9 QUEENSBURY DR - BUILDING INSPECTION The Commonwealth of Massachusetts
ji
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 730 CNIR SdXfar
RevisedMnr 20!!
IBuilding Permit Application To Construct, Repair, Renovate Or Demolish aOne-or Tivo-Family Divellingibis SechoriFor'Official Use Only
g Permit Number;:_.- . Date pp I U11 ting Official(Pont Name) $�gnature, - Date
SECTION I:SITE INFORMATIO
1.1 Property rlies L 3c2 Assessors bt arcel Numbers
1.1a Is this an accepted s eet?yes_o 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(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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Municipal if yes❑ unicipal❑ On site disposal system ❑
SECTION 2:; PROPERTY OWNERSHIP' '
2.1 Ownertof e�orla( '
Name(Print) �� �n� City,Stati,ZIP
-
� �
No.and Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOM& check that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs( Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTIO 4: ESTIivLk D CONSTItUCTI N COS S-
Item Estimated Costs: Official Use Only,.
Labor and Materials
1. Building I $ 1. Building PermitFee: dicdte how fee is determined:
❑ Standaid.City/Town Application Fee
,
❑"Coral Project Cost ,(Item.b)s multiplier x
3. Plumbing S 1 Other Fees: S
i. Mechanical (HVAC) S List,
5. Mechanical (Fire S
Su > ression) fotal All Fees:.S_
Check No. Check Amount: Cash \mout n .
fi "1'ntul Project Cush S / f 0 Paid in Full 0 Outstanding Il Ince Due:_---
SECTION 5: coNSTRUCTION SERVICES
5.1 Construe oft it tervuur use(CSL)
---
t . License umber E.epir ti le
Name of CSL I lok
List CSL Type(see below)
No. a—�ttreet MRCRootrin
- Description
,.,.J icted(nuildin s u to 15,000 cu. tt.)
ted 13c2 Fumil Dwellin
City/"Town, State, ZIP �— r
Coverinw and Siding
uel [laming Appliances
������.�--�[ I I Insulation
Telephone " Email address D Demolition
5.2 Registered Hom nioven e t Contractor(H[C tp
f H[C Registration Number E pir ion ate
1IIC ' m any ai e u 11 t Vane
N Email address
Ci /Tc wn, State, ' IP r Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be complet submitted with this application. Failure to provide
this affidavit will result in the denial of the IssuaricSofifie building permit.
Signed Affidavit Attached? Yes .......... No........... Cl
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[,.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) me
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, [ hereby attest n r the pains and penalties of perjury that all of the information
conta' this application is true and a ura to a be of my knowledge and understandingrr
t
Print Owner's or r uthorizcd:\gent's Name(E c runic Sig,
ature) Da
NOTES:
1. An Owner who obtains a building permit to doll is1her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(H[C) 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.niass."Ov/oca Information on the Construction Supervisor License can be found at www.mass.,at�ido
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. tt.) _ 1-labitable room count
Numheroftiroplaccs_ Numberofbcdroums ----.---_--_--
Number ofbathrounts Number ofhalt'baths --- _
I'�pe of heating..system " _ - _-- ---- Number uFdecks/ porches
f}peofcooling.;y;tan
i "1OI 71 Pny�c[ `l ih rlle ❑Cl' I'Uota,e' lit! nllhihhl[cd t��l'��I�,LII Project(�Ji[
' y
Aa
q
:A 0217 - 111
Ci3mPeE
lb h,
T_Z Me
Ad dress —Alao
Phone
C itty/State/Zip:
'?Check the appropriate box: lype of project(required):
Are yp'4,ean empIDYer 4. 1 am a general cuntracor and I
I a_ 1 am,,employer with ;Qn . 6. 0 New constucti011
have hired the sub-contractors
employees(fun and/or part-time) listed on the.attached sheet.. 7.'[j Remodeling2, 1 am a solo pTop-le'tOf Or Partner- These su I b-contractors have 8. El DLmolition
ship and have noemployees;
employees.and haveworkers' dhu,additimit
working for me in any capacity. cornp.miantnee- 9. El Buil
[No workers'comp..insurance Tporation and its 10-01ileQtrical regale or add,
5-, We are a cc -dddi
Mumbinf,
officers have exercised their ti,Lj repairs or a riots
a homeowner doing all work 11 .
