4 TYBEE LN - BUILDING INSPECTION Gotat�o ZS c , ILA -7(Dt
The Commonwealth of Massachusetts RE
CLI 0 Board of Building Regulations and Statidaf CT10kAL SERV CES CITY OF
Massachusetts State Building Code, 780 CMR SALBM
�p�� , P 2: QvisedMar201I
h 1 Building Permit Application To Construct,Repair, RenoVOl�'JAemolish a
One-or Two-Family Dwelling
This Section ForOfficial Use Only
Building Permit Number: - 'D Applied:, -
1 Building Official(Print Name) - „ Signature Date
(� SECTION 1:SITE INFORMATION
e� 1.1 Property Add r 1.2 Assessors Map&Parcel Numbers
L]a Is this an accepted street. yes_ no Map Number Parcel Number
1.3 Zoning Information: 1A 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 OWNERSffiPt
2.1 Owneyyr���ecyyrd:
`�'�V1 1 �� t11/111=
Name(Print- City,State,ZIP
4-1$— 561Q— 105-
No.and Street Q Telephone Email Address
SECTION 3i ESCRIPTION OF PROPOSED WORIe(check 30 that pply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 91 Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz:
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 deteimmW.-
2.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 ❑Outstanding Balance Due:
Malt M, Bim14V'v 21 Io
212��
rn�1>r� 311 s
SECTION 5: CONSTRUCTIONSERVICES
5.1 Construction Superv7-50ense(CSL)
�T
Lic nse Number Expu h Date
Name of CSL Holde
List CSL Type(see below)
No.and Street Type ,Description
U Unrestricted(Buildings up to 35,000 cu.ft.
� R Restricted 1&2 FamilyDwelling
City/Town,stat M Masonry
RC Roofing Covering
WS Window and Siding
r 1 f J„ Solid Fuel Burning Appliances
�[IJ j� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement C ntractor(HIC)
HIC Registration Number Ex t n Dat
o stra N e
1 ame
No. Stry;t Email address
Ci /Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§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 Issu 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
to act on my behalf,in all matters relative to work authorized by this ding a application.
Print Owner's Name(Electronic Date
SECTION 7bi.OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding
J
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who h ires an unregistered contractor
(not registered in the Home Improvement Contractor(RTC)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.lrov/oca Information on the Construction Supervisor License can be found at wunv.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
CITY OF Siu.&%12 NLkSSACHUSETTS
BumDLNG DEPARTNIEIIT
N 130 W.1sHLNGTON STREET, 310 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KL,,jBERLF-Y DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUUMn-JG CONMOSSIONER
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 acil'lty)
�1.1�V�1f t�1
(address of facility)
signature&of permit applicant
ILA
date
dcbrisatrdm
i
i.
e ✓ :L-� U s�tL?i'z�'[.G�-��GCt=� ✓� U��vr . .tvvhLLJ2L�'.
Office of Consumer Affairs/and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
THD AT HOME SERVICES, INC.
RICHARD FALLONE -7 -
2690 CUMBERLAND PARKWAY SUIT 3VC
ATLANTA, GA 30339
Update Address and returc card.\Sark rea-wn ix
Address Ranewai = Emplocmeet _ Losz C_ru
JJ
01A.0all
Y ® DATE(MMIODIYYYY)
® CERTIFICATE OF LIABILITY INSURANCE 0212472015
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 cerificate 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 10 the
certificate holder in lieu of such andorsement(s).
PRODUCER CNAOWACT
MARSH USA,INC. PHONE Fan
TWO ALLIANCE CENTER N. Ar No:
35M LENOX ROAD,SURE 2400 E-MAIL
ATLANTA,GA 30326. ADDREM:
INSURER(S)AFFORDING COVERAGE NAICII
100492-HorneD-GAW-i5-i6 INSURER A:Steadasl lrSUrN`ce CDBpany 263B7
INSURED INSURER B:2MId1 Arrefimn IIGulairm Co 16535
THD AT-HOME SERVICES,INC.
