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16 WEBB ST - BUILDING INSPECTION C-r- 14 3-1-7 3,3clto The Commonweakt&TNfif;achu Board of Buil4"g?3-'DO�lAlns�t�lM , CITY OF W ' Massachusetts State Building.Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application T J%Ct,keP4dir!1Jnbvate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date App ed: Building Official(Print Name) - Signature Date 1. SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers tL 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 ❑ Cbeck if yes❑ SECTION 2: PROPERTY OWNERSMP` 2.1 Ownert o MR� rd: AAlir l�tdl`�K� Name(Print� City,State,ZIP, No.and Stree Telepbone/ — Ail Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ O er ❑ Speci Brief Description of Proposed Work : SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ I. Building Permit Fee: $ dicate 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: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Constructio,,��e/�''pe License(CSL) 1 r n a umber Lice Expira ate Nam e of CSL Holde6r 1'0 1 1 �r In II ����� List CSL Type(see below) No.an "d{� Type Description U Unrestricted(Buildings up to 35,000 cu.ft. �I^ �—t( R Restricted 1&2 FamilyDwelling City/Town,State,State,ZfP M Masonry RC Roofing Coverin WS Window and Siding SF Solid Fuel Burning Appliances Sib 1 Insulation Telephone' ��Email address D Demolition 5.2 Registered Home Im rovement Contractor(HIC) HIC Registration HIC Comp o IC R ' No.and Stree Email address City/Town, State,Z Tele hone 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 Issuanc f the building permit. Signed Affidavit Attached? Yes .......... d 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 (f6 to act on my behalf, in all matters relative to work authorized by this building permit application. o� Print Owner's Name(Electronic Signature) ate SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my me below I hereby attest under the pains and penalties of perjury that all of the information contained in s ppl'cati is true and accurate to the best of my knowledge and understanding. Print Owner s o u on Agent's Name(Electronic Signature) Date 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 can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at 3nnK.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halFbaths 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" F ai Its SU Co an tril C-11Wn ft7 r-4-j9dk Sp iltv Z- ...t r % S ; 1.14 2w M Sal. , lu eul 0210812016 , CITY OF S.U.F.Nl, TUNSSACHUSETTS BUMDING DEPARTMENT Lfaw' 130 WASHINGTON STREET, 3'FLOOR 'ILL (978) 745-9595 FAX(978) 740-9846 KI\tBERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PIBLIC PROPERTY/BUILDING COWWSSIONER 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: cQA4 � name of haule-r) The debris will be disposed of in : name o r ity (address of facility) ignatur of permit applicant date dcbrivlLdm HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by: PLEASE READ THIS CONTRACT THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike Unit 1,Shrewsbury,MA 01545 Toll Free 8779033768;Fax 8009863610 Branch Name: Boston North Date:12/6/2015 ME Lic#C 02439 RI Cont.Lic# 16427 CT Lic# Branch No: 33 HIC.0565522 MA Home Improvement Contractor Reg.# 126893 Federal ID#75-2698460 Installation Address: 16 webb st SALEM MA 01970 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: Mrs. Kathryn Wisutskie (978)745-6227 Home Address: 16 webb st SALEM MA 01970 (If different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates): Marketing entails will not be sent from The Home Depot. Proiect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,and THD At-Home Services,Inc. ("The Home Depot")agrees to famish,deliver and arrange for the installation("Installati on")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary(where applicable)attached hereto and any Change Orders(collectively,"Contract"): Job#:(Intemal Reference) Products: Spec Sheet(s): Project Amount 8836874 Roofing 8836874 $5,384.60 Minimum 25% Deposit of Contract Amount Total Contract Amount $5,384.60 due upon execution of this cootract 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 Spec 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 Contract or any individual Product(s)included herein,at its discretion,if The Home 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 work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary# 8836874 ,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). 