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5 PRESTON RD - BUILDING INSPECTION
The Commonwealth o)'Massachusetts t Board of Building Regulations and Standards CITY r Massachusetts State Building Cole, 780 C'MR, 7w edition OF SALEM RrrisrJJunnrvs � Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling 1 This Section For Official Use Only Building Permit Number: Date Applied: / Signature: f" Building Commissia dinspmtwbTilmildinp Dare SECTION 1:SITE INFORMATION 1.1 Property Add br{6t ��4� f n 1.2 Assessors Map& Pared Numbers I.to Is this an accepted street?yes no Map Number Parcel Number IJ Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use to Am(sq 11) Frontage(11) 1.5 Building Setbacks(R) From 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: r 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public❑ Private❑ — Check if es❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 r f R qq ntiJ��t�t�lzi7 Name(PrinQ n Address for Service: (go� ( in /r r Q7_4 b Signature / Telephone SECTION): DESCRIPTION OF PROPOSED WORK'(check a hat apply) New Construction❑ Existing Building O 1 Owner-Occupied ❑ 1 Repairs(s) Alterations) O I Addition ❑ Demolition O Accessory Bldg.❑ Number of Units Other ❑ S Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OMCISl Use Only Labor and Materials I. building S t. Building Permit Fee:f Indicate how fee is Determined: O Standard City/Town Application Fee ?. Electrical f ❑Total Project Cost'(Item 6)x multiplier x 7. Plumbing S 2. Other Fen: S 14. Mechanical (HVAC) S List: 5. Mechanical (Fire S Su «ssian Total All Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S ❑Paid in Full 0 Outstanding Balance Out: r m SECTIONS: CONSTRUCTION SERVICES 5.1 Lletas ed Consfrucflon Supervbor ICSW r / I.icense umber I:tpint n to Name 1'C'S •I lulder O 4 List CSL Type(see below) �' Description d U IJ Moicl'i to JS,non Cu. Ft. R Restricted IAS Famil Uwellin Signal ,- M M• Only RC ResiJential Raulin l'orerin 1'eleplwne WS RniJential Window oral SiJin SF Residential Solid Fuel 8umin Appliance Installation D Residential Demolition y r4s.lRegibstered Ho rov et ro-4 or lflit o(ll C Re s r7Reyistrarian/ Espirano Ida T.leplaate SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL / 33C(6)) Workers Compensation Insurance affidavit must bap&nspleted and submitted with this application. Failure to provide this affidavit will result in the denial of the IssuanA of the building permit. Signed Affidavit Attached? Yes .......... No...........O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR AP LIES 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. 9G Sianaturc of Owner Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION I as Owner or Authorized Agent hereby declare that the statements an formation on the foregoing application are We and accurate,to the best of my knowledge and behalf. t�-- PrintN Signature ofOw d thorinedA n1 Day I Si umkr the ai and rwltio of 'u NOTES: FAn Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will gg have seem to the arbitration program or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 IO.R6 and I MRS.respectively. When substantial work is planned,provide the information below: l floors area ISq. Fl.) (including garage, finished basement/attics,decks or