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4 SUMNER RD - BUILDING INSPECTION
S ZZ2m So F-o rZ P The Commonwealth of Massachusetts INSPECTIO AL SA�VI 9; \ Ylv` Board of Building Regulations and Standards �'�ISALEM k,\ Massachusetts State Building Code, 730 CMR ��q CEP �tevv�eIP'0.111 iiBuilding Permit Application To Construct, Repair, Renovate Or D o is a One-or Two-Family Dwelling This Section For Official Use Only . Building Permit Number. Da Applied:: Building Official(Print Name). Siytature Date SECTION 1:SITE INFORMATION 1.1 Property Ad ess• L2 Assessors Map&Parcel Numbers I.1 a Is this an accepted street?yes_t no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arca(sq R) Frontage(If) 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 Informntion: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check ifyes❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Ownert of c rd: t _ T4hme(Print) ( City,State,ZIP o�I JMyy[� �1 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied 17 Repairs(s) Alteralion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work'-: SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Officil7se O ly Labor and Materials I. Building y r— 1. Building Pe it Fee:$ �d' ate how fee is determined: 2. Electrical S ❑StindardCi Town_Application ee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 1. Other Fees: S 4. Mechanical (FIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S Check No.__Check Amount: Cash Amount: 6. Total Project Cost: S �'� 0 Paid in Full. 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Sulervisor License(CSL) / AJ/[1 —�n�2-�fY� ZL License i unY fiber Exp uh n ate Name of.CSL Hold List CSL'Type(sue below) No.and Suect Type: Description A U Unrestricted(Buildings u to 35,000 cu. It.) F1 R Restricted 1&2 Famil Dwelling Cityll'own,State,ZIP NI Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances M- �j 1 Insulation Me hone Email address D UemoJil cm 5.2 Registered Home Improveme Contracto IIC) 1 lC HIC Registrationr .x ration Uate 111C Comp;my Name or IIIC Registrant Name No.ptl tree, r— Email address i City/'—own',State,ZIP 'Tole hone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be corn ed and submitted with this application. Failure to provide this affidavit will result in the denial of the Wuance the building permit. Signed Affidavit Attached? Yes ..........❑ 1No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN, OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING.PERMIT 1,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By ente ng m name Blow, I hereby attest under the pains and penalties of perjury that all of the information contai ed ii ap catio is true and accurate to the best of my knowledge and understanding. ` ' lt owns or At horized Agent's Name(Electronic Signature) at 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 ibLG.L.c. I42A.Other important information on the HIC Program can be found at mww.m11ss.11ov'oca Information on the Construction Supervisor License can be found at wsosr.mas.eov!d tLs 2. When substantial work is planned,provide the information below: Total floor area(sq. It.) (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 halffbaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3' "Total Project Square Foutage"may be substituted for"Total Project Cost" L � . IIVIIN IAIPIWVFWY.NT Ct1NfIb\CT � . . N. I'I,FASe NN\IST111S' ; ' " I pp Sdd PomiskcJvM lnwolkd by.: m' Oraaehtionw:PWm Kurth@SmN. Dalm•ys'L O\`t . THDAsdMne Serritts.Ina� OCO Turn liw Haan Dcpd Amry.61 01545 O N OnlnebNmilwr:}I.uod}} ' - P(IR gglun Turnpike.Dni11.