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13 WILLIAMS ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards Tom ea� Massachusetts State Building Code, 780 CMR, 7"edition Building Dep[ Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or -Fumih Dwelling T s Sec on For Official Use Only A Building Permit Number: Date Applied: t b7 Signature: Building Commissioner/I ctoro u ngs Date SECTION 1: SITE INFORMATION 1.1 Property Ar( s:Uf�II I t f 1.2 Assessors Map& Parcel Numbers I.1a 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 It) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.U.I,C.40,154) 1.7 Flood Zone Information: 1.9 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' 2.1 O R o Irt? t4)111 )111 Wora Name(Prin Address for Service: �. Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(-) Alterations) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ er ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials 1. Building E _ 1. Building Permit Fee: E Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical f ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: E 4. Mechanical (HVAC) S List: 5. Mechanical (Fire 5 Total All Fees: S Su ression Check No. _Check Amount: Cash Amount: 6. Total Project Cost: E ,�` 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Lice ed Construction Supervisor(CSL) License Number Ex vau�n Date N4mc: L-tHpl � � Liu CSL Type(see Ix1uw) AA)!S Ad(rc s Type Description U Unrestricted (up to 35,000 Cu. Ft.) R I Restricted 1&2 Family Dwellin atur M Masonry Only RCResidential RoofingCovering Tel hone WS Rrsidtnti, Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Holz provemen C actor IC) y)/,Q _J HIC Comm Na or HIC Regist me Registration (lumber f 7 r Addrcs c) a ' Expi ion ate Signator Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6)) Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan o(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 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. Libcs/a Signature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 1, �Jla 2 I orw ,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. Print Na e S�Ignatube of 011imer or Mutherized Agent Date Si ned unclefthe Pains and penalties ofperjury) NOTES: I. 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 110.116 and 1 I O.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" CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT I n 'v-y.-4;.y;:lj ♦ I %X 'J'V_V_•Ii� , Construction Debris Disposal Affidavit (ICyuit'Cd li)r all demolition and renovation work) In accordance �%ith the sixth edition of the State Building Code, 780 ChIR scetion 11 1.5 Dcbris, Land the provisions of!vIGL c 40, S 54; Building Permit h is issued with the condition that the debris resulting from this work shall he disposed of in it properly licensed waste disposal lacility as defined by MGL c I 11, S I50A. The debris will be transported by: U r uucl 70 (name of hauler) I he debris will be disposed of in : (namr ul lacility adIaJdrcs<ul racllilVl .I bnatu c of im 111'a .Ipphcanl ]Il ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOOW Y) 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 hcmedepot.certrequestOmarsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 INSURERS AFFORDING COVERAGE NAIC# Fax (212) 948-0902 INSURED WSURERA:Steadfaet Ins Co 26387 THD At-Home Services, Inc. INSURERB:ZUrich American Ins Co 16535 2690 Cumberland Parkway INSURER C:NATIONAL ONION FIRE INS CO OF PITTS 19445 Suite 30023841 Atlanta , GA 30739 INSURERD:New Hampshire Ins Co ' 1 INSURER E:Illinois Natl Ins Co 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 00'rLAGGREGATELIMIT POUCYEFFECTIVE