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25 VALIANT WAY - BUILDING INSPECTION (2) The Commonwealth ofl41P LSERVICE4 F"a 14 Board of Building Regulations an Stan ards CITY OF y Massachusetts State Buildingd 0 SALEM � d 8: 5 5 Revised Mar 2011 l� Building Permit Application To Construct, Repair,Renovate Or Demolish a l� One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Appli ,. n1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Addre v: 1.2 Assessors Map&Parcel Numbers 1.1 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 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? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2_I O vn r'of Wco : {, ';5 Name( n t — City,State,ZIP No.and ireet Tecllephoric Email Address SECTION 3:DESCRIPTION OF PROPOSED WORle(check 2 that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of U_nits Other ❑ pecify: Brief Description of Proposed Wor If: SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 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:$ n--� Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ Ot'.fJ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licens onstructi n Supervisor(CSL)' �� Lic nse Num Exp' do Date Name of S - der List CSL Type(see below) _ Ad ss Type Description U Unrestricted(up to 35,000 Cu.Ft. R. Restricted 1&2 FamilyDwelling re M Masonry Only �} RC Residential Roofing Covering Telephone WS Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Hom mprov t Cont gctor(HIC) — o N r a e ' mHIC C N A e Expira a e i e Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be c mpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuanc f 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 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 application. Signature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION= " I, ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Fr o Auth rii gent Da Si ed under t e ains and enalties of 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Gross U/F BSMT(Sq.Ft.) Garage(Sq.Ft.) Gross FN BSMT(Sq.Ft) 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 CITY OF S.U.&M, 1LNSSACHUSETTS W-V BUILDING DEPARTMENT 120 WASHIINGTON STREET, 3' FLOOR -0 TEL (978) 745-9595 FAx(978) 740-9846 KStBERi T=Y DRISCOLL MAYOR THOAfAs ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%LNaSSIONER 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 : G _ (name of acrl ty) (address of facility) signature of permit applicant date JcbrivlLilw --- The Coinnionwealth of Alassachm.setts Department of Industrial Accidents I Congress Street, Suite 100 0, Boston,ISM 02114-2017 — v :vww.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERrivHTTiNG AUTHORITY. toolicant Information Please Print Legibly Name (Business/Organization/Individual): N_.�pyl y t� - I1 Pv Address: r��-'I(`i ( t (-�71��'�,;zj-�-��°�9�� City/State/Zip: G Phone#: 7V[]Nem0cd'onstiuction Areyou naemployer?Checkktth1e appropriate box. quired): Lam' i nmaemployerwith ,?ZO employees(Full md/orpart-time).* ❑I am a sole proprietor o-partncrhip and have no employees working forme in any capacity.[No workers'comp.insurance required.]i.®f am a homeowner doing all work myself.ltio workers comp.insurance required.}t 10 Q Building addition 1.7 1 am a homeowner and will be hiring contractor to conduct all work on my property. I will ensure that all contractor either have workers'compensation insurance or are sole I I.[]Electrical repairs or additions orooricrors with no employees. 12-❑Plumbing repairs or additions :.