83 VALLEY ST - BUILDING INSPECTION (4) z� (0:5
The Commonwealth of Massachusetts E E`fV€a
Ma Board of Building Regulations an YAL SERVICES CITY
O
^n u Massachusetts State Building Code, 78II10,,C��Mul��R SAL//�� Revised Mar 2011
W Building Permit Application To Construct, Repair,dviAifoe�dth b�D�rriosh�a5
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date App 'ed:
Building Official(Print Name) - Signature Date
SECTION 1: SITE INFORMATION
(� 1.1 Property ddre 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: PROPERRTT-Y OWNERSHIP'
2.1 Owner f�Recor
�l� { t�?yy��
Name(Print) City,Shate'ZIP
�-o l 5 Yp(I-) E;-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (cheek all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) W1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
t
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:
❑ Standard City/Town Application Fee
2. Electrical $ ❑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: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �pQ
Qo � fi Lice Number Exp ti� t ate
Name o�Hoffeetr ,—� 111
List CSL Type(see below) LA
N tree[ " Type Description
15ff __ U Unrestricted Buildin s u to35,000 cu.ft.)
1( m Ilk R Restricted 1&2 Farinly Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
W Window and Siding
SF Solid Fuel Burning Appliances
4DI9�`�� /3 I Insulation
Telephone Email address D Demolition
5.2 Registered liome Im�prrooveemenent Contractor(HIC) �L
HIC Regi Number Ex ira on Date
HIC Co an yI amnne or Re trant Name
Itl "-fnP
No. Street Email address
Citylfdvm, Sta e,ZIP a ephone
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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... If 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� ��,�` X�
to act on my behalf, in all matters relative to work authorized by this building peribit application.
Print Owner's Name(Electronic Signature) ate
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
coat n d ' thi application is true and accurate to the best of my knowledge and understanding.
Print r s WAiiihorized Agent's Name(Electronic Signature) Date
NOTES:
l. 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.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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"
CITY OF S.U.F"M1 1r'L�SSACHUSETTS
• BUILDLNG DEPARTMENT
P 130 WASHINGTON STREET, 3"FLOOR
T E1- (978) 745-9595
FAX(978) 740-9846
KIxjB Rt RY DR.ISCOLL
MAYOR THomm ST.PtERRE
DIRECTOR OF PuBuc PROPERTY/HI ILDIIVG 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 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 hau er
The debris will be disposed of in
(name of facility)
t
(address of facility)
V �s gnattue of permit applicant
L2 date
dcbriulT.Juc
The Conulronwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, NIA 02114-2017
z w www.niass.gov/dia
R markers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FU-ED R7TH THE PERIIIITTL`7G AUTHORITY.
Aonlicant Information Please Print Legibly
NaMe (Business/OrgmizadorV[ndividual):
Address:
City/State/Zip: Phone#:
Are yo u a mploycr'.'Check the appropriate box: Type of project(required): I
.I. _ lamaemployerwitli Z�employees(full and/or part-time).* 7. ❑New construction
2.F7 I am a sole proprietor or partnership and have no employees working for mein g, ❑Remodeling
any capacity.(No aorkers'comp.insurance required.]
9. El Demolition
3.❑f am a homeownerdoing all work myself.[No workers'comp.insurance required.]!
• 10 ❑Building addition
J.r-�[am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that ail contractors tither haveworkers'compensation insurance or are sole ( I LE]Electrical repairs or additions
proprietors with no employees. j
12.❑Plumbing repairs or additions
5 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
-❑ 1'++.❑Roof airs
These sub-contractors have employees and have workers-comp.msurance.t j I
6❑ re we aa corporation and its officers have exercised their right of exemption per NIGL c 14. tire[ (,
152,i 1(J),and we have no employees.(No workers'comp.insurance requiredl
*Any applicant that checks boy#t mustalso fill out the section below showing their workers'compensation policy information.
f Homeovmers who submit this affidavit indicating they are doing all work and then hire outside rantractors must submit a new affidavit indicatine such
-
:Cobtractors that check this box must attached an additional sheet showing the name of the sub-cc✓ntractors and state whether or not those entitieArive
employees. If the sub-contractors have employees3tney most provide then workers'camp.polio dumber_
I din an eriiploJ?er that is providing workers'compensation insurance jar my employees. Below,is the policy andjob site
information. �^
Insurance Company Name:
Policy#or Self-ins.Lic.9:_�a MM � b- .�7 Expiration Date:
Job Site Address: �S I�/� City/State/Zip:
Attach a copy of the workers' compensa on pally declaration page(showing the policy number a d expiration date).
