17 SURREY RD - BUILDING INSPECTION (2) --- The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 C NIR S•�LGAI
'a.�.. Ne rierJ.1 Grr'rl l l
Building Permit Application To Construct. Repair, Renovate Or Demol'
One- or Two-Familt Dn elliep
This Section For Offlcial/tf'sc only
Building Permit Number: Date; plied:
lhilding OI}icial(Print N;unc) . ignature Doc
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors NIap& Par Numbers
Metro
I.la Is this an accepted street?yes no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District !'reposed the Lut Area(sq It) Fmntage(ll)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal Check if esO P y.s stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownera o corder J (I K 7
Namc(Prun) I_`¢UF Lily.Slate. P �--�Z--Q
Nu.and Street telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all t apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Numberof Units_ Other ❑ .Specify:
Brief Description of Proposed Work-:
SECTION a; ESTIDIATED CONSTRUCTION COSTS
!acre Estimated Costs:
(Labor and .Materials) Official Use Only
1. Building g I. Building Permit Fee: $ ` Mdicate how fee is determined:
'. [:Iectrical S 1 ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier __ x
.1. Plumbing S '. Other Fees: S -- -
4. Mechanical III\':1(l S LisC_
%lechanieal nFire
S
Ru„ression) Tural :\11 Fees: S_ --__ - -----'- ---------
Total Project Cost: ) Check No. _ Check:\nunmt - - Cash:\mount: -
Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVI('ES
5.1 Constructiol upen isor L'••I e(C'SI.)
License Number Icpna oI I
None ol'C'SL I Told r--111
List CSI.
I.,., I)pc Vec below/-_-
'1 Description
No. and Street `1
It PC
hnrextrieteJ(lluiiL!Ln�s Iip to 35,0110 ul. It.l
_ R Restricted 1&3 Famil Daellin
Cityil,mil. tat _-- M klasonry
DRC RootingC'uvcrin
-- o �" WS Window and Sitting
SF Solid Fuel Burning Appliances
q�rj'!/�i�h� ga? g I Insulation
'felt hone �-Z bmml adJres. D Demolition
5.2 Registered Home Ingtr vemet ntractor HIC)
I IIC Regi"- slr;aion Numhcr iraf m I
IIIC 'oI p or I11C Itegistr t
Nu.and cet r Email address
City/Town, State,ZIP Rl! ho" ne— —
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.0 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 a 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_{ oalz;�'
to act on my behalf, in all matters relative to work authorized by this building permit app tcation.
Print Owner's Name(Electronic Signature) 7at,
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest ut er he pains and penalties of perjury that all of the information
costa' in this application is true and accu .to to he st o y kl�Owledge and understanding.
r
t0;% •r's or:\uthorirc .\gcnt'si Juno lP.kctro (•.Signal D'tc
NoTES:
1. :\n 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 no have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be round at
\�N%\\ nl.n. .;OI 00 Information on the Construction Supervisor License can be found at dp,
2 When substantial wurk is planned, provide the information below:
Total floor area(sq. It.)_ (including garage. finished basement attics,decks or porch)
Gross living area(sq. 11.) _ Habitable room count
\umber of fireplaces_---._ _ Number of bedrooms
N'umher ol'bathruonu __ _ . _ . Number of half halhs -
f)pe of heating s)elcnl Number of decks, porches
I)Ile of coohmg s)4ctn - Enclosed
i -[olal Project Square Footage-m;l) be substituted ror-I'olal Project Cost"
Aug 10 11 01:14P PA
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Famished and Installed by:
alch Name: Boston Date: THD At-Home Services,Inc.
