Loading...
9 SYLVAN ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts � Board of Building Regulations and Standards CITY It Massachusetts State Building Code, 780 CN[R SALEM N[ r1 Revised ti r 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a �o (q One-or Two-Family Divelling u Ihis Section For Official Use Only Building Permit Numbers' Date AppTed 3a / Building Official(Print Name) ., _ �:.'Signature ;.c Date.-- - SECTION 1: SITE INFORMATION 1.1 Property Apd� s: � 1.2 Assessors Map & Parcel Numbers i `�� `-7I 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: L4 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? Public ❑ Private.❑ Check if yes❑ Municipal ElOn site disposal system ❑ SECTION2:, PROP.ERTYOWNERSHIP' Name(Print) City,State,ZIP No. and Street ��— Telephond Email Address SECTION 3: DESCRIPTION OF.PROPOSED WORK'(check al at apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition Cl Demolition ❑ Accessory Bldg. ❑ Number of Units_ ker ❑ Specify: Brief Description of Proposed Work': �— SECTION 4: ES INIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only, , Labor and Materials 1. Building S t Budding Permit.Fee S Indicate how fee is detemiined: ❑ Standard City/'Down Application Fee 2. Electrical S ❑Total Project Cost' (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: $ 1. Mechanical (HVAC) S List: 5. Mechanical (Fire $ Su� cession Total All Fees: S Check No. Check Amount:__Cash Amount: G. Total Pro ject Cost: S 0 Paid in Full ❑ Outstanding Balance Due:_ __ SECTION 5: CONSTRUCTION SERVICES 5.1 Constructim tcrvis�L` (CS^LLe�6 l spir o toLicense EsNameofCSLIto� / �— — List GSL Type(see below) VU4No. and I�~,Ir•2(a)j ((�} Type '- Description �) 1 ( R Unrestricted 2 Family s u el ing cu. ft.) __ � R IZzstricted 1.4e2 F:unil Dwellin City/Town, State, P NI Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation relep one Email address D Demolition 5.2 Registered Hone Improvement Contractor(if CF ) f --e147 kW HIC Regtstruion Number qpi lion Date HICC nor If ' 'n No. and Streev�� Email address City/ own, State, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit mast be co eted 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 PLIES FOR BUILDING PERMIT I, as Owner of the subject property, hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit applica 'on. Print Owner's Name (Electronic Signature) Date SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under pains and penalties of perjury that all of the information contain is application is true and accurat o th b st of y knowledge and understanding. Print Owner's or:\utlwriz`i�ii,\;emu's Name(Elec runic ignntur�) D/ e 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 M.G.L. c. 142A. Other important information on the FIIC Program can be found at wvvw.massoov.oca Information on the Construction Supervisor License can be found at www.ntass.,ov;d 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) _(including garage, finished basement/attics, decks or porch) Gross livim,area (sq. ft.) _ Habitable room count Number of fireplaces.__ Number of bedrooms Number of badu'oottts Number of half/baths Type of heating system ---- —_--_ Number of decks/porches -_-- — — Typeofcoolimgsystun---- ---- -- Enclosed-_-- _—___--Open . -- 3. ' Fotal Project Square Foota,,,o" may be substitutod f;x"Twal Project Cost" - f t Aqj Yr CITY OF SA.I.EM, NWSACHUSETTS ©t.=L\G DEP.IRT\LENT 120 W:\SHL\GTON "° h , 3 FLOOR TEL (978) 745-9595 KimBERLJEY DRISCOLL F.Lx(978) 790-9M A+LAYOR Trlfon BST.PIEMS DIRECTOR OF PUBLIC PROPERTY/BUMJ:)NG CO.%L%IISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with Debris, and the provisio the sixth edition of the State Building Code, 780 CMR section It L5 ns of tbfGL c 40, S 54; Building Permit ik this work shall be is issued with the condition that the debris resulting from l 11, S 1 SOA. disposed of in a properly licensed waste disposal facility as defined by NIGL c The debris will be transported by: RA I namc ofhaulcr) The debris will be disposed of in (name of facility) s' nature permit applicant d<brin.i u'.I.w I Ii 02/27/2813 07:23 17818940331 TODD RIDEMAN PAGE 01 -' HOME IMPROVEMENT CONTRACT PLEASE.READ THIS Sold,pumished and installed by: THD At-Home Services,Inc. Branch Nam: Boston Date: �Ji' l� d/1r/a The Horde Depot At-Home Services -�— 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(8(8))657-5182;loan(508)845-6017 Federal 1D#75-2699460;ME Lic#C.02419:RI