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
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 herebj7 rtif an r the pains and penalties of perjury that the information provided a ove is'rue acid correct
i
Si nature: Date:
Phone#:
Official use only. Do not write in tills area, to be completed by city or town official
City or Town: Permit/License#
M1
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ATLA IT?„ GA 3033� _
_ C?da Add:s card
_'and raurn card. y[3r'c r:vo❑
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'� DAT=IMIAIODIY 9
aCaR CERTIFICATE OF LIABILI i Y INSURANCE ummOIG �
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER..THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATWELY AMEND, EXTEND OR ALT72 THE COVERAGE AFFORDED &Y TriE POLCIES �
BELOW_ THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IISDRER(S), AUTHOR=
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If he certificate holder IS an ADDITIONAL INSURED, the policKiesj must be endorsed. If SUBP,OGATION IS WAIVED,subject to
the terms and Conditions of the PoOcY.Certain policies may require an endorsement. A statement on this certificate does not carder right, to the
certificate holder in lieu of such endorsement(s)_
•RODUCER NCWCT
MARSH USA,INC.
PRO AWANCE CENTER PHONE
fAIr-No ENO: 1AMN.Y.
35M LENOX.ROAD,SURE Z400 ADDRESS:
.
AT LANTA,GA 303PM -
AFWIOmG COVEtAGE r17
10049Z-HOmeD•GAW•tTr17 INSURERA:NSUREo RreOf�t a Laidrpklt�rlmtrrar�Co T1 D ATJ ONE SERVICES,MC.DOA THE HOME DEPOT ATHOME SMILES umuAm C:NwHanpilde Ds CD ��..n..�n�1690 CUMBER.LAND PARKWAY,SUITE MD fig Naffund hBlDame CWHISmy
ATLANTA,GA 30M
INSURERF-
COVERAGES CERTIFICATE NUMBER: ATL-00374VA&14 REVISION NUMBMS
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEIAW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD
INDICATED. NOTNITHSTANDING ANY RMUIREMENf.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIµ THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TD ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR OL SVB POLICTffF .POLICY EXP
LT,I TYPE OP OGVRIe10E o POLICY NUMBER " L.Dalrs
A I X ICONMeaca LGENERAL UABLRY F0FS1R:51MPEROCC
8T/14-06 031012016 03101iY017 EACH OCCURRENCE S. 9,400A00
I `TAIMStAADE OCCUR. ` OANAGEIO a l,OW,IDD
v OF POLICY XS �� }7CLI.UDFJ)
NEO c�(Airyar,eparssnl 3
PERSONPL6AOV uNr1RY s 9•�•�
GEWLAGGREGATE UMRAPPUES PER GENERALAG6BE5ATE F too=
I ^ I POLICY❑ LOc I ?RppUCM-CONPIOP AGG S 9.6a6.U6U '.
orHE a i I I F
3 ,JAUTOMBLE L1nmtOTY ?9�8�13 13N1RA76 031012.017 ��� IS 1,000,000ANYA BODLYIUURY(PvpmmAj F
ALLOWNED SCHEDULED SHF INSURED AUTO PHY DMG BODLYINURY vgrao )j s
I XI AVIS
R NANUTOS N® pR DAMAGE 5
IHI s
D I I I I GGREUXTE s
I oED RETENTIONS
Orz
Rlmes eORweisATlgx 0319'G75(AOSj 03101f1Btfi 03N117017 X �aTrrrE m
D EMPLOYERS UABR3rY
O YPROP(GErOWPARNEMEDMOMWE °® xrA CO1S19Z17(AR.KYNHNd,VTj 071012016 03(012D17 E SICH.ACOOENr s 1p00,OD0
0 n l�•�� 5519216(FL( IXID1RlIt8 D31012ST1 E101GEASE-EA Eh�1 S 1pM,001esCwNllued an Add�liolel P 1,0m.000
scRwTtoN OF OP6iaT10NS b¢loar age - ELDLSEASE-POUCYLOdrt s
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AdAfiawl Remarks Scludui%pray beatmcwd B mme Spam is mqukedj
EVIDENCE OF INSURANCE
- r
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANGS L®BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEI.NER21) IN
Z455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA M339
AUTHOR®REPRESENTATIVE
of Marsh USA me.