right of exemption per MGL- LEI �paars
myself. [No workers' conip� and we have,no
C. M_ §1(4), LEI Roo
,
insurance required.]t. employees.[No workers' .13
comp.insurance required-]
L
S,iy applicant that checks box 01 must also fill out the section below showing theirworkers'compensation policy information.
anewatn
t Homeowners who submit this affidavit indicating they arc doing all work and then hie outside contractor,must submit -davitindicating s=h.
OWN ect showing the name of the sub-contractors and state whether or not those entities have
lcmtla,mrs that check this box most attached an additional sheet
employees. If the sub-contraCtOM have employees,they must provide their,workers, ,mp.policy number.
lam an employer that is providing workers'compezrsafion.h7surance jar iny employees. Below is the policy and job site
information.
Insurance Company Name: K6
Policy#Or Self-ins.Lic.#: Expiration Date:—
Job Site Address'. City/State/Zip:_
Attach a copy of the workers'compensation policy decla6tion 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
ct fine up to$1,500.00 and/or one-year imprisonment; 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 iidvised that a copy of this statement may be forwarded to the Office 01
Investigations of the DI)-for insurance cover-age verification.
Idohere by certify,ur llr ih airy and paialtes ofpe?jury that the information provided above is I u grid correct orrecL7zz
Signature:
Phone#:
nj
Qfjtcial use only. Do not write in this area, to be c6"Tietted by city or to.wn officiaL
City ot;Town: Permit/License
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical inspector S.Plumbing inspector
6. Otb er
Contact Person: Phone#:
]SURANCE 02127,120 13
AlICIC)P,_ZY .-CERARUATE OF IAA I jTY
-,JC�I ONLY AND CONFERS MC Fjr�HTS UPCH THE CERTIFICATE ACLDC-R. THiS
THIS CERT 15 ISSUED AS A MATTER OF INFORNIA.
IFIC AATZ FORCED Y THE POUCiES
S NOT AFFIRMATIVELY OR NEGATIVELY AMEN[), E'--,EMD OR ALTER THE COVERAGE AFFORDED E
CERTiFICATE DOE RIZED
SELOW. THIS CERTIFICATE OF li,]SURANCE DOES NOT CONSTITUTE A CCj I TRACT EE-PPIEHIM THE ISSUING INSURER(S), AUTHO ,
FIEPrIESENTATIVE OR PRODUCER,AND THE,-CERTIFICATE HOLDER. �jc!.Qrsaj. If SUSFOGATIGIM IS WAIIVED, subje.:i co
IMPORTANT: It the hold.-,�. .. the policy(ies) mus, be ; I
L
the terms and conditions of the policy,certain Policies May require a, A statement Cri this canificate does ghtG tD
iha
certificate holder 1 n lieu of such endomement(s). NCONTACT
ANIE
PRODUCER
MARSH USA,INC. Est)
TVIC ALLIANCE CENTER EMAIL
3560 LENOX ROAD,SUITE 2400 MAID
ATLANTA,GA 30326 INSURER(S)AFFORDING COVERAGE
��ca Company 26387
INSURER A:------- __
iF
Z I nsurance Co 160492-HomeD-GAW-13-14 loan Insurance Co 16535
INSURED INSURER S:Zurich Anne 23841
jn Ins
Co
Hampshire
THE HOME DEPOT,INC. ...XC
INSURER C- 4ew
HOME DEPOT U.S.A.,INC. allco S CoINSURER. Illinois NallonAIns Ca 23817
