18 SUMNER RD - BUILDING INSPECTION (2) The Commonwealth ofMassachuse CRECtivIONAL SEftVI tiY' CITY OF
Board of Building Regulations and Statid �c�s SALEM
Massachusetts State Building Code, 780 CMR
A 'sed Mar 20II
Building Permit Application To Construct,Repair, Ren r emohsh� `
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A ied:
Building Official(Print Name) Signature V - Date
SECTION 1:SITE INFORMATION
1.1 Property A s 1.2 Assessors Map&Parcel Numbers
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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSBTP'
2.1 Owner' Re o d• /�Q/.� �/'`
Name(Print) �� G - City,S z--
�� ��
No.and Street Te eph ne Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORle(check 5P that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accesso Bldg.❑ Number of Units Oth ❑ Speci
Brief Description of Propos _
S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ —Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: T�'-4.Mechanical (HVAC) $ List: ,e
5.Mechanical (Fire $
Suppression) Total All Fees:$
6.Total Project Cost: $ Check No. Check Amount: Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
SECTION•5::'CONSTRUCTION:SERVIGES-
5.1 Licensed Construction Supervisor(CSL) 9
License Num er Expua e
Name of CS der
List CSL Type(see below)
Addm s --.T e' - �Dmerilition
U Unrestricted p to 35,000 Cu.Ft.
Si R Restricted 1&2 Family Dwelling
/� M Masonry Only
/ RC Residential Roofing Coverin
Telephone WS Residential Window and Sid'
SF Residential Solid Fuel Burning Appliance Installation
' DI Residential Demolition
5.2 Registered Hpm InI row t Co t1 actor OUP
_ 7
H any N e or MC s n r R. 'st 'on umber
A
Ex f n Date
e Te hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GIL C.152.§ 25C(6))
Workers Compensation Insurance affidavit must b completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu ce of the building permit.
Signed Affidavit Attached? Yes ........ ❑ No ...........❑
SECTION 7a:.OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENYOR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, rb&q�� 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.
Signature of Owner Date
SECTION 7b OWNERt OR AUTHORIZEWAGENT,,DECLARATION
1. 1 1 t���n t�I ✓ as Owner or Authorized Agent hereby declare
that the sta eats and in rmation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Nam
1
Signa o ero Au rized Agent D e
Si ed under the ains and.penalties of
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.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"
i CITY OF �'L�SS.aCHUSETTS
BUULDING DEPARTNIENT
• 130 WASHNGTON STREET, 310 FLOOR
TEL (978) 745-9595
FA.r(978) 740-9846
ICI�tBERLEY DRISCOLL
MAYOR T HomAs ST.Pi RR&
DIRECTOR OF PUBLIC PROPERTY/BuuzL\G CoNMSSIONER
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:
+yl ,
(�nam- Of hauler
The debris will be disposed of in :
(name of facility)
�l J�V�lt�l
(address of facility)
A 1 .�
signature of permit applicant
l
date
•JcdriutLilix
HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by:
PLEASE READ THIS CONTRACT THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
909 Boston Turnpike Unit I,Shrewsbury,MA 01545
Toll Free 8779033768;Fax 8009863610
Branch Name: Boston North Date:4/19/2016
ME Lie#C 02439 RI Cont.Lie#16427 CT Lie#
Branch No: 33 HIC.0565522 MA Home Improvement Contractor
Reg.#126893 Federal 1D#75-2698460
Installation Address: 18 Sumner Road SALEM MA 01970
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
M/M AnthonySalvo (978)744-5659
Home Address: 18 Sumner Road SALEM MA 01970
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):victoranthony2l I(a)yahoo.com
Marketing entails will not be sent from The Home Depot.
Project 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 famish,deliver and arrange for the installation("Instatlati
on")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(where applicable)attached hereto and any
Change Orders(collectively,"Contract'):
Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount
9201002 Roofing 9201002 $12,156.30
Minimum 25% Deposit of Contract Amount Total Contract Amount $11,156.30
due upon execution of this contract -
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 applicable,each
Customer under this Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included
herein,at its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations
due to a structural 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.
Payment Summary:
The Payment Summary# 9201002 ,included as part of this Contract,sets forth the total Contract
amount and payments required for the deposits and final payments by Product(as applicable).
06177114-SA Page I d 7
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS CONTRACT
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time of 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 of this Contract,Customer agrees to pay The Home Depot the costs 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 OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE,
WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVER OF SUCH AMOUNTS.