06117114SA Page 1 of 7 HOME IMPROVEMENT CONTRACT PLEASE READ THIS CONTRACT ROOFING SPECIFICATION SHEET DESCRIPTION OF WORK Customer Name: Mrs.Kathryn Wisutskie Date: 1 2/612 01 5 Branch Name: Boston North Job#: 8836874 Sales Consultant: Jeremy Fraley (LINE# I. APS,Timberline HD Lifetime, Fox Hollow Gray Material Removal Additional Leak Barrier to be Installed= No,Synthetic Undedayment Upcharge=Yes, Synthetic Undedayment Upcharge-Roll=2 Number of Squares(excluding Low Slope)=6.66, Number of Flat Roof Squares=0 Flashing Misc Linear Ft of Drip Edge to be Installed= 100, Color of Drip Rigid Ridge Vent=Yes, Linear Ft Ridge Vent to be Edge to be Installed=White,Chimney Flashing= Installed= 10, Rigid Ridge Vent-Color=Black, Low Masonry-Relead, Chimneys Requiring New Flashing= 1, Profile Vent=Yes, Number of Low Profile Vents to be Color of Chimney Flashing to be Installed=Galvanized Installed=4,Color of Low Profile Vents to be Installed = MilIFinish, 3"Circle Vent=Yes, 3"Circle Vent-Count= 40, Replace Fascia=No,Cut-up Roof= No, Disposal Fee = Up to 10 Squares Pricing Includes: Chimney Flashing Drip Edge-in 10R Sgmts S1 8-12 10-12 Steep Charge S2 B-12 10-12 Steep Charge Shingle Removal and Application Disposal Fee Synthetic Undedayment Upcharge SPECIAL CONSIDERATIONS: PRE EXISTING CONDITIONS: ADDITIONAL CHARGES__ If rotted or damaged wood is discovered AFTER removing the existing roofing,or could not be identified at the time of sale,there will be an additional charge of$ 88 per sheet of 4x8 sheathing and/or$ 10 per linear ft.of dimensional lumber for decking. If additional layers of roofing are discovered AFTER removing the first layer,or could not be identified at the time of sale,there will be 061171145A Page 6 d 7 HOME IMPROVEMENT CONTRACT PLEASE READ THIS CONTRACT NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time of sign.Do not sign 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 forth 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 PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVER OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Contract is the entire agreement between Customer and The Home Depot 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 Contract cannot 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. You are entitled to a paper copy of this Agreement if you choose. If you consent to an emailed copy,your consent applies only to this Agreement.By contacting sales office (g77)go'i-176g ,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement at no charge. By signing below,you confirm the following: • You consent to receive only an emailed copy of this Agreement • You have access to a computer that can receive and open emails and PRE(Adobe Reader Version 10.1.4 or later)formatted documents. • Your email address is correctly listed on the Home Improvement Contract Submitted by: Accepted by: 7r��/1 Sales Consultant Jeremy Fraley Customer License Name. Signature: Mrs.Kathryn Wi6u15kie (Cleo 6,2016,4:02 PM) (877)903-3768 Customer Telephone No. Signature: Sales Consultant License No. (as applicable) CANCELLATION:CUSTOMER MAY CANCEL THIS 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 IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE 06117114SA Page 7 of 7 ' The Coinmonweadth ofMrrssachusetts Depa►7ment oflndustria[Aed dents ®fJiee mfZ,tvestigeltiolis 600 Washingtorc Street Boston,M4 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Bugders/Contractors/Eleclricians/Plunmbers Applicant Information —� Please Print Lezibly Name(Bnshiessioramizatibn/Individual): Address: 8a City/State/zip: _ Phone Are u an employed Checkthe'appropriste box; Type of project(required): I. I am a employer with oZ 0 4 ❑ I am a general contractor and i 6. ❑New construction employees(full and/or part-time).