porch)ss 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 ). "Total Project Syuare Footage"may be substituted for'Twal Project Cost" Itf 1lrltt"uLawnc a ul{>t.i d.0 i` i 8uard u! Ituildon S{t>PO •/* l.iceose f:Ori,IYLICGOP • f 8L795 Restficted o: 0 EVAPIGEIOs WAY# 8 LEDGEW�1964 PEABOD riatlrotwn:5T13f�!! { Tr9:J074 I i The Commonwealth of.4fassachusem Department oflndustrial Accidents Office of Investigat' "ns kv 600 Washington Sfreei Boston, iVA 02111 :t:�3' www.ntass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �' Please Print Legibly Name (Business;Orcanizatioa'Individual): 1 r�1,>, ,(��7 Address: a i�c n •- 4444k��VlJ r 1 l`T City/State/Zip:_ � } - Phone #: [2. re an employer?Check the appropriate box: Type of project (required): f am a employer with 4. ❑ 1 am a general contractor and Iemployees(full and/or part-time).• have hired the sub-contractors6. ❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9_ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their .10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.[] Ronfrepairs insurance required:] * employees. [No workers' L�J 0 comp. insurance required.] 13. Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homcm%Mcrs who submit this affidavitindicating they arc doing all wort:and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the time of the sub-contractors and their workers'comp.policy information. i am an employer that is providiwg information. workers'compensation insurance for my employees Below is the policy and job site •f Insurance CompanyName: —T Policy #or Self3ins. Lic. #: Expiration Date: Job Site Address:_ 1Pi��l p<` 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby ceRi a der!/ s and penalties ofperfmy that the information provided above is true and correct. Signature: �+.� Date: Phone#: ��—1 7 � Official use omll•. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other CITY OF SALE M PUBLIC PROPRERTY '. DEI'ART'NIENT Construction Debris Disposal Allidavit (rryuiretl li)r all dcnwlition and renoruion work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5 Dcbt is, and the provisions of 1viGL c 40, S 54; Building Permit tr is issued with the condition that the dcbris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 111. S 150A. The debris will be transported by: Q Ir WOW t name of hauler) I he dcbris will be disposed of'in (nalnr ul Facility) die a 1p�Cv t;IJdress ul'I'acJity) �igual cuF p. mit ,y\pheant 08/26/2010 15:26 15087568823 THD AT HOME SERVICES PAGE 01/06 10-AUG-H 01:01PM FR*-Kole Dtpot 2000 WTOT401402 T-21S p.001/000 F-009 . 'PLEASE READ THIS Said,Furnished and Inamlled by: Branch Name: Banner Dame O THD AI-Home Smvfcm,Inc. dWa 77ie Homo Dam At Horne Services 343A Greeawoud Sweet,Unit 2,Worcester,MA 01ti07 . Branch Nmoharn SI Toll Free(M)657•SI8 2; Fix(SOS)75&8M tided ma 75-269"M*,ME Lies C 02439;fit OWL lien 1"V Cf UC a 565422:MA Nome laptovenrm,t Cagoaem R S M 1=93 Immmtmn Adam: 5 a.rs.esmrA 724`; SMteJ6. AA.A. O t g-1 to City Sees 23p Aaximar(s)a ark prone; B®,a litigMr Cal rhme, 79 cpg ] „ oriir4tcra '7ir�1_o I.i� [ J 1 97jo 9-19 4D9 [ l Home Address - !ffgPAM'r�. pF different$om Installation Addroj4 City. $rate Zip hrmng Address(in receive ptojxt camnmotcations ads Home Depot npdx1W):5D UZ.o e-ErJ y O te7 %Jeri x as , NET" �- ❑f DO NOT wish to receive any tnedceriag mnens Rote The home Depot �� 7rdlrtnatlotp Uaderaignw CClatottteh'7,the owaen of the property located at the shove installation address,agrees to boy.. ate'(' At ees,inn.