� I an a.eneral contractor and I have hired the sub-contractors listed on the attached sheet. 17 f reps These sub-contractors have employees and have workers'comp.insurances 1 e I - Other 6.0 ;. ar^_a co omrinn and its officers have exercised their right of exemption per 1IGL c. 444 152,§1(4),and we have no emplovecs.[No workers'comp.insurance required.] °Any applicant that checks box M must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached in additional sheet showing the name of the sub-contractors and statewhetier or not those entities have employees. If the sub-contractors have employees,they must provide their worker'comp-policy number- I art an employer that is providing workers'compensation insurance for illy eutployees. Below is the policy and job site information. r� Insurance Company Name: 7 -� Policy#or Self-ins.Lic-#: 1 l Expiration Date: Ci !S tate&i : Job Site Address: h P o the policy nu er and expiration date). workers' con ensation policy declara on page shown y P Attach a co of the wort. p p y p e (showing P PY Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 a y p day against the violator-A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify r id r tl pal s and enalties ofpetjoy that the information provided above 's true and correct Signature: Date: Phone#: n [6. cial use only. Do not write in this area,to be completed by city or town offciat or Town: Permit/License# ing Authority(circle one): oard of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector S.Plumbing Inspector thertact Person: Phone#: ��®® CERTIFICATE OF LIABILITY INSURANCE D0211012016DMn 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 polfcy(ies)must be endorsed. If SUBROGATION IS WANED,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 TWO ALLIANCE CENTER ' arc Nn: 3560 LENOX ROAD,SUITE 2400 E+NAII ' ATLANTA,GA 30326 ADDRESS INSURER(S)AFFORDING COVERAGE NMCx 100492-ri0meD-GALA-16.17 INSURER A:Steadfast IRSUMnM Company 126387 INSURED INSURER B:ZUnm American Insurance CO 16535 THD AT-HOME SERVICES,INC. DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins Co 23641 2690 CUMBERLAND PARKWAY,SUITE 300 INSUFaN D-Il6nob National Insurance Company 23B17 ATLANTA,GA 30339 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003746646-14 REVISION NUMBER:8 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 13Y 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 POLICT EFF POLICY EXP ILTR TYPE OF INSURANCE I O POLICY NUMBER M/OD MMID UNITS A X COMMERCIAL GENERAL LABILRY GLO488T7%(16 0310112016 0310112017 EACH OCCURRENCE S 9,000,000 OAMAG 0 RENTED CLAIMS-MADE M OCCUR PREMISES nee,nance S 1,000,000 LIMITS OF POLICY XS MED EXP(Any one pa.r) S EXCLUDED OF SIR:51M PER OCC PERSONALSADV INJURY S 9,000,000 GENT AGGREGATE LIMIT APPLIES PER GENERALAGGREGATE $ 9,00g000 X POLICY❑JECT LOC PRODUCTS-COWIOP AGG S 9.000.000 OTHER: S [,� a oo n-E unelurY BAP 2938863-13 03/012016 0W0112017 I COMBINED SINGLE LIMIT S 1,000,000 E amdeal XNMIY AUTO - BODILY INJURY(Per person) S ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per a dent) S lylrr_—t'll AUTOS AUTOS NON-0WNED PROPERTY OHMAGE S r HIRED AUTOS H AUTOS PeraWdent S UMBRELLA LAB OCCUR EACH OCCURRENCE 5 EXCESS LAB CLAMS-MADE AGGREGATE S DEp I I RETENTIONS S C WORKERS COMPENSATION WC015519215(AOS) 03/012016 031OUM17 g PER OTH- ANDEMPLOYERS'LABILRY STATUTE ER C YIN WC01 5 5 7 9 217 AK,KY,NH,NJ,V� 03/0112016 031012017 E.L EACH ACCIDENT 5 1000,000 AFFICM EMBERIPARTNDE/EXECUTIVE NIA O,stet IMEMDER EXCLUDED'! D (Maudamry