33 VALIANT WAY - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards arY OF
Massachusetts State Building Code, 130 CNIR Ravi SALEr12U!!
0 Building Permit Application To Construct, Repair, Renovate Or Datnolish a
One-or Two-Family Dwelling
[his Section Use0ril
Building Permit Number 0a
Building Official(Print Ndmia Date
SECTIONI:SITERNEPIALATION
I.l Property A 1.2 Assessors Map& Parcel Numbers
1.la 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 0system
1.5 Building Setbacla(ft)
Front Yard Side Yards ReProvided Required Provided Required1.6 Water Supply:(M.0.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage DispoPublic❑ Private❑' Zone: Outside Flood Zone? Munlel el❑ On sitCheck if a❑ P
SECTION I; PAOPERtV-OW0ERSt1R1
2.1 Own q t R.cord:�
�IYI fit
Name(Print) di tale,
No.and Street ! Te eph Email.4ddreas
SECTION S: DESCRIPTIONOFPROPOSED.WORK°(checkal :apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)iff Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ r ❑ Specify:
Brief Description of Proposed Work':
C
SECTION 4: ESTIVLATED CONSTRUCTIONCOSTS-
(tcm Estimated Cosro: OfRclal Use Qnly.
Labor and �fateriols
1. Building g I. Building Permit Fee:S dicate how tee is determined:
2. i:tectrical y ❑Siandud.Cityfrowrt Application Fee,
❑'rotalPidjectCostr(Item 6)xmultiptier x
t. I lumbin.y > ?- Other Foes .S
I Mcchanit:31 (HVAC) i List:.
i. ,\lech.mic.tl (Pin:
n r ai.nq S 1'0111 All Pees: i
:'hark Phr. Cheek \nwwit: ('.c:h :lnwnnt
I'rnjcr[ ( 'mt i -- - -----
f (] I'.ii l in Pull ❑thd;t:w lin I1,iLu:ea I!ua: _ " — --
SfCI'ION5: CO;VS'fRUC'1'IONSERVICas
5.1 Construct u Supervisur ''case(CSI,) _ _
License Nu� G't11PI,'I, u a
N,unt of CSL I loldcr List CSL rype(sce below) L l�
rype Description
,No. an Sir et ��/ U Unrestricted Duildin s u to I ,000 cu, tt.
n ��—► /r� — R Restricted III "Intl Dwallin
r �I btasonr
Ciiyi rown, Stutt, ZIP
RC Ruutin Cuv¢rin
\vS window,aid 5ldin
SF Solid Fuel 1lurning Appli;incts
( Insulation
Air: hone
Email address D Demolition
5.2 Registered Hmne I i ray 'grit Contractor(F,
111C liegistrtion Number *pitionTate
III a IC It 11mna
n
v Email address
No. tree
Ci /Town State ' P rtle hang
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 25C(6))
Workers Compensation Insurance affidavit must be co pleted 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...........t7
SECTIO�7let OWINERAUTHORIZATIONTO HE cioraLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PEMUT
I, as Owner of the subject property,hereby authorize I(
to act an my behalf, in all matters relative to work authorized by this building permit app icatton.
D,to
Print Owner's Nrunt(Electranie Signature)
SECTION 7h: UWNERi OR AUTtfORIZED.kGEN'r DECLARATION
By entering my nama below. I hereby attest cr a pains and enalties of perjury that all of the information
cunt 'n in this a • ti n is true and a. rats to h st a' y knowitdga and understanding.
_ ate
Print w ar'surAudturittd:\gen , .unt • mtruni Siguatur )
NOTES:
I. ;\u Owner who obtains a building permit to do hivher own work,ur an owner who hires an unregistered contractor
(nut registered in the 1lonte Improvement Contractor(HIC) Program), will nu have access to the arbitration
progr:un or guaranty tiutd under JL(U. c. Ig?A. Other important inrannatiun on the FI(C Program can be round at
tiww nru+ auv%Oc1111,funnation on the Construct
ion Supervisor I.icense can be found at www.ma>s• LIL'1
when submanthll work is planned,providd tilt information btluw:
2. (including g;u;tgt, linislied basemendattics,decks or purch)
fatal Iluur.rrca(sq. It.l __---" — 11.ibitable rumor count _
tiro,itivingnre.iOil. tt.l _-- Nowilerurbcdruoms
\Inmbcrnflil-gLrccs _-----_. --
----- -- Muud.cr,rfh.dt'b.uhs
\lumber of h.uhmum.; — — -- ----
- —
IL�tc „rhd.uiu,; ;ya`in
Pnela;cd
i - -
I I .. I,,i it I'r,y..•.r � I,i ,r,� Pd.r;c" w.ry ha cnh,una:, t;,r . l ,t.il 1'rnl,�,l l ,,,t"
07/19/2013 06:33 17818940331 TODD RIDEIMIN PAGE 01
HOME IMPROYEMENT CONTRA4.1'
PLEASE READ THIS
+7 `q sold,Furnished and Installed by:
eoaeoo Norm&South Date:(JAI J - THD At-Home Services,Inc.
