178 WHALERS LN - BUILDING INSPECTION 1 --- I'lie C'omntunwealth of M;usachusells
y: Board Of Building Regulations and Slandards CI'1.1.OF
2 3)' y, b1;Issaehusetts Slate OuiWing Cute, 73B C'fslR SALReviled EM
{N 13uilJing Permit Applicatiun 'fb Construct. Repair, Renovate Or Demolish u
One.or Tnn-P2tarilr Dm ellin,\r
This Section For
Ott 'al Use O"I
Building Permit Number. Da ,\pplied:
BwlJiny Ulticml(Print N,unc) Siallaturc Uolc /
SECTION 1:SITE INFORMATION
1.1 Property Add rff t� �4hl� 1.2 Assessors,flap& Parcel Number
I.la Is[his an accepted street? •es no �lup N"ITIN r Parcel Nwnhvr
1.3 Zoning Information: 1.4 Properly Dimensions:
Luniny District I'nrpnscd(Ise Ent Arun(sy 11) Pnn-4a,III)
1.5 Building Setbacks(R)
hrunt Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.I.e. qo.§14) 1.7 Ftoo d Zone Informations I.g Sewage Disposal System:
Nlblie❑ Pricute❑ Zone: _ Outside Flood Zone?
Chock if es❑ Mwieipd❑ On giro Jisposul s)xtem ❑
2.1 Owner, SECTION 2: PROPERTY OWNERSHIPS
yJrd� ^
N;mw(Print) (u),SIJIa,ZIP
I r•� e257 SW Icx17
No.and Street relephune Email Addmss
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) AI[eratton(s) ❑ Addition ❑
Denwlition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Speciry:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs.
(Labor and .Materials) Official Use Only
1. Building S I. Building Permit Fee: f Indicate how f'ee is determined:
2. Iflectrical S ❑Standard City:Tuwn Application Fee
J I'tumhutg S ❑Total Project COst'(Rent 6)x multiplier
'. Other Fees: S_
a. \4dl.mic,11 ill\ 1('1 S List:
9 11cJh.111ic.d afire S
<u uessum l fJtd .\II Fce3:
n 1'olal Prnjcct Crest S (I1e`) No. CBeek:\nunine
0 Peid in Full ❑Ou15t:mding RaLaw;: Due:
sJ.'CI'IONS! ('ONSI'RU(-noNSFHN'I('FS
�(•)/� ! �y,C�R
5.1 ('unstru tun Spiso COW( ,- I ieeuae" Numho! _ _�—pi ratiary u uIC
N.une nfC.�I. III.IJcrI� � r �. I nt l'SI. 11pe Isee helulll.__._1.S.ItJ- _
—I)PC Description
NU .mJ�tr it IlnrestridcJ tlhlilJin Yli to lt,lllltl eu. ll.l
R I1c�rrictdJ I t2 P.unil Dllcllin
N \lo:on
Lit%ifo State,LIP
RC' Hlnnin Cowrin
µ'S µ'indow,nJ Sidin
' SF SUIiJ 1'uel Burning:\pphanCCY
Ilulduriun
L� f.mail aWN, D DYmolitiun
'I'elc honY
5.2 Registered llume I oprov merit Contractor(IIIC)
cgiYlruiun NumM;r F +iru In DaIY
I IIC•C 11 qqj,N Ifr py lGl l ;IIItY
Finall JddRS!
No. and ' '•t
Ci /Town,State ZIP rely hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.e. 152.y 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 a building permit.
Signed Affidavit Attached? Yes .......... No••• O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR B ILDING PERMIT
1, 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.
Jle
Print Uoner's Nwne(Eleetwlic Signature) ,
SECTION 7b:OWNERn OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby 'Itterund r the pains and penalties of perjury that all of the information
contained ' is application is true and a orate t be of my knowledge and understanding.
Print lhlncr'Y or:\uthorircJ Agcnt'Y Nano 1 '.lYctru is Signat rtYl .
D Y
No rES:
I. .\n Owner who obtains a building permit to do his her own work,ur nn owner who hires an unregistered co tractur
Inot registered in the Hunle lalptovenitnit Contractor IHICI Program).will nu have access to the arbitration
program or guaranty fund under M.G.L.c. 1!_':4. Other in+punam information on the HIC Program can be florid at
„ 1 Information on the Construction Supervisor License can be found at
\then substantial ourk is planned, provide the III_1 inctludinglgarage. finished basement attics,decks ur parch)
rotai tlour area 111.1. 11.1 - --- Habitable room count
(iruiilivingarealsy. 11.l __. .
