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3 RANDALL ST - BUILDING INSPECTION
S�til � w> ��P3a; Cr, 3j�, The Commonwealth of Massachusetts RECEIVtu Board of Building Regulations an4wVEIGAP F1AL. SERVICE CITY OF LEM Massachusetts State Building Code,780 CMR S Revisedd MMor ar2011 , nn �� U n I Building Permit Application To Construct,Repair,110A1 .O3Hen olista I One-or Two-Family Dwelling t-- This Section For Official Use Only t Building Permit Number: I Dat V Applied: IV— U , Building Official(Print Name) - Signature Date I SECTION 1:SITE INFORMATION 1.1 Property Address: ✓,� ^d 0.II n t, 1.2 Assessors Map&Parcel Numbers �J L l 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(11) 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 OWNERSHO' 2.1 Owner of Record: M ` J l M a 0 9 7� Name( ) City,Stage,ZIP 2A� ii � ��- 2)g , - a 3 39 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed World: r t c op s l,dt+ Sh Kyles 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: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x. 3.Plumbing $ 2. Other Fees: $ - 4.Mechanical (HVAC) $ List: _ 5.Mechanical (Fire $ Suppression) Total All Fees:$ 6 Check No. Check Amount: - Cash Amount 6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: Ynra k L-e� sA-s V-= SECTION 5: CONSTRUCTION SERVICES 5.1 Construgtiign Supervisor License(CSL) 1- ' I V Q. 1 Q License Numberl Expiration Date Name of CSL Holder List CSL Type(see below) q7 r' S t�49 rc Cy1- ft1 No.and Street J Type Description U Unrestricted(Buildings up to 35,000 cu.ft. Restricted 1&2 Family Dwelling City/Cown,State,ZIP VV M Masonry RC Roofing Covering WS Window and Siding y u( . SF Solid Fuel Burning Appliances I Insulation -Telephone Email address D Demolition q 5.2 Registered Home Improvement Contractor(HIC) /a 6 093 L _ 3 -/A 1-6n,Q_ 1 9 r HIC Registration Number Expiration Date HICCompany N�pieorfflTp tr� m�ae,�D i1T Y � lSS r`" No.and Street Email address S0,-t,.J58vrx mR yul - B99 - -t139 city/Town, State,ZIP Telephone 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 Issuance of the building permit. Signed Affidavit Attached? Yes ..........W No...........❑ SECTION 7a:OWNER A THORIZATION TO BE COWLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize �v fY1Q V IJl to act on my behalf,in all matters relative to work authorized by this building permit application. S L L C tryvt,+✓ vV 7 0 61 - /5- Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' 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 a placation is true and accurate to the best of my knowledge and understanding. c ,.i( V.. �ft 1, 1) ` 2 G) - 15, Print Owner's or Autho zed Agent's N e(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 w�nv.ntass.govroca Information on the Construction Supervisor License can be found at www.mass_gov/dPs 2. When substantial work is planned,provide the information below: Total 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 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" r _ TIM Cosnirdroniveaffli ofHassachusseas —_ Depar€..nent of ndastr/al Accide zts __ _ ice of 1"a9t4aatzans a©® waslinzagon Street -- BostoZz,J JA 02171 - :'JYetFN.r's2^.�SS.aata�dZg Walters' Compensation lomwance Affidavit: li uHders/Contrastoa s/Eleep¢iieians/Plaambelrs w ppoiennt Rnformation Please Print Legibly Nanle(13usines40mrunizationfindividural):_00)Ft�l 4,� Address:�OS 6 0 540 �tJs`NpIY-� City/State/Zip: S vLfj 4 ts ' Phone : �2- Are you an employer?Check rue appropriate box: "type of project(required): 1.❑ 1 am a employer with 3- Eff I am a general contractor and I 6. ❑New construction employees(full andlor part-time)' a have hired the sub-contractors 2.❑ 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 I0.