�l_u___ d/b/a The Home Depot At-Horne Services
345A Greenwood Street,Unit 2,Worcester,MA 01607
Toll Free(NO)657-5182;Fax(508)756-8823
Branch Number.31 Federal m#75-2698460;ME Lie#C 02439;Rl CAL[icS 16427
CT lic#HIC.05655522,MA Home improvement Contractor Reg.#1 ZM93
Installation Address: 17 Sttseru RL1 SAle Yin im6 019T76
Parchaserts): Work Phi Home Phone: : J
20 Vio U ] 33g4i l Eat V-71b-748
Home Address:
(H diffetem from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to mceivx any marketing emails from The Home Depot
Pmiert Informaum; Undersigned("Customer-),the owraas of the property located at the above installation address,agrees to buy,
and THD AI-Home Services,Ira('Tbe Home Depor')agrees to furmsb,drover and arrange for the installation("Installation")of
all mmerials 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 mad Payment Summary attached hereto and any Change Orders(collectively,
'Contract"}. i
Job#: aae.u� Spec Sh s)#: Pro'ectAmmut
Roofing Sidra" Windows lnsuladon
5g4Zo5, ❑Gua¢rsICavers ❑ErmyD— ❑ F) 1 $ {Z00(D
Roo§vg ❑S-idin -di insulation $
ovens ❑Fntry Doors ❑
Roofing❑Siding ❑Windo lumladan
5`I 63 ❑Gmtcs,C. ❑EmyD..0 4a390 $ i boC�
❑Roofing id+vg Windows ❑bunlation $
❑Gutters I Covers ❑Eatry Doors n -
hT®mm25%Dep®t of Contract Among due ape execution ofthis,container Total Contract Amount
Maine Purchasers may addepail more lhoaexadrddtlw CordmeArmemrL l�^�
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 soy balance due. As applicable,each Cuatomrer 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 t eratinate this Contract Or anY individual Pmdtmt(s)included herein,m
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 homq euvuonmerrtal hazards such as mold,asbestos or lead paint,other safety concerns,pricing coon;or because
work required to complete the job was not included in the.C__-ontr�ac��t.
Payment Summary: The Payment Summary# -19B�y.�c C> , included as part of this Contract, sets forth the,total
Contract amount and payments requited for the deposits and final Payments by Product(as applicable).
NOTICE TO CUSTOMER You are entitled to a completely BRedtin hmpy of the Contract at the time you sign. Do Oct sign a Completion Certificate(tote: t
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 Horne Depot the mats of materials,lab",expenses
and services provided by The Home Depot or Authorized Service Provider tbmugb the date of termination,plus any other . -
amoudts set forth In this Agreement or allowed under applicable law. THE HOME DEP�T MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LMHTUN G THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. -
Acceptance and Authorization: Customer agrees and understands that this Agreement is the cram 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,rel , o said Products and Installation.This Agreement cannot be assigned or corroded except by a writing signed
by Customer and The L Customer acknowledges and agrees that Customer has read,untl.MIands,voluntarily accepts the
tams of and has received a of this Agreemetd.
t ..
Am y: � :Subtdy: $GUi r's Date tam's Si Dale
O-a.... b Telephone No_
C Date Sales Consultant License Na
CANCELLATION CUSTOMER MAY CANCEL THIS /a appliobirl
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDMGHT 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.
NOTICfs:ADDITIONAL TFRM AND CMDRIONS ARE.STATED ON THE REVERSE SIDE AND ARE PART OF THIS CO_VTRACT
10-18-10 GSc WNta-B2rmh Fie Yeflow-Customer
a CITY OF S.V�&NI, t%LASS,1cHL'SETTS
BLLMLIYG DEP.IRTIE.`T
120 WA►SHLNGTON STREET, )iO FtiOpR
rM (978) 745-9595
F.Vt(978) 740-98"
K)N®EJtLEY DRWOLL
MAYOR -Mmw ST.PMUA
DIRECTOR OF PL SLiC PR0PERTY/9v amLYG CONNISSiON ER
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 a 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
111 work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 1 1, S I SOA.
The debris will be transported by:
� _1r
(n une of outer) /�
The debris will be disposed of in :
( meof'rutlity)
(address or racihty)
4,gnpplicant
IJfe
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, sew, (} ak Phz.l m Sclite 5170
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17 BEACH RD. APT
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ROBERT POCZOdU{
T70EACHRQADA?T 45
LYNN,MA'Q7Sl)2'.
i b..nu us.ueh� Tom:�99699 t-
t
DATE IMMIUDIY YYY)
CERTIFICATE OF LIABILITY INSURANCE 02,21,20L7
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TF{IS
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 INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies) must be endorsed. If SUBROGATION IS 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).