.. - \unlherul'hedruants _
\unlhcrol'lirrpiaces __ --- Number ol'hall'haths
\tnohcr al bathrooms . . _ \t1inhcr ol'Jccki, pordla
I'\Ite of Naafi tg S'%'will - I�IIe IP�eJ ..(lpell
I\pc pl C.`Pllllg i%itelll
t. "ral,ll I'nljctil SIlu;1lC P.lmaye••In:n) be elh'liluted t1or'•focal Project Coll"
CITY OF S,Uz%r, NEUS.1CfJ(:SETT3
JLULVG camAniviT
120 %V.U.4LNGTON Sr"jJr, j'd FLOOA
rEL k973) 741.959S
'U31:911CRI Y OXIMOLL P•Vt(973) 749W
.tiUYo>t fHows ST.Pa.)us
01"xTCa Of Pt SLIC PRC PEATY/St:MDLN43 COSO)I3SIO,V EX
Construction Debris Dlspasal At'Hdavit
(required for all demolition and renovation work)
In accordance with the sixth edition otthe State Building Code, 730 CUR section 1 l
Oebris, and the provisions of MCL o 40, S 54;
Building Permit At this wvr is issued with the condition that the debris resulting from
k shall ba dispascd of in I 11. $ I JOA. a properly licemed wrote disposal racility as dcBncd by A ICL c
The debris ill be transportcd by;
(n+rnf ufhauler)
The debris will be disposed of in :
-- (namo
of
bur`
(,ddras a(rI,d,1y)
44n ,*
vrrermir ipplianf
Jul 1912 10:48p BOB DANGELO 9785157765 (�p.1
HOME IMPROVEMENT CONTRACT c e-Z
PLEASE READ THIS J"per t Y7
Sold,Furnished and Installed by:
Branch Name: Boston Date: J,:,, er 0 O r z THD At-Home Services,Inc.
"a The Home Depot At-Home Services
908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free(800)657-5182;Fax(508)945-6017
Branch Number:31 Federal ID#75-2698460;ME Lic#C 02439;RI Cant Lie# 16427
/ CT Lic#HIC.0565522;MA Home Improvement Contractor Reg.#126893
Installation Address: � 7 A Ki//o It is /�eORJP SoAPm - /V A O/9),
City State Zip
Purchasers$ Work Phone: Home Phone: Cell Phone:
Home Address.•
(If different from Installation Address) City - state Zip
E-mail Address(to receive project communications and Home Depot updates):
®I DO NOT wish to receive any marketing entails from The Home Depot
Project Information: Undersigned(,customer).the owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services,Inc. C'The Home Depot").agrees to furnish, deliver and arrange for the installation("Installation')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 attached hereto and any Change Orders(collectively,
"Contract"): .
Job#: 0.�d st a .«t Products: See Sheet(s)#: Protect Amount
Roofing OSiding ®Windows0 Insulation
❑Gutters I Covers []Entry Doors ❑ 1! 4116 S $ 3 a3
fing Siding Windows Insulation
❑Gutters 1 Covers []Entry Doors 171 $
Roofing ❑Siding ❑Windows Insulation
❑Gutters I Covers ❑Entry Doors rl $
Roofing OSiding Windows Insulation
❑Gutters t Covers []Entry Doors rl $
•M ido min 25%Deposit of Contract Amount due upon exeatlon of this contract . Total Contract Amount $
Maine Purchasers Amount.rs may not deposit than onerh'vd of tlreCantrad Amount.
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 # 917A94/ , 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).
NOTICE TO CUSTOMER
You are 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 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 RECOVERY OF SUCH AMOUNTS
Acceptance and Authorization: Customer agrees and understands that this Agreement 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
am]or written,relating to said Products and Installation. This Agreement 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.
