 0310112016 1,OD0,000
(Mandatory In NH) ( ) EL DISEASE-EA EMPLOYEE S
If DE SCRIPT ION OF OPERATIONS dbe antler Continued on AdGttioml Page EL DISEASE-POLICY LIMIT $ 1,000,000
below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AddNlonal Remarks Schedule,R more space Is required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DRA THE HOME DEPOT AT-HOk4E SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2465 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manasht Mukhegeeu-
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
fi" L
CSSL.099699
ROBERTPOCZOOUT
172 WHALERS LANE
Salem MA 019707
02/0812016