Acceptance and Authorization: Customer agrees and understands that this Contract is the entire agreement between Customer
and The Home Depot with regard to the products and installation services and supersedes all prior discussions and agreements,
either oral or written,relating to said products and installation.This Contract 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.
You are entitled to a paper copy of this Agreement if you choose. If you consent to an emailed copy,your consent applies
only to this Agreement.By contacting sales office (g77)9()1_376g .you may update your email address,withdraw your
consent,or obtain a paper copy of the Agreement at no charge. By signing below,you confirm the following:
• You consent to receive only an emailed copy of this Agreement
• You have access to a computer that can receive and open emails and PDF(Adobe Reader Version 10.1.4 or
later)formatted documents.
• Your email address is correctly listed on the Home Improvement Contract
Submitted by: Accepted by: pr
Sales Consultant Jeremy Fraley Customer
License Name.
Signature: WMAnToOnybaNO r
(877)903-3768 Customer
Telephone No. Signature:
Sales Consultant
License No. (as applicable)
CANCELLATION:CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BI
DELIVERING WRTfTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY
AFTER SIGNING THIS AGREEMENT.THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM
TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE
66117114SA Page 7 of 7
Office of Co¢sumer Affairs&Business Regulation 4
ME IMPROVEMENT CONTRACTOR ,
egistration:: ,{60618•. .t TYPa• `
sa
xpiration r8B12016 Ltd Liability:Corparu
BETTER BUILT ENTERPRISES LLC y q
EVANGELOS LIAPIist�� - ' ' r`
100 CUMMINGS CENTER SUITE 2- .
9 ERLY,MA 01915 Unders "- - -
} � a
AEL Massachusetts Department of Public Safety
�f Board of Building Regulations and Standards
Construction Supervisor
License:CS-M795
EVANGEI.OS LUAjhS
12 STONE STREET {1�rr��----���
DANVERS MA 6i9
y
y `V
t
'j t .11 ."'ions Expiration
Commissioner 05/13/2017
The Commonwealth of Massachusetts
Department of LtdustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
oyti. wrvw.niass.govldia
Wwrkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED N'ITH THE PERMITTING AUTHORITY.
Apolicant Infornintion_ Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you a mployer?Check the appropriate box: Type of project(required):
I. I am a employer with_Z2—employees(full and/or part-time).' 7. ❑New construction
2.[:]1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.[No workers'comp insurance required.]
9. ❑Demolition
3.[]l am a homeowner doing all work myself[No workers'comp.insurance required.]
I 10 ❑Building addition
m a.❑1 a a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plu Ing repairs or additions
5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13 oof repairs
These sub-contractors have employees and have workers comp.insurance!
14.❑Other
5.❑We are a corporation and i6 officers have exercised[heir right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp insurance required.]
'Any applicant that checks box 81 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,
Cghtraetors that check this box must attached an additional sheet showing the name of the sub-ccirtractors and state whether or not those entitieshave
employees. If the sub-contractors hae'e employees;
must provide their workers'comp.policy dumber.
I ant an employer that is providing workers'compensation insurancejor my,employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins.Lic. N: in Expiration Date:
Job Site Address: 16Lo Intr 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 tinder MGL c. 152, §25A is a criminal violation punishable by 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. A p of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do{ J'c un err pa' s dpe ties ojperjury that the information provided a ove is rue attd correct.
Sin re: Date:
i
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
I
City or Town: Permit/License#
Issuin Authori-....:eivele one), -- - - '
- o3rd,0 �t ":Bin ingDepaifm"ert'i kafy 6 Cl J—1: CecrtOffirspecfor S IumbingInspeEfr
6.Other
I
Contact Person: Phone#:
I
ii
Dare p4rnmDr/'r!Y) -
ACOMa, CERTIFICATE OF LIABILITY INSURANCE 671,aY16,6
6��
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 GOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IN9i4RFR(S), AUTHOR17F
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER -
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the POHM 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).
coNrAcr
PRODUCER N FAX
—
MARSH USA,INC. PHONE INC
PNO ALLIANCE CENTER xo:
3560 LENOX ROAD,SUITE 2400 E'MAR'
ATIANTA,GA 30326 MaDRER APPORomO COVERAGE NAICa
100492-H6meU-GAW-16.17 INSURER A:61 dWIRIVI I6PCHPnpany
INSURED INSURER e:ZUridl AmBaan[1093=CD
TW AT-HOME SERVICES.INC- INSURER C:NewHampglRe IRS CO 1
DBA THE HOME OEPOT AT-HOME SERVICES - 17
2690 CUMBERLAND PARKWAY,SUTIE3R0 INSUREN a_Mnds NafionN If151PUnw Company
ATLANTA,GA 3OM9 INSURER E:
INSURERF:
COVERAGES CERTIFICATE NUMBER: ATi,-=46S46.14_ REVISION NUMBER:P
.THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUl : : NAMED ABOVE FORTH 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.
