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9 SALTONSTALL PKWY - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and StandarilsR'Q£CTIONAI S RV IC TY OF Massachusetts State Building Code, 780 CMR SkLEM �H JEB 12 hvaM Mar 2011 Building Permit Application To Construct,Repair,Renovate r emolish a One-or Two-Family Dwelling This Section For Official Use Only N Building Permit Number: D e Applied: Building Official(Print Name) Signature, - Date SECTION 1:SITE INFORMATION . ' 1.1 Property Ad Tss• �1 -� (7l/y 1,2 Assessors Map&Parcel Numbers p 1.1 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(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'- . 2.1 Ownert of Re o 11 ( ATbI t p 1 ], 1 � Name(Print) City,Stat f,ZIP _ q;j2 lul- 2S- C, s No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK?(check a that apply)' New Construction❑ I Existing Building❑ Owner-Occupied ❑ Repairs(s) Erl Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of UnitsOthpr ❑ Specify Brief Description of Proposed Work : SECTION 4:ESTIMATED CONSTRUCTION COSTS.. Item Estimated Costs: Official Usg Only abor and Materials) 1.Building $ 1. Building Permit Fee: $ - Indicate how,fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee.- - ❑Total ProjecCCos0(Item 6)x multiplier, x 3.Plumbing $ 2. Other Fees: $ ." 4.Mechanical (HVAC) $ List: f' - 5.Mechanical (Fire Suppression) $ Total All Fees:$ -` Check No Check Amount Cash Amount: 6.Total Project Cost: $ ❑Paid in Full , ❑Outstanding Balance Due'' Z(" P�1.DI W_o I11p Nc CntJOO LM JIQet 4' \�fYt �i cklz i``f`� lFe�M1Rt- 3� t O m F)k I L. C-1 311 rt SECTIONS: CONST_R_ UCTION.SERVICES '. 5.1 Construction Superviso ease(ICSL) ,�t��r�/j¢ � /I IY Lift se Number Exp" ti Date Name of CSL Holdey i t� 1.���L_ List CSL Type(see below) No.and Street Type - Description �� U Unrestricted(Buildings up to 35,000 cu.ft. Cityfro Stat"e,ZIP R Restricted 1&2 FamilyDwelling M Maso RC Roofing Coverin WS Window and Siding SF Solid Fuel Burning Appliances �yllf" I Insulation Telephone Email address D Demolition 5.2 Registered Hinme Improvement Contractor(HIC) N HIC Registration Number Ex uaf n Date a o stra ame No. Str i t Email address Ci /Tow(n,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 Issu of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR:BUILDING PERMIT 1,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by thismldi bng erm application. (In 4wr Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION'-' By entering name below,I hereby attest under the pains and penalties of perjury that all of the information contained" a plic 'on' true and accurate to the best of my knowledge and understanding Print Own or A th rized Agent's Name(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 www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 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.UEM, XL--kSSACHUSE-M ° BUIMLNG DEP,,RTJIE.�iT 120 WASHIINGTON STREET, Yo FLOOR TE1- (978) 745-9595 FAX(978) 740-9W KI%,iBERLEY DRISCOLL MAYOR T Hor-ms ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUu-DI\G COMMSSIONER 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 11 L5 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: cpm—t" (name of hauler The debris will be disposed of in : (name of facility) (address of facility) A _ signature&Ofpermit applicant date Jcbrivtf:Jn HOME IMPROVEMENT CONTRACT PLEASE READ THIS I_ Branch Name:New England Date: ," ab/•6. Sold,Furnished and Installed by: - �- / THD At-Home Services,Inc. Branch Number.31 d/b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit I,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID#75-2698460;ME Lic#C 02439:RI Conl.Lic#16427 q 1 CT Lit#HIC.0565522;MA Home Improve ent Contractor Reg.#126893 Installation Address:. _ / �g// 6/yS�.4// p/��r!(why� S�I rya /�/SJn City State 5�-Zipp Purchasers): Work Phone: Home Phone: Cell Phone: EE [ [ [ 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 Proiecf 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 the installation("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#: a.r,ea arrrh.,a, products: Spec Sheets #: Pro ect Amount ❑Roofing ❑Siding Windows Insulation x�F U(� / 6pt/ ❑Gutters/Covers Entry Doors ❑ V / f SW $ p?' 311 Roofing Sidmg ❑Windows Insulation" ❑Gutters/Covers ❑entry Doors ❑ $ ❑Roofing ❑Sidiog Windows Insulation ❑Gwters/Covers ❑Entry Doors❑ $ ❑Roofing ❑Siding ❑Windows ❑Insulation ❑Gutters/Covers ❑Entry Doors ❑ $ Minimum 25%Deposit of Contract Amount due upon execution of this Contract Total Contract Amount Maim Purchasers my got m f deposit ore than oniqur tLd of the Contract Amom $ .,.7 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 applicableth.Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. 