22 SAVOY RD - BUILDING INSPECTION (3) -r Ll -I 7 j CQ�t_CK
'rhe Commonwealth of NlassachustNSPECTIONAL SER CITY OF
Board of Building Regulations and Standards tt��QCITYSAL O
Massachusetts State Building Code, 780 t NOV 10 A R'gsed,Uur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
t Building Permit Number: Date Applied:
Building 011lciai(Print Name). Signature- Date
SECTION 1:SITE INFOR,NIATION.
1.1 Property Address: c;) �1 JD, '�F/) � 1.2 Assessors,Nnp& Parcel Numbers
I.I a Is this an accepted street?yes V, no !clap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arco(sq R) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Requin:d Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,g 5d) 1.1 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private Cl Zone:
if yes13
SECTION 2: PROPERTI(OWNERSHIP!'
2.1 Owner of Record: ne �1 p� sq l I a A,\. 0A C, U 1 7�
�1me(Print) r City,state,�_
� rt
O. I/ds� \j
No. and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) �. Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other Cl Specify:
Brief Description of Proposed Work':
U vG7 L r C CSJ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I
tem Materials)Estimated Costs: Official Use Only
Labor and
S p(�- I. Building Permit Fee:$ Indicate how fee is determined:
❑ w
Standard City/Ton Application Fee
'-• Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. plumbing S �,gtherFees: S
d.Miechanical (FIVAC) S - List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cust: s 3 3 U6_ 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONsTutu 'r1ON SERVICES
5.1 !C�onstruction Supervi ur Liceuse(CSL)
�'; .!( �� ?..� rly � License Number Expiration Dale
Name ofCSL Holder 11 List CSL'rype(see below)
hale rl h n type Description
No. :���111 Street s
J f C, VVL V" t Y I () R Restricted I&2 Family Dwelling
City/town,Slate,ZIP rM Masonry
RC Rooting Covering
WS Window and Siding
q V j_ `('j q Qk/3 ( SF d Fuel burning Appliances
NI t Insulation
suulation
Tcic hate Email address D Demolition
5.2 Registered home Improvement Contractor(HIC) / ?& S 7 2::,
Mpf 21e AI r H 4)d A - Oo^2 J-Ztrt) HIC Registration Number Expiration Date
f I I Cgqnt .my tel HIC Re fits ant Name-
No. and Strce 6q� ,a y Email address
sk(-,e ')sb�ff/hYr yot _39
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.QL C. I L¢ 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 Ishuance of the building permit.
Signed Affidavit Attached? Yes .........(X No...........❑
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�/v
I,as Owner of the subject property,hereby authorize r 1 a r Iz °ac?A°L
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
SEA' C'Dr^ gf-ctI �'
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
V i t,,,, l Mar )l � 'C 0CL
Print Owner's )r Autht riV a is Name(Electronic Signature) Date
NOTES:
I. 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 NLG.L.c. I42A. Other important information on the HIC Program can be found at
w+vw.mess..1•ov'oca Information on the Construction Supervisor License can be found at w+vw.moss.�sov�'dys .
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) ' :(including garage, finished basementlattics,decks or porch)
Gross living:trea(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. "rotal Project Square Footage"may be substituted for"'fot:d Project Cost"
I
f Massachusetts - Department of Public Safety
Board of Building Regulations.and Standards
Construction Supem Nor Specialty �
_icense: CSSL-099699
ROBERT POCZPOUT
172 WHALERS L ANF, -
Salem MA 01970?
9,2.+ �✓� . P i9 " . ni.?irati4 i`
Commissioner - 02/08/2016
1
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Coatractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organizano n/Individual):, ✓��s
Address• S_ /j, /CAS
City/State/Zip: GL AjY� �/7. 3o, V Phone#:
Are you an employer?Check the appropriate_box: Type of project(required):
1.❑ I am a employer with 4. pq r am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- sheet. 7.
listed on the attached ❑ 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.❑Roof repairs
insurance required.]t c. 152, §1(4), and we have no 13.2 Other c e A
employees.[No workers'
comp.insurance required.] W 1.-d OLAU
'My 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 most submit a new affidavit indicating such.