POUCYEXPIRATION LIMITS TR N RPOUCYNVMBER AT MM T MM A IPR 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $4.000,000 ENERAL LIABILITY LIMITS OF POLICY ARE EXC SS PREMISES HE.wcurence 51,000,000 ADE aOCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Anyone person) $EXCLUDED PERSONAL&ADV INJURY $4,000,000 GENERAL AGGREGATE $4,000,000 UMIT APPLIES PER: PRODUCTS COMPIOP AGG $4,000,000 PRO LOC B AUTOMOBILE LIABILITY BAP 2938863-06 03/01/09 03/01/10 COMBINED SINGLE LIMIT ($.accident) 51,000,000 X ANYAUTO ALLCWNEDAUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS - - BODILY INJURY - $ (Per nadri NONOWNEDAUTOS X SELF INSURED AUTO PROPERTY DAMAGE $ JOFFICE�EBEkEXCLUDEO7 HYSICAL DAMAGE (Peraccidenl) ARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $ ANY AUTO - - OTHERTHAN EA ACC $ AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY, IPR 3757 606-02 03/01/09 03/01/10 EACH OCCURRENCE $5,000,000 - X OCCUR CLAIMS MADE AGGREGATE 55,000,000 E $ DEOVCTIBLE E RETENTION $ U. _ 3566916-ICA) 03/01/09 T03/01/10 X Wqy TIMIT OR YWORKERS'UAE NSAiION AHD -YERS'LIABILITv 7566915(AOS) 07/01/09 1/10 EL.$ACM ACCIDENT $1,000,000 ROP RIETORIPARTNEWEX ECUTIVEER EMBEREXCLUDED? 3566917 (FL) , 03/01/09. 1/10 E.L.DISEASE-EAEMPLOYEE $1,000,000 describe unoer ' - E.L.OISEASE-POLICYLIMIT $1,000,000 IAL PROVISIONS Celow0.ers Compensation 3566918 (KY, MO, NY, WI, ) 07/01/09 O3/01/10mployersExcess TNSC45699422 (T%) 03/01/09 03/01/10' ccurrence/SIR 25M/2Hers Compensation 5801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN TND AT-HOME SERVICES, INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO BO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KINDUPONTHE INSURER,ITS AGENTS OR 2690 CUMBERLAND PARKWAY REPRESENTATIVES. SUITE 300 ATLANTA, GA 30339 - AUTHORIZED REPRESENTATIVE USA ACORD 25(2007108)ckomraus -hd ©ACORD CORPORATION 1988 11172180 The Commonwealth ofMassaehusetts Department of industrial Accidents Q Office of investigations . 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El please Print Legiblyars Applicant Information Name (Business/organization/individual): 1e a Address: _ City/State/Zip: p4, C---,r, Phone #: Are yo an employer? Check the appropriate box: Drepaus roject (required): 4. ❑ I am a general contractor and I EJ construction 1. am a employer with ] t"� havehired the sub-contractors employees(full and/or part-time).' modeling listed on the attached sheet. I 2.❑ I am a sole proprietor or partner- molition ship and have no employees These sub-contractors have working for me in any capacity. workers' comp. insurance.. ilding addition [No workers' comp. insurance 5. ❑ we are a corporation and its Electrical in repa rs or additions required.] officers have exercised then umbing repairs or additions all work right of exemption per MGL 3.❑ I am a homeowner doing C. 152, §1(4), and we have no Pitt' epausmyself. [No workers' comp. employees. [No workers'insurance required.] t ther L comp. insurance required.] 'Any applicant that checks box Ntmust also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this ef6davit indicating.they are doing all work and then hire outside contractors must sulmu[a new affidavit indicating such tContrac wo that check this box must attached an additional sheet showing the name of the subcontrectors and their workers'comppolicy information. kers'compensation insuralrce for my employees. Below is the policy and job site I am an employer that is providing wor information - —� Insurance CorrrpanyName: Expiration Date: Policy# or Self-ins.Lic. Job Site Address: T ( IAl1I City/State/Zip:,leL n. 4 h�1L� 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 $250.06 a day against the violalor:-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 n er the p s and penalties of perjury that the information provided ab ve il true and correct Date. Si arure: 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 Z-Building Department 3. City/Towu Clerk 4. Electrical Inspector 5.Plumbing Inspector. 