35 WEATHERLY DR - BUILDING INSPECTION 3w
The Commonwealth� IQrA..SERVICES CITY OF
Board of Building Reguliiit'ons and Standards SALEM
/a Massachusetts State BuildingC�ucJe,.,�3��M es
`]K� �,t • �{' Revised.t(arl0!(
Building Permit Application To Construct, epalr, enovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Zh l
Building Oftcial(Print Name). Signature- -I Date
SECTION 1:SITE INFORNIATION
1.1 1.2 AssessorsNln Pro pert A & Parcel Numbers
P Y1 P
1.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
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❑
SECTION2: PROPERTY OWNERSHIP'`
2.1 Own r o rord:
Rme(Prin A City,State7ZI
No.;rod Strect telephone ne Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check a at apply)
New Construction❑ 1 Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) Ell Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ .Number of Units I Other ❑ Specify:
Brief Description of Proposed Work,: �
lye
20
SECTION 4: ESTIM:\ ONST UC' ION OSTs
itu Estimated Costs: Official Use Only
Labor and Materials
Building S I. Building Permit Fee:S ' Indicate how fee is determined:
❑Standard City/Town App ncation Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x
1 Plumbing S 9. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) 'Coed All Fees:S
Check No._Check Amount: Cash Amount:_
6. Tutu Project Cost: S ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5:'CONSTRUCTION SERVICES
5.1 Con ruck n S Li ense(CSL)y+; ,�4 ) -J�+
s
I uperviso License Number E.tptra on ate
Nano of CSL f older ' '" •i-'t ,}J .71 PIK
List CSL Type(see below)
No. and Street Type , . :? '.; Description
U Unrestricted(Buildings tip to 35,000 cu.it.)
R Restricted l&2 Family Dwelling
Citylrown,State,LIP bl Nlisoary
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I insulation
'Ccic hunt Email address D Demolition
5.2 Registered Honk} provent nt CoutraeEe•(HI )
HIC Rc tstMion Number Gep ano fT,u
LI
i �i o f ame
t , ^ Email address
fate,ZIP Telephone d
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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 Wtrance of uilding 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) L 115are
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby,tte under the pal and penalties of perjury that all of the information
coat in this at on is true nd acc rate the t o knowledge and understanding.
/ /"/
Print( w ter s or Author cd Agcat' ame u i Si' mture) •to
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 NI.G.L.c. 1 12A.Other important information on the HIC Program can be found at
wkvw.mass.go v oca Information on the Construction Supervisor License can be found at w�v'dns
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. •Total Project Square Footage"may be Substituted fur"rota) Project Cost"
i
HOME RNPROVRMENT CONTRACT
PLEASE READ THIS
� ZeL1ly Sold.Furnished and Insultled by:
Brarnch Naorc:Owtun North&Suulh Late: ._ TIID At-Hume Services.Inc.
