14 WHALERS LN - BUILDING INSPECTION (3) a I I the Commonwealth of Massachuselts
` 1 Board of Building Regulations and Standards CITY
ALEM
Massachusetts State Building Code, 780 C'MR, 7"'edition OFdAinua
Ret'iard J�tnu�tm
Building Permit Applicatipn'ro Construct, Repair, Renovate Or Demolish a 1. 'uo,v
ne-or Ti o-Family Dwelling
This ection For Ot)icial Use Only
Building Permit Numb r. Date Applied: t
Signature: 1• 7 2 C L.�
Building Comm nspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Ad rgss: ( 1.2 Assessors Map& Parcel Numbers
P
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 It) Frontage(R)
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: PROPERTY OWNERSHIP'
2.1 Owner P(Record: r
Name(Print) /+ Address for Service:
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
S
h
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S I. Building Permit Fee: $ 4ndicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanicaf (Fire S
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) qq�
License Number lispir is I ate
Nance ' 'SL• I uIJ
List CSL-Type(see below) ��5
J • s WSFRe,ritcdential
RcJ u m Is 11e tiTelephone tial Solid Fuel Burning Appliance Installation
U I Residential Demolition
®Registeredo r ement ontyp (HIC)
or M Regi r - Registration m/�/�I3Expimti toTelephonolne�JJ _: WORKERS' COMPENSATION SURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu a of the building permit.
Signed Affidavit Attached? Yes ......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, : VIzCt as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
11 i ry
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, -41 , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
��—
Print
S14ture of )wner or Auth rize gent Date
Si ned und4r the pains and penalties or perjury)
NOTES:
I. 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. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage• finished basement/attics,decks or porch)
Gross living area(Sq..Ft.) Ilabitable 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 Fnclosed Open
3. "Total Project Square Footage" may he substituted for"Total Project Cost"
10-10V-08 03:47PN FROM-Hoes Depot 2686 +9797401402 T-002 P-001/007 F-742 / Y
HOME IMPROVEMENT CONTRAt:t
PLEASE BRAD THIS
' Sold;Furnished and Installed by: .
d
Data:` ��� . . THD At-Home Services.Inc.
Branch Name: Boston - Wa The He=Depot At-Horne SerVitaa
345A Greenwood Street.Unit 2,Worcester,MA 01607
Toil Free WO)657-5182; Fax(508)756-8823
Branch Number:31 Fedanl ID$75-2699460;M61ic$C 02439;RI Coot Lic 164273
CT Li,$565522:MA Homc Improvement Copmn or>�•
Installation Address: City - State zip
Work Phonm Home Phone: Cell Phone:
Parehaser(s)- 1603 6�o
Herne Address: _ city Zip
t, store
(Ifd fromInstallation Address) u );I3 EL-1 �t- • Lr/N+
i�Address(to receive project ptM"cadom and Home Depot l�
DO NOT wish m rc Live any marketing entails from Tiro Home Depot located at the above installation address.agrees m btry,
ptni�t infort tm : Undersigned("Cnstamer"),the ownets'om�ishe�l-deliver and anauge for the installation C�s��bon")of
and'1'HD At-Home Servi.xs.Inc.(` Me Rome DeP60 agrees s rated into this Contract by othis
rematerials wbtaayapit ibelow and On the referenced iable State Suppimeant and Pay ins SSuummary uncombed betetot and any Change Orders(collectively
referetttx,along
"Contract"): 1 -
S e $._ Amount
sob$: anw..t� ,,,hb�,r ]amino n'f
acing Siding � S 'j.�o� $ y'��j�
r-,"3t{ n�y priutttsr/Crean+ OF+tliv ra;era [l — — —•
u.a..,.-....:-.... tom......,....,, f'1
ng OSid"wg Windows ❑Inmladan $.
flli¢ofioe 1 jSYding U wmaows IJ L. � P
I3r..mnn l r.amt I-llinrry
i .' .ddin offlor Ya • . i . r i tot, S f�'.F f-yam vv
... -r-•.--__- .� rC
. ....
C joe,mr agrees mat.iffnm m' y sW_""'r,unv.•..<.,_—"-t-'w .u.na'.zoan.�.•�tr..ai..v wln'...ut,tw u C..+p ants rttt Cut:
an balance due. As apPb^-able. earn tatswum. w..t... a,,.
