12 PRESTON RD - BUILDING INSPECTION (3) bz q
The Commonwealth ofMassachusett
cS�T413Ml�LgERVk la
Board of Building Regulations and Stan CITY OF
• Massachusetts State Building Code, 780 CppMR SALEM
V I� yleY 2 b AS' Wised Mar 2011
ID Building Permit Application To Construct, Repair, Reno a e r emolish a
One-or Two-Family Dwelling
This Section For Official Use Only
U I Building Permit Number: Date AppC
6 �
'--' Building Official(Print Name) Signature Date-,r
SECTION 1: SITE INFORMATION"
I� 1.1 Property Ad r s : 1.2 Assessors Map&Parcel Numbers
I—' Lla Is this an accepted street?yes_ no Map Number Parcel Number
111 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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❑
SECTION'.2: PROPERTY OWNERSHIP t
ecor :..< �+-�.} .:.
2.1 OwnnName(Print) —k' + City,
I _f
2� _��
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check hat apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other.,R Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED;CONSTRUCTION CO
Item Estimated Costs: Official se Only
(Labor and Materials
1. Building $ I Building Permit Fee: $'. dicate how fee is determined:177
2.Electrical $
❑ Standard City/Town Application Fee
❑Total Project Cost'_(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List::
5. Mechanical (Fire $
Suppression) Total All Fees: $;
Check No. Check Amount: Cash Amount- .
6.Total Project Cost: $ ❑Paid in Full - ❑ Outstanding Balauce Due
(P 1 -1
SECTIONS- CONSTRUCTION SERVICES
5.1 Construction up or License(CSL)
i
Licedse e Expiqipw.•
Name of CS old
List CSL Type(see below) L 1,
No.and Stree}� pp Type .� -Descripti '
U Unrestricted(Buildings up to 35,000 cu.R)
1_ R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�IAn rY SF Solid Fuel Burning Appliances
V 1 Insulation
Telephone Email address D Demolition
5.2 Regis red Home Improvement Contractor(HIC)
HIC l�
egistrntion umber Ex ion Date
egistrant Name
n• Email address
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'.-COMPENSATION INSURANCE AFFIDAVIT(M.GiL.c.152.§.25C(6))
Workers Compensation Insurance affidavit must bepompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Tssu a of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a; OWNER
'AUTHORIZATION TO BE COMPLETED WHEN
OWNEW 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERt OR Ai)THORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
containedA this app 'cation is true and accurate to the best of my knowledge and understanding.
S
Print Own;o Au onze gent's Name(Electronic Signature) Dat
`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(TUC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the RIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dus
2. When substantial work is planned,provide the information below:
Total floor 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S��I.EtI, NUNSSACHUSETTS
BuILDLNG DEPARTMENT
120 W ASHNGTON STREET, 3°D ftom
TET- (978) 745-9595
FAX(978) 740-9846
KINiBERLEY DRISCOLL
MAYOR T Homm ST.Pw-RRe
DIRECTOR OF PUBLIC PROPERTY/BUTMLNG COMNUSSIONER
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:
(nam of hauler)
The debris will jbe isposed of in :
(name of fac lity� y)-�
(address of facility)
gnature of permit applicant
*dat
dcbriulLduc
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
c.., ({'c9 Sold,Furnished and Installed by:
Branch Name:New England Date:�4 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
Toll Free 877-903-3768
Fed ID#75-2698460;ME Lic#C 02439;RI Cunt Lic#16427
C c# 565522 H me Im�plrovement ontractor Reg.#12689
Installation Address: ��J �� �1 L 1
City State p
Purchaser(s): Work Phone: Home Phone: Cell Phone:
a
Home Address:
(If different from Installation Address) City State . .Zip
E-mail Address(to receive project communications and Home Depot updates): -
❑ I DO NOT wish to receive any marketing emails from The Home Depot .
Proiect.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 theinstallation("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#: <tmwet aceertunl Products: Spec Sheets #: Pro'ect Amount.