d/b/a 'Ihe Home Depot At-Home Services
Branch Number:31 and 33 W8 Boston Turnpike.Unit 1,Shrewsbury.MA 01545
Toll Free 877-903-3768
Nedeml M W 75-2698460-MI'r,I.ic 0 C 02439;RI Cont.ties L6427
_ CT'Lic C HIG0565522:MA I tome Improvement Contractor Reg,d 12(i893
Installation Address: 5 G,Tne r It�`�7 �m A. C297d
(sly State Zip
Purchaser(gl: Work Phase: Rome Phone: Cell Phone:
�e3% Re ai , f — 17013L19
Home Address:
(11 dillixent from Installation Adthass) City State Tip --
E-mail Address(to receive pnhjet conun inicatrm.and Home Depot update%):
V I DO NOT wish to receive any marketing counts from The Home Depot
Pm'eel Inr r UndernilmW("Costumer"),the owners of the pnnwrty located at the above installation addn.•%,-agrees to buy,
and THD Ao-I one,'ervicu, Inc.("the Boole Depna")agrees Co furnish,deliver and atrange for the installation("Installation")of
all materials described on etc below and oil the referenced Spec Sheet(s), all of which are inorcjuaated into this 0moact by this
refercrec,demg with any applicable State.Supplement and Payment Summary attached hereto and any Change Ontors(collectively-
"Contract"):
Job 8: a..can,....; ins: S Sheets #•
1 - 1'mjeel Amount
R swfing Siding a windows insulation — '�—
�732(o4W EIGutters/Cnvers (]EnavDoors o- 55M.76 A
RrnNinp, $idiag Windows Iowla Unt 1 y7,
[Xutlen/Cavrts ❑finny Door, o
❑Rswrimg Siding Winduws Insufatmu -
1 OCuters/Covens Ql:al(y Doors❑
[][touring Siding Winduws Insulation t
06oltps/Covers ❑Enny Doors Ej $
Miolmnnn 26'R Ikyorair oPCwbacf Alnomnl due alamgenditn edNb eraurnal. Total Contract Atnulmt Maine ILrrlgxn rmY nea ekpeMt mar IhaaelrothW nfthe fbntred Amauu 5 58 2-?0
CustOuaa all=that. inunedinuay upon completion ul'the work for each Product.Customer will execute a'Completiou Cerlilicate
(one for each Product as definul by an individual SINx:Sheet)and pay any balance due. As applicable,catch Customer under this
Contract agrees it,be jointly and severally obligated and liable hereundea'. -
The Herne Uciml reserves the right to issue it Change Order in terminate this Contract or any individual Product(s)included herein.ar
its discretion.if'lhe Home Depot or its authorised service provider deterrhines that it cannot perform its obligations due to a srructu"
prohlern with the home,envir(Nlmental ha/ard%Such as lorild,usheSC(a Or lead paint,other safety concerns,pricing errors Or beeauw-
work required to complete the.lob was not included)it
the Contract,
Payment Summary: The Payment Summary AS) '( 95 , included as part of this Contract, sets forth the total
Contract wnount and paynhans required for the deposits and final Payments by Product(as applicaNcy
NOTICE TO CUSTOMER
You ore entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Uvrtifieate(mite:
there is too Completion Certificate for each lined 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 Time Depot the costs of materials,labor,expenses
and services provided by The Homo Deped or Authorized Service Provider through tine dale of tenmdnadun,plus an'other
amounts set forth in this Agreement or allowed under applicable law. TILE HOME DEPOT MAY WITTIHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DE SIT PAYMENT OR OTHER PAYMENTS MA3)E, WITHOUT
THE HOMF DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Aece on A d ulhnrlvati • Customer agrees and understands lbld this Agreement is the entire ag cement between Customer
and The llowe 'Pill wall regard h)the Produces and Installation service.,and suporsedcs all prior discussions and agreements,either
oral or written•relating la said Products and Installation.'Ihis Agreement ctmnot be assigncl or tmhendcl except by a writing signed
by Customer and The liotnc Depot.Cusita nir acknowledges and agrees that Customer has read,understands,voluntarily accepts the
terms of and has received a COPY of this Agreement.
CamAc S,'u�teal by:
. ,/1 - x I!2(,./l�1
CuanrnuT s Signaure DAIc Sal Consultants i ore
�JDatte7 h/
�— '1'elcpheme Na 9)927— 7`'�r y
Customcr's Signature Date "—
Sale,Crmsoltan(License No. _
S:ANCRII,LATION: CUSTOMER MAY CANCP:I. THIS ono apW4amm
AGREEMENT WITHOUT PENALTY OR OBLTGATION
BY DELIVERING WRITTEN NCYI'ICE TO T'HE HOME
DEPOT BY MIDNIGHT ON THE THHCD BUSIIVE.SS
DAY AFTER SIGNING THIS AGREEMRN`r, THR
STATE SUPPLEMENT ATTACHED HERgI'O
CONTAINS A FORM TO USE IF ONE IS
SPECOTCALLY PRESCRIRED BY LAW IN
CUSTOMN,R'S STATE.
