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14 VERDON ST - BUILDING INSPECTION
(J oc ,T9=aa,Ye„ The Commonwealth of Massachusetts v_ s Board of Building Regulations and StandardsMI A k'� Massachusetts State Building Code, 780 CR Revkksed Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a r4(Jb -5 . A D 9 C• One-or Two-Family Dwelling DO This Section For Official Use Only 1 Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Propey rid res 1.2 Assessors Map&Parcel Numbers 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 ft) 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 Or iof Reyordrt ` I M (Q( rn Name(Print) City,State,——Ivr — No.and Street �i elel p� Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check a 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: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town.Application Fee ❑Total Project Cost' (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: ��l,o M rpt L_� Q'o C'6Z-ov • � j . •-A, D. No - S (�3L SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Su r"sor License(CSL) WA fi �i _@ Lich Number`_i� Expir ti Date Name of CSL Holder Q L-4 N� List CSL Type(see below) L�}J No.and Street Type Type Description �/r�_ U Unrestricted(Buildings u to 35,000 cu.ft. kln- 0- R Restricted 1&2 Family Dwelling City/pow , tate,ZIP M Masonry RC Roofing Covering WS Window and Siding 4p SF Solid Fuel Burning Appliances �� I Insulation Tele hone Email address D Demolition 5.2 Registered' Horn ovement Contractor(IHC) Qom/ �J1/�/ {-}� .,C7 HIHIC Re istmtio n Number E it ton ate C Y I A a an Name No.an et — r- Email address Cit /Town, State,ZIP Tele 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!.2ne building permit. - Signed Affidavit Attached? Yes .......... wl, 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 644�:� to act on my behalf, in all matters relative to work authorized by this buildm" g permit application. Print Owner's Name(Electronic Signature) i Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name ow,I hereby attest under the pains and penalties of perjury that all of the information contained in this app ' a ' n's a and accurate to the best of my knowledge and understanding. k. Print Owner's or Autho zed Ag n[s game(Electronic Signature) Date 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.e. 142A. Other important information on the HIC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.eov/ds 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basementlattics,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" HUM MIPROVnIEN CONTRACT - PLEASERF-ADTRIS _ -- '� y3 s x' .Sold,Furnished and Installed by. e Branch Name:Kee,EngJarq .Dow.. ` : - ?HD As-Horan Scrviccs,:lnc: . dlNa.The Hom Depot At-Home Services - Branch Number:31 '- - .s 9U$Batoa 7lsmpike,tJail 1.Sltretesbtrry,ASA 01545 , Tall Free 877-W3•3768, x • 1'ederai16e77?-293N<CB;AhG'li01Qq?439Ri Cknc Gicai ibt17 CT'ftc B 141C.6565-M NIA flown InVio ernent Coottactuf Reg.t1 IIM3 Installation Address: .. . '.., ,,. . .: City .Sara - 'Zrp _. .- ,,-.._ Ptrrcltasel{s}e Wtirk.Phmre Horne Pbaa: Cell Phan: :rl+urcl [6171FtXF#O/C RVI 7"0a:X Home Address flldillorent from hlsallsamt Addrewt.'. City State ,J lip nI OAddress tuioreoceprany caamm�gcalsits aro The ometupd>ues}=�7LC.,...y y�!.�a(�7�r�,.�.L eor✓t !DONt7f'wish tnrettoivc any marketing en.Aila from The Hume Dopa . ' Itifemiatim:`Undersigaadf'Cu5tnmer"i,fire rtamurs M(le prmlrrrly fixated at the above iaSta}tadataadrrsa,agrees to buy, At. one Services.[no,("Itte Us=Depot")eges eto Pomi,Lr tlelvaand aeraatgc.kr ifia anatolatiaat('11tutaBatium")o£: all matcauls described an the Wow and on the mJetanued Spec Shcesisl,all of:which ere hicorpmvted into this Contract by this aftasncx along wYth Roy applicable State s'uppte tem and Payinem Summary'aua sed level"soil say C hat ge Orden(collectively, "Contrail"}: .. . ' Jab R; 4a0rndailVMM PYadocw $P -�eeas' t Kootn$ sen.g wl'tYIOA'9 hKtl10YFgII. (} yv'.p»....{.y�. /yJ9-! Jl oaaaerleol ,otntryome,{:} 00 ,,. ' Keating UMAg U Gwia&ws (]Guam t Cmtirs IFaay Deas C1 $ Itoofmg 0sidals 0 1L`Woles.