❑Roofing Siding ❑Windows ❑Insulation-
❑Gutters/Covers ❑Entry Doors ❑ , *&7 / $ l `
4� ❑,]�R.Ro�oofing []Siding ❑Windows ❑
t� Insulation $ O
trutters/Covers [-]Entry Doors ❑ /
Roofing ❑Siding ❑Windows ❑Insulation
[-]Gutters/Covets 7❑Eutry Doors❑ $
❑Roofing ❑Siding ❑Windows ❑ Insulation
$
❑Gutters/Covers ❑Entry Doors ❑
Minimum 25%Deposit of Contract Amount due upon execution of this contract.- Total Contract Amount $
Mahn Purchasers may not deposit note than one-third of the ContractAmmt ot -
.. Customer agrees that, immediately upon completion of the work-for-each Product, Customer will execute a Completion Certificate
. . (one for each Product as defined by an individual Spec Sheet).and pay any balance.due. As applicable-, each Customer under this 'l
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.Pmduct(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 the Contract
Payment Summary: The Payment Summary # 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 tilled-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 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 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 t ived a copy of this Agreement, n
Bill
442
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The Convnonwealth ofMassachusetts
Department of lndustrialAccidents
I Congress Street, Suite 100
Boston, AM 02114-2017
www.mass.gov/dia
Wwrkers' Compensation [nsuraoce Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED NvrrH TEM PERhHTTWG AUTHORITY.
Armlicant information Please Print Letribly
Nagle (Business/Organizatiomrndividual):
r
Address:
City/State/Zip: V71Phone#:
Are you employcr':Check the appropriate box: Type of project(required):
1. _ l am a employenvith��employees(full and/or part-time).` I 7. New construction
2.a[am a sole proprietor or partnership and have no employees working for me in i $. Remodeling
any capacity.pJo aarkeri comp_insurance required.]
9. ❑Demolition
3, t am a homeowner doing all work m}setf.(No worker,'comp.insurance required.]'
6.❑I am a homeovmerand will be hiring contractors toconduct all work an my property. I will I0 ❑Building add.CiO❑ i
ensure that all conmcmrs either have workers'compensation insurance or are sole I 11.❑Electrical repairs or additions
proprietors with no employees. !
12.[]Plumbing repairs or additions �
i.❑[am a These sub-convmcgeneral contracmr and I have!tired the sub-connactors listed on the attached sheet 1
mrs have employees and have workers'comp.insurancet I VOther
repa s '
6❑we are a corporation and its officers tare exercised their right of exemption per MGL c lrl' j
1 i2,J I M,and we have no employees.[No workers'comp.insurance required.] I
*?ny applicant that checks box 4 t must also fill out the section below showing their workers`compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside rcontracors must submit anew affidavit indicaune such.
tCgptractors that check this box must attached an ffiditional sheet showing the name of the sub-cclrttractors and state whether or not those endtie!hove
empioyecs. tfthe sub-conhacmrs have employees tlicy must provide then workeri comp.policy duimber.
!am an employer that is providing workers'compensation insurance for m)i employees. Below is the polity andjob site
information -�
insurance Company Name:
Policy#or Self-ins.Lic.n: Exp ration Daze:
Job Site Address: W�b City/State/Zip:
Attach a copy of the workers'compensation pCill1cf,declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under IAGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
andror 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
l do hereby cer jy nd th of and penalties of perjury that the information provided a ove is rue and correct.
Si nature: Date:
Phone#:
EOfficial use only. Do not write in this area, to be completed by city or town official
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Hr)m-. IrItpr0vM':gjContractor Registranon
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EX09flOn" 81" 2016
THD AT HOME SERVICES, INC.
PICHAIRD FALLONE
2090 CUNABE-RLAND PARKWAY
ATLANTA, GA 30339
update Address and return card.*-vLark mason For than-S.
; Employment Loit Card
Address 7 Renewal I
jcf�3, iad',Vidul use oniv�!
License or ragis--rl,-Igft valid
b-fore tit--:piradon data. If found return to:
FZMENT COMTRACTOP-
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Types: Ig p iric F laza-3 ui-,a 5 1'10
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LIMY.,GA 30339 Underseentary of