PRODUCERFAX
1-404-995-3000 CONTACT
Marsh USA, Inc. PHONE
-
EMAIL
homedePOt.COrireQUe9t®dlar9h.COm ADDRESS:--- ""'-- -- �
Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURERS AFFORDING COVERAGE NPICd
Atlanta, GA 30326 __— t1------ -_...._ .. ._
Steadfast In.-CO 26307
._Fax (212) 948-0902 INSURER A: —__ __--.- - -'- -"'
Zurich American Ina CO 16535
INSURED INSURER 8: ._
ar"
The Home Depot, Inc. INSURER C Hampshire Ins Co _
: New _ -238.41-
Home Depot U.S.A., Inc. Illinois all Ins Cc 23817
2955 Paces Ferry Road NWINSURER O' --- - ""
Building C-20 III PER Is NATIONAL UNION FIRE INS CO OF PITTS 19445
Atlanta, CA 30339 ais Union Ins Co 27960
INSURER F Il lin
COVERAGES CERTIFICATE NUMBER: 19E34692 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PE14100
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
ADU ?; BR PDLICYEFF POLICY EXP LIMITS
TYPE OFINSURANCePOLICY NUMBER MMIDDIYYY MMIDDfrYYY
RAL LIABILITY GL048a7714-01 03/01/1' 03/01/12 FACHOCCURRENOE S 9,000,,000
'6WMAG �TW ce1 f1000,000
COMMERCIAL GENERALUASILITY PRFM SEE IE ._ ..CLAIMS-MADE �OCCURMED E%P L one 0eraonLIMITS OF POLICY XS PERSONAL 6 ADV INJURYOF SIR: $1M PER OCC GENERAL AGGREGATET AGGREGATE UNIT APPLIES PER:POLICY PRO-MOBILE UABILRYBODILY INJURY(Per Pars") S
ANY AUTO -ALL OWNED SCHEDULED - - BODILY INJURY(Par eccMdnO S
AUTOS AUTOS -- -NON-OWNED PROPERTY DAMAGE yHIRED AUTOS AUTOS I nt SIR AUTO P YS
UMB0.ELU LIAB OCCUR EACH OCCURRENCE _ fEXCESS LIAR CLAIMS-MACE - AGGREGATE_—_ S
DED RETENTIONS WC STATU- OTH.
KERS COMPENSATION WC061967352 (ADS) 03/01/1 03 01/12 X EMPLOYERS•LIABILITYYIN O7/O1/12 E.L.EACH ACCIDENT S 1,000,000
PNOPRIETORIPMTNERIEXECUTIVe❑ WC061967354 (FL) 03/01/1 ICERMEMBEREXCWOED7 N MIA
WC061967353 (CA) 03/01/1 03/01/12 E.L.DISEASE-EA EMPLOYE S 1,000,000
dalery In NH)a.deun0eunaer - E.L.DISEASE-POLICY LIMIT S1,000,000
CRIPTION OF OPERATIONS below
C Workers Compensation WC061967355(KY,MO,NY,WI, 03/01/1 03/01/12
F TX Employers XS Indemnity THSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/1M
E Workers Compensation WC1192378 (DSI) 03/01/1 03/01/12 9Io 1M
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AddiVeml Ramarlo Sdndule,if mdn space b n4ul,ad)
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
HOME DEPOT V.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS.
2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE
BUILDING C-20
ATLANTA, GA 30339
USA
C 1983.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
jfiero_hd
19834682
The Coit ntonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
4 600 Washington Street
X Boston, NIA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �� L�1r- J J
Address: �11 f
City/Sta /Zip: Amelpitt �YLhone
Are;tan employer? Check the appropriate box:
Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
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'
[No workers' comp. insurance comp. insurance.*
9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ f repairs
insurance required.] t c. 152, §1(4), and we have no
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.
tt:ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they 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: ►fit>�1 ) (iny??_ l l fid� C��
Policy #or Self-ins. Lic. :�� ��7 `7 Expiration Date: 7 _
Job Site Address: �/ 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 certify und4ieins pnd patties ojperjury that the information provided above is true and correct.
r
Sip nature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permif/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
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OMEIMPROVfMENTCONTRACTOR.
UP
Re9+stration�''42689] TYFE
Supplement,
..'Exp+ra6artyBf201;?„ .
The Home Depoes - +
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RICHARD FALLO�NE
2690 CUMBERLANR
30379��—� Underie�cres�- - -