2455 FACES FERRY ROAD;NW INSURER 0
BUILDING C-20 INSURER!,
ATLANTA,GA 30339
INSURER F:
CERTIFICATE NUMBER: ATL-OMIS9545-04 REVISION NUMBER:7
COVERAGES LISTED BELOWBEEN ISSUED 70 THE INSURED.NAMED ABOVE FOR THE,PULIUY,FERIOO
IS IS TO-C ED BELO'
THIS CERTIFY THAT j. ,Ir,_URj' E LI HAVE
INDICATED. EI�i_iiiRM OR CONDITION
NOTWITHIS- PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
I rANbING ANY REQUIREM OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
13E ISSUED OR MA`Y'PER
CERTIFICATE MAY SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
EXCLUSIONS AND CONDITIONS OP.S A OIL 5 ER OU EFF POUCYEXP LIMITSI
INSR TYP50 INSURANCE I R nIIrYwU BER 4M D - MMODD 9,000,0001
ITR I GLO4887714-03 0310112013 � 03110 191M4 EACH OCCURRENCE:,
A GENERAL LIABILITY i .�. L-, 1,000,000
PREMISES E nence
X COMMERCIAL GENERAL LIABILITY EXCLUDED
LIMITS OF POLICY XS. MED EXP(An ...P..n.) $
OFSIR:$IMPEROCC PERSONAL&AOV INJURY $
GENERAL AGGREGATE $ 9.000,000
PRODUCTS-COMPIOP AGG S 9,000,000
GEN'LAGGREGATE UMM APPUM PER $
X POLICY PRO- LOC.
031OV2013 0310112014 COMBINEDSINGLEHUMIT 1000,000
-8 AUTOMOBILE UABILFIY BAP 29388 6340 e ocident S
BODILY IN
RY $
ANY AUTO
ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per acddent)
AUTOS AUTOS PROPERTY DAMAGE $
NON-OWNED er eccide
HIRECAUTOS AUTOS $
EACH OCCURRENCE
UMBRELLAWAS OCCUR
AGGREGATE 3
EXCESS LIAR CLAIMS-MADE
$
DED RETENTIONS WC033576314(ADS --j-1111111113 F3/0112014 X WC STATU- OTHWORKERS1,000,000
C WORKERS COMPENSATION
AND EMPLOYERV LIABILITY YIN 4VC033575316(AK.I') f"f" 0310112014 E.L.EACH ACCIDENT $
C CFFlC a EXCLUDED? NIA WC033575316(FL) 03/0112013 03101/2014 SAL DISEASE-FA EMPLOYE 3 1,000,000
0 1 ..det. I.N 1,000,000
If ,d scribe under EL DISEASE-POLICY UMIT S
Des R ON OF OPERATIONS Inelore,
0310112014 (EL)LIMIT 1,000,000
C WORKERS COMPENSATION WC033575317(KY,NO,NH,VT) 0310112013
wC0335753113(NQ) 0310112013 0310112014
C
DESCRIPTIOKOFopEPATONSILOCA-nONSIVEHICLES (Attach ACORD1oi,Addfli.nMR...riu,Schedule,H more.1-ee is
ru,.ur.d)
EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY Of THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE HOME DEPOT INC. BE DELIVERED IN
HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL
24551PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING C-20
ATLANTA,GA 30339 AUTIORGI REPRESENTATIVE
of Marsh USA Irc
Manashl Mukherjee
198 12010 A D.CORPORATIOWA 11 rights reserved.
'ACORD Z5(2010105) The ACORD name and]ago are registered marks c3f ACORD-14
s�
(Lifise of Coe unier Affair aw'ldn.,mess ltu u!atEon Liceu>e:or registration VOW to? wilt iidn?
HOME Iftll'ROVCN7ENT CONTR,ACTOF before the expsrahoss dat= if found return to:
Regiaxration a't26 93 t3,s,ce of Cor n uer.affair_a sd Business
F v Ex aed its s $ -Tups lfl p2T€.PLza Suite'5170 i
pi3T�0'i4 Supplement Floston,Pl�t9 GZllo
The.Home Depo ,4-�i{.QW
RICHARUi �.