6. Other Phone #: tli3-A-3'3 a3-a3 DH Vin-L I .V_nlio N77C _aa ,,...i 2-H,J 1 I V:.^-`,ca dz QcbLz - Wdord Fsram'slcn 3;32" GL:vs, I 1.33 am V!1_-ia . Adn4 No' Lan!na Ud CLaaa 19!n �!Srlo LanLnado ® No G.L13 I' 4Ln c:J LL!ar . ENERGY PERFORMANCE RATINGS . . VaILLA=N DE MMIM ENiO DWK ET1er.= - U-Factor solar Heat Gain Coefficient - �� CaeAdartcGanrGa datrcqu solar /0 . 32 1 . 8 0 . 29 ADDITIONAL PERFORMANCE RATINGS EWLLIAM14 SUpI.EMelTAM CE RENDIIAFMO - Vlsi ble Transmittance ' Tranm+islon da LiaVYm4 - - - 0 . 52 muth4aar»>�rC Gess r"mrdam m 6Wb[Y f6RC pandas kr dsesrnlfi0»404 P pa{pa'n`NRC . tela ye deaimtr+ad far a Nod rt of am4vutrrml anIfts rd a Valk perd etre.MTC does not tacanv Wd 90'pe= -. .. esd mm mt NvrvN 6a sulaMtY of+ry RW tr m1 vodk ua oy"nsfi064art swan br oew pvAri p ka ato ` Ydams9on gwn+drtap . -- --- . - rm%Vlis s aapud vas aaws�s aa'dm mr ba p �.c�m d rant pn artwesdftm ,u r 301"M Doll hl _ pw 1,L, &W"a oQ WRC am dawMezMl por un woAm Ap d�� Y v)CID m m�ii -- sperdlta Mnt W=W&da*V-pod=f na V W=ata r WIdId t . . .. . m6ao dr tUtUm pR r uso Yaopada do nab PDXI'L W*41Ac4rO .. . - Unitap,a,Ufla f for ENERGY 9LY4 _ - cngion(a) : Nocte¢cn, No,tls Cant.al, -70..En Cant.al, 9o.tna.4. rNER6t SUA - - La un Ldad aaLLfita.pa.a 14(s) raTLOn(u) QNOACY STAR: Norte, - .. Noctn C¢nLcal, 9uc Cnntcal, 9vc. .• • " - ` IND: fteirt DU/CLaaf 3/31"/H-Ra1. 3 - - T¢�CtC 91aa: 36' x 63' - - ' IND: 8afunrao 04/VLde Lo 7.3.1 an/H-Ra3 . , 45 -45 7[aaaado pcobado: 91.1 c-u x-160 ca- DP 10773 . H9 Hoffu a 2911110. . - (alp Td k6J for pazi;*m�t STAR'mhcla.To lemn man hm wrrr.muq(ftta/m, Goalie am a*tm pm6 pr�ks nambahas EHEA6Y SG.L'Pah alNtm mds amlm dI asm,�hIL wxvicene�7yswr-Ioc 1oam...0""ealls a�, oac�.rmlfa �- Board of Building Regulations and Standards : HOME IMPROVEMENT CONTRACTOR Registr3Lgg;• 126893 - - Es Qlcat0 1. /2010 =5upp�ement Card _ The Home Dep ol A(€{Q{ne=any RICHARD FALLONE-�'�._ ;_! V � ' 3200 COBB GAILERI,AFPl4WY9t20 ATLANTA,GA 30339`__r �L Administrator FIPR-20-09 21:S0 RICHARD H. GIRHRD TEL:SO3-524-SISSO P:01 .. HOME I NI PRO VENIENT CONTRA(A PLEASE READ Ti115 Sold,Pun9shdl and Installed by: Rranelf Name.: Bostan Date: jZQl. 'ZoOLi THD At Hume Nervier• Ine. d/h/a flee Ilonle Depot At-Dome.Sn.ievs Itrainch Number; - 345A(lrceuloeal Suecl,Unit Worcester.MA 01607 Forth 33 nSnpth 3l 1011 Frit(Mal)057 51 Xo. HIX O 4)756-IX2i 11 '111)4 ;1 h1b3Ml,Mt-1¢ACO24iJ K1 W111 Lic# I 04_7 CIL 11 b , '_:NA l Int.c Ir(uIp /l mu11(.arli U/nrarR:'g.4 1.W9., lustallatiun Address: � u--�!�M S S ( 5/F/�/lr'� _M Or O ` 1 k-j �el y ' 'try Soalo %ip Par,baser(,): _ Work Phnnr: linmr Phone: Cc 11 Plwne: Hone Address. (if diffetan Gum loeraliaton Adrb'ell) Ciry State /,o E-mail Address(to iective larliezr communi talons,nd I lone Depot updaw')� _.._ F1 I DO N01 ,1I h n,rcu:iIC.ury nIca'keling emaita unn:The I tome Depot Proieet infarnialion: llnAcrsigncd('7:mh,mer t_tic"woos of Iht pruparty lucalo(t at the above Inxtallahnn address,agrcce 10 hely, and lHD At Home Screiccs,tele.i-The Home Depot'I agree,,u1 furnish,deliver and arrange for the insudlimun('hislollad,n,")of all materials described oil the below and on the rolerenced Speu Sheel(a), all ell wlrlch are ineorpol'ated into this (onn'do by Lhis rcfcrcncc, aloin with any appheahle Sluts SUPplcnam uud Payment Summary loathed hetero and any Change Orders wotic:lively, "CnnlracF'): shah