d/Wa The Home Depot At-Home Services
..o Nutt$er.31-and 33 90g Boston Tumpikc,Unit 1,Shrewsbury,MA 01545
Toil Free 877-903-3769
Tcderal ID#75-269PW:ME lies#C 02439;RI Coal.Uc#16427
nn ,/ l CT 1.lc#H/�C.0565522;MA Home Improvvlement Contractor Reg.#/126893
Installation Address: -7 ViM11bmf—% tig!j 5f/nYl 1rr 019: U
city State Zip
Purchaser(s): Work Phan: Rain Phone: Cell Phone:
G [ 1V 1 -53 9
Home Address:
(If different from installation Address) City State Zip
E-mail Address(to restive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing emails from The Home Depot
PToied Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
and TH AtHome Services,Inc. ('"the Home Depot")agrees to himish,deliver and arrange for the installation ("Installation')of
all materials described on the below and on the referenced Spec Sheet(.$), all of which are incorlxtrated into this Contract by this
reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively,
'Contract"):
Job#: a a�rr dhr Products: Sheets)M. Pro' Amount
t Roofing Siding Wimlows Insulation
—76 aN ❑GatW /Cores.❑EntryDa ❑ ''7%1 7
Roofing Owing LA Windows Inwlation
`7 p Po l ❑Gutters/Covers Q&t y Doors [:1— 1 G �? So
Rooting LJS,diog U Windows U houlation $
❑Gutters/Covers ❑Entry Dori❑
Roo£mg Siding U Windows U Insulaion
❑("naters/Covers ❑Entry Dotes ❑ $
Miamamzs9�D � Ama�tdaaapnne�,4n4�mke dI TOW CealbaetAmount $
Maine Fordrasus may ad tltposn rearethan me Mr sm d orthe Contrail AmM,
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 Spa Sheet)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 Contractor any individual Product(n)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 ashesms or lead paint.other safety concems, pricing errors or because
work required to complete the job was not included in the Contract. ' J
Payment Summary: The Payment Summary # O �T_ 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 eompletel tilled-in copy of the Contract at the time you sign. Do out slgrt 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 set path 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 PAYMENT'S MADE, WITHOUT
LIMITING THF.HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
•m lance and Author ixis : Customer agrees and understands that this Agreement is the entire agreement between Customer
an a Home oepor with regard to 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 lr amended except by a writing signed
by Customer and Thu Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the
leans of and has received a copy of this Agreement
Xccepfed 1 � • t�^ Snbntitt
Customer's Si a ate ,y Saliti Consultant's Signature - Date
Xt Telephone No.
Customer's Signature Date
Sales Consultant license No.
CANCELLATION: CUSTOMER MAY CANCEL THIS
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MHINIGHT ON THE THIRD BUSINESS
DAY AllTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NtrrtCR:ADD1MCe1AL'MRMS AND CONDMONS ARE 4TATRD ON TOR 1tE',F W SIDE.AND ARE PART OF THUS CONTRACT
08-04-13 While-Branch Eila Yall"-Customer
CITY Ok S.IL.E,�,[ jbL15S wHUSETTS
Qct1.OLrc o
,.\:��, 1'/�jHcvcTov 5T�iEfiT', 3"F'Caod
<!S(OERL ;Y 0RISCOLL F��(�79) 7.1Q•g3{,f
,b A YO;i (Mann ST Ptaatta
OfAxCTartaPPCOLICFROPEaTY/et OLVcCo.auSSlovEZ
Construction Debris Disposal Aff7davit
(required for all demolition tu'd runovation work)
In accordance will' the sixdt edition of the State Building Cad Se 730 C�btR secti on l 11.3
Debris, :u'd the provisions of,�(GL c 40, S id;
Building Prtmit 4 i9 issued with the condition that the debris resultin
Ihts wu shall be disposed of in a properly licensed g tram
Itt, sl sn,`,. waste disposal Facility as defined by ,L(GL a
1710 debris will ba mwsportcd by:
r--
(a�
(name ut'haulur)
The debris will be disposed orin
--- (roman( `acrlii�)
�t
,i•Ivamro ni permit appli�•.uit
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
kv�vp) 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
- f,
Nalne(Business/Organization/Individual): ( C
Address:
City/State/Zip:
Are you an employer?Check the appropriate bpf Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction
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
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers'comp.insurance comp.insurance.
required.] J ' 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
Y (N
myself. o workers'cosP. right of exemption per MGL
12.❑Roo airs
c. , or have no
insurance required.]? §14 and( ) 13. Other W
- employees. [No workers'
comp:insurance required.] .,
*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 alland then hire outside contractors must submit a new affidavit indicating such _^
-$Contractors that check this box musfattached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'eomp.policy number. - -
I ant an employer that is providing workers'compensation insurance formy employees Below is thepolicy and job"site
information.