$Arll 1.ry.MA OWS Toll Frtxg77.703•y76d - fNmIIPA 18;U96♦<4HELk aCpyc RICmt 40 IM911 E Ut0 NC (d3'.:DIA Nuns lmAryAmrmeN Cwuuaa R<EP1:6gp} IosWDmlat AlMnm; SU-mn2'C 1\l7 111� � U- - - . . - . . .Cite St. zi I'ottimend: %Vnrk Phmm Hawmate: CID Pboar. tc t 1 Icam 795"1 Lffl t97�3o KEY t r t 0)W llHageAau Rout au mp InmllNion AJJrmal ' ' - Coy '' fwc Tp e �moll Addw (tormdnprolmconmunkwkmsmd Name Dcpwupdw is IIyD NOI'wish to raeive onySmrFOinDemaitr frwn The i(mN U'paf - - ' formilln Under.Apol l•Cusanicelibeawners orthepropmy hsatoJnt the above installation address.ag=wboY. O m c DAt-,one i«s.louf'fM1e llome DepN"y ogm'swfumtiM1.ddiyN ate amnBe for dN lmmliadm("Immlltdos")of all n,Nk,dewibed on the below and on Be ogre wed Sp.Shoals),aR or xhich No Igsnspmatel into this Ca unua-by this ,cDntmrttfemtne, )!. xftM1 any opplietNe State Suppkmeet vnJ.Pa)mwk SamwrY wmchN heraoaadanY CtmnSYthdtrsleoileniyny. • Je40:nsmewp.a Pralann 5 Sh slp� Pm iAmnnnt ,p Sduq 0 wimous L3 I.W. - S ODNanl Cmem OPaq'Pomn�' wa2 a B^^n^B Siam¢ sYUWiws N,ubJm � o oGwm;:um,r EnayPmr❑ ? a0ta3 s q83. Rnndn6 Strong w. a,a WOkula, URW c Lmen Qra"du*t0 (� RoNuK INnO Windom,U MsuWbn pl , OcwmaJtmrm QPmryOaas❑ 3' /J N AEdmtmYSW BetxdtdCbwNnAwmt@nupmewWbedmkemwd / �^ Blwx Punlmemmynae.rv.3 mmrthmmmtldNdtlp;CadmdAnmR Too Cmlrm1Amounl S /� }�/Kny��j/'J�••)-Ifs' pCuuuma-.open lhN,imniedinlelY upon canpkdon of the x>Yk Tm each PrWucL CnttarxrwlBindle. aCamplmimunda we• { /D� (me fm cash PraJaa u defiaed,by M indiyiJuil SpN Stew)and WY.anYbalulee,duL As applicably wcM1 Ctmomer uSMR this '90{ 0: Conwwugmmto Mjotnllyaud xevvdlYONigaled and liable hmcundtt.. ' aD'. The Home Depot mwean the light lactate aChmgc Order"wmimethis Conmot wary individual Ovluct(s)included herein.a Q Its dtlsmtion.line Home Ocm mks Nthorieedeu,ice Provider delerlWda that kawal mrmm its obligatimsd&to asiriwtumt V' problem with tiro home.envirunmmbvl kimda stxh m mold adimtm o Iwd point,aka safctyeweaos,prking emon ar bsouac �.� wok MNirulwtaoDlttethcjob war nm mdudedw Na ConwfctL�. N' Foment Summary: The Payment Sumnwry B p'39 1-i imlu&d ON ire of this Cm+vna..ads,(mds ate total' Cenuact arnuuat and pymmB nal ied for the&paunafpd final taym N by Peldecl(aE npplicalikV . . . . NOTICCTO CUSTOMER Yw arc enRlkd to o tomyylekly Nled inecooppYof theC.oulmetat the Runciymousign.Dow sign A CompletlanCerNirote(note; Ilwro Is onto,Complelioit Cerli(liula Tar loon Ifsted Produel as&Rrwd_hy Ltdigdwl8pec5hnBj bylole,xarlt on list Praduet' Is cmapkN. - . . In ale event of lermfauden Of thl Coutrdel,Cmtomer agree,la Pay The flame Depot the caw or materiatc.labor.esynsxs . mad seMees proAded by The Of..Deltas or Authostaed Senfce Providerflnrea"mhh the date it termiwdasy phss eta oNec; tmpunb.st forth In this Agrecmeat or wiomed under aPyylkoMeta..THE,HOME the MAY WIT!MOID AMOUNTS, OWED TO THE HOME DEPOT FROM THE DEI di-? PAYMENT OR OTHER PAYMENTS MADE;1VITIIOUE LIMITING THE,ROME DEPOTS OTHER REMEDIES FOR RECOVERY OFSUCH AMOUNTS: ; CWtamr:agteas aqqd un&rnonda that Agretfneot it the mare ap[emeN htwttn Conover oa to t told (*the PiadmeIs and luswlladmt amviem and supmedesaN prior discussions and agromses.eistu m'alvwrhten, ting intend Prod asudlnvdladon.This bl Cuamne eNmwOcpoi w Customer acbnrosw.eamwl6o uvigndaauwnded exwpt hyaaYitiog irgn.V that Nstmwrhas loud,unkimands.whtnuily ucttpu the 1 w 'I IvcdampY odds AgramenL A y: L ( .. Sub db. SpK2:. .,tolls a Oale Sak aulwnt'x S:g lure Oaw x .. .,t �g27- 4 _CodomrfsSgnwWe;. Dude. .,•-•-,..