NOTICE:ADImI l'IONAL TERMS AND CONDITIONS ARE STATRO ON THE REVERSE SIDE ANO ANE PART OR TH IS CONTRnt T
06 04-13 wna>_o,.,,,.n ca..
9/t d SHtl 30dea awoH << LO MM6 A149992 EV% 52-W-W?
Massachusetts •Department of Public Safety
Board of Building Regulations and Standards
Cunctruction Supennnr Specialh
License: CSSL-0M99
ROBERTPOCZOOUT 'r
172 WHALERS I
Salem 119A 01970 %,
J Expirations
Commissioner 02/00/2016
fF
. , The Commonwealth of Massachusetts prltlt r omit. .
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, [ILIA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: )guilders/Contractors/Electricians/Plumbers
App icgnt Information . Please Print LeEibiv
Name (Business/Organ ization/Individual): H-nwy"
Address: ( /���f yyly�Qt
City/State/Zip: Phone#:
Are you an employers Check the appropriate box: Type of project(required):
I.❑ I aru'a etriployer�vtth 4. ❑ Tam a general contractor and I
employees,(full:and/or part ttme).* have hired the sub-contractors 6. ❑New.constmetion
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
workin forme in an capacity. employees and have'workers'
g Y9. ❑ Building addition
[No workers'comp. insurance comp, insurance.
t `
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I i.❑ Plumbing repairs or additions
myself o workers'comp. right of exemption per MGL
Y M p 12.❑ Roo pans
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13. ther
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 all work and then hire outside contractors must submit a new affidavit indicating such.
-.,=Contractors that check this box must attached an additional sheet showing the name of the,sub-contractors and state whether or no[those entities have
employees. If the sub-contractors have employees,they must provide their workers'.comp.policy number.
I am an employer that is providing`workers'compensation insuranee for my employees. Below is the policy and job site
information.
Insurance Company Name: ) ' III)
V
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 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 $1,560.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a 5ne
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 ceiti under tke pains and enalties of erja that the information provided above is tr a and correct
Si naturei _ 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 ;
`4
6. Other
CantaetPprgnne - Phone#: - '�
UP;E imlllli�j
CERTIFICATE OF LIABUTY INSU, RANCE T2-1,
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORNIA19ON ONLY AND CONFERS NO RIGHTS IJIFON THE CERTIFICA71 '.-FOLDER. Tln!s i
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEN13 OR ALTER THE COVERAGE AFFORDED EY T I- POLICIES I
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTiTUTE A CONTRACT CEDYFFN THE ISSUING INSU-7-I[S), AUTHORIZED I
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
F POPOR rANT; If the certificate holder is an ADDITIONAL INSURED,fhe pcl"'cyflle, nrus!IsQ Piidef5erl. V SUE*jClE,�TII>A IS IP,'AIVFTj,SUbj-Ux to 1
I I
the terms and conditions of the policy,certain policies may reyArean endorsement. A slaiLesent oil this certhl-ate closer not Conlon ri,,Ilts to the
mantle).holder in-fivu of Such ancherez
I POODUCER NVIAE
MARSH USA,INC. ------____
T'NOALLIANCE CENTER
ATLANTA, SIJITE24OU FE01-
ATLANTA,CA 30326 I_ADDFIES9---
rN5URERjS)AFFOR ING COVERAGE — NAIC 11
1J492-HomeCi INSURER A: Steadfast Insurance Company .26,397
INSURED Zurich American Insurance Cc 16535
THE HOME DEPOT,INC. INSURER R:
HOME DEPOT US A,INC, INSURER C: New Hampsinfer Ins Cc 23V1
2455 PACES FERRY ROAD,NW Illinois Nallion Ins Co 23817
BUILDING C-20 INSURER 0:
ATLANTA,CA 30339 INSURERE
INSURER F
COVERAGES CERTIFICATE NUMBER: ATL-003159545-04 REVISION NUIViBER: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.
