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4 RED JACKET LN - BUILDING INSPECTION i The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY • y ) SALEM Massachusetts State Building Code, 780 CMR, 7"edition OF dJuntw Rn•iserlJurtuury (^ Building Permit Application To Construct,Repair, Renovate Or Demolish a /• 2orM7 I/NI One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date pp ied l Signature: "/Fsf��'/ /7 10 Building Commissioner/Inspector Buildin Dale j SECTION 1. 1 FORMATION I.i Property Add ss, Vi.i Assessors Map& Parcel Numbers i.la 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 it) Frontage(tt) 1.5 Building Setbacks(It) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provide) 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[3 Private Cl Zone: if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Own r of Recor 42-2 1 Name(Print) Address for Service: 4f:30v ��y-fr�c S I-7 1 R(a3� Signature r-- Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': =-a— SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S ` I. Building Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard Citylrown Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IfVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S Check No._Check Amount: Cash Amount:_ 6.Total Project Cost: S ❑Paid in Full 0 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Constructlan Supervis r(CSL) Liccnx uN tuber lispi iu )atn Namcof C'S Ifolder List C'SL*type(see below)�L f Description ss U tlntestricted u to 35,000 Cu.Ft. R Restricted 1&2 FamilyDwellin Si at a M Masonry aso Oil �"t✓ -�(GCJ OD C Residential RoutingCovering Telephone S Residential Window and Sidin F Residential Solid Fuel Bumin A liance Installation Residential Demolition 5.2 Registered,#qxell rove ontr or(HIC) t'PICIV .3 I I a of ll 'Regi t Registration N nber dre e �j Expiration at Si elep tone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 the building permit. Signed Affidavit Attached? Yes .......... No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'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. ` 3 3 Signature of Owner Date ECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and be f. r -Q� rint e t i a of Ow ror Authorized Agent Dat I. im d under the nains and penalties of 'u NOTES: 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 gpf have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors 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"may be substituted for"Total Project Cost" NAR-16-2010 12:47 From:THE HOFiE DEPOT 9787401417 To:Hone Deect AHS P.1,5 HOME IMPROVEMENT CONTRACT PLEASE READ THIS 2 Snld,Furnished and installed by: Branch Name: Boston Date: ✓ /' o IHD At-Homc Services.Inc. db/a The dome Dcpol At-Ilomc Services 345A Greenwood Sheer.Unit 2.Worcester,MA 01607 Branch Namher:31 Toll Free(800)657-5182; Pan(509)756-9923 Federal lD If 75-21,98,160;hfE Lic u C 02439;RI Cunt.I,ic#16427 '1 /�,+rr� .lA.,,1,.,..,. CT Lic N 565522;�MrA Honro hnprovcmlan.Contractor Reeggr.N 126993 Installation Address: 4 !�-t.+ ^-)ft�'t"T.t J — JY1 City Slate Zip Purehaser(s): _ Work Phone: Home Phone: Cell Phone: �f4rlCe So ��LyUAr� [ l [ ] [b1�1 794 �63 Home Address: _ (if different from installation Address) VCity State Zip Address(to receive project communications and Hoare Depot updates): .L/�t-r S 1 3� r�G»M A, �- C t)/k DO NUT wish to receive airy marketing cmails from The Home Doper Proieet 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 Delnt"i isgmes to famish,deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Shect(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hcmw and any Change Orders(collectively, "Contract"): Job H: ........"