Conl.Litd)16427 Branch Number:31 p C' lIt HIC.0565522;MA Home I�ympymvemcnl Conuacto f Reg. 4 12690 Installation Address: 1 J,SI'�/A P"`�' o / 0- " "'_' City State Zip Purchaserls): Work Phone: Heme,[Lone_ CCU Phum:��� �n �� L 1 { Q- Home Address:: (11'diffcrent from Installation Address) City State lip E-mail Address(W receive Imuject cummunicatiuns and Home Depot updates): - ❑1 DO NOT wish to receive any marketing entails from The Home Deposit ro' Inf u tion: Undersigned("Custer r"),the owners of the property located al the above installation address,agrees ti)buy, and THD Al-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the insluMtinn ("installation")of all material described on the below and on the referenced Spec Sheet(s), all of which are incorpurated into this Contract by this reference.along with any applicable Stale Supplement and Payment Summary attached hereto and any Change Orders(collectively, I "Contract"): /�.,/✓�,l//1 Job#: Products: Sper S s #: Pmiect Amount_CT „ R,wRng []Siding fR Windows. LJ Inwlanon I/7�j,.J r�ry �r �( 2 ❑Gutters/Covers ❑Entry INxtts ❑ 6 6?J / J $ �/�3� V 6 Runies Siding try D uwx In elation $ 10001 D\ y} ❑Gu(tm/Covers []Entry Dwrs ❑ M a Rrrafing Siding Windows Insulation g ❑Guttets/Covers ❑Entry Utwrs❑ .._ _ Rwfing Siding Windows Insulatio ❑Gutters/C,ov¢rs ❑Entry Doors ❑ n Minimum 754E I/epoeit MContract Amount due[rpm wrenilan of Oils contract Total Contract Amount s 1� ` D 6 Maiva PurNmes may not dgmWt moreen d one4bad ofb'e Cont=dAtrmuot. (�.ustomer agrees that. immediately upon completion of the work for each Product,Customer will execute a COMP106011 Certificate (one for each Pmduot w defined by an individual Spec Shect)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 Depm car its authorised service provider determines that it cannot perform its obligations due to a structural problem with the home,cnvinmrrawtal hazards such as mould,asbestos or lead paint,other safety concerns,pricing combs or because work required to complete the job was not included in the Contract. D t r / � Pavment Summary: The Payment Y�Summary# / S 9 , included as part of this Contract, sets forth the cowl Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely tilled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(none: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)behmre work on that Product is complete. In the event or termination M this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services Drlovided 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 WITHROhD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIM[TING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Cmtumer agrees and understands that this Agreement is the entire agreement hctwoen Customer and The Home Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements.either and or written,relating to said Pnducts and Installation.This Agreement cannot he 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. At Submitted CiAeater's Signature Date Salcc Cons/ultanl's Signature Date X _ Telephone No. Cuslmner's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS Ws appli.blen AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THY. 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. NOTICE:ADDD IONAL TERMS AND CONDITIONS ARM STNrEtt ON THE REVERSE STOP AND ARE.PART OF THIS CONTRACT 10-11-12 Whine-Branch File Tellaw-Customer i i + V rPtassachusetts-Department of Public Safety Board of Building Regulations and Standards' I License CSSL-099699 ` ROBERT POCZOBUT 172 WHALENS LANE Salem MA (11970 Exprrafion G:omrrs...saavrr 02/08/2014 I a i rY .. The Commonwealth oj'Ia assach asza'ts Department of Industrial Accidents dlffit:e oflnvestigations 600 Washington Street Boston, MIA 02111 twnvw.mass a owdia Workers' compensation Insurance'Affidavit: Builders/Comtractorst leetricians,,/Plumbers ARplicant Information Please Print Legibly Name(Business/Organization/individual): YRvr ems ` Address: City/State/Zip: Phone #: / .Are yo an employer?Check the appropriate box: Type of project(required): 4. ❑ I am a general contractor and I 1. . I a employer with * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time}2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub contractors have g, ❑Demolition employees and have workers' Building addition working for me in any capacity. 9. .❑ o workers'com insurance comp.insurance./ re P 5 10.