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80 TREMONT ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Mar Revised Mar Z011 \1 Building Permit Application To Construct,Repair,Renovate Or Demolish a One or Two Family Dwelling ,a.. hTUc ,S a'".. r�Thls et�O FOT Q IC1a1 5&M&5� ..rx.s ots BuddingPennrtumber y 7a �?DateAphed sx N''kt.: ' mtdmgOfficiah'(PrmtNamej �,=�' ,.,,t x^ Sa e r� �`n n & at u 1.1 Property Addr 1.2 sses p arcel Numbers 1.1 a Is this an accepted street?yes no Map Nu 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.1 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 if yes❑ s, SRCL)ON2 EROPERTO�VNERSIIIPt ,ua > 2.1 Owner cord: �G 5 Name(Pant �� City,State,ZIP 4, �r rvl� � No. and Streeter Telephone Email Address _>^ x SECIION3 bESCRIPIONQFPROQOSI,+DtiVOA'(checkal hat apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Othe ❑ Specify: Brief Description of Proposed Work2: n SECLQIN4 EST > t' LED C6NSTR ( F ONCO$ S ?" ' ter Item Estimated Costs <�� Qffic al iTs�OnlyF ` t Labor and Matenals .: �.00 � . s�k��XYI_� ' 1.Building $ r. ) B uldu gPexmttFee $ Indtcate.how feerrsdete !hed y rm fa "&- � K, ro `wi' w 3 <, - ;, ra s r ❑Stan,Baxd Cttyl ownApp)Acaha�tl�ee� 2.Electrical $ C. _ a ❑Total�Pr$ISctCost��Item6�aG ultrplier 3, �' �* _ � 3.Plumbing $ at2 Qther fees$$a � Vic' tti < 4.Mechanical (HVAC) $ FErst s , �v U r 'x 5.Mechanical (Fire ' F: $ TcilAees $ _ � Su ression) 1L"F K Gheck�No �,� ',Check�A�otiut� *_��' ���CashAmouriY�n, * '� 6. Total Project Cost: $ ❑Pard muI �, ,IO Outandmg$alauce I?ue r Ai " SECTION 5: CONSTR_UCTION SERVICES'.` 5.1 Constructio p1ervvisorrLic e(CSL) �— ,y / License Number Expirati n te� Name of CSL Holder , , tt 1�2 )61 f y� List CSL Type(see below) W T No. andStreet Unrestricted(Buildin s u to 35,000 cu. ft.) eut�7 '�^ HA _ I ��� Restricted 1&2 Family DwellinCity/Town,State,ZIP MasonrRoofin Coverin Window andSidinSolid Fuel Burning Appliances � Ix ,33 I Insulation Tele hone—� Email address D Demolition 5.2 Registered Homelv3provem nt Cont actor(HI HIC Registration Number Exp' a a e is I a t N e FV ,q-; lown Site e r !' Email address , State,ZIP Telephone MSECTION 6 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M G L c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuay6 of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ ` SECTION 7a: OWNER AUTPIORIZATION TOM COMPLETED WHEN ''t �s �OWNER'SAGENT OR CONTRACTOR'APPLIES FORBUR;DING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this buildini5ermlf application. Print Owner's Name(Electronic Signature) Eat SECTION'7b: OWNER' ORAUTHORIZED AGENT DECLARATION-,—,',,' By entering my name below,I hereby attest unpyhe pains and penalties of perjury that all of the information contain is applic 'on is true and accur t bes of y knowledge and understanding. r Print Owners or Authorize gent's Name(Elec r ntc gn ture Da r< _ ; .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.rnass.vov:/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns 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"maybe substituted for"Total Project Cost" '+''"'. � 7'.]1-'. �D�1;✓23ii`7 ire{l�ii1 G,�.3Yj1S.5i31'�'ia:���.�� T_2p arimem of lnd�stria3i cc denim 1l a fljfacz o Znvesiigations 00 'ashtngton st, ~z ' Gj Boslore,M4 02111 �`a �'' 3neryv,r�I:3ss,gosj/»lz� Workers' t ompellsatiari h3u nllce Affidavit: B3i3I&rs,1CDv1i sw�iG i iti Ciii lu�uiR al�v ci Applicant Information Please Print Lggibh Name(Business/Orgmuzationlindividual): y ty,— y IEM1 _1 J i) Address:-- � � ll '9 Y%tYYtyi � - _ Ciry/S /Zip: iLIL3) "Phone 4:_ Ore y an employer?Check the appropriate box: _ r Type of project(required): 1 I am a�. era to e'r-•with 4. ❑ I am a general contr actoi and 1 p Y 6. ❑New construction ` employees(full and/or part-time).* have hired the sub contractors 2.�] I am a sole proprietor.or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-con have g. ❑Demolition 1 v oriCin for in an ca aci employees arid have workers' g Y P city 9. ❑Building addition [No workers' comp. insurance comp.insurance.T required.] 5. ❑ We are a corporation and its I0.