`"""`) Products: Spec Sinxt(i)#: _ Pm'ht Amount Roovers Siding mMws hrznlado�-r o i $ 0 e 3 H QCiutrers/C'avcrs ❑Pn(ry Derrrs ❑ L � Rooting Siding []W induws ❑Insulation $ J QGoners/('overt []Entry Doors D ❑R....ling ❑Siding C3 Wm(luws ❑insulation I S ❑Goners/Covers ❑Envy Doors❑ ❑Itcofing�Siding ❑Windows lnsulahun � OCutters/Cm'cis ❑Entry Duurs ❑ hiinimmn 25%Deposit ofContractApastim due upon exception of this contract. Total Contract Amount $ Maine Purchasers myna deposit moo•.than anNhird of the Contract Amount '^^ CLLcI(m1cY agrees that;1[nthedurt2lpUPnn chmpictinn Uf TIC NOYIC for G1Ch will cx,FcuCe a Lrd[nplettOn CreriiltCaAC (one for each Product as defined by an individual Spec Sheet)and Pay any balance due. As applicable,each Customer under this Contract agrees to bejointly and severally obligated and liable hereunder. The Hume Depot reserves the right to issue a Change Order or termhaate this Contract or any individual Pmduet(S)included herein,at its discretion,if Tire home Depot or its authorized service provider detenr)ineti that it Cannot perform its obligations due to a'tmcmral problem with the home,envimnrnowl hazards such as mold,&%bestos or lead paint,other safety concerns,pricing errors or because work required to complete the job Was nor included in the Contract. t� C Payment Summary: The Paymrrn ZZ t Summary # (ea I t.-[ o, included as part of this C'oatraCt, sets forth the total Contract mnbunt and payments required for the deposit.and Final payments by Product(as applicable). NOTICE TO CUSTOMER You am entitled in a completely 111hal in copy of the Contract at the time you sign. Do not sign a Cmnptiroon Certificate(note: there is one Completion Certilleate 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 material',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 WIT HHOLD AMOUNTS OWED TO THE: HOME DEPOT FROM THE. DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUF LIMITING THE HOME DEPOT'S OTHER REMEDIES FORRECOVERV OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and unders lands that this Agrcumem is the entire agreement between Customer 1 and T'be Home Depot with regard to the Products and installation services and supersedes all➢nor discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be asiigned or amended except by a wi'lthng signed by Cuslomu and The fwme DepuL Customer acknowledges and agrees that Cashp u'read, uuderstau volummrlly accepts the terms of and has received a copy of this Agreement. Accept by: _ ( `(v Submitted by: C Cuslemum,%Signature Date Sales Crusullam'SSi,gnatuire �f Date X Telephone No. n i 3 -7 1 Customer's Signa m Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (suapPfi.ble) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DF.T.IVF.RTNG WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE. THIRD BUSINESS DAY AVTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED ITERETO CONI'ABNS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:AV of1'10N'AL TERMS AND CONDITIONS ARE k'I'A'I E.D ON THE RF V FRSF SIDF AND ARE PART OF THIS CONTRACT 7.15-09 C-SC While-Branch Pile Yellow--Custaner Plink-Sivas Consultant Massachuselts - Dcp:u Uncnt nt Public Safctc 9 Board of Building Rcuulaliuns any: Standards 4 ' Construction Supervisor License - License: CS 74722 Restricted to: 00 \ KOSTANTINOS S VAITIS 16 HANSON ROAD d - SAUGUS, MA 01906 Expiration: 7/5/2011 (' nnnissinmr Tr#: 19412 //. 1000JL/)IO IlWC6t/G2 O� NJ6L)LUdCUd Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration 129206 ExpirationT 7/22/2011 Tr# 290357 Type: SBA AEGEAN CONST.Rt1C,TION _ Kostantinos Vaitis,� t' - 16 Hanson Road — --�6 _ Saugus, MA 01906 - Undersecretary The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 111ashington Street Boston, MA 02111 U-,p' mvimnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information --� Please Print Legibly Name(Business/Organization/Individual): # V1J E Address: D Lqt,Wtt ��-� ,jL�/ City/State/Zip: j�ya' 6 Phone#: Are y an employer'Check the appropriate box: Type of project(required): 1. I am a with employer 4. ❑ general I am a contractor and 1 P —�`� -* have hired the sub-contractors 6. ❑New construction employees(full and/or part-time).*me). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.; ` required] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Ro epairs insurance required.]t c. 152, §I(4),and we have no employees. [No workers' 13. ther I comp. insurance required.] *Any applicant that checks box#1 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 contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. c I aat at employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. - 1 �- Insurance Company Name: I�y� L7SVI l l'P j�Lj — Policy#or Self-ins, Lic. #: Q �t' 1 / Expiration Date: Job Site Address: t ` Q/l__ 11�C IkG��(}�8G—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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORT: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 certify and r t e p 'its a penalties of perjury that the information provided above is true and correct Si nah re: Date: Phone# t0l�i��t_ coj " Official use only. 