(one for each Product as defined by an iu�vithta]Epee Sheet) and pay Y . .
contract agmes to be jointly and severally obligated and liable hereunder- - included heroin,
The Home Depot ttraervcS the right to issue a Change Order r terminate this determines thaztitmcant Or m Pe divid in Produ Koss due no a structural
its discretion,if Tiro me. m Depot or its hatandzed service Pro ceps,Pricing aunts or because
problem with the home,eav"vortmtnual m included
such as mold,asbestos m lead paint.other safety
work required to complete the jots was not included in Contracts Contract, sets faith the total
Pavnmut Summary: The Payment Summary$ part of of tthi
Contract amount and payments mquire ��� included as pad for The deposits and final by Product(as apt
NOTICE TO CUSTOMER a completion CertiPrcato(anti.
Yon are nodded to a completely� -lo copy of the Coatnuc at the time You sign. Do not rigs °Work on that Product
there is one Cumpletion Certilicafe for each]bled Product as defined by imlividuat Spec Sheets)bacons
is comPlae• labor,expenses
In the event of mradWdon of this Contract,Costumer agrees to Pay The th no&the date of Home Deem the costs or materiaiS pros ony other
and Services Provided by The li m,Depot
or trader izpepd Scrvl law. Tider r HE HOl DEPOT MAY TrFatOL-D AMOUNTS
amounts set forth in this Agreementpp MADR, WITHOUT
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS
LIMITING THE HOME.DEPOTS OTHER RRhiEDIFS FOR RECOVERY OF SUCH AMOUNTS.
.oe and Aatholl"tion: castomcr agrees and understands What thin a alm is l priordismuSa�sioens and ag t ttsbetween swdter
mer
� t with regard to the Products and Imand'adtm services and pit Pt a writing signed
andoral
The Home RepoTit cannot aSSi or amended exce by g s a
or¢l m vmtcen,n:lazing m said Productsc notrrer acknowledges and sand agrees that Qtsto has undenlarldS,voluntarily accepts 0te
by(1LsmltiCr and The tee Dolan mie customer
ter has copy gree
Y 1( (4 sXoa
Date Sales Con ature
Consultant's Sign Date
{ Custo ei s !gas ure ia ;2 q-3
\ .X Telephone No.
tr's Signatum Data Sales Consultant license No- t„s uppamhk)
C,sA_NCELLATI.O_M CUSTOMER MAY CANCEL THIS -
AGREEMENT VV11•HOUT PENALTB OR OBLIGATION
BY DELIVERDVG WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
LAY ABYBR STONING T•IH6 JLCREEMFNT • THE.
STATE SUPPLEMMT ATTACHED n> TITF S
Sd�LT,QM11�ts9;..1}�rI•�ttF•I9•I,�M.-. __
PIT9T9u7}mHnFwbDTTri]14AL mhsasre.r.a",�wu+...............................1-,e..n••,• •,,...... ......... .........rn.rr
M3o-Ptpinrh Rla yellow-Customer
Ugl.iruncnl of 19�hlic?al:n ..
(i 1 ' 1 9r.iLhu R I rtimi i 1.rmd'.Ira,
Fts V:c na c. Y;s
17 9EACH ROAD A?-. 4i
LYNN.MA 01902
��L _¢�� Espirslion: 267012
I•.n�ni..h.m. Tr: 99699
CITY OF S.U.E.tit, iL L-kss.A cHUSETTS
• BI;MDLNG DEPARTNE&NT
120 WASHNGTON STREET, r FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
Kl.,%tgFnr RY DRISCOLL
�U1YOR 'hioi►IAS ST.PIFRRB
DIRECTOR OF PUBLIC PROPERTY/13CMDNG CO%WISSIONER
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 It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued-with the condition that the debris resulting fiom
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris wi H be transported by:
ow— I rL44
(name of hauler)
The debris will be disposed of in
(name of facilit)'
�0 tA01
(address of facility)
4n4aturef p rmit applicant
• to
"Rp CERTIFICATE OF LIABILITY INSURANCE DATE(M"° ",,'
AC-ORD ez/19/lD
rPRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED. AS A MATTFF2 OF INFORMATION
sh DBA, Inc. I7i`IL f AVD CONFERS NO RIGHTS UPON 'It CE"!IFh r
RNL ER Trila CER SIC COF., NC :!'- I� ( ciVC .�.:n-� 4 .c �i -C- _a , .:50 Lencx Road, -e 2400
c , ;C P is Ds ___2 D.3 Ot U.S.A i_z. -_...�1 1\.- _d:t I 13
2455 Paces Ferri Road Net IN SI;R'ZRC.New Hampshire Ina Cc
Building C-20 INSURER D:NATIONAL UNION FIRE INS CO OF PITTS ! 19- 7_45
Atlanta, GA 30333 —. ..__._-.._.._...
