35 DUNLAP STREET - BUILDING JACKET -r 35 DUNLAP STREET
r
r
Cftp of baCem, Ang;arbugettg
i3ublic Propertp Mepartment
�3uilbing Mepartment
One ipalem Oreen
745-9595 (Cxt. 380
William H. Munroe
Director of Public Property
Inspector of Buildings
Zoning Enforcement Officer
September 21 , 1988
Mr . Michael A . Ventura
35 Dunlap Street
Salem, MA . 01970
RE : 35—Dunlap—Street;
Dear Mr . Ventura ,
Acting on complaints to this office of the above re-
ference property , we posted a Stop-Work order on your property .
You are in violation of Mass . Building Code Sections 113 . 0 and
121 . O , ,working without permits ..
The covering up of asbestos siding is not allowed . To
correct these violations , you should contact this office and
obtain all required permits within seven days from receipt of
this notice . Failure to comply with this order , will subject
you to fines and imprisonment or both .
Sincerely ,
James D . Santo
Assistant Building Inspector
JDS/eaf
C . C . City Solicitor
Ward Councillor -
II �IlEili, a?XCIIE
z �ublic �ropertu Bepxrttneltt
s 5 �
��"ecq,y�.r N`'�� �I� UtJlflti� �PpZtrtritettt
(one �alrru (kjrcrn
715-0%13
'William H. Munroe
Director of Public Property Maurice M. Martineau, Asst Inspector
Inspector of Buildings Edgar J. Paquin, Ass't Inspector
Zoning Enforcement Officer John L. LeClerc, Plumbing/Gas Insp.
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COMMONWEALTH OF MASSACHUSETTS C ASBESTOS REMOVAL DESCRIPTION
DEPARTMENT OF ENVIRONMENTAL QUALITY ENGINEERING 1. ASBESTOS CONTRACTOR
DIVISION OF AIR QUALITY CONTROL Name: "'. _ / l-' Telephone:( ) 2
)SEE LAST PAGE FOR OFFICE LOCATIONS) Street Address: City/Town:
NOTIFICATION FORM FOR Department of Labor and Industries Certifications f
ASBESTOS REMOVAL AND GENERAL DEMOLITION/RENOVATION
2. ON-SITE SUPERVISOR
Name:
A I APPLICABILITY Department of Labor and Industries Certifications
DeMolition/Renovation operations involving asbeabscontein'mg material(ACM)and DemdF & SPECIFIC WORKSITE LOCATION(S)(i.e.Building name,number,wing.Fim.room,tunnel.Is
tbnlRenwation TE"
tiOn9 are regulated by the Departmed of Environmerdel Ou 'ureednp the job indoor or outdoor!)DivisenOuefyComre"under egEGAL OFFgeneral dero4. ESTIMATED AMOUNT OF EACH TYPE OF ACM TO BE HANDLED(in linear and/or square feet)ngACMlander310CMR7A9(2) boiler,breeching,dud,tanksuAececcatingsTire rg information is required pursued l0 310 CMpR 7.iS -
Capies d"Regulatiara for Me Contrd d Air PblluOon",310 CMR 8A0 to 8A0 may be pumhased hem Thermal,solid core pipe insulation
the State Bookstore, State House, Room tie, Boston,Maeeadtusetla,02133. Telephone number(817) corrugated or layered paper pipe insulation
727.2834.Please Print
. insulating cement
spray-on fireproofing
troweuspray coatings
cloths,woven fabric
B GENERAL PROJECT DESCRIPTION transite board,wall board
other-please describe -
1. FACILITY TOTAL ii>/?.f�/7.'f,-'(� -:f-.7 4 Telephone:( ) • TOTAL IN LINEAR FEET ---
i fila TOTAL IN SQUARE FEET
Street Ada34
: _3f%'�h�LAn=S �G ,.
Cdy/iown:;�
" ----�.� S. DESCRIPTION OF TECHNIQUES USED FOR ESTIMATION
Size of Facility:in square feet: ii O J G a._Y i- !_-s-,�,1_77W
I
In number of Doors: "
Was the Faci ity built prior to 19807 yes 1-� no & ASBESTOS REMOVAL START DATE: END DATE: 9 ,
HOURS OF �'.re -i0.' 0 DAYS OF .E
Current or Prior use d Facility: i" Yin' irrYi_9� OPERATION: daytime. OPERATION: Mon:Fri.
Is the Facility Occupied? Yes `� No evening Sat.-Sun.
j 2. FACILITY OWNER night
Name: Telephone: (NOTE:Any changes In these dates must be reported to the appropriate regional office.11 a removal
p ( ) Is postponed for more than thirty(30)calendar days, spearate notification will be required.)
I
Street Address:- City/Town 7. DESCRIPTION OF ASBESTOS REMOVAL PROCEDURES TO BE USED
I n glove bag
1 3. ON-SITE MANAGER full containment
Iencapsulation
Name: Telephone;( ►__— - ---enclosure -..
Street Address:_—_--. City/Town --- cleanup
disposal only
4. GENERAL CONTRACTOR , other-please describe -- _---
Name: hi_ f._f '.��. S=y. r'/' Telephone (
Slreel Address _. _. . ._.- CII n Vii._ ! L' ' ;' S. TRANSPORTER OF ASBESTOS-CONTAINING WASTE MATERIAL FROM SITE TO TEMPORARY"
WTot" — STORAGE SITE(1F NECESSARY)TO FINAL DISPOSAL SITE
Dees"pro)eellnvW edwre to of idAsrsftmdmol&VAdmaimCandnkvMobrial(ACM) Neme:_/-"'i " • "'W / /-.r-l.=i -- Telephone:
) ,
P 1
as defined and applied in 310 CMR 7.00 and 7.187 Ire No Sheet Address: 11 City/row"
9. TRANSPORTER OF A.SRESTOSCONTAINING WASTE MATERIAL FROM RFMOVAUTFM-
IF YEB,you must Will M full the Mformallon raquaalad In"colons C through d below.IP mot POITAIIV 0101A0L UI I L TO FINAL 0191109AL 911 E
yeu must oupplif MAIN the brMrmelbn M is"I ret D and i. --- Nemn; _ talutdume ( 1
.-... .---...-....__..._............._.....---- ---------..._..---- ------ - BlreelMMreea:-__._ . .---.. _. _ . ...---- cilylfown --
10. 111'1 UOG 111ANNI-0i OIAIION FACILITY AND OWNLN(IF APPLICIIULE) ,
*vNart e: — :t 1.1 i i. • �, ,.,. TeWphone•1 1
Owner's Name:
10.00.E:haneler Stations moat comply with Division d SolidWslds Regulations 310 CMR f T� F
It. FINAL DISPOSAL SITE I None: /H`. .,.',:. /,I'('0ri,.• ,/ EFA�11 te; V Z10111
Name: Tilep one:( ) Street Address: CIOVTbwn:
Street Address:___.-_.__ _ CltyRbwn— --_�y'_L'_ .. THIS FORM MUST BE SIGNED BY THE OWNER OR BY THE RESPONSIBLE OPERATOR OF THE PRO
Owner's Nemo:
POSED PROJECT,
(NOV L:Disposal(A ACM must comply with the Division of Solid Waste Regulation 310CMR 19D(1) r CERTIFICATION:I CERTIFY THAT I HAVE EXAMINED THE ABOVE AND THAT TO THE BEST CF MY
KNOWLEDGE IT IS TRUE AND COMPLETE::"IiNATURE SUBJECTS SIGNER TO THE PROVISIONS
12. FOR EMERGENCY ASBESTOS REMOVAL OPERATIONS,NAME AND TITLE OF DEOE OF- OF THE GENERAL STATUTES REGARDING FALSE AND MISLEADING STATEMENTS).
FICIAL WHO EVALUATED THE EMERGENCY
tc i
Name: TIMI (SIGNATUR� (TITLE)
Date d Authorization: g
(REPRESENTING) 7 (DATE) r'
-- O GENERAL OEMOLITIONMENOArON DESCRIPTION
1. DEMOLITIONIRENOVATION CONTRACTOR
Name: ''. t /i% �.i`-iP r'n/J%� Telephone:( f c,F) 9 27 ..! cCp F REGIONALOFFICE LOCATIONS .
Street Address: d 7/'/'ir/G,'- S'7-. city/Town:_/t//�!1J�(:ri
2. ON-SITE SUPERVISOR AIR QUALITY SECTION CHIEF AIR OUALITY SECTION CHIEF
DIVISION OF AIR OUALITY CONTROL DIVISION OF AIR QUALITY CONTROL
Name: MET BOSTONINORTHEAST REGION SOUTHEAST REGION LAKEVILLE HOSPITAL
3. SPECIFIC WORKSITE LOCATION(S): 5 COMMONWEALTH AVENUE MAIN STREET
C19/i=/„r WOBURN,MA 01801 LAKEVILLE,MA 02347.,
TELEPHONE (617)947-IMI - n
TELEPHONE: (617)935.2160 OR 727-1440 X880
4. WAS THE FACILITY SURVEYED FOR THE PRESENCE OF ASBESTOS CONTAINING MATERIAL OR 727-5194
(ACM)? Yes no z� --
AIR QUALITY SECTION CHIEF AIR OUALFTY SECTION CHIEF ,
WHO CONDUCTED THE SURVEY? DIVISION OF AIR QUALITY CONTROL DIVISION OF AIR QUALITY CONTROL £r
Name:
WESTERN REGION STATE HOUSE-WEST CENTRAL REGION
436 DWIGHT STREET-4th FLOOR 75 GROVE STREET -
Department of Labor and Industries Certification 0, SPRINGFIELD,MA 01103 WORCESTER,MA 01605
5. DEMOLITIONIRENOVATION START DATE: END DATE � l s 4" MAIL TO:PA.BOX 2140
TELEPHONE: (617)792-7653
6. DESCRIPTION OF DEMOLITIONIRENOVATION PROCEDURES TO BE USED TELEPHONE: (413)785-5327
i
(NOTE:Demolition/Renovation Operatons must comply with 310 CMR 7109 to control emissions W
For official use only:
prevent a condition d air pollution.) - Original resubmittal =. s
7. FOR EMERGENCY DEMOLITION/RENOVATION OPERATIONS,NAME,TITLE AND AUTHORF notification incompletelretumed
TY OF STATE OR LOCAL OFFICIAL WHO EVALUATED THE EMERGENCY Dale Cerl.mai) A r
Name: Title:
Authority: Dated Authorization:
GENERAL STATEMENT If AsbesWs-Containing MgadWisuriexpocMdlybaacdordemaped aDertedi-
.ionlRenovation oporation,all responsible parties must comply with 310 CMR 7AQ 7 .7.15 and Chaplet
?1E of the General p d the Commonwealth.This would include butwoufd not be limitedtofilirgan asbestos
emoval notification with the Department andfora noticed releasetthreat of release of a hazardous substance
The Commonwealth of Massachusetts
p� 4 Board of Building Regulation4tandards
dsCITY
OFSALEM
Massachusetts State Building Code, a' edition Revvised✓anuary
Building Permit Application To Construct, Rate Or Demolish a I, 2008
One-or Two-Family ThisS ionFo fBuilding Permit N er:
.Signature:_ t�
J/
Building Commissioner nspector of Buil m s Date
SECTION SI E INFORMATION
1.1 Property Address: 1.7,Assessors map&Parcel Numbers
35 yUnl Sf . SGilet �, pt�l gY
I A Is this an accepted street?yes no M.ipMlumber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) 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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
EIIPn 0nd Wilflon-) VQnloC>,l 255 /)urnlCtp 'SE . SGtIeVYI
Name(Print) Address for Service: -
&--� Qn 8 -'DNS Z GDP
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ At I Other ❑ Specify:
Brief Description of Proposed Work 2: 1 n S#0 I I e l QYl-F r e.p l n c'P.rn e nt Lu tnd Ol,O1
n exts+In13 openin(1�
N FP-C. IG
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 8rjaa -, 1. Building Permit Fee:$ 'Indicate how fee is determined:.
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost;(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ r
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ I.Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 5 a • p Paid in Full ❑Outstanding Balance Due:
�� o6 novt ,e0c/jke/L
SECTION 5: CONSTRUCTION SERVICES
5J Licensed Construction Supervisor(CSL) -�CIO Gl Q
—Fh O M G S p FOX On License Number Expiration Date
Name of CSL-Holder Cedar SiWobuV List CSL Type(see below)
2l�
f DescriptionC U Unrestricted u to 35,000Cu..Ft.
tid R Restricted 1&2 Family Dwelling
Signature M Masonry Only
'l 8 1 q ,Z g 3O0 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition -i
5.2 Registered HoTe Improvement Contractor(HIC) I L((v 5 g '
HIC Company Name or HIC Registrant Name Registration Number ,(
2Co Cecior S+ W UbuYr� 5-5 - 20// ,
A ss
t�✓l.+sie ei�� --7 &1 q 32 23()0 Expiration Date
Signature I Telephone .
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 Issuance 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
I, 0 r)d E I-Er`l VOr-) I CXN-) , as Owner of the subject property hereby
authorize N e(,yZ> to act on my behalf,in all matters
relative to work authorized by this building permit application. -
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, Th CXvI C, S P . Fo X 0✓1 , 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.
-(h om a s P Fo X on
Print Nam�/ +
Signatures o fJ2WM=,for Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 1 IO.RS,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.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
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"
�3C, f 3)
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CI rY OF
Massachusetts State Building Code, 730 CNIR SALENI
Revised.11ur?0/l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied:
' /ll'2ID
Building Official(Print Name). " Signature Date
SECTION C:SITE INFORD7ATION
L I Property Address: 1.2 Assessors blap& Parcel Numbers
�� �� �
I.I a is this an accepted street?yes_ no✓ hlup Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required E
Required Provided Required Provided
1.6 Water Supply:( ) 1.7 Flood Zone Information: L8 Sewage Disposal System:
Public❑ Private Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert rd:of c•�r1;� �Lh i �, 9 v
N�hme(Pnnl)tA I City,State,ZIP
Nu,and Stmet
Telephone Email Address
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 ❑ ecity
Brief Description of Proposed work':
r
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and iMaterials)
1. Building $ I. Building Permit Fee:$ ndicate how fee is determined:
2. Electrical $ ❑Standard City/'fawn Application Fee
❑Total Project Costa(Item 6)x multiplier x
). Plumbi°g S -L Other Fees: .S
d. Mechanical (FIVAC) S List:
i
>. Mechanical (Fire
Su xession) S �rotal All Fces:S
Check No. _C'heck Ainuunt Cash Anount:
ri. 'total Project C'wt $ ❑ Paid in Full 0 Outstanding Balance Due:
cat*ooe
SECTION 5: CONSTRUCTION SERVICES
5.1 Constru n Supery r i ens CSL)
erase t umber E.epirt on ate
Name orCSL lie •r List CSL'rype(see below)_
Type Description
No.and Stree
.�, U Unrestricted Buil irigsup to 35,000 ell 11.)
�yl R Restricted NU F:unil Uwellin
Cilyfruwn,State L P M Mason
RC Rooting Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
�i
% l Demolion
'rcic ume Email address D Ucmolilion
5.2 Registered Home Im nten Contr. r(IIIC�
FIIC Rcgist� 4, ,r5, n Dete
i v y me-r k N;unc
No.andLStfc _ ,� ! Email address
-City/Town,State ZIP 'rele 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 of 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 ( ��Lj L�
trj act on i y be 'n all matters relative to work authorized by this building permit application.
n behalf,t
Print Owncr's Nmue(Electronic Signature) Dale
SECTION 7b:OWNERt O AUTHORIZED AGENT DECI \RATION
By y name below,) hereby attest u er the pa' s and nalties of perjury that all of the information
the a of k vled a and understanding.
con wined loll
ap ' ' true and accur to to g
Print( etc 's or Aut torized Agent's Name(Electronic, ign Lure to
NOTES:
I. .An Owner who obtains a building permit to o his/her own work,or an owner who hires an unregistered contractor
(aot registered in the Hone Improvement Contractor(FIIC)Program),will not have access to the arbitration
program or guaranty fund under NI.G.L,c. I42A.Other important information on the FIIC Program can be found at
teww.nctss. ov'oc❑Information on the Construction Supervisor License can be round at www.ntass.gov'Ar'
3. When substantial work is planned, provide the information below:
"total floor area(sq. ft.) (including garage, finished basement/attics,flecks or porch)
Gross living area(sq. II.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofholf/baths
Type of heating system Number of decks/porches
l)me oFcuoling system
Enclosed Open
i. lbt:d project Square Footage"may be substituted for"'total project Cost"
Sold.Fumisltcd and Installed fit-
1111).V-1lonic Scnites. Inc.
d'ba the I lonac Uepo1:\I-I lomc Sen'icez
06S Boston Tumpikc Knit I,Shrcashun'.\lA I�d� _
lull free S?7411i i766:Pec 80198616 1 0
Branch Name: Boston Aorth Date: IOiW 201' VIP Lic+:C W-131) RI Cunt_ Lich` 16427
CT Lie it I IIC,n?G»" NIA I lomc Imprnvemcnt
Branch No: ;:
C'wurucior Rce. 4 12669: Federal ID
Installation Address: 15 Dunlap Street Salem MON 01970
Cav-- State Zip
Purchaser(s): NN'ork Phone: Home Phone: Cell Phone:
MIM William VanLoon (975)741-3416 1 (978)421-2821 -
Home Address: Dunlap Street Slicm MA 1)19 7(1
(It different from Installation:Address) City State Lip
E-mail address (to receive project communications and Iconic Depot updates):s:denmhd(a ooLeom
Marketing entails twill not be sent tioul'I"he Home Depot _. 0
Protect Information: hndei,tgucd("Custotner'I.the ow ners of the prop rtv localcd at tile.aboru installation iddtess,uftee,I ///���
but. and FHD AI-Home Suv ices. Inc r l he Home Depot") i,pees to li finish. IICh<Ct and amen C tics the inetidl pion(.'lust:dlati
(0ti")of edl matepink described on the Belo" and un life retcrenced Spec Shcell z)-all of which are incurpuralCd into Ihis C0I1MICI
by Ibis reference.alone with any applicahlc Stole Supplement and PLtv'nlCln Sunun:LAy attached horclo and uny Ch:urec Orders
Icollcctiveh."Canh'act"I'..
Job p:(hocroal Refereoee) Products: Spec Shect(s): Project Amount
7140S82 Rootim_ 714Mti' SI"•92omo 1
Minimum 25"/ Deposit of Contract Amount
due„upon execution of this contract Toted Contract Amount S 13.920.00
CLAswnter agrCCS that. inumCdiatdv upon completion of the work lot cash Product CUStOoWl'trill CxecutC if Completion
Ccplificale(one liar each Product as elCIlned by an individual Spec Slices)and pay amp balance LILAC. AS:gtplieoble. cash
Custxnncr uncles this Contract acrecs to be jointly and sevcrall_v obligated and liable hereunder.
Pavmcnt Sununarv: "fhc Pavntcni Sununap_7 7140882 . if1cluded its pan of this Coliunct. sets firth the tow)C'unhact
amount and pavments required flit the deposits and final pad-meats by Product (as appl ica tile). .
GENERAL IEItNIS AND C'ONDI'IIONS
Responsibilities:
'I he Home Depot: twill provide the Products identified ahove. make arrarigemcnu to hevC the:\LAthori7Cd Service Provider perform
the Installation services in a protessional and wrorkmanlike manner.and arnmge proper insurances. Unless otherwise expresslt,
provided for herein.Authorized Service Procidcr will obtain required permits and provide pet mit number:.
Custonncr: will ideutil-\ alit•property lines.casements"co\en:mts.underground or Overhead utililt lines. pre-exi titw physical of
IM0112-SA Pane 1 of 7
NO'1'ICE'1'O CUSTOM
You are entitled to a completely tilled-in cop of this Contract,signed by both you and"file Honte Depot,at the time you
sign. Do not sign a Completion Certificate before the Installation is complete.
Acceptance and Authorization: Cuslonici r;ree5 and understands ihzt this COMMCt is the entire acPUTI 11 be %Wen Customer
and The Honte Depot kith regard to the products and installation Sery ices and supersedes all prior discussions and a.necments,
either oral m lcritten. re I'll im, to said products and installation. This Contract cannot be assiened or amended cseept b% a lumpy
sicnad btu Cusiomcratd'I he Homc Dcpot.
Customer ackno„Iedges and agrees that Customer has read.understands,co[it tariIs accepts the terms of and has received
a copy of this Contract. Customer ackn mledges receipt of the Notice of Cancellation,and that'I he Home Depot has orally
informal Customer of Customer's right to cancel. Customer's signatuic below constitutes Customer's acceptance and
execution of each of the applicable Contract Documents. DO NO'I SIGN 'PHIS CON'I RAC I IF'I HERE ARE ANY
BLANK SPACES.
You are entitled to a paper copy of this Agreement if you choose. If you consent to an entailed cope.your consent applies
onh to this Agreement. By contacting sales office (8771 0-370S ,you nt:n"update your email address,withdraw your
consent,or obtain a paper cope of the Agreenu-nt at no charge. By signing below.you confir Ill the following:
• You consent to receh a only an entailed copy of this Agreement
• l'ou have access to a computer that can receive and open entails and I1DF(Adobe Reader Version 10.1.4 or
later)formatted documents.
• Your entail address is correctly listed on the Home Intpro%entatt Contract
Submitted by:
Sales Consultant Ronald Onion
License Name.
Telephone No. (877)9t13-37GS
Sales Consultant
License No. l; arl,iical,le) Accepted by: ro06 (Oct 9, 2013, 12:52 PM)
C'ANCELL:\TIO:N: C'LS'I OMER MAY CANCEL'I141S CON'I'RAC"I"N'I I'HOL'I PENAL'I Y OR OBLIGAFIO.N' BY
DELIVERING WRI I LN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON 'f HE'1'HIIZD BUSINESS DA1 AFTER
SIGNING 'I HIS C'ON1RAC I TO"I HE ADDRESS LISTED ABO% L. 'FHE S'I ATE SL:PPLEMEN'Y A I"I'AC'HED
HERETO CONTAINS A 1-0101 TO USE IF ONE IS SPECIFICALLY PRESCRIBED Bl LAN` IN CUSTOMER'S
S I'A'f E.
hl -
I InW12-SA Pau. 6 ut 7
M/M William VanLoon (Oct 9, 2013, 12:52 PM)
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CITY OF S�U EMJI --1SIkCHUSETI'S
11,t . BUILDING DEPARTNLENT
120 WASHNGTON STREET, 3iO FLOOR
TEL (978) 745-9595
FLIC(978) 740-9846
KItU3ERLHY DRISCOLL
AWOR Tmo.NusST.PIEm
DIRECTOR OF PUBLIC PROPERTY/BUII.DNG C0J12MI5SIONER
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 MOL 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 N1GL c
111, S 150A.