2690 ClIMB6RLAt. PAEftC]ll41', S
GA 9n339
Undsrses.e[ary of valid s Rhout signature
,r
. p
I
eft J F't ik"k<
J
}, rl 7i t..Jz 1,j S �'y'� � Jet s�si❑ i u .t4� �::.
�S;ye'a4 CSSL-099699
. a
ROBERT POCZOBUT
172WHALENSLANC 'f',, -
Salem MA 01970
02/�0812014 -
M
04/01/2013 19:43 17818940331 TODD RIDEMAN PAGE 01
HOME IMPROVEMENT CONTRACT
• PLEASE READ THIS
/II' +n� Sold,Furnished and Installed by:
Branch Name: Boston Date: J THD At-Home Services,Joe_
—�—/— d/b/a The Home Depot Al-Home Services
908 Boston Turnpike.Unit 1,Shrewsbury, 01545
Toll Free(800)(57-5182;Fax(SOR)845-(i6017Ul7
Branch Number:31 - Federal ID#75-2698460;ME Li.#C 02439;RI Qmt.Licit 16427
�//�� ,, n- CT li/c# IC.0. 522;MA Home improvement Conttactur Reg.#126891
Installation Address: 9 y.Yl w,- j A edg �7.
City State Zip
Parcba eras): Work Phase: Home Pimne: Cell Phones
m / I o t t �9r><1x -7yy1
Himic Address:
gfdil'I'crent from Installation Address) City Stale Zip
E-mail Address(lo receive pniject communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing entails from The Home Depot
Pndect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees Iv buy.
.."ERD AI-Hume Services.Inc. ("The Home Depot")agrees to furnish deliver and arrange fur the installation(-Installation")of
all materials described on the below and on the referenced Spec Sheet(%), all of which urc incorporated into this Contract by this
micrcnce,along with any applicable State Supplement and Payment Summary attached hereto and any Change Ordcrs (collectively,
'Contract");
.lob#: ubwa saxM.»i Products: S Sheets #: Prn'ed Amount
❑Roofing ❑Siding M Windows U In laaoa % W 1
095I ❑Gutters/Covers ❑Entry Dkxirs K1. o �a srtf ��1 /�y $ 3 '�,00
❑Rooting LjSidmg LjWindow, 0 Insulation a
OGuncrs/Coven ❑Entry Doors ❑ 5 ,,, $ 3`75, 00 n�-
Roling Siding LJ Winslow% 0 insulation -Y�(
❑Gunem/Cover; ❑F.mry Damn❑ $
❑Roofing []Siding ❑Windows ❑Insulation
❑Gutters/Covers ❑Entry Doors ❑ $
Mirdrmrm 2S%IkpnatdContrad Amoumdueupon—danafth'saam" Total Contraet Amount $ �7 1 ,20
Maine PurdmxtatmY not depa®t marethanoae-dardefthe Cannad m Amou . V
Customer agrees that. immediately upon completion of the work for each Product,Customer will cxmutc a Completion Certificate
(one for each Product a%defined by an individual Spec Sheet)and pay any balance due. As applicable, each Customer under this
Contract agrees to he Jointly and severally obligated and liable hereunder.
The Home Depot rescrves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Dcput or its aulborized 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 ertnrs or because
work required to complete thejob was not included in the Contract.
Payment Summary The Payment Summary # /V II 3 0 _,..—., 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).
NOTTCE TO CUSTOMER
Volt 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 defined by individual Spec Shmts)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 PAVMF,NTS MADE WITHOUT
I,IMITIN6 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 Tic Homc Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either
oral or wrircn,rciutin•to said Products and Installation.This Agrocinert 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. volunuaily accepts the
terms of and has received a copy of this Agreement.
Accepted by: Sub" J
tgnature Dxle Salo Consultant's Signature Dale
Telephone No.
Customer's Signature Dale Sales Consultant License No- ..
CANCELLATION: CUSTOMER MAY CANCEL THIS (u%appilcab,c)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELFVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED It rRETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE
NOTICE:ADDITIONAL.TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE,AND ARE.PART OF THIS CON'rRACr
1 o-11-12 Whine—Branch Foe Yellow—Customer