88 WEBB ST - BUILDING INSPECTION 2G i - t %4 $25OD z� qq
The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards
W USE
Massachusetts State Building Code, 780 CMR,7th edition MUNICIIPALITY
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January
One-or Two-Family Dwelling 1, 2008
This Section For Official Use Only
Building Permit Number: to Applied:
Signature: l�
ui ding Conniiissi er/ t z ruildings Date O N t 1-
SECTION 1:SITE INFORMATION
1.1 Property Ad ps: L�f �� zZ 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
�j� /� I SECTION 2: PROPERTY
'AOWNERSHIP'
� JI 2.1 Omer tior71G`tl""-r f I't./ i ti' /'? �"eV, ��
QYt �.
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Rcpairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4:ESTIMATED CONSTRUCT ON CO S
Item Estimated Costs: Official
Labor and Materials ��Only
1.Building i— 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑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: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction pervisor Licen (CSL)
r in Lice ul tber T;a/ ' a i 4te
Name of CSL Holder t�/'
List CSL Type(see below)
No.wY STreet Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/1'own,S P M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele one 7 Email address D Demolition
5.2 Registered H e tmpro ent Contractor i
wa HIC Registration Number E$ on' ate
HIC n e i t ame
No. trcet Email address
K
Cityfrown,Siate,ZIP I Tele one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be cornelpted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance a 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 authorizeGj
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest�Pdethe pains and penalties of perjury that all of the information
co ed in this a li ation is true and a rat the st of my knowledge and understandin .
1
Print(Tuner's or Authorrzed Agent's Name( nic i me) bare—
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
Information on the Construction Supervisor License can be found at
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 halfibaths
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"
2013-09-06 05:13 3409-E%PDTR/PHN SLS 16034271474 >> Home Depot AHS P 1/5
HOME IMPROVO4ENT CONTRACT II
- PLBASE READ TxtS
So ,FurniAl and Installed by:
$[prc�N� Boston Date: I'rHD At- ere Services,Inc.
lam/- d/Va The,H mo Depot r-Ilome Service.
908 Roston Turnpike,Il it I,Shreltsbury,MA 01545
Toll Free(800)4 57-5182;F ix(508)845-6017
Branch Number:71 Federal ID#75-269MW;ME I.I eC'112439; UrAaa.LictrI6427
l� _ (T 1:e#EIIC.0565522;MA llonc Impm mem Coat tar Reg.#t26S93
Installation Atldroav: 482 1 .hh �}- akm
City stat Zip
Pureheter(s): Work Phone: Hume Phone: I Cell Phone:
l Q�� I
Hama Addr'css;
(II'dilymmat from Installation Address) Cily I Smtc Gip
E-mail Address(to receive project communication mid Hume Depot updates): ..
❑I DO NOT wish to receive any marketing entails from The Name Depot
P eel Inf floe: Umlcnigned("Customer"),the owners of the property lorvred at the above in Nation art yeas•agrees to buy,
and'M Al-Home Services.Inc.(`"she Home Depnl')agrees to furnish,deliver and arrange for the installatin ("Installation")of
all materials described on the below and on the referenced Spec Sheet(&), all of which are incorpo&led into C is Contract by this
reference,along with any applicable State Supplement and Payment Summary aaached hereto and ar y Change )rde"(enllectively,
"Contract"):
Job#: tr1O41� van: SS�c Sheel(s)#: 11 1 Jeer Amount
❑Reofmg ❑Siding Windows insulation i
7foL5�9y_ ❑� ,(n.� Emy� ❑ 59771y g 35
ItmRng ❑Siding ❑Windows Iavdanun
1 ❑Outran/Covers ❑Petry Doors ❑ $
Ruses idiog Windows tnsvladun
❑Gomtxs/Covers ❑P.nvy serous❑_
Ruufiug ❑Siding Winda.l ❑insulationT
$
❑[.Ltrcon I Covets ❑Envy IMms I--1 I /
Moommu754vlkpahafCmtraa Amawrwen1dird vEmotrblemmum. •tidal ComhmtAmom�1
Nltinc PuooEwna maynm rkpndl taps tlmuvuWhhddrhe(:mmnctAnuopk WU kJ
Customer agrees that,immediately upon completion ul the work for each Product,Cumaner Will a me a CAa npIcLion Certificate
lone for each Product as dcrined by an individual Spec Sheet)and pay any balam;c Sacs As applic ble, each quartimar under this
Contract agrees to be jointly and severally obligated and liable hereunder.
