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13 UPHAM ST - BUILDING INSPECTION 6 l 3� t GK to S(0'1 w 1 The Commonwealth of Massachusetts REC IVED Board or Building Regulations and Standards INSPECTIDP AL S-ERMES Massachusetts State Building Code, 780 CMR SALEM Building Permit Application To Construct, Repair, Renovate Or UARsAG N dFF 44 � One-or Two-Family Dwelling This Section For OffAcial Use Only Building Permit Number: Date Applied: J Building Official(Print Name) Signature re ate Date SECTION 1:SITE INFORMATION 1.1 Property Ad • * : 1.2 Assessors Map& Parcel Numbers I.1 a Is this an accepted stree?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arcs(sq tt) Frontage(If) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Requin:d Provided Required Provided Required Provided 1.6 Water Supply:(iM. L c.40,§54) 1.7 Flood "Lone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check iryes❑ Municipal ❑ On site disposal system ❑ SECTION2: PROPERTYOWNERSIIIPt 2.1 O vn r�of Rec rrhr�rhq,-I��J(J� Noma(Print) �� /.�._l - 0 1 .ia[a,LIP CTT� No.m� — 'I ll f.mail Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building Cl Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: _ Brief Description of Proposed Work':_ C � I SECTI : ESTIMAY6 CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials) Official Use Only I. Building I. Building Permit Fee: $ Indicate how fee is detertnineJ: ENlechanical $ ❑Standard City/Town Application Fee ❑'rotal Project Cost'(Item 6)x multiplier x S 2. Other Fees: S (IIV;\C) $ List: (Fire S Total All Fees: $ Check No. _Check Amount: Cash Amount: (i. Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due: 'vl �-Vf0a BSI SECTION 5: CONSTRUCTION SERVICES .5.1 Construction Supervisor License(CSL) t e license Number Lxpir. ion Dale (Name of CS pHglder List CSL Type(see below) No.and Strcet / TYPe Description U Unrestricted an s u t eu. R.) R Restricted INc2 Family Dwelling City/Town,State,ZIP' M Ntason RoofingCovering Window and Siding Solid Fuel Burning Appliances Insulation Telephone Email address Demolition 5.2 Registered Florae m rove ent Co tractor H C g �) Flegistrrtion umberWpi, Date HIC ,teeny me -II � it Name No.an let Email address City/Town,State,ZI Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be Sgrnpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issua 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 e to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) )ate SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, I h eby attest under the pains and penalties of perjury that all of the information co ed in this application is rue and cur le to the best of my knowledge and understanding. t Print wner's or. Authorized 4,�,etC' Name(EI ctrooi Signature) Du 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 riot have access to the arbitration program or guaranty find under M.G.L. c. 142A.Other important information on the HIC Program can be found at www.ntass.eov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps 2. When substantial work is planted, provide the information below: Total Floor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. It.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Numberofhalf/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" e S x T o y b �x ;#44. A L� � �-SJ y i R �1 � x - �#AIR owl,2. tV k. oaf pub 'M 1, LY ArA'Y�i.'"XT'yi =ppe T" $' 4iv 'hY'h"� ,' ^W"� � L� x qm5 Y.aY :; � .'S'34$+�'�j - drt i R•dEt 1JU 14:'.94$P L€ . `M. "k PROW,x a"zr e ya'� Q ONs{ i a (4b y vp,Y- �' to q��,yt Syk •V1 x '*r 2 '� i XF ,q'.r r _ �' .� —21 . #� � �. ev ems p 3' "TAT. v 5 ���r9� e e�+,�✓ ' ��S`�€ �� � �S't'b.Z ryNs fi,�� 4 � t} '`J F x'� '� '+3'�.}('7,#Y" � �4€� ���f �s,,s++tt,Y- 5�",��'' rr'w' j" , }''#'ar s,e s �;3 �• � i, �tK����� § v @ v 7 ,m -k y dS 1 The Commonwealth of Massachusetts y= Department of Industrial Accidents Office of Investigations * 1 Congress Street, Suite 100 Boston, MA 0211 4-2 01 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: /! Phone.#: r _ Are yon an employer? Check the appropriate box: Type of project(required): 1. I am a employer with go— 4. ❑ I am a general contractor and I 6 ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. .7. ❑ Remodeling 2.❑ I ship a sole proprietor oor partner- These sub contractors have ship and have no employees 8. ❑ Demolition :m :loye and have worke:�a' E31� lamaahomeo iiilIig - 6r ids ,., a; y-capacity. 9. ❑ tsuiidmg addlncu comp. insurance I orkers' comp. insurance 10.❑ Electrical repairs or additions ed.] 5. ❑ We.aze a corporation and itswner doing all work officers have exercised their 11.❑ Plumbing repairs or additions f. [No workers' comp: rightof exemption per MGL 12.