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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building /J
Building Permit Application For.
'(Circle whichever applies) Roof,Reroof, Install Siding,Construct Deck, Shed,Pool
Addition, Alteration, Repa• lace, oundation Only, Wrecking
Other.
PLEASE FELL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings: ,
The un igned hereby applies for a permit to build according to the following specificad
Aviv V/ L Ask4 r G.i s
rsi Owne ame: Contractor.
Street L.L oW /� {ty_! Street C�R££AJc4� City_ ul—acesn2
State Phone ( ) State Phone e7,9)41 S6 9 — S�
Architects City of Salem Lkt
Strut City State LIc# HIP p
State Phone ( ) Homeowners Exempt For0!—.Ye5 L no
Structure: (please circle) Fami , Multi Family q Other
Estimated Cost of job$
Ingle 4/ 1 \
Will building confirm to law',—Z--ycs no
AsbesW?_.yes �Lno
Description of work to be done: _
au.
Drawings Submitted: yes X no Mail Permit to:a
Signature of Application,SIGNED UN ER THE PENALTY OF PERJURY
CONSTRUCTION TO BOMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Per WF"# Zoning Mapli of
T
Permit fee S
COIDEMS:
• ;a
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): O D i
Address: -5 S-(-/ i( Joo� Si
City/State/Zip: oc-lzCESi erz Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.A I am a employer with/0 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. t ® Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.❑ Other
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 contactors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
.information.
Insurance Company Name: I i S GF �Y ►
Policy#or Self-ins. Lic. #: C— _ � Expiration Date: _ — O
Job Site Address: 7 b,)t L L ow J`a t) . City/State/Zip S,'A LElk—
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 form 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 the DIA for insurance coverage verification.
I do hereby certify un er the pains and penalties ofperjury that the information provided above?is true and correct
Signature: 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
6. Other
Contact Person: Phone#:
Information and Instructions,
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal.entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance,with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. ,Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial.Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3Ro FLOOR
SALEM. MA O1970
TEL. (978)745-9595 ExT. 380
00 FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34,I acimowledge that as a condition
of Building Permit# all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III,S 150A.
The debris will be disposed of at: '-)145 Gecf N w OUn '�1 ) 1�02 CP`>'IC 2
Location of Facility
Signature of Permi App cant Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
N NoLA
Name of Permit Applicant
�Aowxt bw6
Firm Name,if any
�ju5 (�E�rvw0ol� � , Ul)o2Cc5ff�
Address,City& State
The above statute requires that debris from the demolition, renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
8/31i2005 The Home Depot At Home Services 4:04 PM `y w
Lead Detail-1926231
Customer Information - Job Information
Homeowner............ Mr.ANN VALASKATGIS Sale Amount..... $4,242.00
Homeowner............ Product............... 6500/6100 Series Windows(8%)
Job Site Address...... 15 WILLOW AVE Status.................. Sale/Released to Production
Salem,MA 01970 Branch................. Boston
SM........................ Louis Milano
County..................... Essex PM........................ Michael A.Defelice
Billing Address......... 15 WILLOW AVE IM......................... Dale Johnson
Salem,MA 01970 PC......................... Linda M.Finlay
Measure PM........ Michael A.Defelice
Home Phone............. (978)741-8040 HIM...................... Russell A.Johnstone
Work Phone.............. Ext OM.........................Alison Kravice
Cell Phone................ Installer................
Pager....................... PIN Crew.....................
Work Phone 2...........
Cell Phone 2.............. Sales
Cross Street............... Commission..................
Consultant Name Term Date
Key Dates Sean Naughton Split
Sale Date.......... 8/30/2005 FLIP Date................. 400.00
Credit Date........ 8/30/2005 FPD-Customer....... B-Back Sale................. No
RTP Date............ 8/31/2005 Post Install Date...
Start Date............. FPD-Home Depot. Marketine
Inspection............ Referral Store............ 2663-DANVERS
Base Store.................. 2686-SALEM,MA
Final Pavment Information Lead Source................ 0019 Self Generated Lead
Source Approval Code HD Store Associate....
I... Customer Check 1... Self Gen...................... Sean Naughton
2... 2... Appt.Generator......
3... 3...
Payments Transmitted
Received Tender Type Check# Payment Anal Payment Type Deposit Date Entered by Entry Date Date
History
Date Time Lead Management Agent Status Appt Date Appt Time Correction
Laura Boggs F<eleased to Production o
8/30/2005 1:12 PM Maudelene McCleary Credit Pending 8/30/2005 9:00 AM No
8/30/2005 1:12 PM Maudelene McCleary Sale Pending 8/30/2005 9:00 AM No
8/30/2005 1:12 PM Maudelene McCleary Order Entry 8/30/2005 9:00 AM No
8/29/2005 8:56 PM Michael Tatliak Sent to the Field 8/30/2005 9:00 AM No
8/29/2005 6:22 PM Leonie Issacs-Bowick Pre-Book 8/30/2005 9:00 AM No
8/29/2005 6:22 PM Leonie Issacs-Bowick Confirmed-Customer 8/30/2005 9:00 AM No
8/29/2005 6:21 PM Leonie Issacs-Bowick Not Qualified/Not Interested No
8/29/2005 5:48 PM Josephine Cabrera Pre-Book 8/30/2005 12:00 PM No
Page I of 2
Aug 30 05 08: 35a asean _ 781 246-0299 p. 4
HOME IMPROVEMENT CONTRACT
Sold,Furnished and Installed by:
Branch Name: /� Date: _�l!J.ice THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
345A Greenwood Street,Worcester,MA 01607
Branch Number: J Job#: /> vZ 3 i Toll Free(800)657-5182; Fax:508-756-2859
Federal IDk 7 5-269 8 460 ME Lic k C 02439 Rl Cont.Lick 16427
Cf Lic#565522; MA Home Improvement Contractor Reg.4126893
Installation Address:
City State Zip
Purchasers: Last 4 Digits of Driver's Lic.#&Exp.MofYr: Work Phone: Home Phone:
( ) ( )
home Address:
(If different from Installation Address) City State Zip -
E-mail Address(to receive updates and promotions from The Home Depot):
Project Information: I,/We/You("Purchaser"),the owners of the property located at the above installation address,offer to
contract with Home Depot U.S.A.,Inc. ("Hwne Dep o�t: to furnish,deliver and arrange for the installation of all materials as
described on the attached Spec Sheet#: G2 c3 ,incorporated herein by reference and made a part hereof.
Home Depot reserves the right to cancel this contract if, upon re-inspection of the job. Home Depot determines that it
cannot perform its obligations due to a structural problem with the home or because work required to complete the job
was not included in the contract.
DEPOSIT PAYMENT OPTIONS
(Subject to fund verification al credit approval.)
/ yG 1. Check,Cashiers Check or US Postal Service Money Order
CONTRACT AMOUNT % (Made payable to The Home Depot).
-LESS DEPOSIT $ 7 2. Credit Card`and'orotlter payment options-Circle One Below
Visa MasterCard Discover American Express
BALANCE DUE
ON COMPLETION $ The Home Ihpor Home Improvement Loan Th m e Hoe Depot Credit Card
Available Credit:S (HIL&HDCC ONLY)
Minimum 25%of Contract Amount due upon execution
f this contract. Accet: Exp.Date:
Name as it appears on card:
Indicate Payment Method For *By my-our signature below,I/we agree to allow Home Depot to charge the above
BALANCE DUE ON COMPLETION: referenced credit card fortlrc deposit indicated.
Cardholdei s Signature Date
t IIIL or HllCC Authorization Codes
Deposit Final Pa -menu
# #
Purchaser agrees that, immediately upon satisfactory completion of the work, Purchaser will execute a Completion Certificate
and pay any balance due. Purchaser also agrees to bejointly and severally obligated and liable hereunder.
Entire A reement:This agreement and its attachments, including any financing agreement, contain the complete agreement
between t e parties and can not be amended or modified unless in writing In a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep
it to protect your rights. Do not sign any Completion Certificate or agreement stating that you are satisfied with the entire project
before this project is complete. Law prohibits Imme repair contractors from requestin or accepting a Completion Certificate signed
by the owner prior to the actual completion of the work to be performed under the confrac[.
You may cancel this transaction at any,lime prior to midnight of the third business day after the date of this contract. See Notice of
Cancellation for an explanation of this right. There will be a service charge equal to 25% of the contract amount if the job is
cancelled by Purchaser AFTER the third business day.
BY MY/OUR SIGNATURE BELOW,IIWE AGREE TO,BE BOUND BY THE TERMS OF THIS CONTRACT. I/WE ACKNOWLEDGE
o r.rr.
WINDOW SPECIFICATION SHEET - Spec. S eet#:';., ;--t238i; ]. Sheet: of
Customer:Z1—k4oT,,,is____________Job#:A726Z3( Consultant: '_ktbN Date:
Q
Existing Window New Window
Measurements Grids Pattern' Pattern''' Pattern1.2 Window Hinge Locations 3
u c m c _ 1° c =° &Glass Misc. csml,cpc.Bay,sow,
Rough Opening c m o ° 10 0 ° o
w Location Style Metal Style Series c iz 6 '� ,� ;� N ;� Options Items Patio B Garden Doom
C 'c
(RoomlFloor) "Code" YIN "Code' "Code" U Width Height IJ t'—' U > _° > _° > 2° "Code" "Code' (from outside,uto Rp
ma is� 04 IVaq 6� A# 33 bLl ��
N `
O 2 r
I
to
N
4
co
P 5
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6'
I V
8
9
10
11
12
Grid Pattern and Location MUST be indicated. Color Of L�
' If a single window or mulled windows require multiple grid patterns,indicate location and pattern in the additional spaces provided. Window I Door Wraps Lj,_iJ j f
3 For Csmts,CPC,Bay or Bow,us "I","R"or'S"(Stationary). For Patio&Garden Doors,use"S"(Stationary)or'x"(Operating).
C
a
BAY/BOW WINDOW GARDEN WINDOWS
1A Projection Angte: (Bay:3e or 45) Top of Window to Soffit(inches) WALL THICKNESS (Inches)
Bay Window Flankers-DH/Csmt. Width of Overhang(inches) SEATBOARD MATERIAL
re Seatboard Material-Birch or Oak If tied to Soffit,color of Soffit material Specify Birch or Oak Veneer or White Pionite
(*) New Interior Casing(BaylBow/Garden/Patio Doors) Construct Roof 1(Yes I No Addilional charge for wall thickness of B"or more.
W Clamshell(CL)or Colonial(CO) a There is no guarantee that new shingles will match existing enter.
O
N I have reviewed and agree with all of the
0 SPECIAL CONSIDERATIONS: job specifications described above.
0
m
D
Customer Sign ure Date
,1
1 5 14 03 SFC..W,VW