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22 SUMMIT AVE - BUILDING INSPECTION (4) y� The Commonwealth of Massachusetts CITY OF WBoard of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling �:'- . This:Sectron For Official,-Use`'Only ,:�;;:� ' �:'r Build ng Permit Number Applte s Building Official(Pru{t Naive) = a'Signature Da[e - SECTION 1 SITE hNFOI31 :11O x 1.1 Property Address: 1.2 Assessors Ma & are u ers P Y�� 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: Zone: _ Outside Flood Zone? Municipal El On site disposal system ❑ Public❑ Private El Zone: if yes[] p { . $KCTto 2``P1�OP,E 2TY'OWIVERSH 2.1 Owner'o co ` f!7 Name(Print) Ct Sta e,ZIP No. and Street � Telephone Email Address SECTION 3: DESCI2IPTlON OF PROPOSED;WORK(check a that.:apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s)- Alteration(s) ❑ Addition El Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': =41 n SECTION 4: ESTIMATED:GONSTRUCTIOIv COSTS Estimated Costs: Offic l Us ia Only Item Labor and Materials �"`' ° r I. Building $ _ 1' Building PermitBee dreate how fee'is determined. ❑ StaLdaid Cry Fee 2.Electrical $ ❑ I pfahProject'Cost t(Item 6):xmulttplier x 3. Plumbing $ 21 Other Fees $' 4. Mechanical (1 NAC) $ Ltst 5. Mechanical (Fire $ Total All Fees Suppression) Check No Check Amount, Cash Amount 6. Total Project Cost: ❑paid'in:Full ❑ Outstanding'Bala $ rice Dpe SECTION $: CONSTRUCTION SERVICES 7N— upervisor License(CSL) ' LicensNum er ExpList CSL Type(see below) � No. and Street �o ,-.;Type bescnption U Unrestricted(Buildings up to 35,000 cu. ft.) City/Town, State, n � �� R Restricted I&2 Famil Dwellin M Masonry RC Rocfin Coverin WS Window and Siding Y SF Solid Fuel Burning Appliances Insulation Tele hone Email address 1 Demolition 5.2 Registered Home I rove ent Coalractor(HIC) `Q I HIC Re isYration Number Exp' at Date HIC me r III e rent Name No. an t Email address Abu r � 61 Ci /Town, State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GiL 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 th tfildmg permit. Signed Affidavit Attached? Yes .......... ❑ No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED' OWNER'S AGENT OR C,ONTRACTOR'APPLIES FORBTT Lb G'-PERMIT'_ . I, as Owner of the subject property, hereby authorized-� to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) to SECTION 7b OWNER' OR AUTHORIZED'AGENT'DECLARATION^,,, By entering my name below, I hereby attest andtr pains nd penalties of perjury that all of the information contained in this application is true and accur to to bes ofm knowledge and understanding. Print Own r' Cr Authorized Agent's Name( leer onic Signa ore) at „ 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 Horne Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under-NI G,.L. c. 142A. Other important information on the HIC Program can be found at www.rnass._>ov/oca Information on the Construction Supervisor License can be found at www.�ns 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" may be substituted for"Total Project Cost" 10/13/2012 22:20 FAX �jy� 4DO01 HOME,IMPROVEMVN'r CONTRACT �5�6 p ),� PI.EASF,READ THIS Sold.Furnished and Installed by: Tlll�At-home Services, due" Branch Nome: Ilostun Dute: �O//3 Z d/bht The Home Depot At-Hoene Services —�—/— — 345A Greenwood Strect,Unit 2.Worcester,MA 01607 Toll Free(800)657-5192;I'ax(509)756-8823 Itranch Number:31 Federal 11)#7.5-2(t9840)0 MG l_ic#C 02439:RI Clint.Lit;# 16427 /� CF Lic#HtC.056952�_• MA idamo hnpt vement Contactor Rug.# 12f,K93 InMaitation Address. .pc_ cij"I i1G S City State Zip Purcilawr•(s): Work Phone: Horne Phone: Cell Phone .._ Home Address:.-__ "-"---- ---._... -' ..---....—." State Zip (If different front installation Address) City E-mail Address(it,receive Pro)u:t cuntmunications and Home Depot updates): -- ©1 Ix)NOT wish to receive any ntarketin)•ennuis frum'lhe Horne Depot Prn)re! Infortnatinn: Under ("Customer'). rho owriers of the property'located at Tile above installation address, ugrees to buy. oral-Cull At-1 Ionic wrvices, Inc. ("The Hoitle Depol-) agr�ccs m furnish, deliver Lord arrange lien the nett inju n ("I»statact b 't of all Materials described on the below and on the referenced Sp C Shcr"t(s)- all of which are incorporated inW this (.nl(C0II by this r'tfercncc, along with any applicable State Suppleuxnt and Payment Summary attached hereto and any Change Order's (cullcc[ivcly. "Contract"); .Inh#: amerrmr XOe—m Products: .. Spe}'.tilrceth)#:_ . .. . .Prrliecl Amount _t i �]ttrn,lin_ Siding IM Winduwa 0 Inxuhainn � ,� a Gs- /CIM-3 I ❑Gutters!Covens ❑IintryUtvro ❑ ...