('The Home Depon agrees to famish.deliver and arranp for the installation C-leslaliatloo")of all materials described no the below and on the referetroed Spec Sheet(s), all of Which me Incorporated into this Contact by this mfermoo,along with any applicable Sims Supplement and Payment Summary scow ed learn,and any Change Orders(Mlleplvely, Job*- n+.wmrry Praasa!a: Sleet tl: FrojeclAcuoung e-Qp SiMng indows W Insuletioa b 5 ! SS ❑r�s/raven Gllh+oyDo. ❑ o i5 S S ! 3 8 1 - . RsaSag Miding L3 vyadeaa 0 Insulation $ Dona n tDOMM strong U Windows *-.•hwim ❑0tutoofCovern ER[mry Doman $ Liltoofts sldiag U wradoav U Inndation $ ❑Guons/Canna.❑ferny Irma fl - . 'A1Mastn 25�Depoatsf Cemeat4Amoo�dR'ttpm na+mllotl a(tNsteamae6 To C.,.........Ana�t Matra Ponitraha easy tm t arpmS aeon tbea oaOhd tithe Can"ff ksaoms. a@wt t8aK'imal2aw?ly STiP n oomptetion oT'the"Wor9<fur®cb"PrtiGue4"CZomW wilf"esacamx ComPleiTdn CEiQ}IIfatle . .... (arse for each Product oe deRnad by an individual Spee Sheet)and pay any balance due. As applicable.each Customer under this Contrutt,agrees to be joimiy and sevrmrty obligated and liable hereunder. The HDme Dcpot tesaves the sight to issue a CbMiSc Order=terminate this Contract or any mdividasl Ptaduci(s)included hedrin,at fn dlseredo0.if The Home Depm Grits euth "I d Service provider detarmines that it cannot pedonm its obligations due to a sttucumal - psobtmn With the home,envimnmenml hazards such an mold,mhestas or land pahs,other safety concerns.Pricing eriona or became wort requited to cw*lete the job was not included In the Contract. Paynneart S m�q; The Payment Summary N a I ;� I 1 S _iooludrd or pad of this Cons!a,L sets tonh tie cowl Concert ammuo ad pnyraeA s requbed for tier deposits and final paymerrm by Product(a applicable). NOTICE TO CUSTOMER Yon on entitled to a aroahtpIt 60«l-in rnpy of We Contract at the Hoe yw t it Do not sign a CooWle6ms Ce flfkvte(note: there is too Completion Certi6eare for tall fisted Prodmn a derymd by i diviiWrt Spec Sheers)before work an that Product is �.In the event at Milan of this corahract6 a to pay The Hoons,Depot the COWS of Materials,tober,expenses ®pp p mry :nd service;provided by The Hanne Dam ov ED TOO TIM O set go. O I iinis pm THE nEPOSYr Pilaw. TI t ROME DEOTHEPOT MAugh the daft f YgRRNC$wl74SHoI�D W oUON7'T8 LIAfITRVG THE HOME DEPOTS 0141B8 RR117TDS DIS POR RECOVERY OF SUCH AMOUNT& Aqurow ang Ar t0asizApjpg; Custoomr apses and undnmaads that this AgM nmc th the entire agreement bnwees Customer mW rs trmro Depot wish M)Wd to the Products and Inscallaton srnicea and supersedes ag grist discussions;and agrcromts,eidat oral or waken,misting to said Products and Inea➢0con.Tbm' Ageement be uselgned or amended except by a writing signed by Customer and The Home Depot.Customer aelanwledges aat agrees that nor has d understands.voluomrity accepts the terms oFa d has recc(eived a copy of t Agrcemeol. Aeeeptod t // $ py; . 