* have hired it sub-contractors 2❑ 1 am a sole proprietor or partner- listed on the attached sheet 1 7. ❑Remodeling ship and have no employees These sub-contractors have 8- 0 Demolition wo for me m any capacity. workers' comp_insurance rking 9_ E] Building addition [No workers' comp.insurance 5. We area corporation and its I0 M Electrical repairs or additions required.] officers have exermed Urea Urea El I am ahomeowner doing all work right of exemption per MGL 11.0 Pity repairs or additions myself(No workers' comp- c. 152,§1(4),and we have no 12 ofiepairs insurance required.]t employees:[No workers' camp_iusurancerequired] 13.0 Other $Any applicentPoat checksboa igI must also M out'he saotioabelow showmgtheir worke&compensainnpoliegiuformatma: Y Homeownerswho mflmit1Ws atEdavitiodicaitug iheyffi doing all work and then ham outside wm±r smustmbrmtanewaffidavitmdicativg such tContmcims that checktMsbox mast Mehed=additional sheet sbowmg the name ofthe subcontractors andtheirwoikeW comp,pomymformetion. I am art employer that fs providingworkers'compensation insurance for my employer..- Below is the policy and job site information. _ ��, Insurance Company Name: Policy#or Self-ins.Lic.#f: T j JM -g� Expiration Date: f Job Site Address: � City/StatwZip:_ Attach a copy of the workers' compensation policy declaration page(showing the policy number and e3pira8i on date). Failure to secure coverage as required under Section 25A ofMGL c 152 can lead to the irm osition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisomneu�as wen as civil penalties in the form of a STOP WORK ORDER and a fine ofup to$250.00 a day againstthe violator. Be advised that a copy ofthis statementmaybe forwarded to the Office of Investigations ofthe DIA for msorauce coverage verification_ I do hereby C r le penalties ofperjury that the information provided above is ri• and correct Si atm Date: Phone#`.. O,ffwid use only- Do not wrfte in this area,to be completed by city or town offrciaL City or Town: Permit/£,ieense# Issuing Authority(drele one): L Board of Health 2-Building Department 3.City/'lawn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person- Fhone#: CERTIFIcAT cars rs rssuEOF LLAIBIL ---- AS A NIAR�F 1�iF0 RANGE i nAr-(Isavnn ry !MLO leWa c uOT`�RMATIVELY e� n®ff ONLY c m rz61s REPRESENTATIVE trAT VE on f .CF tdND GONF�lU RIGPITa' ]PON tFL C€R71�"IC�IYE 1DER TFiiv 'WP RTEAI if th OR FRODtt (7(iANCE DOES 7yOT CONS' �� oR ALM�cr B TZ COvSKApE;Ari 1MP RFANT2 7f#q O�Aill CERTIFICATE HOLDER-17'E A CONTRACT BEI'MimN THE ISSUING IN$u D BY Tel POLICIES (fte>brinBandsaadfttCe� hotderfsanAODPROA(ALtIiiii1 D - �13bAUTHORI?�D CarSHt ttD(derin Ilea OfSBCit Pamefn(s}oAciE�ntyl YaQR(r3 as ent7ot58`111eIJtE A ant on 1lds Su®ROGATION!3 WAtt/-D,su6Joct:o PRnoucER �des aat confer rlgit4s to frie NARSH DS0.WG �. 3560i CA iil 2460 PAO E Ai1e0- Gq,TR326 AY Ap !PI 199g92-Hvmzp-Fj{Ij�clS76 IN$RtZttO - 9cbmpmltalSCp as O(DA7HDMESfftY10p,WC. tNSRt1EaA-9�diMUAswanm Nmpmy Nactt QaAWHOMEEEPOTAT�i(�E�RWa Sisun®ta: ^A�RciB�, 20M7 "IQ GI ERIUQPAW(WAY SE WW @ �C7 16Si6 AnAv ii s � 23601 ' ne�nisNaKmal Ns�aP®q�Panr tNStitiERE: 2zstr CO 13 IS is TO C ui50naiP: INDf 15 TO CERTIFY THAT(I(E PO cMD OOP INSDRgNCEsell A-I(-�6G2d2MS06 CiliP-D; Nrnvl6rtigtgrroq,�6ANY SCEDBELOWHAVE R�IS/OftNumeal�7 CER77Fl(JffE MAY gE(y.S(Im OR M y PERTNR�F 7TBiM OR CONOrtiON BEEN ISSUED TD THE MSURED �CtliStONSAND COND1TipNS OFSUCFIPOLI(AWE'THEINSURANCEANY NAIIAEJ]--VE FOR THE POLICY PERIOD Ta YVPeoP LI007I3SHOWN NWYH•i�RO� THPOP It;S 06SCRBt67 CUMENT WITH RESPECT TO WHICH THIS A G ALI7AeR.RY tNsumnaee n VE BEEN REOul BY PAR]CUIIMS HEREIN IS $UBJECT TO ALL 7HE 7ERM5, PO1tOl'NOAIeEA P Pp EKP X CQNc�CIaL L GL04887714-05 �iALUt1BRITr R3I01/2W5 0310U2076 u6R75 CLAMMIMVE ERCHOCCURRENCE S 9,OW,000 x OxuR U��PDUCYxS O> SBt MMpEtOCO a,® m I s 6w,a6s (ftMPamnAI - a EI(CLUDEp x .As...- t$A7•App�p� Pe'RsoNa-BAov RJ,IRRY 5 9.OW,D00 X p L.y PR0.j s s,6s9,6a6 9 A4fONO66E LOO BBiERAtAGGRESATE UA91Uty.1 PRODUCT_ x ANrAUiO ' SZt6663-72 CCNPICPArm s '9,000,0R0 III �W� 03IO1rL615 03f0UZ016 Nw®Av`os ANot SHFWSURMAUTOPHYDill BOOILYm41RRY(P¢IPpisnR) 5 7pW.000 AHIDs eonarmalM;r(Pnramc®0 s llidRRcr 13AE - O E 5 OLCESS UAB OCCUR ,•ti^+NAOE S O ' ONS 1 EACHOCCURRENCE s . 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