RISR ADOL SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR )AND POLICY NUMBER (MMIDDNYYY) f%IMIDDNYYYI LIMITS —
A GENERAI LIABILITY GL04B87714-03 0310112013 00112014 EACH OCCURRENCE g 9000,000
-DTJTA—GL TO—RENTED —1000000
COMMERCIAL GENERAL LIABILITY PREMISES(Eir germercm $
CLAIMS-MADE ff]OCCUR LIMITS OF POLICY XG MED EAP(My one person) I EXCLUDED
OF SIR:$IM PER OCC PERSONAL&ADV INJURY 111 9,000,000
GENERALAGGREGATE $ 9,000,000
GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMROP AGG $ 9,o00000
ElX I POLICY PRO- L06
AUTOMOBILE LIABILITY BAP 2936863-10 0310112013 0310I/2014 COMBINED SINGLE LIMIT 1,009,068
Ea accitlent
X ANY AUTO BODILY INJURY(Per person) $
ALLOWNED SCHEDULED
AUTOS AUTOS SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) S
-O NONVdNEQ PROPERTY DAMAGE $
HIRED AUTOSAUTOS (Per ii ntl
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIARH IMS-MADE AGGREGATE $
DED I I RETENTIONS $
C WORKERS COMPENSATION VVC033575314(ADS) 0310112013 0310112014
MIT C AND EMPLOYERS'LIABILITY YIN --100-0—000
ANY PROPRIEIDWPARTNEWEXECUTN L- WC013575315(AK AZ) 0310112013 030112014 E1.EACH ACCIDENT $
F—Nj MIA
OFFICER/MEME
D (Minds',in MIT) VVC033575316(FL) 0310112013 030112014 F.L.DISEASE�EA EMPLOYEE —------
If yes.describe under 11000P000
I DESCRIPTION OF OPERA PIONS ball. E.L.DISEASE-POUCYLINIR
C WORKERS COMPENSATION WC033575317(BY,NO,NH,VT) 0310112013 0310112014 (EL)LIMIT 1.000,000
C WC033575316(NJ) 03101013 0310112014
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Andumnal Remarks Schedule,if more space is 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 Manst,USA Inc.
I Manashl Mukheqee
1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Grfct of,Cbn v.ilrnu f flins lr 13us mils
mw . --rR .: t r-r - - h 1Dxa#i;zetp �>�a .�9it 1'TSraa3s] ie+nr i*
G faIL7E1��7i?ROJti'�I�EPfFGOfljfr�,��r. _ oma ofconsnar r Affairs Mill B113M,. 3,:;_ .. ',.^, .
RPgi irafron 26 93 TIp 10 Park an-Silk_Si TO
a. Expirafi4> I M-14 suapdei7zr .ard B Dgtm,MA 0311
The Hem Dep Vtt-R e..efyixes
RC ,fALLO obNV MCg
2690 CUMBERLAI P�3h�113/j�`S g '�--�-�^d i !y . �✓���. — _ .,
.A f3iA,GA 30339�'^ ' dDt valid ithOut Signature
Undeis c;e"I, -
CITY OF S'uEm. 1WSACHUSETTS
t . BUILDIING DEPAR-M&NT
1 70 WASHNGTON STREET, 3AO FLOOR
* T EL (978) 745-9595
FAX(978) 740-9846
KimBERLEY DRISCOLL
INL L.XYOR TI-10s S ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BL'ILDMG CO\LMSSIONER
Construction D 'Debris Disposal Atfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
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
l 11, S 150A.
The debris will be trans ortcd by:
y
(name of hauler)
The debris will be disposed of in
— - t (name of facility)
(address of facility)
signature of permit applicant
date
del>ni;tlf d•x