DBA THE HOME DEPOT AT-HOME SERVICES INSURER c:�'Fianpsfnre Ins Co 23641
2690 CUMBERLAND PARKWAY,SUITE 3M INSURER D:1111nds National lnsuranm Company 23817
ATLANTA,GA 3M39 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-=426B5D9 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.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILRSR DL SUM - - POLICY EFF POUCYIDP
TYPE OF INSURANCE MR.WAPOLICY NUMBER D MMDD LIMITS
A GENMALLIABILIT' GLO48B7714J)5 031112015 031012016 EACH OCCURRENCE S 9.000.000
% COMMERCIAL GENERAL LIABIT/Y PREM o SEB rswrence S 1,DD3,000
CLAIMS-MADE OCCUR LIMITS OF POLICY XS N ED EXP(Any One person) S EXCLUDE
OF SIR$IM PER OCC PERSONAL A AM INJURY $ 9,DW,000
GENERALAGGREGATE $ 9,'"'000
GENI AGGREGATE LIM IT APPLIES PER PRODUCTS-COMP10PAGG $ 9,00D.000
% POLICY JET LOG S
B AUTOMOBILELt1BILRY BAP 293866112 03/012015 ONIR016 COMBINED SINGLE LIMIT 1,000,000
Ea accltle $
% ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $
AUTOS MOON-OWNED PROPERTY DAMAGE S
HIREDAUTOS AUTOS Peracr:kle
8
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCEMLUUI CIAIM&MADE AGGREGATE S
DED I I RETENDONS I S
C MMERSCOMPENSATION W0017731493(ADS) 031012015 ONI2016 % we s7ATu- OTH-
ANDEMPIDYERSLWBBJTY O LIM
O ANY PROPRIETORmARTNER/FJtECUrrvER/M ED? NIA
YIN WC017731495(AK KY,NH,NJ,VT) 03MI2015 03/012016 EL EAGHACCIDENi L000,000
OFFICEEMBER EXCLUD 8
D (Mandatory In NH) WC017731494(FL) 03101015 ONIM16 ELDISEASE-EA EMPLO S 1,00000
OE�SGIRIPTION OFF OPERATIONS bal. CDdlnued an AddlOonal Page EL DIBEASE-POLICY LIMIT S 1,000,OW
DEWRIPTON OFOPMATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more space Is"unad)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DRA THEHOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA.GA 3=9
AUTHORIZED REPRESENTATIVE
0f Marsh USA Inc.
Maneshi Mukherjee �+4cLaaanu
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
The C®rrmma meaM of Massachusetts
Sk
-- Deparmant ofInd►sstaBttd Aceddena
QBkeof1xv ns
600 Was8ftlon S&wt
Bost®ea,MA 02111
u ww was&govldla
Workers, Compemsation)ii uffamee Affidavit: BufleflerWCa®ref6rS/Eflectricians/Plumbers
A lac"t I<nfformadmM Please Paint LeEibly
Name(Business/Organirstion/lnddividual):
Address: t 09 6 o$-4-70 :Ito �
City/State/Zip: 4igO.4vL4j , ®/Sags Phone#: SoS'
Are you an employer?Check the appropriate boa: Type of project(required):
I.0 I am a employer with- 4. ® I am a general contractor and 1 6. New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner-
listed on the attached sheeL 3 7. Remodeling
ship and have no employees These sub-contractors have 8. E]Demolition
working for me in any capacity. workers' comp.insurance. g. E]Building addition
[No workers'comp insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
of exemption MGL 11.[]Plumbing repairs to additions
3.❑ right i am a homeowner doing all work � �P )�
myself.[No workers' comp_ c. 152,§I(4),and we have no 12.1-]/RRZ'f repairs�,
insurance required.]t employees.[No workers' 13, Other
comp.insurance required.]
*Any applicant that checks box d t mast also tilt out the section below showing dreir waiters'compensation policy mfmmation.
t Homeowners who submit this affidavit indicating dhey an doing all work and it=hire abide vontracmrs must submit a new affidavit hWcating sorb.
teonMwtm tint check this box must attacked as additional sleet showing the name ofthe sub-caotrachers and their workers'aomP.Policy mfatmetiaa.
'eorapensgdota insuraneefop nay gmployeer, Below Is the policy and joke site
I wipe are ertaplayer that ffi provLddrag worriers
fnforraatiorr. l
Insurance Company Name: `e'r J ys��i#f r`J' ✓
�l/rr�Cy' 2 5 v0
Policy#or Self-ins-Lic.#: �/1/ iG 1ry ,/ J /7 ! Expiration Date: 3
Job Site Address: "r Ina I a" -City/State/Zip:
�—
Attach acopy of the workers'compeosahlo popsy declaration page(showing the policy member and expiration date)..
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to Ahe 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 eerldyy er and penaties of perinry dka t bw tnforr don provided abom Owe and correct
Si e: Q Date: f
Phonecb
76.0ther
use orally. ®o rood write Pdais area to be conepleted 8! city or mwa offrciaL
Town: Permit/I.ieense#
Authority(eircle one):
d of(Health 2.Building(Department 3.Cityribwn Cleft 4.Electrical Inspector S.Plumbing Inspector
Contact Person Phone#:
110 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialh'
License: CSSL-099699
,-i i i, o'
ROBERTPOCZOJjIIT �'�
172 WHALERS DIVE $
Salem MA 019707 z7I/ l
cJ- y� '`Y n �;+•; • expiration
Commissioner 02/08/2016 -
HOME IMPROVFMFNT CONTRACT
YLEASY,NY,AU THIS i
Sold.Furnished and Installed by:
Brunch Name:Nev England Dale:I_/ (pi_F_ THD At-Home Services.Inc.