Acee ted by: Submi
Customer s)5igna re Date Sales Consultant's Signature Date
-0 0 NF�Zshli-,Vo!5
V/orkersl
ix Pleape Ld1itLt9_L_1kV
Naaue (3us_Hess/Organizatior/Ilidi,/idual):
Address:__ CL,
city/state/zip: tM4j,,)V
;J23aT_ Ph melka
4. [11 am a general contractor and 1 E. N 1 [ 1 am a e ow coo."Mucti.-a
, 7mplover with
Are y an employer? Check the appropriate box: :Type of project(recluirr
bave,hired the,Rub-contractors
employees(full and/or part-time). listed,on the attached sheet. 7. n Rciriodehyip
2.El I ain a sole proprietor or partner-and have,no employees
,ship Th ir ese sub�coractors have S. ❑Demolition
working, for are in any capacity. employees and have workers' 9. Building addition
insurance.{workers' comp. insurance comp. l 7 10.0 Electrical repairs or additions
5. We are-a-corporation and its
required.]
3.❑ 1 am a homeowner doing all work officers have exercised their ILE]Plambing-repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[]Ro f repairs
insurance required.]t jc. 152,§1(4),and we have no 13.�Zthcr �Aj rpje)ull�
employees. [No workers'
comp.insurance required:]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy intomation.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicatfig such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or I not those end I tieshavc
employees. If the sub-contractors have employees,they Must Provide their workers'comp.policy number.
I am an employer that isproviding workers'.compensation insurance for my employees. Below,is the policy and job site.
information.
Insurance Company Name: l r0
Policy#or Self-ins. Lic.M K73 Expiration Date:
Job Site Address: ca lo3�� City/State/Zip:__
Attach a copy of the-workers' compensation policydeclaration 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 form of a STOP WORK ORDER and a fine
of Lip to$250.00 a day a . t the violator. Be advised that a copy of this statement may be forwarded to the Office of
ams a
U"Pin,
investigations of the IA r insurance cnvqrpuq verification.'is is
I do hereby certify rider ains 112 it- s ofperjury that the information provided above is true nd correct.
ff 1c
atur c
n :7443
S1 Date:
Phone 4:
Official use only. Do not write in this area, to he completed by city or town official
Of
ficial
Do
not
in this
y write
City or Town: Permit/License#
Issuing Authority(circle one):
Authority
.1 ].Li.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Phone#:
Contact Person:
� t �4i:rscarhu;ut p3 . Department of Public, Sat.;i'
i
� ^.naal ci 9r.ul+lmy Regnlations : nd St.vxlarci;
Lrr,2 it se: CSSL-099699
ROBL+RT POCZOBUT - --
172 WHALL+NS LANE.
Salem MA 01970
i�<�nirtv,+suuer 02/08/2014
/
'ATE OF UABIWITY NSI-MAN
;_, T U _ w E , ?-
.�THIS CERTIFICATE 15 ISSUED AS A�;ERTIFIC Uri
MATTER OF INFORMATION ONLY A,4D COPS.='„5 NO RIGHTS PON THE r I--%;17 �yx a�E .. v
j THIS CICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE ,POIL Lip3 ,
j BELOW. THIS CERTIFICATE OF INSURAAICE DOES NOT CONSTITUTE A CO9iTR>lCT B'cTT1EE3d THE ISSUING INSURERjSj, AU7NO+REEP I
i, REPRESEN7ATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. ..- .'
7MPORTAN7: 1#the tsr#ifivats holder is Bn ADDITIONAL INSURED,#hB pv3ivy+lesj m:asi'Ds sndar. n s -Ttificata doss ay .art s/c l'I su#J; to ±
1 Rhe terms and canditions a#tY,a palicy,csT#ain policies may TegDiTs an endaTsamEDT. A rs oYT'chl�c„Tsllcat dv s n.t v,roar riyi�as,a t,�. i
� aariifica3e balder in lieu of auch EndvrssTnent�sj. --...-.------�-_------ "�
1-855-966-4584 CONTAC
j PRODUCER - �ME' 'A:(
➢idrah IISA InC. PNONEe LAIC.drop
c
E-MAIL
homedepot.certrequest®marsh.com ADOI+Ess: —
Two Alliance Center, 3560 Lenox Road, Suite 24+00 INSURERS AFFORDING CO`fERAGk' NAICA
Atlanta, GA 30326 INSURER A: Steadfast Ins Co 26387
Fex (212) 948-0902 16535
INSURED INSURERS: ZUYLCh Ameri C8Il IIIS CO
The Home Depot, Inc. INSURERC: Na- Hampshire Ins Cc 23841
Home Depot D.S.A., Inc. INSURER D: Illiaois'Natl Ins Cc 23817
2455 Paces Perry Road NW
Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445
Atlanta, GA 30339 INSURER F: Illinois Union Ins Co 27960
COVERAGES CERTIFICATE NUMBER: 25776028 - REVISION NUMBER:
F INSURACE LIb I ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDIND CATED. FOR THE
CNOTWF THSTAND NG ANY POLICIEST' AT THE REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIDTH VE RESPECT TOLICY WHICH TIHIS
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.