Tic Hnme Depm reserves the right to ismati a Change(htla ur laminate this Contract or my individ Pmduct(s included heroin,nl
its discretion,if The Home Depot ca it,sensitized service provider drhmmines that it cannot perfral 11111 uhligutior 5 due to a structural
pmhlem with the home,envimmarcntal hazards such as mid,a"ba:"roc nr taint pour,other safety con an.,prich g extras or because
work required to complete the job was not included in the Contract.rac
Pavmeut Summary: The Payment Summary# RZ_875Z . inVImIed as Part of III q Contract, seta froth the told
Contract notoum and payments required for the dCpnita and final payments by Product(as.applicehlc).
NOTICE T O CUKWMER
You ere eatilled to a completely fi W4n copy or the Contract at the time you sign. Do nut sign a ompl Certificate(note;
[here is one Completion Certtlicate far cosh Usted Producl ais defined by individual Spec Sheed)1hefore wu on that Product
is complete.
In the event of termination of this Cre tract,Customer agrees to pay The Hoeffi Depol the coals)of matcrE labor,expenses
and services provided by The Home Depot or Authorized Service Provider through the date o terminati n,pins any other
amounts set forth in this Agreement or allowed under applicable Iaw. THE HOME.DEPOT Y WT'rll OLD AMOUNTS
OWED TO THE HOME DEWYT FROM THE DEPOSIT PAYMENT OR OTHER PA '15 M TV., WITHOUT
LIMITING THE HOME DEPO'1"S OrEHPJR REMEDIES FOR RECOYF,RY OF SUCH AMOP.
Acceptance,and Authorization: Custonntr agnx.%and understands that this Agreement is the entire agreement)between Customer
and'I'Ire Hume Duper with regard to the Products and Installation services and supersedes all prior di. ."ions an agreements,either
oral or wrilu:n,relating to said Products and Installation.This Agreetttem cannot be amigned try anon led except�sy a writing signed
by Customer and The Home Depot.Custoutur acknowledges and agrees that Customer has read,untie stands,vnl nerdy accepts the
terms of and his,nxaaced a copy of this Agreement. I
77/(JFJ/�-` I /
Accepted bY: -'yL ' Submitted by: /!
X I ){
Customer's Signam Sal Coasultanl's gnat Da .
X I '1'chgdnmc Nn. V.TI 2
Cusu,mer s SignaNte Dale
I Sales Comullam License:No.
CANCELLATION: CUST'OMEB MAY CANCRL THIS I (:n app cable/
AGREEMENT WITHOUT PENALTY OR OBLIGATION I
BY DELIVERING WRnWN NOTICE TO THE HOME l
DEP(Yr BY MIDNIGHT ON THE THIRD BUSINESS I II
DAY AFTER SIGNING THIS AGREEMENT. TILL II
STATE SUPPLEMENT ATTACHED HERETOI
CONTAINS A FORM TO USE IF ONE IS II
SPECIFICALLY PRESCRIBED BY LAW IN I
CUSTOMER'S STATE.
NOTICE:ADUfDONAL'IYnh1S AND CONDITIONS ARE STATED ON TILE REVERSE SIDE AND ARE P RTOF TH CIINTRACI'
10-11-12 White-Ilmch Fle, Yelow-Cuetomer
The Commonwealth ofillassachusetts
g Department oj'Industrial Accidents
Office of Investigations
600 Washington Street
k "+ Boston, AM 02111
./
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly-
. Name (Business/Organizadon/Individual): {npNr�7j
Address: �/�� t t �ry(}�lvat! ,:2
City/State/Zip: hone#:
Are you an employer?Check the appropriate box: Type of project(required):
t.❑ I am a employer er with 4. ❑ I am a general contractor and I
6. New construction
employees(full and/or part-t me).* have hired the sub-contractors
2.❑ lam a sole;proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
<'.ip r- ' '' ees These sub-contractors have v f, namnlition
working for me in any capacity. employees and have workers' 9 ❑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 It.[] Plumbin repairs or additions
myself.
m se o workers' com . right of exemption per.MGL
y [N p 12.0 Ro repairs
insurance required.] r c. 152, §1(4),and we have no
employees. [No workers' li. ther__
comp. insurance required.]