tNSURERE Illinois Union Ins Cc 27960
COVERAGES -
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THEINSURED 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR OD'L POLIOYEFFECTIVE POLICY EXPIRATION LIMITS
T POLICY NUMBER q MMI T M I NV V
: IYPF OF
GL04 8 37 714-0 0_ 03/01/10 03/0?./].7 EACH OCCURRENCE S4,000,000 _.
UAMAG TO R NTED
t—
GENI RCIAL GENERAL LIABILITY PREMISES Eaa curtence 81,000_000
IMS MADE �OCCUR - - MED EXP(Any one Person) $_EXCLUDED____
PERSONAL 4 ADV INJURY - S 4,000y 000 _
GENERAL AGGREGATE S 4,000,000__
GATEUMIT APPLIES PER: PRODUCTS.COMPIOP AGO $ 4,000,000 PRO- LOCB LIABILITY- - BAP 2938863-07 03/01/10 03401/11 COMBINED SINGLE LIMIT $ 1,000,000
- (Ea accident)
X ANY AUTO `--'----.
ALL OWNED AUTOS - - + BODILY INJURY $
(Per person)
SCHEDULED AUTOS - --- ------
HIRED AUTOS BODILY INJURY S
(Peracadent)
NON-OWNED AUTOS —
X SELF INSURED AUTO PROPERTY DAMAGE $
(Per accident)
PHYSICAL DAMAGE
ARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $
—7
ANY AUTO - OTHER THAN - EAACG $
GRAUTO ONLY: AGO S
A EXCESS I UMBRELLA LIABILITY GL04807714-00 03/01/10 03/01/11 EACH OCCURRENCE S 5,000,000
X OCCUR - -1CLAINts MADE AGGREGATE - Y �,000,000_ _
$
DEDUCTIBLE
RETENTION S $
C WORKERS COMPENSATION WCO20342355 (ADS) 03/01/10 03/01/11 % -WC STAID OTH- -AND EMPLOYERS'LIABILITY Y I N
D ANY PROPR15TOIWPARTNERIEXECUTNE� WCO20342356 (CA) 03/01/10 03/01/11 E.L.EACH ACCIDENT _ $ 1_000,000_--_
OFFICEWMEMBER EXCLUDED) -
E (Mandatory in NH) WCO20342357 (FL) 03/01/10 03/01/11 EL.DISEASE-EAEMPLOYE S 1,000,000
If yes.describe under - E.L.DISEASE-POLICY LIMIT S1,000,000
SPECIAL PROVISIONS below
OTHER
E TX Employers Excess TNSC46242373 (TX) 03/O1/30 03/01/11 Occurrence/SIR 30M/2M
D Workers Compensation WC0910566 (QSI) 03/0'1/3003/O1/11
C Workers Compensation WCO20342358(XY,MO,NY,WI, ) 03/01/10 OJ/O1/11 -
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER - CANCELLATION
SHOULD ANY OFTHEASOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
THE HOME DEPOT, INC. -
HONE DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR -
2455 PACES PERRY ROAD NW REPRESENTATIVES.
BUILDING C-20
AUTHORIZED REPRESENTATIVE
ATLANTA, GA 30339
USA
ACORD 25(2009/01)sthornton_hd O 1988-2009 ACORD CORPORATION. All rights reserved.