POLICY EFF Pinion EXP LIMNS
ILTR TYPE OF INSURANCE POLICY NUMBER MIDDIY MMI00
A GENERAL LIABILITYGL04887114-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000
TO EN 1,000,000
E PREMISES aoaunence E
COMMERCIAL GENERAL LIABILITY MEp EXp(Any one lxrton) EEXCLUDED
CLNMS-MADE a OCCUR 9,000,000
g LIMITS OF POLICY KS PERSONAL BADV INJURY S
E OF SIR: $1M PER OCC
GENERAL AGGREGATE g 9,000,000
PRODUCTS-COMPIOPAGG $ 91000,000
GENL AGGREGATE UMITAPPUES PER: E
X POLICY PRO- LAC
BAP 2938863-09 0 0 03 0 3 EOaBINtlSINGLE LIMIT 1,000,000
B AUTOMOBILE LIABILITY
BODILY INJURY(Perperson) E
X .-ANY AUTO - _ - - —_
ALLOWNED SCHEDULED BODILY INJURY(Paraccitlent) S
AUTOS AUTOS PROPERTY DAMAGE $
NON-OWNED - Per -tl t
HIRED Al1TOS AUTOS S
X SELF INS PHY DMG
EACH OCCURRENCE $
UMBRELLA lL1B OCCUR
AGGREGATE $
EXCESS WB CLAIMS-MADE - -
E
CEO RETENTION WC STATU- OTH-
C WORN ERSCOMPENSATION WC019736915 (ADS) 03/01/1 03/O3/33 E
ANDEMPLOYERIi LIASILITY YIN WC0197 3 6 917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT E1,000,000
D OFFICEWMEMBERUCLUDDED? UTNE� NIA S1, 00,000
E (Mandalay IYPROin NH) NC0197 3 6 916 (G) 03/03/1 03/Ol/33 E.L DISFJSE-FA EMPLOYE 0
IIyne H) E.L.DISEASE-POLICY LIMIT S 3,000,000
DESCRIPUONOFOPERANONSbebw pC1392499 (DSI) 03/01 1 03/01 13 SIA (ADS)/SIR (GA) 1N/750,000
E Workers Compensation
C Workers Compensation WC019736928 (NI) 03//O1/1 01/1 03/01/33
/SIA 30M/3M
P TX Employers Re Indemnity TNSC96566397 (TX)
03 03/01/13 Ocnurreace
OESCMFnON OF OPERILT ONS I LOCATIONS'VEHICLES(Attxh ACORO Iet,AddMonW R=wMs Schedule,Nm e m to reputmd)
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE 80MB DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ROME DEPOT U.S.A., INC.
2455 PACES FERRY ROAD BN AUTHORIZED REPRESENTATIVE
BUILDING C-20 �f(�_7���•
ATLANTA• GA 30339 USA
0198$;2010 ACORD CORPORATION.^PALL rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marksl9#ACORD':"
y� J�C L/O%WJ2dl{ll22G1/r O�.//1L04:1R4�{S ltw
Office of Consumer Affairs&Business Rega!ation
OME IMPROVEMENT CONTRACTOR
Registration'1126893 Typt:
s .`Expiration=8/�3/20124 Supplement
The Home Depoi Rt Hn eSenn°r'res
RICHARD FALLOIJE-;- ,et -
' 2690 CUMBERLAND Al -
A'�L`AN'I GA 30339�`- undersecretary
WINGS
ENERGY PS R=OR.AANGE Sa
VAWACiGNGENc_NCIMIeNTG E�SoIa Heat Gain Coefficient
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nAnes ue deumined fenAspd seloi enulmtu^enW ca�dens aM aspecYm Ptoduct:I:e.NPAC wss mstrccemmerdanY Product
and doesnotYnma^I InfmmaTen.wxxntm.W -_�_. .-
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