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22 SURREY RD - BUILDING INSPECTION I� The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF �u1rt Massachusetts State Building Code, 780 CMR SALEM �,• Revised Mar 2011 Building Permit Application To Const uct, Repair, Renovate Or Demolish a One-or Two- antrly Dwelling This Se on For Official Use Only Building Permit Number: iDate Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property ss• 1.2 Assessors Map& Parcel Numbers 8C�� trt��_1 I.I 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 R) 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? Municipal❑ On site disposal system ❑ Check ifyes❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owtier'o ec •d !S4 4 m ©» Nae(Print City,State, � ry No.and S reet Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) I. Building $ 1.. Building Permit Fee: $ Indicate how fee is determined: �. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost"(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Exp a[ion a[c Name of CS colder List CSL Type(see below) No. and Street Type Description ©�O U Unrestricted(Buildings up to 35,000 cu.R) R Restricted 1&2 Family Dwelling City/I'own,State,ZIP M Mason RC Roofing Covering WS Window and Siding `" )o 1 Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home I nprovem nt Con(F for(Hiq HIC Registration Number Expi tion ate IiIC C�n ue or HIC Regi st ant N: 17 No. t tre t 0 Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be3oCpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan of the 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 15 �� / to act on my behalf,in all matters relative to work authorized by this building permit ap ication. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest un a pains and ,enalties of perjury that all of the information contain this application is true and accur pt of y kno ledge and understanding. 1C Print Owner's or Authorized Agent's Name(E ectroni Signaturef Da 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 can be found at www.mass.,ov%oca Information on the Construction Supervisor License can be found at www.mass.,ov/dps 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" a Office of Consumer Affairs&Business Regulation AVOME IMPROVEMENT CONTRACTOR Registration 426893 - Typc. _ . Expirattan _8E3f20?2..,. _ Supplement IV The Home Depo ojne.Set ices , RICHARD FALLONE ' 2690 CUMBERLANQ.Pk_RKWAY-S A'(Z`At TY , GA 30339. Undersecretary - The Commonwealth of Massachusetts Department of industrial Accidents office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gav/din ers Workers' Compensation hignrance Affidavit: Bcu?ders/Contractors// l Pltri�PAY L b bl LY Applicant Information Name (Business/Organ stidn/Individual): Address: City/State/Zip: Are y au employer? Check the appropriate boa: - - Type of project(required): 4. ❑ I am a.general.contractor and I 6 ❑New construction 1. I am a employer with� have hued the sub-contractors employees(full and/or part-time).° 7. Remodeling . Listed on the attached sheet ❑ 2.❑ I am a sole proprietor or partner- These sub-contractors have g-, ❑Demolition . ship and have no employees employees and have workers' 9 Building addition working for me in any capacity. comp. insurance . ❑ [No workers' comp.insurance 5 El We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 11.❑PI mg repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 12 cof repairs myself [No workers' comp. c. 152, §1(4), andwehaveno insurance required.]t 13.❑ Other . employees. NO workers' comp.insurance required.] 'Any applicant that cbecks box#1 must also fill out tte section below showing their wOrkm[$compensation policy information. t Homeowners who suhnut this affidavit in they arc doing all work and then hire outside contractors must submit anew affidavit indicating such. their tCantmcton that cbmck this boxmuees st attached an additional sbwt showing the Dams of the subconn b�and s whether ornot those entities have employ . if the subcontractors have employees,they mustpruv!dt workers'comp.policy jam an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. _ Insurance Company Name: / • Expiration Date: 3 P 0licy#or Self-iris.Lic. #: City/Stzte/Zip: Attach a copy of the workers' compensation policy eclaration page (showing the policy number and egP