—. .__ -- - --- ❑Runfiop ❑Sidins ❑ N'indaw> []htnula[iou ❑C+uttcrs/Govern []Iintry Dtwt� ❑__. --- S Roa17n� ❑Siding ❑Windows ❑ Inudalian ❑Gutters[Covers ❑t:ntry uu+nn❑._.__.... 7. ._.—_.. ...__.__... ....__ ❑Rturfiug ❑Siding ❑Windows ❑InsuL•uian ❑Gutt¢rc l Covers ❑Iintry Dw,r, ❑ millimnm 2-5`4. Ihpash or Ctnumct Amtmnt due upon execution ofIbts salmi, Total Contract Amount $ Nisdrce I'urchtrn�vs rainy lint dcywnit none limn MX-4111rd 4if tin:Cimtratt Amaral. Customer agrees Thal, intntediately upon completion of the work for each Product, Customer will execute it Completion CcrlifiC.tc (one. rim each Product as defined by an individual Spec Sheet) Lind pity ;oty balance duo As applicahlc, each Custcinicr cutler this Contract agrees to he jointly Lind severally obligated Lind liable hereunder. The Iloine Depot reserves the right at issue it Changc Order or lcimiriate this Contract or any individual Product(s) included heicin, at it.,discretion, il-The hunts Depot or its authonzed service provider determines shut it cannot perform its oblignlions due M tt suvetival problem with the home,enviroumcut:d hazards ouch as mold, ij lheshts or iced paint. other naf-ty cuucems, pricing errors or becuitnc work raeluired to Coa)PletC the job win not included in the C'onrract. , included as lit of this Contract. sets Ibrlh the total Pn ,nent Summer The: Payment Sumuruy #. irO fS/ ..�L._..... . ...__ P: Contract amount and payment%ir-quiled for the deposits and final payments by 1'rOdltel(its applicable). ' NOTICE TO CUS'roMER You are entitled to a completcly tilled-in copy of the Contract at th4 tint:you sign. Do not sign it 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 lite went of lernihiatlon of this(,lunti-act, Customer agrees It) pay The llunle Depot the costs or materials, labor, expenses and services provided by The Home Depot or Authorized Service Provider thrutigh the date of termination, plus :my other amounts set forlh fit Utis Agreement or allowed under applicahle hew. 'fill? HOME I)I-;POT MAY WITHHOLD ANIOUN7'S OWED TO THE HOME DEPOT FROM THE DhPUSIT PAY]IVNT OR OTHER PAYMENTS MADY, W1111011T LIMITING THE HOME:DEPOT'S OTHER RP.MEDIP,S FOR RECOVERY ON SUCH AMOUNTS. 1,ccent,LiLL and Auorization: Customer ❑grcoti and understands that this r'lgrccmcnt is Ill" "Mire. arl'CerncuL betavucn CllalOrtlel' and 1"he I lot»c Dcth l>,tt wish rolord to the Products and histallalion services ;md superncdes all prior discussions and a;rrccntenla,eilhcr urtd or written, relatim, it)said Products and Installation. This Ajgoeeo)cnt cannot be assigned or amended except by n wt'ilill M."ll el by Customer and I"he Flours Depot, Custmmer acknowledges Load egress dlat C'uaonier has read, understowk, voluntarily accerls tilt' terms of and has 1Cccivcd a copy of this A,+reemeal. The Commonwealth of Massachusetts UVDepartment oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/organization/Individual): Address: ,X%,, � At City/State/Zip: y�r _Cj JL Phone.#: e" &2g7 C� Fre n employer? Check the appropriate box: - - 4. I am a general contractor and I Type of project(required): a employer with ❑ g yees(full and/or part-tune).* have hired the sub-contractors 6. El New construction sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling nd have no employees These sub-contractors have 8. ❑ Demolition ng for me in any capacity. employees and have workers'orkers' comp. insurance comp. insurance.$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its ME]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 insurance required.] t c. 152, §1(4),and we have no 12.❑ f repairs employees. [No workers' 13. Other _ 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 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 sub-contractors have employees,they must provide their workers'comp.policy number. Iam an.employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins, Lic.#: 7� I Expiration Date: Sob Site Address: r _ ^—rryYlJ 2- 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 $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 DIA for insurance coverage verification. I do.hereby cc ify r t e pal sand penalties ofperjury that the information provided above i true and correct. Si ature: r Date: Phone#: FOther only. Do not write in this area, to be completed by city or town officiaL n: Permit/License# hority(circle one): . Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: t�y,ig Massachusetts -Department of Public Satety �`�♦'� Board of Building Regulations and Standards License: CSSL-099699 +* ROBERTPOCZOBUT 172 WHALENS LANE Salem MA 01970 i Exmration C3tnmisskaner 02l08/2014 � lei 1�� lug O fice of Consumer Affair and Business Regulation 10 Park Plaza - Suite 5170 Boston, l assachusetts 02116 Home Improver ze. ontractor Registration / Registration: 126893 _~ s Type: Supplement Card Expiration: 8/3/2014 The Home Depot At-Home Service — RICHARD''FALLONE 2690 CUMBERLAND PARKWAY�SU �--3 a ATLANTA, GA 30339 _ Update Address and return card.Mark reason for change. Address Renewal ❑ Employment Lost Card DPS-CAI 0 50M-O4/04-G101216 ' r i i"� Da E ,� C `MMIODI Yt} -_I CERTIFICATE OF LIABILITY INSURANCE 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 BEWJEEN 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 he endorsed. If SUBROGATION IS WAIVED, subject io the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate dces not confer right,to the certificate holder in lieu of such endorsement(s). ROOUCER 1-866-966-4664 CONTACT Zrsh USA Inc. NAME PHONE FAX No.E:R)i AIL No): Omedepot.CertraQneat@maieh.COm E-MAIL ADDRESS: wo Alliance Center, 3560 Lenox Road, Suite 2400 Clarice, GA 30326 INSURERS AFFORDING COVERAGE NAIL# lax (212) 948-0902 INSURER A: Steadfast Ins Co 26387 SURED INSURER B: Zurich AmeIicaun Ina Co 16535 he Hose Depot, Inc. ome Depot U.S.A., Inc. INSURER C: New Hampshire IOB CO 23841 455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Cc 23817 uilding C-20 NATIONAL UNION FIRE INS CO OF PITTS 19445 tlanta, GA 30339 INSURERS: INSURER F: Illinois Union Ina CO 27960 OVERAGES CERTIFICATE NUMBER: 25776028 REVISION NUMBER: 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. SR ADDL SUER POLICY EFF POLICY EXP LIMITS TR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDD/YYYY A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 X - DAMAG ORENTIED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence 5 71 CLAIMS-MADE OCCUR MED EXP(Any one person) SEXCLUDED -- X LIMITS OF POLICY XS PERSONAL B ADV INJURY $ 9,000,000 X OF SIR: SIM PER OCC GENERAL AGGREGATE It 9,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9,000,000 X POLICY PRO- 7 LOC S JECT E AUTOMOBILE LIABILITY HAP 2938863-09 3 0 03/01/13 COMBINED SINGLE LIMIT 1,000,000 Ea accident Ix ANY AUTO BODILY INJURY(Per person)ALL OWNED SCHEDULEDBODILY INJURY(Per accitlen0 $ AUTOS AUTOS NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS AUTOS Poractltlen[SELF INSUR D I PHY DMG $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED- RETENTIONS $ L• WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 X WC STATU- IER DTH- AND EMPLOYERS-LIABILITY TSI D ANY PROPRIETORIPARTNER/EXECUTIVE YIN WC019 7 3 6 917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? � N/A E (Mandatory In NH) WC019 7 3 6 916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYEE S1,000,000 If yyes.describe under DESCRIPTION OF OPERATIONSDBIoW E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Workers Compensation WC1192994 (QSI) 03/O1/1 03/01/13 SIR (AOS)/SIR (GA) 1M/750,000 D Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/iM ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) E: EVIDENCE OF COVERAGE ERTIFICATE HOLDER CANCELLATION r f SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CHE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 1455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 LTLANTA, GA 30339 r— IISA ©198✓}1-2010 AC,ORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORW rthornton hd A 1 CITY OF SAL.EE1I, NL-ksSACHUSETI'S BUILDING DEP.hm[ENT p 130 WASHINGTON STREET, 3" FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KIytBERi FY DRISCOLL )MAYOR TtioNus ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILONG CO',L,1ISSIONER 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 111.5 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: (name of hauler) The debris will be disposed of in (name of facility (address of facility) signature of ermit applicant to Jcbri5a l%.Lx IMPORTANT:OWNER OR CONTRACTOR MUST ARRANGE FOR PERIODIC INSPECTIONS DURING CONSTRUCTION.SEE CURRENT BUILDING CODE CHAPTER 1 FOR LIST OF REQUIRED INSPECTIONS. CALL 978-619-5641 TO SCHEDULE AN INSPECTION