❑Electrical repairs or additions required . ❑ We are a corporation and its officers have exercised their 11,0 Plumbing repairs or additions 3.❑ I a homeowner doing all work right of exemption per MGL myself. [No workers' comp. 12.0 f repays c. I52, §1(4),and we have no Ci insurance required.]t 13. Other employees. [No workers' comp.insurance required.] *Any applicant that checks box p 1 oust 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 hue outside contractors must submit anew affidavit indicating such, tContramrs that check this box mast attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors bm employees,they mast provide their,workrrs'comp.policy number. lam an employer that is provid ng workers'compensation insurance for my employees. Below is the policy and job site t information. Insurance Company Name: , /� Policy#or Self-ins.Lic.#: ��iA `j' Expiration Date: Job Site Address: -1 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 D or insurance coverage verification. I do hereby certify u der it abr and penalties of perjury that the information provided above is up and correct Si attire: Date: Phone Offwial use only. Do not write in this area,to be completed by city or town ofciaL City c;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#: - �� 2omv�nomwaa/!/ o�✓�a�ac/i,.reetG, . Office of Consumer Affairs&Rusmess Regulation License or registration valid for individul use only - G.''ItiOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation ' Registration:-72b"893 - - Type:, 10 Park Plaza-Suite 5170 Expiration g(g 201,4_ Supplement :ard - Boston,MA 02116 The Home Depot Itt HomeServip`e's - RICHARD FALLONE # 2690 CUMBERLAND PARKWAYS XY15klM,GA 30339 t Undersecretary of valid ithout signature 9\ DATE(MNVODM )) 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 policy(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), coNTACT PRODUCER NAME: FAX MARSH USA,INC. PHONE ac No): - TWO ALLIANCE CENTER c f Ext: 3560 LENOX ROAD,SUITE 2400 E HAIL ADDRESS: ATLANTA.GA 30326 iNSURER(SI AFFORDING COVERAGE NAIC If 100492-HomeO-GAW-13-1 4 INSURER A: Steadfast Insurance Company 26387 ' INSURER a:Zurich American Insurance Co 16535 INSURED 23941 THE HOME DEPOT,INC. INSURER C:New Hampshire Ins Co HOME DEPOT U.S.A.,INC. Illinois National Ins Co 23817 2455 PACES FERRY ROAD,NW INSURER D: BUILDING C-20 INSURER E ATLANTA,GA 30339 ' INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003159545-04 REVISION NUMBER:7 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. AODLS BR POLICY EFF POLICY UP LIMITS La.iNBR TYPEOFINSURANCE R POLICY NUMBER MMIDD MM/DO 9,000,000 p GENERAL LIAB)LITY GL0488771403 03/0112013 03/0112014 EACH OCCURRENCE $ DAMAGE ORENTED 1,000,000 PREMISE Ea ccmuence X COMMERCIAL GENERAL LIABILITY S $ a LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED CLAIMM.s-MADE OCCUR 9,000,000 OF SIR:$1MPER OCC PERSONAL a ADV INJURY $ GENERAL AGGREGATE $ 9,000,000 PRODUCTS-COMPIOP AGG $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER _ $ X POLICY PRO- LOC COMBINED SINGLE LIMIT B AUTOMOBILE LIABILITY BAP 2938863-10 0310112013 0310112014 Ea accidant g 1,000,000 BODILY INJURY(Per person) $ - X ANYAUTO BODILY INJURY(Per accident) $ ALLOWNED SCHEDULED SELF INSURED AUTO PHY DMG 'AUTOS AUTOS NON-0WNED _ PROPERTY DAMAGE $ Per accitlent HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLA LIAR OCCUR AGGREGATE E EXCESS LIAS CLAIMS-MADE $ DED RETENTIONS WC033575314(AOS) 03/01/2013 0310112014 X we sTATo- oTH- C WORKERS COMPENSATION rf. C AND EMPLOYERS'LIABILITY YIN WC033575315(AK,AZ) 0310112013 . 03/0112014 E.L.EACH ACCIDENT E 1,000,000 ANY PROPRIETORPARTNERIEXECUTIVE E NIA 03101/2013 0310112014 1,000,000 ' D MFandatoMEry NH) CLUDED? WC033575316(FL) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,tlescdhe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C WORKERS COMPENSATION WC033575317(KY,NC,NH,VT) 0310112013 03101/2014 (EL)LIMIT 1.000.000 C WC033 575318(NJ) 03101/2013 03/01/2014 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Addifional Remarks Schedule,Hmore span fs required) EVIDENCE OF COVERAGE CERTIFICATE HOLDER - CANCELLATION III THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME DEPOT USA,INC. r THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 24551PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS. - BUILDINGC-20 - ATLANTA,GA 30339 - AUTHORIZED REPRESENTATIVE of Marsh USA Inc. - - ManashiMukhadee ©1988-2010 ACORD.CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks df ACORDy+