❑Electrical repairs or additions 3.C1 I am a homeowner doing all work right of exemption per MGL 1 LD Plumbing repairs or additions myself.[No workers' comp. c. 152-. a 1(4),and we have no I2.M Roof repays insurance required.]i emplovees.[No workers' comp_insurance required-] 13.0 Other `Any applicant than cheel<.c box d 1 must also fill out the section below showing their 1%vTkers'compauation policy information r I lomeottners who submit this a111davit indiwtms they arc doing a1I work and them hire outside cantmetms must minnita new atbd wit indicating such -Contractors thm ebe ck this box must attached on additional sheet showing the none of the subcontrwAms and their mvrke w wmp.policy information. Jam an enwiarer that is prodding workers'compensation insarancefor nay employees. Below is the policy and job site iaifnrinarion. insurance Company Name- ( vr` 1 lr//GA€1�c'�r/tr e --ri1$ ti0 - Policy'---or Self-ins-Licic.: Ci1 t 17 3 �� 6 g .3 Expiration Date: ('3 l 1 70/6 Job Site Address: a �b n eia � ' I City/State/Zip: n"A, 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 orcriminal penalties of a fine up to S 1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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- l do hereby ce:@5,under the pairs penaities of perjury that tlae iafornumon provided above is true and carets N Sianature: -AAA w. L Date: Phone il: 5b Official use only. 3o not rvre isr this areq to be coantefed by city os torn official City or Fovvo: Permit/Llcense# issuing Authority(circle one): I.Board of Hcaltb 2.Building Department 3,Gity/a own Clerk n-Electrical Inspector 5.Plumbing Inspector 6.lather Canraet Person: Phone#: CERTIFICATE OF UABILITY INSURANCE M12412015 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 AFFORD® 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 cerli tcate holder is an ADDITIONAL INSURED.the pD1-icyC�l must ba enao�sed- tf sulaROGgT10N IS wlwEp,suyjeGt to me ferns and conditions of the policy,cerfein Policies may require an endorsement Astatement on this certificate does not confer rights to the certificate holder in lieu of such endorsem mt(s). PRODUCER MARSH USA INC. NAM TWOAUJANCECEJTER PRONE 3STi0 LENOX ROAD.SUITE2410 Re ATLANTk GA 303M AD INSURER[ AR-0RDRHGCOVERAGE TAKE t004 SURE HMne0.GgbtI.15-16 INSURvtA:SI�daX nswall�Cmlpan}. ZMV INSURE THO AT-HOME$E(NiCE$,INC. w'UPgRe:—m �OG 16M D13A THE HOME DEPOTAT-HOME SERVICES INSURER C:NWHNnIxNM IRS CO 23041 2699 CUMBERLAND PARKWAY,SURE M0 ��D•MIIdSNa6oI®I InsIDMILaCMr�ly ATIANTA•CA 3033,9 23T17 DsuRER E• ' IBAURE2 F: COVERAGES CERTIFICATE NUMBER A11,4IDT242SISJH REVISION NUMBE3R,7 THIS IS IU 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 DOClIME4T WM ma:pEcr T V",,,Vt CERTFTCATE Niwv BE ISSUED OR MAY PERM19,THE HNSLRANCE APFOFMW BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-UNATS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF WSURANCE 0 PDLfLYN01T®HR POLIO EFP O ElP TFGMtA�R --MEY L� GEO4M7714415 031012D15 millird11e EACH OCCURRENCE 5 - Rom GENERAL LINBRRYo� 54ADE aaCCUR UtaTSOFPOUCYXS rd®FXP(Mral¢persPl6 5 EXIYUD�OFSIRSIMPEROIX: PERSONALIIAOVINturtY s 9.000.m0 S"arAPiPUIES PER PRODIICTG-CDNRpppGG 5 9,MQOWJH.T I I LOC 5 6 XroNOetLEL IAetLRY RAP2938963-12 03AV2015 03MM6 �4 sRNSLEuurr S tcmaw ANYAUTO SODdYINX1RY(Perpemn) s ALLOWNEO IAUTOSUL® S$FINSUREOAUTO PHY OMG BODLYINNURY(Pefeaddvl) 5 AUT03 HIREDAITi W' qU pv SMM OPENLY E S s UMBRELLA LWB I OCCUR EACH OCCURRENCE 5 EXCESS LUiB CUUIJSMADE AGGREGATE 5 OED ( RErEIMONS S C woRKErs COMPENSATION HCOIZ494M Tr31 D(ADS) 0310VID15 MQUx16 wcsrATU- &W C ANDERPLOYERSUABUM ANY PROPRIETORIPARTNERlr7(ECUTWE YIN �Qi((KY,MR NJ.UT) MIM0I5 4Rr0MS EL EACH S 1,000,OW D OFFICERCNvdBER EXCLUDEdt a NIA 1,OOD,000 (Myaensdatory In NH) MIM2MS 