+.�{ . Saln Cwsulwnt tta¢Nw CANCELLATIONS CUSTOMER 61AY CANCEL THIS - W spWoB!1 eP' AGREEmElfr WVCROUT PENALTY OR ODLIGATION 0 BY DELIVERING WRITTEN NOTICE TO THE HOME - _ DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREENIENT.' THE N ; STATE SUPPLENIEWr ATCACIIEO HERETO CONTAINS A FORS! TO USE. IF ONE IS ' ll SPECIFICALLY PRESCRIBED RY LAVY IN CUMMER'S STATE.'. . . •- xrrtrmE AammavnLnavtBAvomaamutm AaEsrArNnovTNoaeYTttw.BmawNpasEPurra'TluvtruTaµT� ' F'. aeutr . . 'wrew-e'«earw vow-cm,a� . . The Commonwealth of Massachusetts Department of Industrial Accidents — ( Office of Investigations r; — ' 600 Washington Street x Boston, tYfA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): — Address: City/State/Zip: Phone 9: 6j / Are an employer? Check the appropriate box: Type of project(required): ]. I am a employer with_X_ 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ 1 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' q ❑ Building addition [No workers' comp. insurance corn p. insurance' required.] 5. ❑ We are a corporation and its t0.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions right of exemption per MGL myself e r workers' comp. 12.❑.RI repairs insurance required.]' C. 152, §1(4),and we have no employees. [No workers' 13. Other comp. insurance required.] *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. '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 ditional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Ifthe sub-contractors have employees;hey must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 1/ n M o z', — Policy#or Self-ins. Lie.#: l��7J7 Expiration Date: Job Site Address: SL1vI�YleL� City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy num turf J¢ate). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition crim'nal p nalties 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 surance coverage verification. I do hereby certify under t e pa s d p alties of perjury that the information provided a ove is true and correct. Si nature: Dater Phone#: r ,:;. Official use only. Do noLwrite.in- this urea;to tie 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#: Office of Consumer fairs d Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registratian: 126893 Type: Supplement Card Expiration: 813/2016 THD AT..HOME SERVICES, INC. R1Cf-iAf�D_-t=ALlONE_' --.- -. - 2690 CUM-EIM RN-b PARKWAY SUITE_ 300 - ATLANTA, GA 30339 --._ ---- - Update Address and retarn earl.Mark reason for ebange. mat 0 zdsosm —. Address 71 Renewal Employment L Lost Card '°`S friee of Consoncr Affairs&Bodaess uladoa Reg' License or registration valid for individul an only OMEIMIPROVEkEPITCONTRACTOR before the e;gbatwndate, If found return to: T. - •- OffieeorCessomerAtfairs and Business Regofntion ni AaglStiation; 1�93 Type: 10ParkPlaza-Suite5176 -Eitpiraeon__B'W0'16 SupplemenfCard Boston,' 16 -THD AT HOME SERVICES.I74C: . 7 HE HOME&POT AT HOME SEROCES RICHARO FALLONE - ?690 CUMBERLANC PARKWAYS -1M-A- 6UfF— A �`A,CaA 303 Underacretary ' d: DATE MM10C/N'(rf! A � CERTIFICATE OF LIABILITY INSURANCE 02 W2014 u,. THIS CERTIFICATE IS ISSUED AS A.MATTER OF INFORMATION.ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELO.VIf.'-THIS.CERTIFICATE OF_INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESkNTATIYE'OR PHODUCER,.:AND THE CERTIFICATE HOLDER. !MPMANT;i Ifahhgyertlfieate holder is an ADDITIONAL INSURED,the pollgy(les) must be endorsed. It SUBROGATION IS WAIVED,subject to .,._....__- .r_. ._. the teririe.eod eondlUDne d the policy,certain polities may require an endorsement. A statement on this certificate does not canter rights to the eeNfleat'e'ilolder in Ileu-of such endorsement s), : N T PRCOuCER - FAX .-:WRSKUSA;INC. PHONE. (All N ' TWO AL0ZECENTER 35M LENOX ROAD,SUITE 24CC ADORIL s: ATLANTA"GAS 30326 INSURERS AFFORDING COVERAGEANAICi00492 HomeO-GAW-14-15 INSURER A: Steadfast Insurance CompanyNSURED � INSU0.ER B: Zurich American Insurance CoTHDAT-HOMESERVICES.INC. New Hampshire lna CoDak THE HOME DEPOT AT-HOME SERVICES INSURER C2455 PACES FERRY ROAD INSURER D: Illinois National Insurance Company :.ATLANTA(GA-3D339 - .. _ . .._ - :."`, . .. -INSURER E: INSURER F:::_. COVERAGES CERTIFICATE NUMBER: ATL4=426MI REVISION NUMBER:3 THIS IS TO CERTIFY THAT THE POLICIES CIF INSURANCE LISTED BELOW HAVE.BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED:LNOTWITHS_TANOING 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. INTR POLICY EFF POLICY EXP LIMITS TYPE OFINSURANCE D - 'POLICY NUMBER MM D MM 9W0000 'A GENERALLIA CITY .. GL04887714-04 03Po72014 031012015 EACH OCCURRENCE E X COMMERCIAL GENERAL LIABILfTY EXCLUDED CLAIMSWADE OCCUR LIMITS OF POLICY XS MEO EXP Pn one arson E OF SIR:$iM PER OCC PERSONALSADV INJURY $ 9,�0,000 GENERAL AGGREGATE E � 9,WO,000 PRODUCTS-COMPlOP AGG E 9,000,WO GEML AGGREGATE LIMIT APPLIES PER: $ X POUCY PRO- LOC 1,000,000 0310112014 0310112015 COMBINED SINGLE LIMIT 0 AUTOMOBILE LIABILITY BAP------3-11 oa yIN ' BODILY INJURY(Per person) E X ANV'AUTO BODILY INJURY(Per accident) $ PLLOWNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS - AUTOS PROPERTY DAMAGE $ NON.OWNED n HIREDALTTOS AUTOS E UMBRELLA LIAR OCCUR - EACH OCCURRENCE E AGGREGATE $ EXOESSLIAB. CLAIMS-MADE b DED� RIFTENTIONS WC04910 882(A S) 0 011201 03101120 5 WC STATU- OTH- C WORKERS COMPENSATION - 1,000,000 ANOEMPLOYERVLMBEITY YIN - WC049101894(AK,AZ,VA) 0310172014 0310112015 E.L.EACH ACCIDENT $ C ANY PROPRIETOR IPARTNERIIXECUTIVE NIA - - i,000,000 DFFICERIMEMBER EXCLUDED? WC049101883(FL) D31OV2014 0310112015 E.L.DISEASE-EAEMPLOYE S D (Mandatory"In Niq' L004000 If M.RdssCliba uMar EL DISEASE-POLICY LIMR $ DESCRIPTION OF OPERATIONS below - 1,000,000 C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 0310112014 0310112045 (EL)LIMIT C WC049101886(NJ) 031OV2014 OM112015 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD TO%Additional Remarks Schedule,it more space 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 of Marsh USA Inc. Manashi Mukhedee ©1968-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 4 { L=ya7117UP ?T rnn>trv-einn su�cntm.y Speciolr: Is J �y ommissione CITY OF S.U.&NI, NAksSACHUSETTS BI:ammG DEP. RT.%iE. T ` 120 W:1sHiNGTON STREET, r FLOOR TEL (978)745-9595 PAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR T HomAs ST.PmitxE DIRECTOR OF Pusuc PROPERTY/BUUMING CONDUSSIONER 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 facili l d ►4.1 (address of facility) si lure o permit applicant date dcbrimfUm