I .
Manashi Mukherjes �`�CcLuxA'<+• <-r- I
a 1999-2014 ACORD CORPORATION. All rights reserved.
cm
3Ja 3u �o�� �a ion> �, S'a�t a'd>
}: CSSL-099699
ROBERT POCZOBUT
172 WHALERS LANE <
SALEM MA 01970
o - 02108/2018
HOME LMPROVEMENT CONTRACT .. .,• a— s
PLEASE READ THIS - -
. Sold.Furnished and Installed by. * ,�
,C .THD At-Home Services,Inc.
Branch Name:Barton North&South Dace:Jv1/�_ - .dlNa The Home:Depot At-Home Services
` 908.Boston Turnpike,Unit 1.Shrewsbury.MA 01545
Branch Number.31 and.33. - Toll Free 877-903-3768
"� ; . .. v...:
Pederalm#75-2698460:ME tic N C 02439;RI Cant.LicA 16427
s Y ' Cr I c#HIC.0%5522;MA.Home Improvement Contractor Reg#126993
Installation Address: '. m
•. N m a City , Stale Zip
..; Parchacer(s):r ,.. +% .Work Phone:` Home,Phone: Cell Phone:
Horne Address:
.�.(Ifdifluent from Installation Address) City State. Zip
E-mall Address(to receive project communications and Home Depot.updatexl: -
° ❑I.DO NOT wish to receive my marketing mails from The Home:Depo -
Prolect Informati m:Undersigned("Customer'),the owners of the property located at the above installation address.agrees to buy. ,
and THD:At-Home Servtcea.Inc.('The Home Depot")agrees to famish,deliver and arrange for the installation("Installation")of
:all materials described on the below and on the referenced.Spec Shcet(s): all of which ore 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#- nwrtewmi •° arts; • S Sheets #: Pm Amount!JJty
c• Roofing Siding iDoms Insulation �
y �Gutert)Core oEatryDoor ❑ 16,760' . $ ,3
Ronfnng Siding U Windows U Insulation- $ _
(]Guners I Covers[]Emry Does❑ °
Roofing USidins U Windows Insulation r $. i _-
OGmters I Covers.(]Entry Doors❑
Roofing USiding U Windows. Insulation' $
OGaonrs/Covers.OEnuy Doors 0 - , * - ". ""
&Gahm 75%,Depn*efCo u Ao dmupmenaWmdBnammast Total Contract Amamt $
Maine Pairtilsrs mayRu depidtmaetlmnoneeldrd dike CamtrMAnioum. �i Jo
Customer agrees that immediately upon completion of the work for each Product,Customer will execute a Completion Certificate
(me for each Product as defined by an individual Spec Shect)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 Contract or any individual Product(s)included herein,at
its discretion,.if The Hone 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 safety concerns;pricing errors or because
wok required to complete thejob was not included in the Contract.
�Z
Payment Summar
y: The Payment Summary# I'M/0 , included as pan of this Contract,sets forth the total
Contract amount and payments required for the deposits and final payments by Product(as applicable). -
r NOTICE TO CUSTOMER v,
iYm an entitled to a completely filled-In copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there Is one Completim 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 dale of termination plus any other
amounts set forth In this Agreement or allowed under oppiicabie 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.
Acceotance and Authorisation: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The ome thth regard Depot gard 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 canna be assigned or amended except by a Writing signed
by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the
terms of and has received a copy of this Agreement -
Accepted._by. t Submitted b : -
x x. „�oasCustomer's Signature. • Date Sales Consultants Signature Date r
Telephone No. 2�
Customer s Signature p�
Soles Consultant License No.
CANCELLATION i CUSTOMER MAY CANCEL THIS _ (as aPldtcaWm
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 LS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE..
NOTICL ADDMONAL TERMS AND CONDRIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OFTHISCONTBALT
OYlyd3 WMe-:&arohfao Yellow-Cusiomor -