03101=6 DESCRIPTIONA O11 F OPERATIONS beta COMTMWMAdMang Page �" -FA s t EL DRFASE-POLICY wrt s 000.0D0 DESCRIPTIONOFOPERATIONSILOCATDNS/VE1113EStlt ACORDIM.Add NMWReMadm edurgN—sp—lslewdreQ EVIDENCE_OF OISURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOMTHEHO HOME POTAT.NC. SHOULD ANY OFTHEAROW DESCRB®POLLS ISECANC91®BEFORE 245 THE FEDEPOTAT-HOME SERVCES - THE EXPRATION 12RTE THERwF, NOTICE wD1 BE DBJUF7RED IN ATLANTA.GA 30339 - ACCOROANCENmH THE POLICY PROVISIONS. ATLAMA GA 30339 AUTHORRED REPRESENTATIVE mhmisn usA mr: I Manaehi Mukhedee ©1988- 010 ACORD CORPORATION._All rights reserved. ACORD 29(2010105) The ACORD name and logo am registered mmim Of ACORD ..ii.:.� �.,�/� CJ7tx ', aad7r��2�2L�1/eC�GL�� a�U�/�tr,1YJC�cVGCc�Ii - Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Itnprovemp t:,gontractor Registration Registration: 126693 Type: Supplement Card THD AT HOME SERVICES, INC, Z 4;;.. Expiration: 81312016 MARK NIADNA :, ..r; :::;i' ; . ATLANTA, GA 30339 2690 CUMBERLAND PARKWAY SULT Update Address and return card.Mark reason for change. scot .; 2om•06111 0 Address r Renewal ❑ Employment c Lost Card r7i73,•Yt'riirruarrenrn�/�r�i:.A"jjrr'/...... . -s= mce of Consumer Affairs A Business Regulation License or registration valid for individul use only tP10MEbefore the ex iradoo date, if found return to: IMPROVFrMENTCONTRACTOR P Office of Consumer Affairs and Business Regulation Reglstratipp;'.:12 693 Type: 10 Park Plaza Suite 5170 Exptratl9 ,913f2016.; Supplement Card Boston MA 0211 6 THD AT HOMES C � • ERYd E$,;ING : THE HOME DEPOTATyQlffl SERVICES MARK NIADNA 2690 CUMBERLAND PA, 'Y 8 4 ArYCA`1'V9`A,GA 30339 Under secretary ��tvalid ithou slganture 11 HOME IMPROVEM ENT CONTRACT PLEASE READ THIS CON`rRAC'1` NOTICE TO CUSTOMER You are entitled to a completely idled-in copy of the Contract at the time of 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 RECOVER OF SUCH.AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Contract 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 Contract cannot be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has ready understands,voluntarily accepts the terms of and has received a copy of this.Agreement. - - - You are entitled to a paper copy of this Agreement if you choose. If you consent to an emailed copy,your consent applies only to this Agreement By contacting sales office (877)9b1-376g ,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement at no charge. By signing below;you confirm the following:. • You consent to receive only an emailed.copy of this Agreement_ • You have access to a computer that can receive and open emails and PDF(Adobe Reader Version 10..1.4 or later)formatted documents. • Your email address is correctly listed on the Home Improvement Contract Submitted by: Accepted by: Jeremy Fraley Customer C� G� Sales Consultant .Signature: License Name. (877)903-3768 Customer Telephone.No. Signature: Sales Consultant License No. (as applicable) - CANCELLATION:CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION - BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT.THE STATE SUPPLEDIENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE 06/17114-SA Page 7- d 7 a — =--- V )µ Sk NOP .. /�Ij ee''er� g¢ 21 WMG It:= Cl � t t.. �. - ) i OTY OF SALEA AI ASSAC'.HUSEM . BuiLDnvG DEPARTAENr 120 WASHNGTONSTREET,310RDOR TLL(978)745-9595 KIMERLEYDRISODIL FAX(978)740-9846 MAYOR THCMAS ST.PIERRE DIRECTOR OF pmUcPROPERTy/BuELDM COMMISSIONER 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# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (nam e e of hauler) The debris will be disposed of in: (name of facility) �u.��.-,,� s�,-�-, ltil � © tom► o—� (address of facility) Sig ature o applicant 0 -7 —3e� — r5 Date f