penalties atioa date). of a pail Le to seatre coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal 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 maybe forwarded to the Office of Investi lions of the D - r insurance coverage verification I do hereby serf un e he 'ns d p aloes ofperjury that the information provided ab ve is rue and correct Date: — Si ature: Phone#: Offrcial use only. Do not write in fhis area, fa be completed by city or town official PermitUcense# City or Town: Issuing Authority(circle one): - Inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical 6. Other Phone#: Contact Person: 11-APR-23 02:59PM FRW-Hoas Depot 2665 +0787401402 T-325 P-001/005 F-735 PLEASE READ THIS Sold Furmshcd and Installed by: Branca Name. Boston Dose- .. THD At-Home Services,Inc. I The Home Depot Ar Home Services- �I 345A Greenwood Street,Unit 2,Worcester,MA 01607 Toll Free(8W)657-5182;Fax(508)75"823 Branch Number.31 Fed"ID#75-2699460;ME-Lic#C 02439;RI Cont.Lic#16427 CrLic#.HIG0565522;MA Home Improvement Convector Reg.#126893 I�a➢ab s oa AdtIl : 5V t�d - s G.s't. M4 619 6 Q City Siam ZIP - . (s): Workphane: - Hama Pharr: Cell lam: [ l [mil 715 [ ] [ l I [ l [ ] Home A—rH 42— (IfdifCe from m lnstallnuon Ad km) City np State tip E-neaB Address(m receive pmj communications and Home Depot updates): ,v .--.- ❑I DO NOT Wish to receive my marketing ema)Islrom The Home Depot - afflInforunatim: Undeas' ("Customer').the owners of the pioperty located As above installation address,aaccs to buy. At Honor Rmvimr In .C'Ttto Flnma Dapan arowa to furnish deliver and irrarw fur The inamnntinn("budalladau)of all materials described on the below and on the referenced Spec Sheet(a), all of Which are incorporated into this Contract by this reference,along with any appli�ble Stara Supplement and Payment Summary attachod hereto and soy Change Orders(collectively. "ComrscC): Job#: tn.mta prods S. Protect Ansainat Siding Ll 7 []GutwafCo`ers ❑Envy Doors ❑i El WindowsIasuladoo 1��36 $ s5 qqs ❑Roofm ❑Siding Windows insulation $ ❑Guth as C'.aven nany Doa6 1`1 El Siding M WirMows ❑lesoladon $ ❑Guuers(C-q ❑Famy Doors fl (]R Siding vvindowi 0 Innttadoo $ QCaraers Covers ❑Entry Doors n MW®E5%DUPOWaar Am d:opmewcoHmofims000nact Total Contr#etAmoant $ 4 9 Marnepesds wsrosy rntdepose mare thm000lhbd arthe LaatrOftArpamt Customer agteertha5 bomediatply upon completion of the wa&fo ach Pneduct,Customer will.execute aCompletion Cemficam (one far 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 dinars Depot rastnvae than m caeue a Change Order or terroinare this t.'natrtrr nr any inrliviAnal PrtaltxY(s)inclndM herein.at its discretion,if The Hattie t or its authorized service provider determines that it cannot perform its obligations due m a structural problem with the home,euviro tal hazards such as mold,asbestos or lewd paint,other safety concerns,pricing errors or because Work required to complete the j t was not included in the Contract. carmen[ Summary; The i'a t Summary# 476 !'� - 1w]W...t . pu...,f d:ia Cv.Ib t, x� 1.th tar. eatal Contract rununn and payments --lied for the deposits and final payments by product(as applicable). NOTICE TO CUSTOMER You are eotitl d to a comp fiBed-in copy of the Contract at the time you sigh. Do not sign a Completion Cerfiftcate(note: there Is one Complctimr 1e far each listed Product as defined by individual Spoc Shoals)before work on that Product is complete. In the event of termination or this Contract,Customer agrees to pry The Home Depot the costs Of ttmteriais,labor,expenses and services provided by The Hence Depot or Authorized Service Provider through the date or termination,phis any other amounts set forth in this or allowed under applicable raw. THE HOME DEPOT MAY WTTHHOID AMOUNTS OWED TO TAE HOMED FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME D 'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance andn A n Customer agrees and mdersouK.that this Agrcemem is the entire ulprernent between Cusmmer and The Herne Depot with regee a m We Products and Installation services and supersedes aft prior discussions and agreements,either oral m vrtinen,relating to said Products and Tustalaton.This Agaexmem Canlrot be assigned or amendd except by a writing signed by Cusurv,.t aml TIM Hwuc D.LAW.Craw, ar.K..k gts add agrees that mar read,understands,voluntarily