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t C. 15.2, §1(4),and we have no employees. [No workers' 13.5�''Other S comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing then workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a pew affidavit indicating such tContractors 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 subcontractors have employees,they roust 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: Policy#or Self-ins.Lic. Expiration Date: Job Site Address: ( d�Myhn 1 �f 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 cerVuder, e pains nd naldes ofperjury that the Information provided above . true d correct. S' afore: �L - -- Date: Phone#• Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# _ Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: "� �� O five of Consumes Affair and�us�_es5 Regulataoii l� � I 10 Park Plaza Suite 5.1-70 ,;, ,, ostnra, ssach�setts.O-- Honie Iilprove t'�IonixactorRegistiation R ag ls4ra{Ion. . 120 893 ...: h✓ _ Type: Supplement Card Explra{Von: 9/3/201d r De of At-Home Se ., I RIGHMO ALL a_ The Home � ONE m t ' 2690 CUMBER LAND PARKWAY ATLANTA, GA 30339 . . ti `- .yav Update'ddress acid return card.Murkrenson.inr chnngc. .. f Ad.dress [,I Renewal- .rj Employment Last Cnrd �IFiA 'tOdHW)[O�t[UIIOGV� 6�✓1�u>Ld6Gtud6 - ' .. . c onsumer Affnirs&Business RegulnNon License or registration valid for Indn tdu! use only f Co l „ - before the expiration dnie. Yffound return..to:' h���Q• 'F (THaNIE IMPROVEMENT CONTFiACTOF'i - {} { f)f4fce of Consumer Affairs and Business Rcgdlniron Regi%tratlon, 120e63 TYp°t Id7 Park Plaza-Suite517U 7 Expl mi(on '�U4C}��l�r - Supplem M ant Card Boston, A02116 ' _ - "rh,�. I-orim Depal ,AI HMMII , aw-tas f-If HARD FALLfSNE, - 21190 c:UMBc PILA�11��Al2kGvt��S -^°6"�6 �-.'— lid w'tof vn ut sl.'nature LFli-.I�ii•-GA 303a9" .-... IIndcrsccretnry - f1 LIABILITYy�R AT- r D YY CERTIFICATE OF LIABIL9 INSU ANCE D2, ,,i2012 _ _ I THIS CERTIFICATE 15 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 BETIWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. If SUBROGATION 15 WAIVED, subject tD 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 1-866-966-4664 CONTACT Marsh USA Inc. PHONE FAX No.E I INC,No: homedepot.certrequest@marsh.com ADDRESS: Two Alliance Center, 3560 Lenox Road, Suite 2400 - INSURERS AFFORDING COVERAGE NAICk Atlanta, GA 30326 _ Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURER B: Zurich American Ins Co 16535 The Home Depot, Inc. New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. INSURER C: P _ 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ina Co 23817 Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER F: Illinois Union Ins Co 127960 COVERAGES CERTIFICATE NUMBER: 25776028 REVISION NUMBER: 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. _ MSR ADOLTYPE OF INSURANCE INSR MID SUER POLICY NUMBER MM/DDM'YY MM/DOPOLICY EFF Y/fYYYPY LIMITS LTR A GENERAL LIABILITY - GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE S.9,000,000 -DAWAGE TORENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ed occurrence S1,000,000 CLAIMS-MADE Fi�OCCUR MED EXP(Any one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL B ADV INJURY $ 9,000,000 X OF SIR: $1M PER OCC - GENERAL AGGREGATE 9 9,000,000 GENT AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG S9,000,000 X POLICY PRO- L005 - B AUTOMOBILE LIABILITY HAP 2938863-09 / 03/01/13 COMBINED SINGLE LIMIT 1,000,000 Ea it S X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED - PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) IX SELF INSUR D I PHY DMG S - UMBRELLA LIAR OCCUR - EACH OCCURRENCE $ EXCESS LIAS CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ I $ L• WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 X WC WORKERS DER TH- AND EMPLOYERS'LU1BILfTY D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA WC019736917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N❑ E (Mandatory in NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 Dyde `e meer SCRIPNOOFOP- ERATIONSbelow E.L.DISEASE-POLICY LIMIT a 1,000,000 E Workers Compensation WC1192494 (QSI) 03/01/1 03/01/13 SIR .