U: o.... r.,...... prrxlucu. _ Spec Kheetls)4; v,s ,t Arnouui �^I I�Rn000 ('Siding []\\'mdnu. IJ7 lion p�7 J{�� Tg.2�a uyte, r�ry-cn_Utntry door. _i- _. �1 6G.. M ' 0 l'J9 J � ❑1-;utter, Lewis � .,Dor,, p I,.al ti.n, � z Ck, a� p<}utters/ o pi'.nlry 17„or. ❑ _ - �_". ..ORovliug pSklinr ❑Wiudo.,n ❑Insulation "- pe,.,r„g ❑smine wlndnl.. ❑m..Ll LiIIIr NI -nun,25-,b Depositor Canna,+A .untdueup(mexenlao-111 ud1-1-A-L Total 0adracl Amount MWne 1'urchrxn may lu,cdclnmit nv,m tl,..,,o,rrth Irttiwtn,ntract Auwunt 1llr I C,n,lonlcr agrees that.,mn,ecl a civ upon cuulpletion of the work fur tech Prilducr. CUSIOnICT will eserine a Conylletiun Ca'lilioate luno 10, each Ihnduct:n dclined by :u, mdlv,duut ,Spec Sheell and Puy any bahulce dor. As applicable.each Cu,luasi un•ier this Conp.,n nurccs to bc.joiuny nod.cruelly obli¢amd,'M liable bemmIdel. The Horne Depot reservcs the right m Issuer Chanes ONer Or terminate.this Conn-acl u: any uKlrv'Ideal PiLICIU I)included heroin,ar its discm ion,if Tile Hume Depot Or ns willoriicd sefNoe provider dUWj IIuuus Ilea h emIlma Perl'm'ni its obGyaunnc due to a,i Lanni] problem with the hun1C,elrotionmental hai.ndy each;IN mold,ashatva or lend Pam,,other solely a,nasi n., prieanc-error,o, ,•ccautir waft required ill mulplem th Joh was nut 1 l luded m the Comrau. Paymeut Snplmary' The P15111tall Smnolaf NL 1 ' -_ irLIUdcd :Is Parr ut [his Coital I. see, fOrdl CK I01.11 Cmtn'ael an,ouut and payments ICCI(orod fir mC depu,ac and final pwyurcnll LY Ilold.L,t as apillle'abln. No I'IC'F.TO(lLSI"OMFat You are entitled to u completely filled-in copy of the(:onlract at the time you sign. Do nut sign a C'nmpletion Ccrtifirp4(nate: there is one 0anpleti0n Cerlil irate for each listed I'+'oducl as defined by individual Spec Sheets(befol'e work on Ilwt 1'rl,duct IN colli III the event of Va'-f anion of this Contract.Cpvlumer ngroes to Pat)' rbe Home Depot the costs of nmterials,labor.expenses and services piviided by The Ilonre Depot ar Aplhorized Servlce Provider Ihropgh the dale of termination,plaN UM otter nmounts sel forth in this Alirccment or allowed under applicable law. 'I11I?H(/M F.DEPOT TIAY WITHHOLD AMOI INTS (IYVED '1"0 THF HOME DFPO'I FRCIVI THP: ULI10SIT PATNfFNT OR OTHER PAY'DIRNTS MADF, Vill I HOL F LIM 1'I'INO THF:U(1N]F DEPO1"$OTHER REMEDIES FOR RECOVERY OF Ski('11 AMOI!NT'S. Acceptance and Aulhutl'lahon: CUStU1n 1 1 i> .ua.l nndcrvlaaj, own this Asrc. ear i. tae L.n1Te aeleenleot I IwSen C ea aner and 1Ile Ihall Depot wish ruglud to the Prodi LI':ln I hlsll,Ihoon sr'vi,"e a I ,.Pal . III prim di "Isions and auolenn,al either unl or wnucn relaunu Lu aged PrOdUCtl a,d t.1 1a11 :nn Thi, Agreement uun,u• he i.'. .•nod or.nr,dad c.repr hN , w-nnn slguud h, (C.ualolner and Thr Home Drlu)r. Cm 'usto (r'a knowi..dges and agars that C'usio nt' 11a read. L ndermands. .C.111,'IttkyjIN aal -pis the knee of and has o-:thud a cL:pY of thi.,A)gmcn,eaL til 'ILeJ I>7: a GZ=�cc,f�AF /f - S / Customer.St•_mritbrt Dade ! Sa _nuallanl-ISI r�''naLtne pry Da�a)/ �p'L�.(�a 1--IJ-`�- [Su.auu)Cl':.SigALALIJ Duce Sale.Clmsuh;Ld i loose NO -. o„nPpncanhn.— CAN1L'!'LLATION: CUN'IO,\jFR MAY CAN'('lil.. THIS AGREF.MEN'1' %VITHOL'1'PENALTY' (IR OItLt(.ATION BY DELIVRRIM; NIK ITEN NOTICE TO '"fill HOME DFPO'I' BY MII)NIGHT ON TIIE THIRD 11USINE-iS DAY AFFER SIGN;\C: '1.1115 AHREENI RN'1'. THE STATE RCPFLF:MUN'I ATFACHIA) 111:RETO CONTAINS A FORM T'O USE IF ONL 15 51•ECIF'IC.ALLY 1.8FlCRIBED RY' LAN' IN . Cl_jSTOMF.R'S STAT F. N(Il'11:F:ADD1'I'IONpl.TF.RN1S ANI)luNIA IONS ARG til'\IIA pN'1'HF RC\'nKtit.JIIIF.:\VII ARE PARI'UF'1 HIS I ONT12Al'1' 10-22-08 fair B-05-08 C-SC whlto-Branch Fle Mallow-Customer Pink Sales ConsLltanl