's SignµmrDgeSates Consults 'a Signature Dow awrher's SI re Dam Talepbone No. rf Qi A Sales Conauham License No. AN tT�TTON CUSTOMER MAY CANCEL TRL9 (ss ngakoenl AGREEMRMfr UT PENALTY OR OBLIGATION BY DELIVERiN WRITTEN NOTICE TO THE HOME. DEPOT BY h9H MOM ON TIM THUM BUSINESS ' DAY AFTER SIGNING THIS AGRERMENT, THE STATE MWPLEMRNT ATTACKED HERETO CONTAINS A FORM TO USE Hr ONE 'e - SPECTMALLY PRESCRIBED BY LAW' IN CUSTOMER'S STATE NOTICE!ADI)MONAL TRRAIRAM OQMMW 9ARRSTATRO UM TUR RSVRRla IRDR AND AM pA&P OFIM DONPRACP 5-7.10 (SSO WNto-&anon Sp Yolow-Cuaatner OF LIABILITY INS L_ r CERTIFICT\T' E UPZA -,ICE T 6 1 G [arsh USA, Iv_. �LI_ GA T Ho1e Depot, I-c b.-- Te __. . nai . spot G.S.i. . Net, 2405 Oad :'J T � - 1 ° - W'_?0. _ __95' j 9ui:3in3 C-20 Atlanta, GA 30339 ; ;p;ct;RER=' 3"r`inc-s Union Ins Co NCIVV COVERAGES THE POLICIES OF INSURANCE EIS, COND TIONVOF ANY CONTRACT ORFAVE BEEN ISSUED OOTHERSD CUMENT W THORESFECT TO WH CHT HIS CDERTIFICATE MAY BIEIIS OF SUCH ANY REQUIREMENT. MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS ANO CONDITIONS OF SUCH _____ .._. .._..—.—.. ---- ..._._.._._.._. LIMITS POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. O IM EPFEN vY rPOuc a xPIRmTIOy j INSR Do POLICY NUMBER A T GL04887734-00 03/01/10 03/01/11 FAM^OCCURRENCE.�EN f 9,000_000_-____. A GENERAL LIABILITY $ 1,000,000 _ PREMISES E pccwg^coL_ .__--, -- X COMMERCIAL GENERAL LIABILITY MEDEXP(MYone Persco_�_ SEXCLUDED,___:_ _ CLAIMS MADE OCCUR PERSONAL&ADVINJURY f 4_000.000_ I GENERAL AGGREGATE PRODUOTS-COMPIOPAGG S4y000.000 GENT.AGGREGATE LIMIT APPLIES PER: X POLICY PRO- LOC 03/01/11 38863-07 03/Ol/30 COMB SINGLE LIMB f 11000,000 B AUTOMOBILE LLIABILITYHAP 29 (EC ac.dent)ritleml__-__, X ANY AUTO BODILY INJURY 4 ALL OWNED AUTOS (Per Person) _.. SCHEOULEOAUTOS BODILY INJURY f HIREDAUTOS (Per a<ciden0 NOWOWNED AUTOS PROPERTY DAMAGE S X SELF INSURED AUTO - (Perarodent) PHYSICAL DAMAGE AUTO ONLY.EAACCIDENT GARAGE LIABILITY OTHER THAN F'r, EAACG S ANY AUTO AUTO ONLY: AGO S GL048B7714-00 03/Ol/10 03/01/11 EACH OCCURRENCE f_5.000_000- A EXCESS I UMBRELIALIABILT' AGGREGATE__, $ 5: X OCCUR ED CLAIMS MADE DEDUCTIBLE - - f - --- .. RETENTION 1-__.__ WC STATE- OTH-03/Ol/10 03/01/11 %- RY11MRi C WORK ERS COMPENSATION WCO20J 42755 (A05) 1,000,000____ AND ELIPLDYERS LIABILITY YIN 03/01/10 03/01/11 E_L_FACHACCIDENT f _ D ANY PROPMETOP/PARTNERIEXECUTIVE� WCO20742356 (CA) _ OFFICERM5 BER EXCLUDED➢ KCO20342357 (FL) 03/O1/10 03/Ol/11 EL DISEASE-EA EMPLOYE S 1_000,000 E (Mandatory in NH) E.L.DISEASE-POLICY LIMIT S1,000.000 II Yea,deswbe under SPECIAL PROVISIONS bcl 3 OM/2M OTHER THSC46242373 ITX) -' 03/01/10 03/01/11 Occurrence/SIR E TX EMP10Yere Exteee WC0910566 IQSI) 03/01/10 03/01/11 D Workers Compensation C Workers Compensation WCO20342358(%Y,MO,NY.WI, ) O7/01/10 03/01 11 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN FPXCES T, INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL DEPOTS.A., INC. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR RRY ROAD NW REPRESENTATIVES. BUILDING C-20 - AUTHORIZED REPRESENTATIVE ATLANTA, GA 30339 USA ©1988-2009 ACORD CORPORATION. All rights res ervrd. - - 02. Pa> laf Office of Consumer ARairs&Business Regulation — OME IMPROVEMENT CONTRACTOR Regfstratiow- 126893 TYP Expiration 8/3124Y2.n Supplement The Home Depot�At HoJn ry ce e Seis € r r2 RICHARD FALLON�Eq 2690 CUMBER LAND,P RfCN/AV S Af ,GA 30339 \�= Undersecretary j