"Any appl{'cant that checks box#I must also fill out the section below showing thew m n workers'compensation policy inforatio
t Han eo ant
who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
nCort actors that check this box must attached 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'comp.policy number.
I am an enri Boyer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.It: 1 4 Expiration Date:
Job Site Address: L) V46 41- 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.,500.00 and/or one-year imprisonment,as well as civil penalties in the forth of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of IA for insurance coverage verification.
I do hereby certi un r pal and naides ofperjury that the Information provided ab ve is true and correct.
Si ai Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: PermitiLicense#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
'S ( (a � }"� 3 �`, >J i..i '3( (=r , d l ' -.j..aJ lf;:',J'3 t..�iz
1 unp,'G., -
_ _
'HIS CERTIFICATE IS ISSUED :AS A MATTER OF INFORMATION Ot'Y AND Cut PS me_R' al UPON-T.--'- C�:RTIRGATE HOLDER. T' I'.
CERTIFICATE DOES NOT AFFIR.SIATIVELY OR NEGATIVELY AMEND, EXTEND CR 'T—K THE COVERAGE AFFORD BY THE POLICIES
EELOL'7. THIS CERTIFICATE OF INSURANCE DOESNOT CONSTITUTE A CONTR f ETIAEEN THE I5SW;1> NSJJR >ti S) AUTHORIZED
R: PRFSENTATiVE OR PRODUCER,AND THE CERTIFICATE HOLDER. -
I.1POE7ANT• I`the cerhficai a Felder- an AODITIC1,a IN4UPE0 I—hp p !I �Ile) n o' "e ' I I qI. r lCa I sir I�S A'v� u,
'the f Ca and ldar In hens ci`the p 7 y certa'l POCcie,rev i Guire Bn c:,.,_,-__m nt A..faieri a O- I,iis ,I „L+_d>_s n.,.,.,1 2, Fish,. ,�khe—i
c c nc=.e haldar In lieu o{s� h erd rssment(s).
j r MARSH USA,IK 'anti __ _ _ - _ _. i
. 11 TWO ALLIANCE CENTER, PAONN I_ - _ _ - I ___._
356U LENOX ROAD SUITE 2400 lAxE+IAJI
} ATLANTA CA 30325 - ADDRESS
INSLIR HI IA DRO:N3C RAG NAIb$
INSURER A S' cta t iasurl e C mply
INSURED — _... .—
THE HOME DEPOT,INC. INSURER B:Zurich American Insularce Co - .- - 1653S
HOME DEFOT U.S.A,INC. IasdR°R c;Now Hampshire Ins Co 17841
2455 PACES FERRY ROAD,NW Now
BUILDING C-20 INSURER D,IIOrois National Ins Go 236j7
- ' � � '
ATLANTA,GA 30339 INSURER E-
INSURER.E;
COVERAGES CERTIFICATE'NUMBER: ATL-003159545-04 REVISION NUMBER:7
THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN.ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,-NOPMT ISSUEI ORANY M REQUIREMENT, TERM Oft 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,
INSR - ADDL SUER —
LTR TYPEDFINSURANCE POLICY EFF. POLICY EXP
A GEPoERgI:LIAeILrry — n' WvD POLICYNUMSER __ _ IMMIDD%YYY MMIp R/YYYY LIMITS ..