-_..._El In%uboiko,. S OGaOMtCauz>rt j]FiuryDooMn -...Roofing Sidiag Kuoaws h4sulattea.; - �"— :: ,:['ICnatarslCarcts C:Ifmuy tkwxf� _ k} ARattnrr1125%DrprnitdCearad AnairaCstuergancvtiattianafdrisrxartrart. 'PomY CorttraN Amount $ Atkblt PAnRlYnOS may MliMwJR apnalfan arrAt({ad UftbR Granl(AARNUTL 1 ' Customer agaves that.ittm odiately upon completion of the weak for each PrMoa,Cltswtaer.Ma esamte a C niplaim Certificate toric ftr:each product as defined by w individual Spec Shos)and pay say balance slue. As app}ieuble.each Gtsnomer ander this. Contract Agec,to be;jnindy mid stwmily aMizvoid mid liable ber"vider. - - The time Depot reserves the tight to issue a CMM Order or wrnifize this Conus or any Individual Product(s)meluclal!ardn,au. . }' hsdeureflowlifThe HanreDe"(ait,ambcattedsc;Vimprovider ddlrolimsthat itcarmotpir£cstmits ObUipikinastime toa>upconsi problem lith the home pntatiatroenud butinh suet,as mold-a.Wcs"s ar lead paint,eche€safety&COCWma,pricing arras Mth"Cl pse - `' wast,moulted to complete the job was not included in the Ctinvatt.... - PasTtteat Smm�arvr.: 'the Paymteot.Summary tt;,.. -4 a 773�,_,,,.,,ioSudod as pen of lhi Cmultm,scis(wlh(he,lcaal Contract amount and paytttmts required for the deposits And Mail payineas by Product(as Applicable)., NOTICE TO CUSTOMER . - Van an eadded to a emmptr'My Bl e"copy of the Cmttrbd at the time j w st Do not sigma Completion Cerdfleate(ode: there Is ane Campltthm 11flente for each listed Product as defined by ltoiv dual Spte Sheets)berore work ort that Product Is complete In the evert at termitsati m of this Contract,Customer agrees to pay The home Depot the curs of materials.labor."parses and services provided:by The Home Depot.m'.Aohorlycel Service Provider through the date of teradva tion,phis ao".other armounts set forth in this ABreeasent or allowed under applkahle Ise. TBE HOAtE DMT NL%Y.WITHHOLD AAI6UATS -. OWED TO THE.HOME: DEPOT FROM THE DEPOSIT PAYMENT OR O"IHFAt PAIMENTS MADE, WlTHCHT LUNITIT`VGTHE HOME DEPOT'S OTHER REMEMIIS FOR RECOVERY OF SUCH AMOL NIS. ', Acer stand Authurlurtion: Cuski o r agrees and*mdersha ds drat dtis Agreemont rs the entire agreement herwreen Customer wall t'he Homepi conA regard to the tyrducvs soil btstaltation sl colo&and st pkrsedcs tilt prion d6cucsim.s and 3gt-eement5,.ether .,. oral or wrinen,relating to said Products and Installation"'lids Agrretacut cvanot he assigned or:amended except by a writing.vgrted by Cuutiiner and Tice Home Depot,Cusaumcr acknowledge,.end.gr�et that C'estorncr has feast,ualer icmds..volumartly accepts the - terms of sad his received a copy df this.Agreement. ,Accept y: Submitted by: 3I6 S a D Z41 — X s Sales Cousuitant'A Signature *Dore!_ Tekphmelad.. Q7 65+7 Customer's S*amre Dort - - '.Sales Cwraotaac timcnsc\To. - - CANCF.LLA7ION:. CUSTOASER AIAY CANCEL THIS -. f.saPd«,oboes - c AGR MIENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN:NUnCE TO THE HOME:' - DEPOT BY IMIDN'lGHT ON THE:THIRD:9USJNESS. - - DAY AFTER SIGNING THIS AGREUNIP.NT. Tltf;:: STATE - SUPPLEMENT ATTACHED HERE?O ' CONTAINS A FORM TO LSE IF,. ONE IS'.' SPL'CWICALLY PRESCRIBED BY LAW IN .. CUSTOMER'S STATE: NUtiC1:.ti1T)tTIntiAI,TER41S.tNUfU\'b17'IONS ARE 51'ATttu U`tTHI:RF.4F:R.41:Etna Atih;4RF;PART OFTRISCtiNt' M 0303.15 While-BrarchfYo melee-Cuatenrsr .. ,t.,- -;> csSL-099699 ROBERT POCZ08UT R� '172 WHALERS LANE SALEM MA 01970 02108/2018 ,. o .3 _3 A fi qrj= 17 .-la 1,3l=f 217381 MrCf� w.� Mama& 19 Ili I I a� In, xlR1.,gno aa ,aua� aimzru4s;Nc- 'Yo ,LLrmcE AQ.w.air, Samf-2qc7x?aAa--.LF---Nza LACr L;;A 1025 'am=aMwfr ULM 15:5 MAI MO MMMSMME;2APKMA:(, Lr,-=ma i MUM A- arzm,;Mmr.y l I.- ! 