INSR L e PMIDOPMF. POLICY EaP UNITS
LTRI TYPE OF INSURANCE POLICY NUMBER
A I X I COMMERMALGENERALLIARPJTY I GL04BM14-06 03m120% 0316112617 EACH 000UPRENOE S 9,000,600
DAMAGE nE� s 1,OW,600
CLAIMS"E I OCCUR TEES awl Mlfl EXCLUDED
- 1 ' LIMITS OF POLICY XS MED E�(A,mm Parsant S
�Iu—I OF SIR 51M PER OCC PERSQNAL&Anv NUURY s 9,000,0011
E'LAGGREGATE LIMO APPLIES PER I GENERALAseREGATE s 9.000,000
❑PRO- ❑ PP.ODUCT9-COMPIOPAGG �S 9,000,000
X POLICY .IECT LCC
OTHER: S
0 AUTOMOBILE UNBRUTY BAP 293BPfi113 0310112016 0W017 Cow®SWGLELIMIT s ,,000,000
X - BOOILYIWURY(Per"—) S
ANY A JTO
AUTO$ SCHEDULED SELF WSURm AUTO PHY DNG PORKY IPUURY(Pmac3dRN) S
AUTOS AUTOS
NONNXI M4ED PR AMAI3 $ .
HIRED AUTOS AUTOS mamoPn
S
UMBRELLA LIAR OCCUR I EACH ONCE 5
EXCESS LIAB CVWaSMAOE AGGREGATE 3
DED RETENTIONS S
C WORHERS COMPENSAnox 5519215(ADS) 03MIM16 031M12017 X ;� OTM
C AND
EMPLnYEk9'IJI1Bnm YIN FrMAftued
S19217(AICRY,NH,NJVi) 0310112p16 03I012U77 EL EACHACCmENT s 1,0M,000
ANY PROPfUETORMARTN9tID0iLlmUE NfA
0 OPTacEr6MEMemr EXCL1i 5519216(FL) 0 (111WIT BJm12S17 ELDISEASE-EA Ea1P1. s 1,006•MO
(Mandvbry qL NH)
yss� on Addlonal Page EL OLAEase-POLIC'r LOdrt s 1,660,000
0ESCRI•P ONN OF OPERATIONSeebw
DESCR1PnON OF OPERATIONS f LOCATIONS I VEHICLES IACORD 101,Additional Rmwks Schedule,may be aeerLed R mom apam Is mWlmd)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCFLI BEFORE ail
OBA THE HOME DEPOT AT-HOMESERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WRH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED Er
of Marsh USA Inc '
Manashi Mukherjee
I 401988-20t4 ACORD CORPORATION. Ail rights reserved.
-s5j�pu tion
�
offi '- Of CoL-I-�um--F Affairs ant Busin Stilt- 5170
10 Park Plaza
Bo3ton, IVIassa-,hilsetts 02116
Home Jmprovemett* Rea stration
�Q-qntractor
Registraton 126893
v
Type: Supplement card
Expiration: 81312016
THD AT HOME SEPVir-FS, INO-
RICHARD FALLONE
2690 CUMBERLAND PARKWAY
ATLANTA, GA 30339
ddress and return card
Update A Mark reason for chance.
7t Renewal I—_j
-7 Address Employment L Lost Card
V License or res,istration valiff for iudividul use u7iY
rIII DE Consumer
Affairs&Business RaVialtiuft
before the expiration date. if found return to;
'E WOROVEMENT CONTRACTOR C;fice of Consumer Affairs and Business ReautatIOG
Type: 10 ParlcPlaza-Suite 5170
S'pptamsm'Can, Boston.NLk 02116
iD AT HOME
4-= HOi41=-DEPOT A-TtiME P�qicEs
CHARD FALLONE
CUmsc.RILAND PAWRAY
Not tid wit on signature
Undersecretary
LAFfa. GA 30339