in NHl WC075519276(FL) 03/01/2016 031012017 EL DISEASE-EA EMPLOYE 9 71000, If yes,describe under Conitnued on Additional Page EL DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD iOt,Addieanal Remarks Schedule,may be atmci ed N mom space is required) EVIDENCE OF INSURANCE - CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORVED REPRESENTATIVE of Marsh USA Ina Manashi Mukherjee ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD CA Office of Consumer Affairs a'nd Business Regulation `y 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home lmprovement Contractor Registration Registration: 126893 �"`-�-•— -- - , -Fi.� - Type: Supplement Card Expiration: 8/3/2016 THD AT HOME SERVICES, INC. RICHARD FALLONE `-0 2690 CUMBERLAND PARKWAY SUITE-L3150 , l`z' ATLANTA, GA 30339 - Update Address and return card.Mark reason for change. Address ❑ Renewal LLl Employment ❑ Lost Card ;CA 1 0 2OM-05r11 GG ���n ``'onetrtcr t eel( �'2/lladdae�ru.,ft rice of Consumer Affairs&Business Regulation License or registration valid for individul use only '3O OO& before the expiration date. If found return to: -&-.t_ )ME IMPROVEMENT CONTRACTOR - Office of Consumer Affairs and Business Regulation . . - . � egistration:-=j_26893.=- Type'M _ 10 Park Plaza-Suite 5170 Z; Expiration gI312046 Supplement Card - Boston,NIA 02116 rHD AT HOME SERVICES INC THE HOME DEPOT AT HOME SERVICES RICHARD FALLONE 2690 CUMBERLAND PARKWAY-S A�IA�NStA, GA 30339 - _ Undersecretary 7 Not lid wt hoot srg ature Jul 28 15 09:40a Richard Madison 9782770685 PA Massachusetts Department of Public Safety Board of Building Regulations and Standards . License:CS-030000 Construction Sac=rviscr ` : RICHARDJ MADISON - 3 MADISON AVE `` F GROVELAND MA//01034 izzK Expiration: Commissioner 07/21/2017 -Ofnce orConsomer Affairs&Ras7oess ftalation qE5xpirabow- WEIMPROVEMENT-CONTRACTOR egistration: 118509 Type-329/2017 DBA R.J_CONSTRUCTION RICKARD MADISON 3 MADISON AVE GROVELAND,MA D1836 "Undersecretary , C..t r o C9 a t� 1 t Feb 171610:31a Richard Madison 9782770685 PA KITCHEN INSTALLATION ESTIMATE WORKSHEET - USA a�� 2686 R.J.Constructiion Mark Verkennis 978.778-8720 2MO12016 Demo and Haul Away $Z,9T7.00 Electrical $2,080.00 Piumbing $1,340.00 Tnelliardwood Flooring $3,910.00 Drywall $990A0 tine"Appliances $4779.00 AadlOonal Charges 1 Materials Customer Signature: Y / C/ �ZGe� Dabs• Associate Signature: Date: GC Signature: Data: i 2016-02-17 07:56 11971 9782170685 >> 2686RTV u � � Z d 9990LLUL6 u0sipe" pieyoib d44:90 91 S0 AV — -1363" A a of .... ..... -87 3 29 Legend 1: TF390 19",-- -35:' - - 32" -30" 2! w89024RTL M 1 3: TEP2490WL) 4: F330 5: B30RT 6: 3OB18 12 1: 7: F330 IL W361824 9! F336 0 Z 5 TS W3036 1 11 6 7 Z — A CS98 101 Ln -Z 00 11: W301 5 (D 00 12: W1830R 0 V 13: F336 IN N 14: F330 15: 618E 16: SK1 824 i 25 17: S1330STCM ? 18. SEPF3AER 19: W1836L 20: VV48 21: W3323,5 lo$ I EIDT766SSF§SaK23-1 BOWL , 15 11' 22: W2`1 36R 23- FFDR-W C. 24: 642 22 A 21 19 25: FPEB-B — —IT 26: B12FHR 27; F330 28: VV4236 29: FPEB-W N 135 13 A 1 501 30: SHlil ; " ' i 31: MIP L 61" 32: W1236R UP 33: F336 0 34: RD21-DRW-B 225 737" 24" 35: R016-B 0 3B: FTK :G 37' ID26-EP 38- 1015-W N 39: F336 21 Designed;2/6/201 This is an original design and must if> All dimensions size designations not be released or copied unless iprinted: 217/2016 Lo given are subject to verification on lr-- -- - -- - 6 applicable ree has been paid or job i C) 'job site and adjustment to fitjnh order placed. conditions. Ln C) Ill,"qn-5' < .-1egend Drawing ll FNo Scat' fk00015