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I m6cr0maet r-em-wy" 411=7 'owl, I L 1.1m.dag 'jwlca -,F:rrLC7 71 CF:j1p:;`.M'CjJ�Ze xwms— =Rrm L,.LJwi Vuoc, 11WSOK—,'-JAf- ':!'Z EK:7 I aura ,,amp I ' 1Wila6; jf1y�&jG iSEn W295 Wms ag UNBZq/ytrAs I =R TCH-IrML'ML�- 2�JA34AAM ;safari amilla MW IM h4t) assrlwrttaN IF ammmms www daued in Aliftiml Pm L ULT i 1,100, 0 C-7-� W IFS ON 3F,.3FFArQNS t WrAT(ON3 Vrdi(Cus okcaRD ,Ad9ffmcw1mmuk, �,ERTIFICAI--HOLDER CANCELLknoN THE "O'l" 3r GAM '71 CE4 THE FaLr op Z mag-RCM9 1GRAMS4 NC. 68A-,,.e,(ctAaaEFOT,1.T4iGME !95Y PM;Es Few RAPD3,1LUM,GA=9 -r The ComneonweuZth of Ltassachusett Department of Industrial Accidents Office of Investigations I Con o¢cess Street Suite 100 J' Boston,.Yt4 02114-20171 www.mass.;ov/dia Workers' Compensation Insurance Affidavit: Sunders/Contractors/Electriciaas/Pjumbers A &cant Information Please Print Legib 1l Name (Business/CJrganizazioo/Lndi'ndual): i J/ 0 :Address: 00-9 615'l�- ' �tlrll J� City(State/Zi a1 w J l'r� Q Sy> Phone#: Are you an employer? Check the ap ropriate box: Type of project(required): 4. I am a general contractor and I 6 ❑New coustructlon 1.❑ I am a employer with * have hired the sub-contractors Y' (full and/or part-time). listed on the attached sheet 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- These sub contractors have g, ❑Demolition ship and have no employees em loyees and have worker' 9. Building addition working for me in any capacity. p ❑ comp.insurance x [\Io workers' comp. insurance 5. Electrical repairs or additions 5. ❑ We are a corporation and its 1p, required-] officers have exercised their L I. 3.0 repairs or additions 3.❑ I am a homeowner doing all worn right of exemption per MGL l-, rep 7 ❑ airs myself RID worker' comp. c. 152, j 1(4),and we have no - insurance required.j t employees. [No workers' . Other comp. insurance required] upolican[that check s 60K dI must also fill out the sectio¢below showing their workers'compensation policy informa[ioo. t Homeowners who submit this affidavit indicating they are doing all work and am lair,outside contractor must submit a a"affidavit mdicatiug;uch. rcontractors that check Lis box most attached an additional sheet showing the time of the suboL ontrac he®d stale whether or oe[Lase entities have employees. If the sub-contractors have employees,they must provide their workers'comp.p y ation insurance for my employees. Below is the policy and jab site I inn an employer that is prwidmg workers'compens infonnation. 1 — L-lsurance Comp any Name: � �y / C�1 J �!j Expiration Date: / Policy#m Self-ins•Lic. #: VV l..i © � Job Site Address: �`Y �AFy CitylState/Zip: Attach a copy of the worker' compensation policy declaration page(showing the policy number and expiration to a Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties fine up to$1,50o.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip 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 her y ce t pal d p al es of perj th the information provided above is true and correct .I Date: Si e: Phone#: 09 6 i Official use only. Do not write in this area,to be complefed 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 j 6.Other Phone#: Contact Person: ' I Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvem nt,ontractor Registration 1 Reqistration: 126893 - yrZt l� Type: Supplement Card Expiration: 8/3/2018 THD AT HOME SERVICES, INC. RICHARD FALLONE 2455 PACES FERRY ROAD, HSC IDA ATLANTA, GA 30339 t 5'd Update Address and return card Mark reason for change. SCA 1 r, 20M-05/11 Address ❑ Renewal [-] Employment ❑ Lost Card V/ze�orvnzoauiie�i-/l�C o�P/�cva�ivaed`a 1"ce of Consumer Affairs&Business Regulation License or registration valid for individual use only Q OME IMPROVEMENT CONTRACTOR before the expiration date. a found return to: Office of Consumer Affairs and Business Regulation Registration 126893 Type: 10 Park Plaza-Suite 5170 0" Ex ITtlon6-�' .. P 8/3L20'48f,;- Supplement Card -Boston,MA 021-16 - THD AT HOME SERVICES THE HOME DEPOTgF_=HOMESERVICES `v� H Tei RICHARD FALLONE� 2455 PACES FERRY A!l kNTA,GA 30339 Undersecretary of valid with t si ature CITY OF SMENI, 2vLxsS.ACHUSETTS BUILDING DEPARTMENT • 130 WASHLNGTON STREET,3"FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KIJtBERLEY DRISCOLL MAYOR THo?.w ST.PmRRB DIRECTOR OF PUBLIC PROPERTY/Bt1LDLWG COMMSIONER 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 MGL 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 MGL c 111, S 150A. The debris will be transported by: � n (name of auler) The debris will be disposed of in (name of facility) �f facility) i nature ofermi-applicant P PP date dnr�,:,trauc