❑ Ro repairs nce required.] f c. 152, §1(4), and we have no 13. Other employees. [No workers' comp.insurance requited.] *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 hike outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the dame 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. n insurance for my employees. Below is thepolicy and job site lam an employer that isproviding workers'compensatio information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: �� City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy num er 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 cerd under ai a d alties o er'ury that the information provided above 's true and correct Si afore: ---- - -- Date: — Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: EVERETT . Permit/License# Issuing Authority(circle one): ity/lown Clerk 4.Electrical Inspector 5. Plumbing Inspector 1.Board of Health 2.Building Department 3. C 6.Other 617-394- i �� ® DATE(MM/OOIY'(YY) ACORD CERTIFICATE OF LIABILITY INSURANCE 0219120/4 THIS TIFICATE 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. ,!MPORTANT: 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: MARSH.USA,INC. PHONE FAX AIC No TWO ALLIANCE CENTER EMAIL 3560 LENOX ROAD,SUITE 2400 ADDRESS: ATLANTA,GA 30326 INSURE1AFFORDING COVERAGE NAIC a 100492-HomeGGAW-14.15 INSURER A: Steadfast Insur 26387 INSURED - Zurich America 16535 INSURER B:THDAT-HOME SERVICES,INC. New Hampshir 23841ORA THE HOME DEPOT AT-HOME SERVICES INSURER C2455 PACES FERRY ROAD INSURER D,Illinois Nationalany 23817 ATLANTA,GA- - INSURER E: INSURER P t - -COVERAGES - CERTIFICATE NUMBER: ATL-003242685-01 REVISION NUMBER:3 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. INSR DDLAlB POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIODfIYYY MMIDOfIYYY 9,000,cOO A. GENERAL LIABILITY GL04887714-04 0310112014 0310112015 EACH OCCURRENCE 3 DAMAG o o EDnc $ 1,000,000 X COMMERCIAL GENERAL LIABILITY EXCLUDED CLAIMS-MADE a0C0Uft LIMITS OF POLICY XS MEDEXP Any one person $ OF SIR:$1 M PER OCC PERSONAL a ADV INJURY $ 9,000,000 GENERAL AGGREGATE $ 9,000,000 PRODUCTS-COMP/OP AG G $ 9,000,000 GENL AGGREGATE LIMIT APPLIES PER: $ X POLICY PRO- M LOG BAP 293886341 0310112014 0310112015 COMBINED SINGLE LIMIT1,OOD,000 B AUTOMOBILE LIABILITY Ea accident 1111 BODILYINJURY(Per person) $ X ANY AUTO ALL AUTOS VIED AUTOS SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ PROPERTY DAMAGE $ NON-OWNED a accl en HIRED AUTOS AUTOS § EACH OCCURRENCE § UMBRELLA LIAR OCCUR AGGREGATE $ E%LE99 LIAB CLAIMS-MADE - 'DED RETENITON$ WC049101882(ADS) 0310112014 0310112015 WC STATU- OTH- D WORKERS COMPENSATION 1,000,000 AND EMPLOYERS'LIABILITY WC0491111884(AK,AZ,VA) 0310112014 0310112015 E.L.EACH ACCIDENT $ C ANY PROpRIETOPJPARTNEWEXECUTIVE YIN NIA i'uuU'UUO 'OFFICERMIEMBER EXCLUDED? Wg049101883(FL) 0310112014 03101I2015 EL DISEASE-EA EMPLOYE S (Mandatory In Nin 1,000,000 If Yea,describe under E.l-DISEASE-POLICY UMIT S DESCRIPTION OF OPERATIONS belov 1,000,000 C WORKERS COMPENSATION WC049101885(KY,NO,NH,VT) 0310112014 03101f1015 (EL)LIMIT C WC049101886(NJ) 0310112014 03101/2015 DESCRIPTION OF OPERATIONS ILOCATIONS I VEHICLES(ANech ACORD 101,Addit onal Remarks Schedule,If more apace Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION _ THDAT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION WITH THE POLICY PROVISIONS. INOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ATLANTA.GA 30339 ` AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhedee ©1988-ZOJU ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD �C> a �,i Office of Consumer Affairs d Business ReWation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. Expiration: 8512016 RICHARD-FALLONE - - -- 2690 CUMBERLAND PARKWAY SUITE 306 - --- ATLANTA, GA`30339 Update Address and return eard.Mark reams for change. SCAT -5 2p6W1 _. Addrea _! Renewal ;J Employment `j Lost Card - niiteofConsocer Affairs&Business Regulation BeB License or registration valid for individul use only O ONE IMPROVEMENT CONTRACTOR before the e:pvation date. Iffoundreturn to: Offiee of Consumer Affairs and Business Regulation Reffistration: 126M - Type: . .� ice:. lOParkPlan-SuiteSlfi Ex P 9l32016 SupplementCard Boston, 16 THD AT HOME SERVICES,INC. h� - 7 HE HOME DEPOT AT HOME SERVICES RICHARD FALLONE 2690 CUMBERUWD PARKWAY S - AAYA,GA 30339 Underwcrebry of vat CITY OF SALEM, MASSACHNSEM BUILDING DEPARTMENT 120 WASHINGTON STREET,31D FLOOR TEL. (978)745-9595 KIMBERLEY DRISCOLL FAX(978) 740-9846 MAYOR TY-IOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER 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 c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: I�rn CDY]n riz� (name of hauler) The debris will be disposed of in: 0yk- - (name of facility) u�AL (address of facility) Sign ture of applicant D � ae —.�._..,..-_ �LlfYkt)MTaIF_wratirKrytwc7° �' iMpAswi kFAn Yt11S ��q'� j�' Sold.F.misheS mW lnxtalled by: THU At-Hulse Services.Inc. JMa The Ilene pag(4 Af-Hutnc.5,emces Aboa tlWAW JIk iw*M 908 RiatWt Torupilop Unit I,Shrewsbury.NIA 01.545 ` - Toll Rrcc$77-9n3-i 76R cay fruca 11)A 75?fA?,F:ptl AIF t.ic ll CO2479 Ill Conf.Lich I6437 ' a�•'t 01 a`ohnt5pl;Atq)lance fognnvrmenrCwfuacow Reg if 126K93 I . 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