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 Contact Person: Phone#: ATF �`oRo® CERTIFICATE OF LIABILITY INSURANCE 0211110MYY) 2/190 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com 3560sLenom ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE _ The Home Depot, Inc. NAIC# INSURED -- --------- INSURERA:SteadEast Ina Cc L6387_ Home Depot U.S.A., Inc. INSURERS:Zurich American Ins Cc 16535 —_ 2455 Paces Ferry Road NW ----- I(C19945 - ---. - INSURERC',New Ham shire Ins Co Building C-20 p _,_ 23841 Atlanta, GA 30339 INSURER D:NATIONAL UION F IN_S NIRE CO OF PITTS I INSURER E:Illinois Union Ins Co i 27960 COVERAGES I 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. __ -- ILTR DD'L -------._— ATEIMMFFECTIVE -DATE EXPIRATION T POLICY NUMBER ryY DATE / Y LIMITS A GENERAL LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE S 4,000,000 X COMMERCIAL GENE EN RAL LIABILITY DAMAGE TO RTED ----' PREMISES Ea oco.nencel 81,00or 000 CLAIMS MADE X OCCUR _ MED E_XP(Any one person) _ $ EXCLUDED _PERSONAL 3AOV INJURY $ 4,000,000 GENERAL AGGREGATE _ S 4,000,000 GENIAGGREGATE LIMITAPPLIES PER PRODUCTS-COMPIOP AGO $ 4,000,000 PRO- X POLICY LOC B AUTOMOBILE LIABILITY BAP 2938863-07 03/01/10 03/01/11 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY(Per (Per person) _ HIREDAUTOS NON-OWNED AUTOS BODILY INJURY $ (Peraccident) X SELF INSURED AUTO PHYSICAL DAMAGE PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY - AUTO ONLY_EAR CCIDENT $ ANY AUTO - _------- OTHER THAN EA ACC AUTO ONLY: ADS S A EXCESS lUMBRELLA LIABILITY GL04887719-00 03/01/10 03/01/11 EACH OCCURRENCE $ 5,000,000 X OCCUR CLAIMS MADE AGGREGATE $ 51 0001 000 DEDUCTIBLE - —_..... g RETENTION $ i G WORKERS COMPENSATION WCO20342355 (ADS) - WC STALL. YIN 03/O1/10 03/O1/11 -X D Y _ OT D ANY PROMEMBERIPARTNERIEXECUTIVE❑ WCO20342356 (CA) 03/01/10 03/01/11 E.L.EACH ACCIDENT $ 1,000,000 OFFICERPRIETOREXCWDED? N _ E (Mandatory in NH) WCO20342357 (FL) -03/01/10 03/01/11 E.L.DISEASE-EAEMPLOVEE $ 1,000,000 _If yes,describe under _ SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT 51,000,000 OTHER E TX Employers Excess TNSC46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 30M/2M D Workers Compensation WC0910566 (QSI) 03/01/10 03/01/11 C Workers Compensation WCO20342358(XY,MO,NY,WI, ) 03/02/10 03/01/11 DESCRIPTION OF OPERATIONS/LOCATIONS(VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN HOME DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,B UT FAILURE TO DO SO SHALL 2455 PACES FERRY ROAD NW IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR BUILDING C-20 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2009I01)sthorneon_hd ©1988-2009 ACORD CORPORATION. All rights reserved. 144818B9 The ACORD name and logo are registered marks of ACORD p .. — U-Factor SolarHza GainCoe�cizni FatJrU .GxA'1^-.t Gum�,a da Enr9ii`�(ar - ;Q: 32 1 . 6 A.D070PIAL PER CE RATINGS �uuk-roN sun�m�r�Ls oe a�l+�a VisibItTrantmi ton ce franatriilan'de Lr¢Wmia 0 : 52 7t&a ewft�WIC — ra'm Nur,n7'd M t Aad t.t d rnlurterlol saDPary rd,®clt aQaa>m.1Ar d®M rammrad+*f aaaa _ _ rd da+M"r r an, LA^ pmd.tr arc�`s m�.m rtc�.Z srmro+ia ae�pond.a.ie r a Em.titre,.ate r r. m em m ' `n b��.vs erE4rolr Y.�dwV h yxoD,m . wv—lk?mm19 a.d •-" ' ..aa�dtn IFF'L rm reN/u hVs?��'!'^O✓��', Y��� . Edam*A urcwft .. V,L[ Q+]I-ICLu :oc CU,E RcY .9 Lll. a¢q o�@il,: vo tih ca, Na=Cn . <FtE aL r SrM C�.��La+doaLCilca _p+.a L](•) . cajten 1•a) awanat 7t�: ' Noccc Car cciL, '4..c Can Cc al, 9�c_ - .__. INII H-a f..a a Oaf YLdc Lo 2-JI ,n/H,R+} ids �.-4j - tualrta e�on,aa : 7L.e UC 1d 773'. R3 %o(Cun 271L lItl l w gag%rt -Ahafn.Tolwn rton'kh r-r+.mrryrtt¢V°r.. . :- Carud]uta redo pPa.9oaWa mmwb¢t OIEl6TStlC'Iwo m�zcuam mim da ala.'k11•'r+-t Flri7rttacWc , .. Board of 8midiog R<gulan...and Standards—• � HOME IMPROVEMENT CONTRACTOR Registration 126893 - Expiration 8r312010 Ty pe�r Supplement Gard . t; The Home OePat Al dome Service ¢ i Dir- HAPn FAtLGNE