d/wa The Home Depot At-Home Services
• .'•t+- Branch Number.31 908 Boston Turnpike.Unit I.Shrewshury.MA 01545
Tull Free 877-90-37hil
Federal ID C 754699";ME t-ic e C 02439:RI Cimr.Uce IIA27
Q:(= CT Ile a HIC.fr/5�M15/5�12�MA Bow Improvement Crmuaacw,keg.It 126693
Imaidlattoe Address: - \Yul6/ X. �CL` " 0 /F / I
—r City State Zip
1
- purehaserfs): Work phone. Home Phone. Cell Flown, ,
q
04
't' Home Address:
•�' it State Zip
i. (if Address C �
( ) Y
9.S. v m nicztions and Home u Email Addreas(to receive project corn u Depot palatal)-
w;'.- ❑1 DO NOT wish in receive any marketing entails from The Home Depot
Proiect Information: Undersigned('Customer').the owners of the property[mated at the above installation address.agrees to buy.
and THD At-Home Services.Inc.("The Home Depot-)agrees to fomish,deliver and arrange for 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
►yr reference,along with any applicable State Supplement and Payment Summary attached herein and any Change Orders(collectivel).
n
'Contract y + V 1
'r` Job B: .der ad=s.ar Products: Suit,Sheens)a: Protect Amount
Roofing oSidirig 0 Windows LI hoularion (/^ 4 t
❑Gumxs/Covers ❑Fmry Dann ❑ `o�e3 f/y� (o
J Roofing Siding Windows Insulation s
❑Gumrs/Covers ❑Envy Doan ❑
r
Roof rn8 OSiding 0 Wll iows Insulation
S
❑Wnus/Cover, ❑Fnnry Doors❑
F
❑Roofing OSidirig ❑Windows ❑Insulation
aces/Corers En Doors❑fist ❑ try ❑ J
Mkar®254e Depmit ofComan Aware doe olimewcalue urthemmran- Total Contract Amount $
Mane PrvrJ>ates mry ml depaat mow thanune du d tithe Coneaa Arnett
Customer agrees that,immediately upon completion of the wort for each Product.Customer will execute a Completion Certificate
feat for each Product as defined by am individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly all severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or my individual Products)included herein.at
its discretion.if The Home Depot or its authorized service provider determines that it canna perform its.obligations due to a structural
problem with the home,environmental hazards such as mold asbesws or lead paint.Other safety coos-ems,pricing conks or because
work required in complete the job Was not included in the Conant. f�
Payment Summary: The Payment Summary a ' T 3 , inchded as pan of this Contract, sets forth the total
ail Contract amount and payments required for the deposits and find payments by Product lac applicable).
NOTICE TO CUSTOMER
You,are entitled to a completely rifled-in copy of the Contract at the lt.you sign- Do rat sign a Completion Certificate ImrM: I -
there is am Competiom Certificate for each listed Product as defined by individual Spec Sheers)before stark on that Product
is complete.
In the event of teredrution of this Contract,Customer agrees to pay The Home Depot the costs or materials,labor,expenses
and services provided by The Home Depot or Amborized Service Provider through the date or termination.plus any other
amounts set forth in this Agreement or allowed under applicable law, THE HONIE DEPOT MAY W ITHHCII.D ANItHIN TS
OWED TO THE HONE DEPOT FROM THE DEPOSIT PAYNIENT OR OTHER P.AYAIENIS MADE. WITHOU V
LLAIITLNG THE HOME DEPOTS OTHER REAIEDIES FOR RECOVERY OF SUCH ANIOUN 1\
Acceptance aid Authorization: Customer agrees and understands that this Agreement is the entire agmment between Custunwr
and The Hume Depot with regard to the Products aid Installation services and superscsies all gripe discussicros and agrernwnls.either
oral or written-relating to said Products and Installation.This Agreement cane be avigmd sv arrwmteJ esc<pt by a writing sigmsl
by Customer and The Horne Depot-Customer acknowledges and agrees dul Customer has read,understand`vol rtly as�vpts tlw
terms of and has received a copy of this Agreement.
A Su ed by
Sah C:r- Itant SCignani Date
yf Telephone No.
Customer's Sigtunme Dote i.Sales Consultant LivYnw Co,
CANCELLATION: CUSTONER \1.AY CANCEL THIS 1iP 0rt�iM°
AGREENIE'sT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY %RDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREE-ME\T. THE
STATE SUPPLE\IE\T ATTACHED HF-RETO
CONTAINS A FOR\I TO USE IF ONE Is
SPECIFICALLY PRESCRIBED BY LAN' IN
CUSTONER'S STATE i
NOTICE:ADDI RO\AI-TFJON AND CONDITIO SAREJTATED eAN TW Rl:\'EM MFW AND ARC P\Rt IIF tNkN aIMNAI-T
ssf"e—Branch Fie Yellow-Customer