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102 BRIDGE STREET - BUILDING JACKET �' C Lilo 4DCITY OF SALEM, MASSACHUSETT&f Y OF SALEM: MA + • BOARD OF APPEAL CLERK'S OFFICE. 120 WASHINGTON STREET, 3RD FLOOR SALEM, MASSACHUSETTS 01970 (� /� STANLEY J. USOVICZ, JR. TELEPHONE: 978-745-9595 DEC 29 A to: 50 MAYOR FAX: 978-740-9846 ' DECISION ON THE PETITION OF RAYMOND& CYNTHIA JERZLO REQUESTING AN ADMINISTRATIVE RULING FOR THE PROPERTY LOCATED AT 102 BRIDGE STREET R-2 A hearing on this petition was held on December 15, 2004 with the following Board Members present:Nina Cohen Chairman, Richard Dionne, Bonnie Belair, Edward Moriarty and Nicholas Helides. Notice of the hearing was sent to abutters and others and notices of the hearing were published in the Salem Evening News in accordance with Massachusetts General Laws Chapter 40A. Petitioner is requesting relief to allow continuance of use of existing third dwelling unit for the property located at 102 Bridge Street located in an R-2 zone. The Board of Appeal,after careful consideration of the evidence and after reviewing the plans at the hearing,makes the following findings of fact: 1. Petitioners Raymond and Cynthia Jerzlo of Salem appeared before the Board accompanied by their legal council,Attorney William F. Quinn. 2. Petitioners purchased the property from Cynthia's parents about ten years ago; her parents had previously owned the property continuously since 1964 and for years before that. 3. Cynthia lived with her parents at the property in her early years, and has been at the property thereafter throughout her life. 4. Cynthia testified of her personal knowledge that the property has always contained three dwelling units, including the dwelling unit on the third floor. 5. City Councillor Joseph O'Keefe appeared at the hearing in support of the application, and upon inquiry from petitioners' council,testified that he lived in the Bridge Street area prior to 1965. He further testified that he was elected as the Ward 2 City Councilor in 1970,that he visited with Cynthia's parents in their apartment in the property at that time, and the building did contain a third floor unit at that time. Councillor O'Keefe further testified that he lived in the neighborhood in and before 1964, and based upon his knowledge of the neighborhood and the property,he believed that the building contained the third floor dwelling unit before 1965. DECISION OF THE PETITION OF RAYMOND&CYNTHIA JERZLO REQUESTING AN ADMINISTRATIVE RULING FOR THE PROPERTY LOCATED AT 102 BRIDGE STREET R-2 page two 6. Cynthia testified that the building had continued to contain the third floor "^--'d%Qing unit oontinmowk-since before`1964;that the City of Salem had always assessed the property as a three-family, and that her parents and she had always paid the taxes on it as a three family. 7. Petitioners submitted evidence from the City of Salem List of Polls and the Polk's Directories that the building had continued to be occupied by three families continuously since 1972. 8. Petitioners submitted a tag affixed to the firmace serving only the third floor unit evidencing that it was installed in 1968. 9. Petitioners submitted a site plan prepared by North Shore Survey dated December 2,2004 as evidence that the site provides seven on-site outdoor parking spaces for tenants of the property,plus a two-car garage on the site. 10. Petitioner;also submitted a petition signed by several neighbors to the property in support of the petition. 11.No one communicated with the Board or appeared at the hearing to oppose the application. 12. The Board takes notice of the fact that the Zoning Bylaw as enacted in Salem in 1965 Therefore,based upon the evidence presented, including much evidence that was not presented to the Building Commissioner at the time of his consideration of the issue, the Board voted,with four in favor and one opposed,to,make a finding that the existing 3 family use of the property, including the dwelling unit on the third floor, is legal as a pre-existing non-conforming use that existed at the time of the enactment of the City of Salem Zoning Bylaw in 1965 and has been used continuously as a 3 family since 1965,and that use is entitled to be continued unless the property loses such legal nonconforming status in accordance with applicable law and the provisions of the City of Salem Zoning Bylaw. ADMINISTRATIVE RULING GRANTED Nina Cohen, Chairman DECEMBER 15, 2004 Board of Appeal DECISION OF RAYMOND dt CYNTHIA JERZLO REQUESTING AN ADMINISTRITAVE APPEAL FOR THE PROPERTY LOCATED AT 102 BRIDGE STREET R-2 page three A COPY OF THIS DECISION HAS BEEN FILED WITH THE PLANNING BOARD AND THE CITY CLERK Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts General Laws,Chapter 40A, and shall be filed within 20 days after the date of filing of this decision in the office of the City Clerk. Pursuant to Massachusetts General Laws Chapter 40A, Section 11. The Variance or Special Permit granted herein shall not take effect unit a copy of the decision bearing the Certificate of the City Clerk that 20 days have elapsed an no appeal has been filed, or that,if such appeal has been filed,that it has been dismissed or denied is recorded in the South Essex Registry of Deeds and indexed under the name of the owner of record or is recorded and noted on the owner's Certificate of Title. Board of Appeal $ tq T5 - L q-1 ZoS RECEIVED The Commonwealth of MaKAL ce Department of Public Safety� W �Ylassichtisetts State Building Cude(7,��gNt{� i UL '1b A Building Permit Application for any Building other than a One-or Two-Family Dwelling (Phis Section For Official Use Onl ) Building Permit Number: Date Applied: BLidding Official: •114 SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) D 19 76 No.and Street . City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used Z If Nov Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix L) Change_yf Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer R(Yiew ret ued? r Yes ❑ No Brief Description of Proposed Work: �O D �)r /1/Dt' "f'r ih1 1%e Ag tIY' /D Sn , YV ek rivr S ' inn /Ydkti/ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR , CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Grou p(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Fluor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-L❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ FI: Hi h Hazard FI-L❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ I-2❑ 1-3❑ 1-4❑ hh Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-L ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) [A ❑ IB ❑ IL1 ❑ IIU ❑ IIIAa IIIB ❑ 1 IV ❑ I VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zane Information: Sewage Disposal: Trench Permit: Debris Removal: Public(2, Check if outside Flood Zone❑ Indicate municipal e A trench will not be Licensed Disposal Site❑ required O or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA f I. I n �'onwn si n ir,v I r 'ra: Not Applicable O• Is Structure Wlt[iiii airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes O or No❑ Yes❑ No ❑ SECTION B:CONTENT OF CERTIFICATE OF OCCUPANCY Edition ul Cndc Use Group(s): Type of Construction: _ Occupant Load per Floor:_ Dues the built ing iontain an Sprinkler System?: _ Special Stipulations: S� nl D TO SECTION 9: PROP I O VN V t AUI'IIORIZATION Name and Address of.Property.Owner ) UjvW 2i `..'f�A, 1 a4ld �a.:�r7f�cr 5 .SGi�P/r\ 01 Name(Print) No.and St City/Town Zip Property OsCn r ContTct Informations ' P !!11 Aer\ 1 .� .� r �ua.ldl o0 'Title Telephone No.(business) Telephone No. (cell) a-mail address If applicable,the property owner hereby authorizes Name Street Address City/'town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this bUdding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and or not under Constmction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. a-nail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10..22'General Contractor n Com any 1Name r' ikY\ 1):^)yer GC - /03DIS� Name of Person Responsible for Construction License No. and Type HA licable fb ISO)( C20W -,CA r'en, ,G 6 Street Address City/Town fate Zip Telephone No. business Telephone No. cell e-mail address SECTION r M.C.L.c.152. 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes 13 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1. Building S Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical S appropriate municipal factor)=S 3. Plumbing S .1. Mechanical (HVAC) $ Note:Minimum fee=5 (contact municipality) 5. Mechanical Other $ y,Enclose check t rble to 9 6.Total Cost $ � f (contact municipalip.ty)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. n -6�v IP e;ue p�r�icnt,tnJ siKn ns yie �Q/� 'title Telephone 19 70 Date r�v 'e,r X o�!'niOX M /1 O // Street Address City/Town to Zip —7 Municipal Inspector to fill out this section upon application approval: 0" J Name ate Massachusetts Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-103018 STEPHEN J DRIY�R Sa em ST9707, �1 � Salem 1NA 01970% Expiration Commissioner 06/29/2015,1 j C- ,lie V�omvrxoaurrea�c a' o�C�aaaac�uraeCG, X Office of Consumer Affairs&Business Regulation MEIMPROVEMENT.CONTRACTOR egistration 1*76148 Type: xplratlon kt7F12/20i5, Individual I f_ Z, f STEPHEN J.DRIVER"` - r e=' STEPHEN DRIVER 4 HENRY STD- SALEM,AMA 01970 ^ ` n f .... � -. 5 Undersecretary Rat •�- �-_-�,,.._.,'...�._�...,..--� /f 1 CITY OF S;1l.,EM, LtiG15S.1CF(USETTS ,. OU'LOL`(GDEPART tE,rr h� 120 1(/.UHLNGTON STREET, 3 '°FLOOR TtiL (973) 745-9595 KEN 0ER1.EY 0IZISCOLL RUC(973) 7-10-984S ,�,L3Yo;2 'r-tosLAS Sr.PMUM DIRECTOR OF PUBLIC PROPER7y/BC(LDLqG C0AL%11SSIONEX Construction Debris Disposal At'tldavit (required for al l demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 C&fR Debris, mid the provisions of tbIGL e 40, S 54; section l t I.S 11 Building Permit y 1 is issued with the condition that the debris resulting from l 1, S 1 SOA. work shall be disposed of in a properly licensed waste disposal facility as defined by bIGL c The dchris will be transported by: y ) (name ut'haurer) The debris will be disposed of in (nantao(tacility) S In Z ) (:ddroscaftiicility)�— sisn�rurcufJAI, .tppficant J - 7 STEVEBUILT CONSTRUCTION Construction Contract STEVEBUILT, henceforth known as "Builder," and Paul Murphy (102 Bridge St), henceforth known as "Client," are entering into this contract this 8th day of July, 2014, for the purposes of establishing the provisions of the construction of exterior repairs as described in the proposal located at 102 Bridge St., Salem MA_ 01970 • Client agrees to the estimate provided by the Builder on June 30, 2014, with the following changes (to which the Builder has agreed): NA • Pursuant to the estimate, and the changes listed above, the Builder agrees that he will be repairinglreplaceing exterior trim at 102 Bridge St., Salem Ma. • Client agrees to pay Builder according to the following plan: Total of$2308.70 of which $577.70(25%) is due in advance. The remainder, $1731.52 is due upon completion of the work. Final payment is due within 14 days of completion. • Client agrees that if payment is not made according to the above plan, Builder has the right to stop all work until such time as payments have been brought current. • Client understands that if changes are necessary during the course of construction, the Builder will provide the Client with a change order, and the Client will be responsible for the additional incurred costs of the agreed upon changes. • Builder will be responsible for all materials and equipment necessary for the completion of the job, which the Builder agrees were included in the estimate, or were added with the changes listed above. • Builder agrees that construction will begin on July 16, 2014, with an estimated date of completion on July 23, 2014. • Builder agrees that any delays and/or changes not agreed to in this document must be discussed with Client before work is to continue. • Builder agrees to hold an insurance policy worth 2 Million dollars, which will cover equipment, materials and all employees and/or subcontractors_ • Builder agrees to obtain all necessary permits for the construction, the costs of which will be the builder's responsibility. • Builder agrees that he will remove all debris, equipment, materials, etc. from the location upon completion of the construction. • Builder agrees that all employees and/or subcontractors will be legally permitted to work in the United States. Invalidity or unenforceability of one or more provisions of this agreement shall not affect any other provision of this agreement. This contract is subject to the laws and regulations of the state of Massachusetts. Stephen J. Driver Builder Name Bui er Signature Paul Murphy/IOz rll^� St It Corm- g1S�Cl -,a� Client Name P Client Signature CITY OF &V-EM, NL1sSACHUSETI'S BUILDING DEPARTMENT 120 WASHINIGTON STREET, 3"o FLOOR ,1 r TEL (978) 745-9595 Rti-x(978) 740-9846 KIMBERL.EY DRISCOLL NLAYOR Tm6us ST.Pmua DIRECTOR OF PC BLIC PROPERTY/BC ILDfNG COSL\IISSIONER Miricers' Compensation Insurance.Aflidavit: Builders/Contractorv/Electricians/Plumhers Applicant information L a P Ilease Print eeibly Name (Husivass,,�,Org,vtieation;Imlividu:Jh — S�n�ilf�i�u I l / "�1 OI U+ro Jf� Address: PO �iOX o2C�f1110 Al n MM D/gZd _ City/State/Zip: Phone I/: Are you un employer'!Check the appropriate box: F6. 0 project(required): I.❑ I am a employer with 4, ❑ I am a general contractor and I ��ntployeee(full and/or part-time).• have hired the sub-contractors ew conswaaion2.LVI Ituna sole proprietor or partner- listed on the attachedvhect. t emodelind ship and have no employees These sub-contractors have emolition working din me in any capacity. woilrers'comp. insurance. uilding addition[No workers'comp. insurance 5. ❑ We are a corporation and itsrequired.] officers have exercised their lectrical repairs or additions 7,❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers'cutup. C. 152, §1(4),and we have no 12.❑ Rcof repairs insurance required.) I employees. [No workers' j;•Q Other cutup. insurance required.) •,env uppm liut duet vltecks but AI mast also fill out the%colon below shaving their workers cum Natation pulicy inI;,rmotion. '16'mcuwncn who whn,it this al}idnvit indicating they arc doing all work mud then hire uutide u'llectors mma uahmit a new a fr.daviI indicating ouch. $Gnatr ton thus chick this boa must anacha)an:Idditiu,ml.Mca shuwing aia mune of the tub<amrseton and their workers'camp.put ley inib motion. f cant can eurpfayer that is pruviding workers'compensation Luurunce for my employees. Below is tho policy and fob.riff, ittfrrntation. Insurance Company Name: ___.._--- Policy 4 or Self-ins. Lie, 0: Expiration Date: dub Site Address: City/Stale/Zip: ' Attach a copy of(he worlrelf"compensation policy declaration page(showing the pulley number and expiration date). Failure to secure coverage as required under Section 25A of,%fGL c. 152 can lead to the imposirion of criminal penalties of a fine up to S 1,500,00 and/or one-year imprisnnntent,as well as civil penalties in the farm of a STOP WORK ORDER and a line of up to S230.00 a day against ilia violator. Ilradvised that a copy of this statement may be forwarded to the 01 lice of htvrstigaliuns ol'the MA for insurance'covcrage verification. l du hereby certify under the pains art pen aldev of perjury that Ilse hifurinutlun provided Ub e>�u-�_ Phume 1' ✓V I- -U F only. Do not write in this area,tube cunsplerad by city ur fawn nffiviu1 n: _ _ Permit/License N --------. ..- 7fJ thurily (circle one):Itealih 2. Iluildinq I)ep.artment 3.Citylrnwn Clerkt. F.Icetrinl luspadnr 5. Prcun: Ti��) I L4 - I (01 S 3 . i amp The Commo wealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised blur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only Building Permit Number, to Applied: Building )tticial(Print Name). Signature Date SECTION 1:SITE INFORMATION' 1.1 Property 1.2 Assessors tNl ap&Parcel Numbers 1.1 a Is this an accepted street?.yes' iio' --•�• Map Winber Parcel Number 1.3 Zoning Informatio 1 \a \ I. Property Dimensions: PKningistrict Proposed Vsseof Area(sy tt) Frontage(II) ldingSetbacks(R) Front Yard Side Yards Rear Yard ired Provided Required Provided Required ProviJed er Supply:(M.G.L c.40,§5J) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ p y N G ECTION 2: PROPERTY OWNERSHIP, 2.1 Ow a ec t�tme(Print) t ors City,State,ZIPP \ W f t a� W 91122 No.and S rc f- J Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check ai hat apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs ❑ Altemtion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units OQier, ❑ Specify: Brief Description of Proposed Work-: i r SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost?(Item 6)x multiplier s 3. Plumbing $ ether Fens: S d.%lech:mical (FIVAC) S List: 5. Mechanical (Fire S Total All Fees:S Su «scion) _ Check No._Check Amount: Cash Amount: G.'futul Project Cost: $ 't ❑Paid in Full ❑Outstanding Balance Due: �lki L-ev 1l I IS 7-01 u� t , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction up � ense(CS ) 1 _ Lice se Number E.epir iu Uale Wane of CSL Holder List CSL'rype(see below) No.:md Street Type Description U Unrestricted Buildin s up to 35,000 cu. 11.) R Restricted I&2 Family Dwelling Citymwn,Slate,ZIP M Masonry RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Telephone 4 Email address D Demolition 5.2 Registered 110me In rirover tent ntractor( IC) HIC Registration Number s ution ;ue f I IC Con :� a tea r nt ame Nu.and 't a Email address Cit /Town,State,ZIP 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 bui ' permit. Signed Affidavit Attached? Yes ..........❑ No...........❑ SECTION 7a:OWN&BrAUTHORIZATION,TO BE COMPLETED W HEN. OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT' I,as Owner of the subject property,hereby authorize ! C�y6 t9 act on my behalf,in all matters relative to work authorized by this building permit application. r Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my nam bet w, I reby attest under the pains and penalties of perjury that all of the information contained in'th' a tic on i true n accurate to the best of my knowledge and understanding. Print Owner's r t tlmnzcd i genl's N:uno(Elecunic Signature) D: e 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 IM.G.L.c. I42A.Other important information on the HIC Program can be found at ww mamass..111n ora Information on the Construction Supervisor License can be found at www.ntas.uov'dns _ 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) ') .(including garage, finished basement/attics,decks or porch) Gross living area(sq. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of h;df%baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open_ 3. "Taal Project Square Footage"may be substituted I'or"'Turd Project Cost" 2014-08-10 13:08 EXPDTR 9787390618 >> Home Depot AHS P 1/10 ruxt I u� I -. Lead/Branch: 7713848-Boston North SaturdayY" -----" eugding Code Requirements:: Price Book: Boston North 8/9/201411:00:00 AM Soft Coat Low E: Base Stare: 2686 SALEM,MA : Referral Store: 2686 SALEM,MA Interest: Store Associate: 6500/6100 Series Windows ; Customer Referral: ......... ..... ..... _.:....... . .................. ........... Homeowner Name&Address: Home Phone: 617)913-8589 Holly Smith Work Phone: 102 Bridge Street Cell Phone: #102 SALEM, MA 01970 Pager: Work Phone 2: Cell Phone 2: County: ESSEX Homeowner's email:. ., oilysmith83@yahoo.com Nearest Crass street: SC Comments: Homeowner comments: We have nine windows that n Rd their windowpanes replaced due to moisture locked in between the two panes. OLS Additional Information: . :, .�. ., L �' 4{' IAf. ,. "':xµ ni�» �I♦kp�wAll'�V'i'i . Job# .. Homeowner/Address. Home P1 11 Is Work Phone Cell Phone 7635400 Cathleen relay(56 Walnut Road,SWAMPSCOTt (751)95 0 n � Sales Consultant 1 ` d' 1 roject Coordinator: ichelle Lagasse - (774)275 2150 Sales Consultant 2: leld Inspector: anon Olivier! (List second consultant only If commission is split) If appointment is a gALt:: ..d .f #1, Result your Sale on the Web _ Siding _Windows _Roofing _Insulati Q. FAX the Documents IN THE ORDER SPECIFIED below to:(868)520-8390. _ Entry Doors _Storm.Prot. Gutters/Leaf Prot. #3. waster Contra'afdoes(when resulting multiple products)as follows: Sale _Credit Reject Contract Amount >salsa contract(top page only) #4. First Job dots as follow _ Appt. Reset Reason: >Pro-Renovation Form >Spec Sheet(wl signatumrall pages) _ NO Good >Pricing Worksheet(all pages) >Measure Sheet(s) _Sit No Sale _Price Quote Follow Up Call Date: >diagram(if applicable) - >Contract Amend.(if any) it >Lead CA(if applicable) Objections or Issues: 05. Repeat g_II section 04 does for second,third&fourth Jobs - "-" ONLY FAX ONE JOB AT A TIME https://www.tb"thomeservices.conVsalesweb/afApptPrint.asp'?AK 26963&Auto Print=Yes 8/9/2014 ...111, ..,.. .,.W . r,r., r HOMK IMPROVVMENT L �� TRACT PLEASE REAQTt IS f�^^���pp� V Sold,Furnished and Installed by:. Branch Nam:Roston North&South Dute:2l -Ti L r THD At-Home Services.Inc. d/b/a The Home Depot At-Home Services Branch Number:31 and 33 108 Boston Tunipike,Unit 1,Shrewsbury.MA 01545 Tull Free 877-903-3768 Fed IU It 73-269840):ME Lic#('024.9;RI Cont.LIc#16427 CT Lic#Hit 1565522;MA Hume lurpmwmeni Cunuaclur&g.#126893 Installation Address: 1`w' WA (2D I C)—7() City State tip Wrchaser(s): Work Phone: Rome Plwpa: Cell Phone: - 6tl .Sm I'T'h i f I f I Co( T1 f 3.-,rs5 Hume Address: SGiv�- (Ifdili'crcm from Ins(allulilm Addres*) City State Zip mat ddresa(to receive project communications and Home Depot upda _ NOT wish to receive any marketing cmails Rorro The Horde Depot project Information: lintk:rxigmel("Customer"),the owners of the prope I located at the above installation address,agrees to buy. and THD At-Hume Services,Inc, ("I'he Home Depot")agrees to furnish, Iver and arrange for the installation("Installation')of all materials described on the W,ow and on die referenced Spec Slimt(s) 11 of which are incorporated into this Contract by this rclemacc,along with any applicable State Supplen¢nl and Payment Sum attached hereto and any Change Orders(collectively. :Contract"): Job#: taa.nm Reh,ene) . 114 Sec Sheet is)M Pritlect Amount '7p RuufmK Siding Windows lasulaarnr CJ ❑(:u(tem/Caere envy Doma ❑ ❑Rnnl'mg Siding Windnws Ej Insulation a U f g ❑Gullen/(lovers ❑ltnhv Doors ❑ o Roofing LISiding Ll Windows insulatiun- ❑(tuners/Covers ❑Fimy Doors❑ ❑Rnoling ❑Siding Windows Insulation ❑Outers/Cevcrs ❑Entry D runs ❑ S Mnimmn25%llepmttufConlmcY Aprounitluc spat erarardm.iWhmntrxt. 8� and Contract Amount $ M:dmPrrrehxsnu�myv pal tlepodtnraer.ihmr oncNirtl n<tha 1`.renrixtArmunt. Customer agrees that, immediately upon completion of the work for each 7 xluct, Costumer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay an o vdance duo. As applicable, each Customer under this Contract agree.¢to hejointly and severally ubligated and liable hereunder. The Home Depot reserves ul[e nght to issue a Change Order or terminate thiContract or any individual Products)inciakrl herein,at its diuzctial,irThe Ilome Depot or its authorized service provider tletermi, that it wi m t Perform its obligations due w a structural problem with the home,envirotmnental Iniz[rrds such es mold,axhesuss or IAl paint,other safety concerns,pricing errors or because work r'a'(uired to complete the job was not included in the Contract. Payment Summary: The Payment Summary ft included as part of this Contract, sets forth the coal Contract amount and poymems required for the deposifs:md final payments Product(as applicable). NOTICE TO CUSTO ER You are,entitled to a completely filled-in copy ul'the Contract at the Del on sign. Do not sign a Completion Certificate(note: there.is one Completion Certificate for each listed Product as defined b i ndividoal Spec Sbect&I before work on that Pnaluct Is complete. In the event of termination of this Contract,Customer agrees m par Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Pro ler through the date or terminathxy plus an yy other amounts set I'urlh in this Agreement or allowed Ruder apppllicable law. HOME DEPOT MAY WITHHOLD AMOUNTS OWL''D TO T1IE IIOME DEPOT FROM THE. DEP(7SIT PAYM I I f OR OTHER PAYMENTS MADE, WITHOUT LiMITBVG THE HOME DEPOT'S OTHER RKMEDD:S FOR RECO RY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that.t Agreement is Rue entire agreement between Customer and floc Home, with regard to the Products and Installatiun¢cervices; supursules all prior discussions and agreements,either oral tr written,relating to said Products and Installation.Tliis Agreement M.he ussigmed 1R amended except by a waling sighed by Customer and'Ibe Home Depot.Customer acknowledges and agrees tb 'ustomer has reed,unders[arrds, vnlwu[arily secepLs the turnns of and has received a copy of this Agreement. Accepts I S11 y: Cusu r's.,' a a Dam I Sal . ILvtt's S' nature Date _ X I Telephmn o. (i18 Customer s SignaWn; ........- Date S#Ics C:n . lam License No. CANCELLATION; CUSTOMER MAY CANCEL THIS (osnppl,M.Mc) AGREEMENT WI114OUT PENALTY OR OBLIGATION BY DELIY-ERINC. WRITTEN NOTICE TO THE HOME I DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AVI'ER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRHSCRIDED BY LAW IN CUSTOMER'S STATE. WriCa:ADDITIONAL TERMS AND CONDITIONS ARK.Sl ATED ONTIU I IVERSE SIDE AND ARE PART I IF'T'HISCON'I RA(.'r The Commonwealth of Massachusetts 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 Lel?ibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: 6 Are an employer? Check the appropriate box: Type of project(required): 1. I am a employer with,_�_ 4 ❑ 1 am a general contractor and I 6. ❑ New construction employees(full and or par[-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- These sub-contractors have ship and have no employees 8. ❑ Demolition employees and have workers' working for me in any capacity. 9. ❑ Building addition No workers' com insurance comp. insurance." [ P 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Re repairs insurance required.]' C. 152, §1(4),.and we have no 13 Other employees. [No workers' comp. insurance required.] *Any applicant that checks box 41 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. *Contractors that check this box must attached an ditional sheet showing the name of the sub-contracrors and state whether or not those entities have employees. If the sub-contractors have empl-, s1hey must provide their workers'camp.policy number. %am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Vr— Policy#or Self-ins. Lic.#: ��l� Expiration Date: Job Site Address: 1 11 `7[ City/State/Zip: 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 t7c gations of the DIA for ' surance coverage verification. ify under t e pa s d p allies of perjury that the information provided a ove is true and correct. Dater Phone#: FEOther only. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector rson: Phone#: ti ''.S�HRL��PC'•s _ . Crrstrua_;cn Sup[n'isrr Sn "�' . GATE MlGOtt'lYf1 Aco CERTIFICATE OF LIABILITY INSURANCE 9utv(M2D14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CEW IFICATE DOES-NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES _BELGVIf...