(AOS)/SIR (GA) 1M/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 P TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/lM DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more apace 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 ATLANTA, GA 30339 USA l ©198 1=2010 AC, D CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORDJ Jthornton hd � tii, NLuSACHUSMS CITY OF S BI:=N G DEP ARTNMNT `$ 130 WASHNGTON STREET, 3t0 FLOOR TEL (978) 745-9595 F,cx(978) 740-9846 KINfBFRt FY DRISCOLL MAYOR THOMAS ST.Prma DIRECTOR OF PUBLIC PROPERTY/BCILDD4G COSL\IISSIONER 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 Fact i (address of facility) ign lure of ermit applicantzz- , dat a q Massachusetts -Department of Public Safety '�--r Board of Building Regulations and Standards License CSSL-099699f ROBERT POCZOBUT 172 WHALENS LANE." Salem MA 0 970 0 Commissioner /08/2i 02l08l21 044 i 08/31/2012 07:14 17818940331 TODD RIDEWN PAGE 01 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: Boston Date: �Klw l 1/ THD At-Home Services,Inc. d/b/a The Home Depot AL-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(800)657-5182;Fax(508)845-6017 Branch Number:31 Federal ID#75-2698460;ME Lie#C 02439;RI Coat.Lie#16427 ,/ ec rT Lie# IC.0565522;MA Home Improvement C.ba t r Reg.#126893 Installation Address. g6 _ O/q7D City State Zip Parehasi r(s): Work Phone: Home Phone: _ Cell Phone: Home Address: (It different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): _ El IX)NOT wish to receive any marketing mails from The Home Depot - Protect lnfermation: Undersigned("Customer") the awners of the property located at the above installation address,agrees to buy, and THD At-Homc Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange few the installation("Installation")of all materials described on the below and on the referenced Spec Sheens),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: products; Spec Sheet(fl#: Pro'eet Amount ❑Roofing ❑SidingX Windows 0 Insulation L� ❑Guam/Covers ❑EatryDoors ❑ 31ytr6b� ` r l , , q� []Roofing PUSiding Windows Insulation ❑Gutters!Corers ❑Entry Dopes ❑ u � ❑Roofing Siding Lj Windows Lj Insulation❑ $ Cmaers/Covers ❑Entry Doots[I Roofing USJ4ing Windows ❑Insulation ❑Gutters/Covers ❑Ermy Doors Minimum LS%Depmtto(Ca had Amoomdae upon execution of"conhaG. Total Contract Amount $ �7J`/ �O Afame PurWasers may rwtdrymrtt rape than orNAhbd ofthe Conh wm adAm . 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 I tome Depot reserves the right to issue a Change Order or terminate this Contract or any individual Products)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 safely cmcems,pricing errors or because work required to complete thejob was not included in the Contract.. •'� Payment Summary: The Paymenl Summary #�y 7ra! / , 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). NOTICE TO CUSTOMER You are entitled to a comppletely filled-in copy of the Contract at the time you 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 sot 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 RECOVERY OF SUCH AMOUNTS. Aoce lance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer an The Homc Ilapot with regard m the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended ucept by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer In read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Accepted by: - Submitted It x -1J 17 Ctrs is Si tutu to Sales? Signature Date X _ Telephone No. Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL. THIS t°s'pp°caM11cl AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN 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. NOTICEe ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 1115-1042 Vuats-Branch File Yellow-Customer $,THD AT HOME SERVICES INC PERMITACCOUNT 2590 CUMBERLAND PKWY SE STE 300 3911 c ATLANTA, GA 30339-3913 11-24/121011 20000152555' f. Date 'Day to the Order of ® VOID AFTER 90 DAYS weio rays ennw,nn. wrllfimgomm NOT VALID OVER$500 FOR-IT 20000 15 2 58 5 i 5 i'OOOOO 3 9 i i 9u' 1: i 2 iOOO 2 48l: Silo N fi'><"��.`-�'¢ ti-r.,.'�;ys"+kx.,.✓�r `. a1,,..r,�''y �tE' d^'�',;�'�Sf�P,". *ham'-.R-��I`c+�� av, j