:Contractors 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 most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information. / /j
Insurance Company Name: >n st`ew 11� S/t rite- Zy5- Cc ,
/�p g g oZ Expiration Date: 3 f S
Policy#or Self-ins. Licln.�#: rrW C 0 7 7 f� � _J_ P�
— — Job Site Address: d 0.� t/B�/ �d City/State/Zip: �a )n tM /Y) /'p D rg7U
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 $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 $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 DLA for insurance coverage verification
I do hereby certify under the paimy and penaftles ofperjuty that the information provided above is true and correct
Signafore: 1K �fi "I Date:
Phone#: 7 Y " 1 5 a 13 1
Official use only. Do not write in this area,io be completed by city or town offleiaL
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#:
Omce ofC��m�Affa g� .
OME I MPkOVEMENT usin�R�eg ����..
` Regi9tratioea -'- CONTRACTOR
Expiratio 126893;;
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A UM� RLAND PARKVVAI',S .GA 30339
Undersecretary
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off CERTIFICATE OF LIABILITY INSURANCE IDnrsMcOeiMY _I
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 AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BET+VEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 1S WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
MARSH USA INC. NAME:
TWO ALLIANCE CENTER IAIQ No PHONE Esll: I FA Not:
3560 LENOX ROAD,SUITE 2400 E-MAIL
ATLANTA,GA 30326 ADDRESS: __
INSURERS)A FFOR DING COVE RAGE NAIC4
100492-HomeD-GAW-14-15 INSURER A:Sleadfast Insurance Company 126387
INSURED - INSURER B:Zunch Alnerialn Insurance CO 116535
THDAT-HOME SERVICES,INC. —
15BA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins CO 123841
2455 PACES FERRY ROAD INSURER D:Illinds National Insurance Coapany 23817
ATLANTA,GA 30339
NSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-ao3242685 DI REVISION NUMBER:3
THIS IS TO 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I NSRADIJLJS POUCYEFF POLICYEXP
LTR TYPE OF INSURANCE POLICYNUMBER fmMA]DIYYYY MMIOOf/YYYI LIMITS
A GENERALLIABILITY GL04887714-04 03/01/2014 03101/2015 EACH OCCURRENCE $ 9,007,000
X COMMERCIAL GENERAL LIABILITY cc 1,W0,000
X❑ UMITSOFPOLICYXS PREMISES Ea e person)
$
CLAIMSMAOE OCCUR � MEG E%P(Anyone pamon) S EXCLUDED
OF SIR:$IM PER OGG PERSONAL a ADV INJURY s 9,000.000
GENERALAGGREGATE 5 9.000,0W
GEN'L AGGREGATE LIMIT APPLIES PER:. PRODUCTS-COMPIOP AGG 3 9,000,000
X POLICY PRO, LOC - $
B AUTOMOBILELIABILm BAP 2938863-11 03/01/2014 =112015 ea&NEDaceldeniSINGLE LIMIT $ 100D 000
X ANY AUTO BODILY INJURY(Per Person) $
ALL AUTO OS SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE
MIRED AUTOS AUTOS oerarcl e $
$
UMBRELLA LAS OCCUR EACH OCCURRENCE S
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED I I RETENTIONS is
C WORKERS COMPENSATION WC049UU882(AOS) 03/012014 03/0IMi5 WC STATU- OTH-
AND EMPLOYERS'LIABILITYES
C ANY PROPRIETORIPARTNERJUECUTIVE Y I N WC049101884(AK,AZ,VA) 03/012014 03/012015 1 000,000
D OFFICERIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT �- $ __ -
(MandatorylnNH) WC04910IB83(FL) 03/012014 031012015 E.L.DISEASE-EA EMPLOYEd$ 1,000,000
It yea, ascribe under I OW fq0
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT S
C WORKERS COMPENSATION TWC049101885(KY.NO,NH,VT) 03/012014 03/012015 (ELI LIMIT 1,000,000
C WC(M910I886(NJ) 01DI20M 03101 2 01 5
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addltlonal Remarks Schedule,B more apace is required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED REPRESENTATIVE Y
of Marsh USA Inc.
Manashi Mukherjee —VA DL " Jd....lew.a-« -
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD