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123 HIGHLAND AVE UNIT 3 - BUILDING INSPECTION CITY 01, S.U.1:1\I DITARTNIFNT ( 1 _ \I I�nl; _ \`/`�' �]II\\ bIII]l.11 l\�II:I I I � \'I: '.I, \ 'u°\I III °I 'I•n�9 II 11 I 919; ♦ 1'1'. 'I-s--41, '18.10 `T APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS LNIPORTANT, .kEelicanis crust complete all items on this rage SITE INFOItm,vr1ON Location Name Property Address Located in: Conservation Area Y/N Historic district APPLICATION DATE Use Groups (check one) Group Homes Rata_ Residential Q or more Units) R2 Type of improvement Residential (hotel/motel) RI _ (check one) - Assembly(Theaters) A 1 _ New Building_ Assembly (restaurants& clubs) A2r_A2nc_ Addition Assembly(churches) Al _ Alteration Business B_ Repair/Replacement AZ Educational E_ Demolition_ Factory(moderate hazard) FI _ Move/Relocate Factory(low hazard) F2_ Foundation Only High Hazard H_ Accessory Building Institutional (residential care) 11 _ Institutional (incapacitated) 12_ Institutional (restrained) 13 Mercantile M_ Storage S1 _Model:ue li:¢;trd Storage S2_Cory I Lard (1\)'NERSHIPINFORNL%FION(Please type orPrintlearly) OWNER Name Address ; 14-12 Telephone Signature L DESCRIPTION OF R'ORK TO BE IlEjU4+R1NFN) GP VS I IMA rBD CONS FRL'CTION COST I`ll 1 I � P I IP CON"IItA CTOlt [NI-O NIA'['ION Name Address ' Telephone �3 Construction Supervisor's Lic # Home Improvement Contractor# \BCIII'1'ECT/FN(ANBFIt INFO101ATION Name Address Telephone Mass. Registration # __ ..._ __. ._.. 1'IdILN11'T' FI?E CALCULA'T'ION Estimated Cost x $11/$1,000 + $5.00= �^ CONINIENTS The undersigned applicant does hereby attest that all information stated above is true to the best of my knolvledge wider the penalties of peril Signed (owner) (agent) APPROVED BY : �i L DATE: APPROVED: ..�. :.• rnrr r.�nr rnur rr•rriry rr•rr rru•.o JVVIYVLVJL .—.IJ f.VVL/YVi r-4ov { +� a. �i .nchaKttx-Dcpanmrnt of Public JaFiY� i Board of Buildin'. PL",ulations and standards i \ZJ Constructiun Supervisor Specialty License i License: CS 5L 101721 Restricted to: WS I _ } RIC-HAW WRAWNESCO 1 7 PINE SURF A%VWE MF.R WAC.'MA071160 1 Expiration: 1/15/2012. i Trut 107271 Di3-I-'373 AS-43 DH Ni m'i I .VLnLLJ v77C 5.a; 2.o1uc_ - - - - Netloral=ramdan 3�31" Cla¢s 1 2.33 xv VLSr LJ - - Radr9^:"tks No Lax`.na_ad CLaoo -W Lin ftalo ® No Csida P 9Ln s¢JLLLaa ENERGY PERFORMANCE RATINGS . VaLuACIGN DE RENDIN MO ENEAGET= U-Factor Solar Heat Gain Coefficient .Fa=a U - - (oeAden2 Pananda da Enqu`abr '0 . 32 1 . 8 0 . 29 ADDmoNAL PERFORMANCE RATINGS EVALlUA=N SUPUNENTARIA DE RENDWINTO Visible Transmittance hartsmWan de ty¢Vymie - 0 . 52 tAwdatuv*Low 9•a Tea atinp ordam'a QWLW t4AC Pcldm Atr dee RNV wh'W vte oar mkq are&tatted Ar a Itsed at d vow nftW=10"and a Vcft Pock(stet.WX ba.rct n=Wwd 97 Petri .. eed doa rot warrant Te etdhElRy Of 81 ptodnd Ar ary VodAc�0"'t=Mftaeet ftUn b a Qvpodct pskntotra .. Ydcr�trst wnvudtcn0-. - - . .. - .._. Esh Aedtanle sAptb We eeme vdaee aenya mt be ep9ahMe b Mitt Pett bOftmtty d tstdonlab IM dd poduckLIn vakm undal pa MAC etndetsminadca paw=rWm Wbasn1doee arDlsNhy,m Ulm bpMAM - . apKrl MAL w mxnkrjde nttpte vow=Y M porn=tiu d PMLI es edeesdl pen w ePeddm 01wi d mn d . ... hNb Oct(IEIt01b PwidumgYopYN b ab Rn_dctrt> +dtQO Unit tf.allflna for ENERGY STIR - 140.64.d, W09th C¢nt.al, 9ootn Cant.al, Soatna.n. sNER6f STAR - - Ca .n ldad oallfica pa.a la(a).- - r.g10n luj ENCRQY.STM: Noctt, - Nosta C¢ntsal, 9:.r C¢ntral, S.C. - IND: Hain 00/Glatt J/31^!x-Rt3,_ _ _ T¢stal 91¢4: 36' >, 63' DIND: Rafuac.o as/Vld<lo 2.31 n /H-RA3 Dp • +45/ -45 2aaiaho psobado: 91.4 CA . 160 cal E59c�46f 01. 10771 . H9 Hoffcan 2931124 - teep IM W lot pambIs EAER61 Dr Mbdlel To Ian UrUM Yaw vlgisfitpdr, Guotde am e*vm p=pa&d w1cism HIM 5W tmd cowat mm anim M tst,&10 w Kinivisml2a _ . .,/� -. �,i4e tawrvn.o-nuba/!.4 o�✓��amac/u`seCe �-\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR f� Registra�Qfj; 126893 E4catftinn�f2010 1� Fy ap Supplement Card The Home Depot-. RICHARD FALLOME=�'y`:=?rt 3200 COBB GALLERI;AA Pf(WYft20 ��L ` aTI1WTA, GA 30379-'Y - Administrator ACORD„ CERTIFICATE OF LIABILITY INSURANCE 00212 MIDDIYWY) 02/20/09 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Pax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Steadfast Ina CO 26387 THD At-Home Services, Inc. INSURERS:Zurich American Ins CO 16535 2690 Cumberland Parkway INSURER 0.NATIONAL UNION PIRE INS CO OF PITTS 19945 Suite 300 Atlanta , GA 30339 INSURERD:New Hampshire Ins Cc 23841 INSURER E.Illinois Nati Ins Cc 23817 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED 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 ADUL POLIOYEFFECTIVE POLICYEXPIRATION TR NSRC TYPE OF INSURANCE POUCYNUMBER MM 0 T DD LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXC SS DAMAGE TO RENTED -PREMISES(E.ocwrence $1,000,000 CLAIMS MADE OCCUR "OP SIR: $1,000,000 PER CC" MED EXP(Any one person) $EXCLUDED PERSONAL B AOV INJURY $4,000,000 GENERAL AGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $4,000,000 X POLICY PRO- LOC B AUTOMOBILE LIABILITY BAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT % (Ea acoden) 81,000,000 ANYAUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIREDAUTOS BODILYINJURY IS NONOWNEDAUTOS (Perawitlent)nt) X SELF INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE (Psraccitlent) GARAGE LIABILITY AUTOONLY-EAACOIDENT $ ANY AUTO OTHERTHAN EAACC $ AUTO ONLY: AGG $ A EXCESSIUMBRELLA LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACH OCC URRENCE $5,000,000 X OCCUR 171 CLAIMS MADE AGGREGATE $5,000,000 8 DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION AND - 3566916 (CA) 03/01/09 03/01/10 X 1 71'JM - OTRFA D EMPLOYERS'LIABILITY 3566915(AOS) ANY PROPRIETONPARTNERIEXECUTNE 03/01/09 03/01/10 EI EACH ACCIDENT $1,000,000 E OFFICERIMEMBER EXCLUDED? 3566917 (PL) 03/01/09 03/01/10 E.L.DISEASE-EA EMPLOYEE $1,000,000 it yes,tlesuibe under SPECIAL PROVISIONS below - - E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER D Workers Compensation 3566918 1 NO, NY, WI, ) 03/01/09 03/01/10 F TX Employe ra Excess TNSC45694422 (TX) 03/01/09 03/01/10- Ccurrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL 2690 CUMBERLAND PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SUITE 300 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA107 IgIIIIIIjr 44 ACORD 25(2001/08)ckomraue_hd ©ACORD CORPORATION 1988 11172180 The Commonwealth of Massachusetts Department of Industrial Accidents LP Office of investigations 600 Washington Street Boston, MA 01111 www.mass-gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): �7t Address: rnZ(�ffl�yW� I'`'�'�L' I City/State/Zip: 146 Cn- 7it� __ Phone #: 4,r—,7 S)�� Are yo an employer? Check the appropriate box: Type of project (required): 1. am a employer with l c 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 7. ❑ 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 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I Am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions ,152 , and we have no myself [No workers' comp. c. §14( ) 12.0 Roepairs insurance required.] t employees. [No workers' 13.E26ther t til daa 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 contractors must submit a new affidavit indicating such 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is tite.policy and job site information. I _ / Insurance Company Name: Ltdd�. l -���C ^ Policy# or Self-ins. Lie. #: 3�( \ �°i 1 - Expiration Date: Job Site Address: �L�IVlIrt7V Jk7t{I 3e.ity/State/Zip: �- Attach a copy of the workers' compensation p4icy 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 it er hep s and penalties of perjury that the information provided ab ve i true and correct Si ature: Date: Phone#: OjJ<cial 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/Towu Clerk 4.Electrical Inspector 5.Plumbing Inspector. 6. Other Contact Person: Phone #: CITY OF SALEM l rs PUBLIC PROPRERTY DEPARTMENT ., I I I'V'S '4; );-J; I'\X 'i'X.'J_'I.i J,. Construction Debris Disposal .affidavit (required liir all demolition and renovation work) In accordance wtli (he sixth edition of the State Building Code, 7S0 CMR section If I.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit it is issued with the condition that the debris resultin.- from this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c I 11. S 150A. The debris will be transported by: (name at hauler) I he debris will be disposed of'in _ _ag (name ut tacilit V) IJ taddre" d facility) Icnat Ic of punct.y\phc ant date V ` '03-15-2009 03:37PM FROM- +9787401417 T-446 P.001/004 F-679 PLEASE READ TIllS Sold,Furnished and Ins Branch Name: Bosom Date:—^ ! _T THD At-Home Ser d/b/a The Home Depot At-Noma Branch Number: 345A Greenwood Street,Unit 2,Worcester,N1 / Toll Free(800)657-5182; Fax(508) North 33South 31 Federal In#75-2693460;ME Lic A C 07439;Rt Cour,1 J 1 y CT Lic SrSbJIS^5,22 MA Home EnProvement ConlraClor keg ?/%��/ Installation Address !� City r/� State Zip /j vA I �kh� furchaser(s)t Work Phone: Dome Phone: Cell Pt [ ] [ l C l Home Address: (If diffemut fromInsi illation Address) City State E-mail Address(to occeive project communications and Home Depot updates): ❑I DO NOT wish t r receive any marketing entails from The Homu Depot Protect Infnrmatio Undersigned("Customer'),the owners of the property located at the above installation address,al and THD At-Home Services.Inc.("The home Depot")agrees to Iumish,deliver and arrange for the installation("lost+ all materials describ d oa the below and on the referenced Spec Sbcet(s),all of which are incorporated into this Con reference,along witl any applicable State Supplement and Payment Summary attached hereto and any Change Orders l "Contract"): .Tab k: aa.,.,una..mam Products: S Sheets #: Pro ect Ai j I Roofing ❑Siding windows ❑Insulation S 1 'jJ ❑tuners/Covers ❑Entry Doors ❑ r ❑Roohne USiding LJWindows ❑lasilation $ ❑Guuers/Covers ❑EntryDoors ❑ [:]Roofing Siding ❑Wmdows ❑Insalation ❑Gutters/Covets ❑Entry Doors❑ $ ❑Roofmg Elsidi,,8 LJ windows 0 insulation ❑Goners 1 Covets ❑Entry Doors ❑ CNtkdni m2S%Dt�it of Contract Amount due upon exeGntion of this contract. Total Contract Amount ome Purchasers m ry net deposit more man one third of the Cont actAmouaL v V Customer agrws that, immediately upon completion of the work for each Product, Customer will execute a Completio (one for each Product as domed by an iddividual Spec Sheet)and pay any balance due. As applicable, each Custom Contract agrees to bc jointly and severally obligated and liable hereunder, The Home Depot re,erves the right to issue a Change Order or terminate itis Contract or any individuu Pmducts(s)inclut is discretion,if The Ionic Depot or its authorized service provider determines that it cannot perform its obligations due t problem with the hc me,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing erro wok required to car mpleie the job was not included in the Contract. j Pa��ment Summit _ The Payment Summary M f `��r , included as part of this Contract, sets ft Contract amount rm payments required for the deposits and finai payments by Product(as applicable). NOTICE TO CUSTOMER Yau are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certi there is one Compl tion Certificate for each listed Product as defined by individual Spec Sheets)before work on t is complete. In the event of ter rination of this Contract,Customer agrees to pay The Home Depot the costs of materials,lab andl services provided by The Rome Depot or Authorized Service Provider through the date of termination,pit I amounts set forthnit this Agreement or allowed under applicable law. THE HOME DEPOT MAY ViTrHHOLD ON/ED TO THE HObIE DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, L"/flTfNG THE DOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCII AMOUNTS. Acceptance and thorization: Customer agrees and understands that this Agreement is the entire agreement betwe ! and The Home Dep t with regard to the Products and Installation services and supersedes all prior discussions and agree oral or wrinun,Icier g to said Products and Installation.This Agreement cannot be assigned or amended except by a w by Customer and TT a Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntaril lcmuapFvnd has rec t ived a copy of this Agreement S" � �Sulbruundyn,tomcr' i a i D e es Cs Sunumre''(.�y q q tc X Telephone No. ��I�7J L ISR I Customer's Signa Dam Sales Consultant License No. CANCELLATION CUSTOMER MAY CANCEL THIS as eFP,.hiq AGREEMENT WIJrHOUT PENALTY OR OBLIGATION BY DELIVERING;WR[T*TEN NOTICE TO THE HOME DEPOT BY mmqiGHT ON THE THIRD BUSL\ESS j DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPI.EMFNT ATTACHED HERETO CONTAIN'S A. FORM TO USE IF ONE IS SPECITICALLY PRESCRIBED BY LAW IN i CUSTOMER'S ST kTE. NOTICE:ADb nONAL TEMIS AND CONDITIONS ARE STATED ON TILE REVERSE SIDE AND ARE PART OF Thus CONT. 8-06-0E CSG White-Branch File Yeiiaw-Customer Pink-Sales Consultant