.. GL0403771-0-03 031U12013 03101 014 EACH OCCURRENCE 3 9.000,000
X COMMERCIAL GENERAL UAUWTY _ 15 GETORENTEp" 1,DOO,ODO
PREMISES(Ea r.nr 1 $
CWM>MADE :�OCCUR OMITS-0F POLCY XS - MED.EXP(Any one Person) $ EXCLUDED
OF SIR$1M PEP,OCC 9,000;000
PERSONALSAOVIWURY §
GENWEGATPEEGATE - §GEN'L AGGREGATE LIMIT APPLIES PER - - PROPIOP AGG -$XPOLICY PR0. LADSBAuromoslLE ugeairY. - DAP2939SE310 031012013 03N1120A COMLEUMITX- ANYAUTD Ea a'ALL OWNED, ; SCHEDULED BODIPerpersonJ $AUTOS SELF INSURED AUTO P.HY DMG _AUTOS BODIPer accMenIj SNON-0WNED ':HIRED AUTOS AUTOS" PROGE SPerac .rA• ..>.::
UMBRELLA LIAR
OCCUR': EACHOCCURRENCE $
.EXCESS.LIAR. CI-AIMS MADE "
AGGREGATE $
DED �.
C WORKERS COMPENSATION WC033575314.(A05) 0]N112013 0310112014 X we srmu.C —�oTH-
AND EMPLOYERS'LIABILITY r "
ANY PROPRIETDRIPARTNER/EAEDUi1VE YIN NIC033.,75315IAK,AZ) .03012013 D3100014 Lt-aci ACCIDENT $ .1,000,DD0
D OFFICERMEbIBER EXCWOE01 NiA
(Manaamry In NH) W0433575316 IFL) 031012013 03I0112014 E.LDISEASE-EAEMPLOYE S 1,D00,000
-0ES
HyyesEssTn'eN unFder'CRIPIO O OPERATIONS below EL DISEASE[POLICY LIMB 1,000.000. $ ____
C WORKERS COMPENSATION WC033575317(KY,NQ,.NH,VT) 03N12013 0310112014 (E)LIMI'r 1,000,DDO
C WC03357531R(NJ) =12013 03m12014
. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IAnachAW RD Tat,Atldllional Remarkz Sfhetlule,Ifrmrespece lrreyuireAJ ,
EVIDENCE OF COVERAGE
i
CERTIFICATE HOLDER CANCELLATION '
THE 110 iE DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HOMEACESFE R INC. - � THE EXPIRATION "DATE THEREOF,•NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD,NW -OUTGOING G20 ACCORDANCE WITH THE POLICY PROVISIONS..
ATLANTA,GA 30339 - _
— ` AUTHORIZED REPRESENTATIVE
ofMarch.USAlnc.
ManashiMukherjee xt
01986.2010 ACORD.CORPORATION. All rights,reserved.
ACORD 25(2010105) 'The ACORD-name and logo are registered marks cif ACORD ..
£J
.. 1L8�U%�ptdMo86LGA o ✓! !F+wb.Y.'tJ "
;ptfice lCgnsumere#Cjurs A:business AegUlaton LScenS;cx regIst'r2tlan Valid for 111 maui us wily
^° leforetheecprxdondate. iffoundreturnto
pME I V1PF bYEMEt�7 Ca}�TPACTAR Office of Consumxt Affairf alld BLIAnessReuuTn,ian ,
Recdtstratlon�.893 .> i Type 10.1'ark-pInzaLSuReSI
Ex' Im Suppleme t End Boy*on,h3A'02X16
rr
The Home pe2lR
RICHARD FALL r L '
. ZE90 C1;IMBERLA�
XWM,`I,,GA3033t � •po,te�iccretary.. - �.. `oEvafid3ithautsignhtuFd'
,
..r•
CITY OF S.3I_E.NI, NWs-siCHusETTS
° Bt.'ILDNG DEPARTMENT
\ 120 WASHLNGTON STREET, Yo FLOOR
TEL (978) 745-9595
F.Ax(978) 740-9846
KI1tBERL F-Y DRISCOLL
NIr1YOA Tko%us ST.PIERRE
DIRECTOR OF P4BLIG PROPERTY/KaDMG CONMSSIONFR
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
t 11, S 150A.
The dehris will be transported by:
(name of hauler)
fhe debris will be disposed of in
(name of facility)
(address of facility)
s gnature of permit applicant
~ dat
, . � '�.Kr"`.�i' wr}.c Si:;"�E r P^�,'s:L 3'P "`t d'..o--�'M.r.' e�.exp :J •
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