accept,the turns of and bap received a coM of this Agreement Arse by: so C"Mmer's S' Date sales Consuham's Sigosbue Date x TelephowNo, al 3 -73Y(, Customer's Sigoatmc Dane Sales Cousulmnt License No. CANCELLATION. CUSTO)'11BER MAY CANCEL. THIS Ws app.cabte) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRrI IEN NOTICE TO THE HOMR DEPOT BY MIDNIGHT O]0 THE THIRD BUSYNESS _ DAY AFTER SIGNING TITS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE W ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE NU'1TCE:AIMMONALTRaMS ANDCONn1T1,,ARR.TAT®ON THE RRVMM SWR AND ARE PART OF TNS CONTgACr act-t0 C-SC White-Emnch File Yellow--Cusluxux l DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 02/21/2011 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policysies) 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). PRODUCER 1-404-995-3000 CONTACT NAME Marsh USA, Inc. PHONE FAX homedepot.certzequest@marsh.com E-MAIL arsh.com - ADORESS: --- ------ -- Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURERSI AFFOROINGCOVERA_GE NA_ICtl_ _ Atlanta, GA 30326 � _— Fax (212) 946-0902 -INSURER a_Steadfast Ins Co 26387 INSURED INSURER B: Zurich American Ins Co 16535. The Home Depot, Inc. New Ham shire Ins Co 23841 Home Depot U.S.A., Inc. INSVRERC: P — 7455 Paces Ferry Road NW INSURER D: II1inois Nat' Ins Co 2381T Buildin_ C-20 _INSURER E: NATIONAL UNION FIRE INS CO OF PITTS I 19445 Atlanta, GA 30339 INSURE F: Illinois Union Ins Co 27960 COVERAGES - CERTIFICATE NUMBER: 19834682 REVISION NUMBER: TRTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD h115 IS TO CE INDIOAT'ED. NCi':JITHSTANDING 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 ADOL MIND T POUCY EFF POLICY E%P LIMITS LTeI TYPE OF INSURANCE TN-,a POLICY NUMBER -_ MMIDDIYYYY IAMIOOIYYYY — A GENERAL LIABILITY GD04807714-01 03/01/1 03/01/12 EACH OCCURRENCE E 9,000,000 % DAMAGE TO RENTED 1,000,000._- COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence _ E CLAIMS-MADE uOCCUR — 1 MED EXP(Any one person) S EXCLUDED --------" - X LIMITS OF POLICY XS - PERSONAL BAOV INJURY S 9,000,000 X OF SIR: $1M PEA OCC - GENERAL AGGREGATE E 9,000,000 - GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG E 9,000,000 X PRO- S POLICY LOC B HAP. 2938863-08 03 O1 1 03 O1.12 COMBINED SINGLE LIMIT 11000,000 PUTOMOBILE LIABILITY Ea SddIdenl' - __..._._.—_.._.. X ANY AUTO _ BODILY INJURY(Per person) E _.__........ _._.. ALL OWNED SCHEDULED - BODILY INJURY(Per accident) E AUTOS AUTOS Y OPE PRRTY DAMAGE NON-OWNED ROPE IS HIRED AUTOS AUTOS Perac X SIA AUTO P Y E UMBRELLA LIAB OCCUR EACH OCCURRENCE E _ _ _ E%CESS LIAR CLAIMS-MADE AGGREGATE - S OED ftETENTIONY I C WORKERS COMPENSATION WC061967352 (AOS) 01/12P s DTH- - ANDEMPLOYERS'LIABILITY YIN D ANY P0.0PRIETORIPaRTNER/EXECUTIVE❑ WC061967359 (T'L) /Ol/12DENT E 1,000,000OFFICERIMEMBER EXCLUDED? N NIAE (Mandatory in NlqWC061967353 (CA) /01/12EA EMPLOYE E 1,000,000If yes,describe under POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS belowC Workers Compensation WC061967355(XY,MO,NY,WI, /01/12F TX Employers XS Indemnity TNSC46244151 (TX) /01/12e/SIR 30M/1M E Workers Compensation .. WC1192378 (QSI) /01/121M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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 U.S.A., INC. - ACCORDANCE WITH THE POLICY PROVISIONS 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 l— ATLANTA, GA 30339 USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD j Eiero_hd 19834682 �l 1,ia(huutts i)ep utment o1 Pumic :Salo t% 9 B(j trd ut Uuildnt ' R( ul ttwtis uttl �t..tnd 'tds \.Y .�.t :,aCf'�C,I.•;1 :7U�. (;13 ],�._�.IF.3 tty Ur-;-'se License: CSSL 101192tk Restricted to: RF,WS r Fr ZOUHAIR FERRIMY 2 2 ROLLING MEADOW DRIVE MILLIS, MA 02054 Expiration: 1/30/2012 (-„nrmi• i„nrr Tr#t 101192 CITY OF sm.&NI, l�L1SSAC1iUSETTS • BI:ILDL*IG DEPARTMENT ' 120 WASHLNGTON STREET, 3i 'FLOOR TEL (978)745-959S FAX(978) 740-9M KI�BERLEY DROLL MAYORTHo+tAs ST.PIERRs DIRECTOR of PUBLIC PROPERTY/KaZiNG co%LUISSIONER 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 It 1.5 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 defincd by MGL c l 11, S 150A. The debris will be transported by: name of auler) The debris will be disposed of in (name of facility) &opr.---4- I (address of facility) signature of permit applicant date dubnvlf d,ry