The debris will be transported by:
� f i
(name of iaule
The debris will be disposed of in
--- - (name of Facility)
d,( D �—
(address of faclluy)
igna re o et t app icant
dal'
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Workere Corapatasadion 1USILYAW WIDUSIVic Bt;iiilers �'./.Li a..IG+ � Ld: ..� dCSt. oic ._
nnucant Illf�t(Il dr+''l_ __ __ None
e Ixf'Lt
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t lti''dSw�IL17' '.i °Fi+�lt��r_.----f.. +f_l
Arc t_ ac employer^ Check the appropriatebow I Type of project (required). i
1. ''acn a employer wrt', �_ 4- 11 I am a c n ra MM r and 1 l ! +,r
have I +* d rr Lb-emtraacars
c. ;�Ne c s"'::
employees(full anoro pail rime)-` i, ❑R-m+x chnb
list d on +h arrachad sheet.
] am 2 We prcpr it, o paaner- g, D rn wi.on '
Up and bane no e nploy
T!! sesu' crnir!_tntshave i I -
wotkmg for me I any cap sig, employ ts a��c' live ra+o�keg s' I
I !I 9 ❑nail 1tGadd o;t I
I [No workeu' comp su;2lce
Corr,.-i»�t ran:e.'
-�`t I ��e.are. a c.;rrc.ranor and is '!
1(1.❑Electrical rep s or addntons
required 'I -
r— officers nave e� Ic,C o their I I _.�p!u r nr epnus o. r•"claom
S„� 1 am a homeowner doing all work.
myself [No workers' coup.
ru•h! of n,um p N101-- . 13 ' oot,e parts �
t c 152, Flr!t; and t.P have nn I — I
insurance rtc•ureo.] I I ls)� Otn
employees fT)(Iwclk_rc
coma. insurance required.] ,i
anpre:n trm h:e`alo'KI r,uuats�fill ct m cc fir In thrn'. I'c ar e rnp it,+n nnh ii;,� u, 1
t I7 nenwnus wha tut mi F a- hvi.+r ca n ry lu do n all wr,i n ih r hire Cu ti c onu .n t n+ti cLn'e .n nn iA'��n r 1 ai n sncP,.
'Convacrnra on_heck This ,,.hch..d an tht narne Of ih..,u co,.rarnr,a+d mat whch..-cu no Ihote_m li_n hay:
i
emnlo�xs. if nv au?.cent fors gave arolm - N .;rut irm ire the w ' ry con n.P&M mm,F :.
I nnl nn emploner thair.is providmo x orlxra-' compensation urturan.ec for rnr envy alvee;, Belai is tilt policy and joh site - r
information. —
Insurance Company Name.
I
n c I, ; :zp,ranan Date:_— _
q
Poky`o� - e l in in S Lic.
M �_ _--
Attach a copy of the work ere cornpensador poli } dedaranou page ishomAtt the policy number and spiration date.i.
RATES to secure coveragc aS required under Section 25A of Iv3131.L. 152 can lead to the imposition of cranloai penanin of a
We up Lo$1 3OO.OG and/or f,ne year imprisunmenL- a::well as civil penalties in the form of a STOP WORK ORDER and a fine i
of up to-S" o(1(!a das- an m it v Wwm, S abind that a cop"[Ili s a alern »l maV'he 1-rrw arded m th, C) i'
]r s e;tisaticrs of th Dl.If i r i ssr r c e cn vivo.V ,1 ti nI.. -- -----_
I do hereon certify untie th, pat s an it s of per7cry that the Lrntorm.ad:orl provided aLmre rs yrtic and con cct.
Dace: e —
G,namre:
Phrn,c
()fjzgW use ont,.7 Do not rrruc inthis area. to be completed bn gin'nr.torcn official.
ICity or Town: PeraWdLicense x'
Issuing Authority icircle ones II
mhie� Inspector
I.Board of Health 2.Building Department 3. Ci:yfTown Clerk 4.Electrical inspector 5. Piu
I (i, Ofner
I
Phone A
Contact Person: j
I
I'