'r. !'WwW0INRtrHx r6cOep,1 reserves the right to issue.Change Order or a,rnnrune flns Contract or any individual Product(s)included herein,al its discretion,if The Home Depo,or its aumoriz.d service provider deremtines that it cannot perform its obligations due to a simctural 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. •�z Payment Summary• The Payment Summary # is /Wao , included as pan 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 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 Sheets)before work on that Product - . is complete. In the event of termination or this Cont icl,Customer agrees to pay The Home Depot the casts 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 LOWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER IMITING HE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF'S PAYMENTS MADE, WITHOUT SUCH AMOUNTS. "k Acctance and Aulhoriration: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot wdh regard to the Products and Installation services and supersedes all prior discussions and agreements.either ep 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 received a copy of this Agreement. Accepted by: /1 Submitted by: it r16�/ x 0lDia.��ia/ � W--- "2;61G x v[ Of O Date Sales Con tam s Signature Dale Customer's signal X � Telephone No. Customer's Signature Date `wi Sales Consultant License No. rot applirablel CANCELLATION: CUSTOMER MAY CANCEL;THIS ` AGR EEEN'r WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME , DEPOT HY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. 'THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE tIS' J SPECIFICALLY PRESCRIBED BY LAW IN^ e CUSTOMER'S STATE. - I NO IICE:ADDITIONALTF.RMS AND CONDITIONS ARE.5TAT, NNTIIE REVERSE.SIDE AND ARE PART OF THIS CONTRACT whit.-Branch File v'ellow-Caslamer Lx : e apiree ve of&dv-cvFW c hex (� e o �Of Invea� �s 600 Washawon S'&W2 Boston, 02111 9� orkeeg' 0.:o=PeMatn®m Imaaaz era e a emir � da Co�fi tun/E ect�sM8/p aanbera 1�ni@ne a hffmrMLbLe! please li rim- Yee ruche `f J � Sfws 1`I^c�0(EusiaesslOrganiauoe/°.nd/ividusl):�fJ3%4Qi �/�o� AdLress: q®g 6 a 5-.- o --rLN-14 cif/state/Zip: a95 yr <°� - /S`�S P�One #: SO Are you an employer?Check the appropriate box: 'Type of project(required). I.❑ I am a employer with 4. 1 am a general contractor and I 6. ❑New construction Imp (full and/or part-time).* have hired the sub-conlrnctorS 7. Remodeling 2.❑ 1 as a sole proprietor or partner- listed on the attached sheet t ❑ ship and have pr employees 'These sob-contractors have S- ❑Demolition workers'comp.insurance. 9, gujldjng addition woridng forme irr ray capacity. ❑ judo workers'comp,insurance 5. ❑ We are a corporation and its �uL,.�i officers have exercised their I0.❑Electrical repairs or additions 3.© I am a homeowner doing all wort right of exemption per MGL 11.❑ Pluruoirsg repairs or additions myself.[No workers'comp. C. 152 §1(4),and we have no 12.E Rpai�repairs insurance required.]t employees. [!to worker' 13, v'dter comp.insurance required.} .Any applicant that cherics bozo I mast also tffi out dxe secaron heibw showing hirer wmkea'eompemsatioa Policy mformatioa. t Homeowners who sub this affidavit iadicamugthey aaa during ail work and then hire outside c�tsacmm must submit a uew a$duvit bdiwting such. mit �Comraciors that check this box-must atmr�ed au sdditi W sheet showing be vane bfthe curb-wnasrtos and their wothus'mmF-Policy mfommiioa I am an employer s t e tg providb2g tvar�rs'ea�pceasakk¢s kiastzaataeefrrr rY eivrp'aye� Igerin y�8I a paddep Ltd jasb.saL ka}orrnatlon. insurance Company Name: Policy#or Self-ins.Lic.#: G 6) f 3 l s ✓ Expiration Date: Job Site Address: -�� I City/State/Zip:�� -- i4_itaeb a Copy of the workers'coerepea nfiD®policy dee4aration page(showing the po ft member and expiration date) Failure to secure coverage as required under Section 25A of MGL c. 152 can lead toAhe imposition of criminal penalties of a line 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 3250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D for insurance coverage verification. I do Ise-reby Cow awaJ a.,"r Bair the hiformaatara provided tr and correct Sio atur . Date: Phone# 5b Offk-W rise#*. Igo iaak wrft in kirks area,to be coenpleted by chi+or to"06,'W City or Town Permit/I,ieense# Issuing Authority(circle one)- I.Board of Health 2.Building Department 3.City/Town Clem 4.Electrical Inspector 5.PI®m41ng inspeetor 6.Other Contact Person: Phone#• Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CSSL-099699 ._ ., . Construction Supervisor Specialty x j ei ' ROBERT POCZOBUT . 172 WHALERS LANE SALEM MA 01970 �. r ra I^AA -Expiration: Commissioner 02/08/2018 • F c�Y ,j�,e, er��a�v� �:�;atc- c�tj;, Regulation Office of Consumer Affairs and Business Regu 10 Park Plaza - Suite 5 170 _. Boston, Massachusetts 02116 ` Home Improvement Contractor Registration_ " THD AT HOME SERVICES, INC- '_ RIIRD FALLONE CHA 2690 CUMBERLAND PARKWAY SUlT�.3v ATLANTA, GA 30339 Lpda:e.kddre5- and reta rn Card.liar!<re350n I4rLONCard _ address Renewal — EMP10IM113t _ 4 '