Ins urance Company Name: )' 1
Policy#or Self-ins. Lic.#: 131-:5 4� 1 4 Expiration Date:
Job Site Address: ! City/State/Zip-
Attach a copy of the workers' compensation policy declara ion 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 certify and th pai5ps d penalties ofperjury that the information provided abo a is true and correct
Signature: 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
"..\ Office of:CoosumerAffairs.&Business Regulation - License or registration valid for individul usl only .
before the expiration date. If found return to:
OMEIMPROVEMENTQONTRACTOR . P -
- ..f Office of Consumer Affairs and Business Regulation
Regikration "y.2 093 .Type: 10 Park Plaza-Suite 5170 . .
Expiratil 322R.4 _ Supplement 'lard Boston,MA02116 The Home Depo{]A1-_R t braes'-
RICHARD FALLU�NQ `
2890 CUMBFRLAwt
GA:30334'"� _�`' Undersecretary of valid ithoutsignature
A ®® CERTIFICATE OF LIABILITY INSURANCE o0TE 022712013 rrr)
2013
THIS CERTIFICATE IS 19SUED 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 endorsemengs).
PRODUCER CONTA T
MARSH USA,INC. NAME
PHONE
TWO ALLIANCE CENTER - ac No:
3560 LENOX ROAD,SUITE 2400 E-MA L
ATLANTA,GA 3032fi AODRE s:
INSURERIS)AFFORDING COVERAGE NAIC9
100492-Ho=DGAW-1314 INSURER A:Steadfast lnsuramre Company 207
INSURED INSURER B:Zunch American lnsuranaS CO 16535
THE HOME DEPOT,INC.
HOME DEPOT U.S.A.,INC. INSURER C!New Hampshire Ins Co- __ 23841
2455 PACES FERRY ROAD,NW - wsuRER o:Illinoi3 National IILa Co 23817
BUILDING C-20 -
ATLANTA,CA 30339 IxsuRER E:
.-. _. _. INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-00315954504 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. -
ILTR TYPE OF INSURANCE 0 POLICY NUMBER MMMONYYYY MMMDIIYYYPY LIMITS
A GENERAI'.LIABILITY GL04887714-03 03101/2013 03012014 EACH OCCURRENCE $ 9.0W;0)0
X COMMERCUALGENERALLABIUTY PREMISESfEa rte . $ 1,000,000
CLAIMS-MADE ❑X OCCUR LIMITS OF POLICY XS VIED EXP(My one arson) $ EXCLUDED
OF SIR$1M PER OCC PERSONAL S ADV INJURY $ 9.00D.OW
GENERALAGGREGATE S 8,000.000
GENL AGGREGATE LIMIT APPUES PER:X - 2 PRODUCTS-COMP/OP AGG $ . ..:.:n„ 9,000,W7O
POLICY PRO- LOC $
8 AUTOMOBILE LIABILITY BAP 2938863-10 03101r2013 ON112014 COMBINED SINGLE LIMIT 1;coo Goo
Ea accident)' '
X- ANY AUTO ... BODILY INJURY(Per aerean) $ -
'ALL OWNED I- SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(par uci4eM) $
AUTOS AUTOS -
HIREDAUTOS AUTOSAUWNED - P..cddTYDAMAGE otl 3
$
UMBRELLA LIAR OCCUR-- _ EACH OCCURRENCE S
EXCESS.LIAB CLAIMS-MADE AGGREGATE $
DED I I RETENTIONS S
C WORKERS COMPENSATION WC03357 14(A S) 0310112013 0310112014 1 WC STATLI- DTH-
PNO EMPLOYERS'lIABILITY
D ANY PROPRIETORIPARTNEWEXECUTIVE YIN WC033575315(AK,AZ) 0310112013 D3Im2D14 1,000,OW
OFFICEWMEMBER EXCLUDE04 E NIA E.L.EACH ACCIDENT $
D (Mandatory In NH) WC033575316(FL) 031012013 03101IM14 EL.DISEASE-EA EMPLOYE S 1'0DO'000
N yes,desrnDe Imder 1
DESCRIPTION OF OPERATIONS OeIow ELCISEASE-POUCYUMIT $
C WORKERS COMPENSATiON W0033575317(KY,NC,NH.VT) 03101/2013 03012014 (EL)LIMIT 1,000,000
C W0033575318(NJ) 031012013 03/012014
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AIIuh ACORO tat,Additional Remarks Schedule,Ir more space lc required)
EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING C-20
ATLANTA.GA 30339 AUTHORIZED REPRESENTATIVE
of Marsh USA ft.
Manashi Mukhedee _YA vL r "
— O 1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) - The ACORD name and logo are registered marks of ACORD
t P Massachusetts - Department of PubiicSafety
f
Soird of Building Requfattons and.Standards
Ltcense CSSL-099699 .
ROBERTPOCZOBUT
172 WHALENS LANES
Salcm MA 01970
y
cxp:ration
Cc,n�msz�Gaer 02/08/2014