14481889 The ACORD name and logo are registered marks Of ACORD
OJTwe oflnvestigations
600 Washington Street
Boston,MA 02111
www m ass gov/dia
Workers' Compensation Insurance Affidavit: Bwtders/Contraztars/E1Ectrir3ans/Plnxt'bers
-ApPUeant Information Please Print i.e>yibly
Name(su�oraomxuvwu2l)�
t ylState p.
(:i lZi .
Arey5w,an employer?Check the appropriate bos Type of project(regoirexi)
t.Uj am a employer with b C'> 4. 0 fam a gamal ooad(200r and I 6..0 New co=Uucfion
cmploYccs(fun wwOrTMt-d=).s BaveLacdtfie salr ooutrac0o s
liseed'a9ib ;1 _ 7•-[]-Btelmg_ ..;__
z.Q-fama-sole;nopAetoraeparmer- ---`---- —These suboontracmisLave 8- QDemoli0on:
ship and have no employees workers'comp-msacerce 9. Q BmAn►g addition
workrog-for me m any capacity- .
[No worker' exrmp-instaaace 5: ❑ We area corporation and its 10.[] ElecuicalrepAs or additim
regnued.l officers Lave eaercisal dre airs or additions
o ex MGL 11 PfimbiogreP
3.❑ I am a homeownta doing all work r?gLY t' emend we
workers- a 152,§1(4�andweLaveno 12� 12oofiep®r^
myselE(No insurance requi v&1 t. COMP. employees.[No wodtus' 13.�&er •� nfS
cOM.insurance iegdav&l
��yaypHcmcttaacbx ow lub #IaffiasosnGM*v c6anbaow&awmcmcwwabw mmp t�'�Rfi .
tgomeowo�wb saumamsafaavk mwra��z•n.wdtmam�almeo�ae�aesws sata�e.ac.v of viead nama,-
r(;000acbrs matmislgx moo dmeLed aoaddtiaosl aLeR aLowiK 4eneot orme my.aaatixtioasaoBEtea�Yodoto�eomP49 mfosmelion. .
their s +mpg nv�m>everensawa msuraumformy a nployem Bdmvfs drepohry awd;ob srta
I urn art emPlol'Q P
infornlaffox
Insa=ac omp=yNam=
Policy#or Self-ios Inc # EaPitahon Date L�
Job Sipe Address 1, 1 �5 h 0 CiY :
Attach a copy of the workere comPmsaaoa policy declaration Page(showing the policy number and fen date}
nnderSection25AofMGLc 152canleadtodtcimpoamonof�alpenaltiesofa .
Failure to scaae coverage ac :. .N .. - -: =... aTmc
fine np to Si�68:b1i `o � a'SY�OP�E7RK Odd
ofup to SZ50_00 a day against thevroj=r Be afinsed diat a eopyof*s statement may be forwwded,tD ft oboe of
inycsfignions of the DIA ce wveragevan5cx&
I do hertby under
the inforatationProvWed ab&M is.trsra aid cornt e
phone#:
pjfida[am only. Do no write in dWs area,to be eomplded by dly-ortmvn nff gew
(Sty or Town - Yeraritldlwrse
Issuing Authority(drdeone): r 5_Plnmbingbwpedor
1.Board of BeWh.Z_Bullding Department 3-C lgfrown Qerk 4.Electrical Inspecto
6.Ather
Phone#_
ENERGY PERFORwNcE RATINGS
- ClJiW��N7E AEM71iRE-`,TOC��O . _ . -
U-Factor Sclar Heat Gain Coefficient
• (J ." Cak'mocGu+arda da FJxtyia Solar
10 , 32 i . 1, 8 .: CI : 29 .
ADDITIONAL PERFORMANCE RATINGS
. orrAExfo
. lVAIiIALY)N]UPl.F71ft7YTJVlI/.
YlsibleTrarumiftance
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Inp da b6d(w poa�M ENF24T SWP*6Lk teanon'Ad rw:iurglst¢Px. . .
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pp33 Office of Consumer Affairs&Business Regulation:
OME IMPROVEMENT CONTRACTOR - t
Registration:426893 - TYpd
EapiraCon 813(2Q 2, Sapplemeot
The Home Decdt Af-Hdfne-Services
RICHARD FALLONE
2690 CUMBERLAND,PARtM/AY S � B"•-e�--