=THIS..CEATIFICmii OF_lN9URANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 1. REPRESENTATFVE Olt PRODUCER,.AND THE-CERTIFICATE HOLDER. - „IMPOST-PVT,:H,thg.Dertitioste holder b an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms andconditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certltie5te Holder in lieu of such endorsement(s). r - PRODUCER FAX 'MARSILUSA,INC: (HONE . AI Na TWOALLLINCECENTER E-MAa 3560 LENOX ROAD,SUITE 2400 ACRE 19: ATLANTA,GAS 30326 - INSURERS APFORDINGCDVERAGE NAIC9 . - Steadfast lreurance Company 26387 400492-HomeD-GAW-14.15 INSURER A: 18535 INSURED - INSURER a:Zuddl Amedpn lnsurdwe CO •.THDAT-HOME SERVICES,INC. IwsuRER C:New Hampshire Ins Co. 23841 OBA THEHOME DEPOT AT-HOME SERVICES Il0n0is Na00nal Insurance Company 23817 2455'PACESFERRY ROAD - INSURER O: ' ATLANTAGA81B39-. .._.:. - . . -INS.URea E:Stead* COVERAGES CERTIFICATE NUMBER: ATLW324261mi REVISION NUMBER:3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEDBELOW 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 SY THE POLICIES DESCRIBEDHEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. M9p P CY EFF PC It E%P - LIMITS TYPE OF INSURANCE POLICY NUMBER M M,O %�0� -A GLO48U7.14.04 03101/2014 031012015 EACH OCCURRENCE s . t 1,000,000 $ X COMMERCVILGENERALLIABILffY OMITS OF POUCY XS MED EXP are sorer) $ EXCLUDED CLAIMS-MADE M OCCUR - - 9000,000 OF SIR:$1M PER OCC PERSONAL SADVINIk1RY E GENERAL AGGREGATE S 9'000'()00 _ PRODUCTS-COMPIOP AGG $ 9,--0,()00 GENLAGGREGATE LIMIT APPLES PER $ X POUCV PRO- LOC COMBIN ING IT I,OOD,000 B AUTOMOBILE LIABILITY SAP2938863.11 0310112014 031012015 a ml BODILY INJURY(Par Pmsd) S X ANY AUTO ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per acdden0 E AUTOS AUTOS PROPERTY AMAGE $U e HIRED AUTOS AUTOS S LAM SIR ELLALWB OCCUR EACH OCCURRENCE E . AGGREGATE E 'EXCESS LU1B. CLAIMS-MADE ' E DED RETENnDN 1 ) 0310 1 0 WC STATU- OTH- -C WORKERS COMPENSATION .. 1,000,000 AND EMPLOYERS'[fABO.nY YIN WC049101864(AK AZ,VA) 031012014 0310112015 EL EACH ACCIDENT E C ANY PROPa1EMSER EXCWDEDt WCO491RISTORIPARTNEP/EXECUfNE�. NIA Q11012014 O3N72015 ELOISEASE-EA E 1'WOWO OFFICER01B83(FL) D (MaAdatorymra+i -if U the under EL DISEASE-POLICYLIb1fT f 1,000,WO DOyyeess eSa M . ON OF OPERATIONS bel. 1,000,WO 03N12015 (ELIUMIT C WORKERS COMPENSATION WCD49JOlM(KY.NC,NH,VT) 031012014 C WC04910iN6(N4 03M2(14 031012it15 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ANach ACORD 107,Additional Ramada Schedule,N mare apace Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THDAT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DDA THE HOME DEPOT AT-HOME SERVICES - THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATIANTA,.GA=9 - AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(20101105) The ACORD name and logo are registered marks of ACORD �J l"LG' EC'�??`i/r'Z�12+Z(JQCd .1rJ�.C&eoagoz�n OfficeofConsumer Affairs BBusiness Q 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card EKpkation: 81312016 THD AT HOME SERVICES, INC. ' RaCFIAR[3=FALLC)NE- •---- =° . 2690 CUM13ERLRND PARKWAY SUITE_ 300 - ATLANTA;GA 30339 -.. _... — Update Address and return card.Mark reason for change. scut ? A�/// J Address _I RenewalEmployment J Lost Card J11I 4RaN!/f_M!/tPfl�/�f•�`^/(r.;;rM�af(/' ' tries ofConsover Alfaitsde BuiIness ulatioa Reg License or registration valid for individul ose only h OMEIMPRCVEIdENTCONTRACTOR before the Hf000dreturnto: lNfieeofConsuwer Affairs and Business Rcgafation _. Re4istratlo'h: 126593_ Type: 1UParkrl'iva-Suite 9170 tom:, -Expiratiow.Vj9016 Supplemen4Card Boston, 16' - THOATHOMEStkV b%aNC. . 7 WE HOME DEPOT AT 46W SEWCES RICHARO FA 6NE - �690 CUMBEiklMO PARKWAYS _ A �`A,CaA 30339 t:nderstereUry " of vn w aigoa a CITY OF SALEM, MASSACHUSEM BLIILDING DEPARTMENT 120WASHINGTONSTREET,3'FLOOR TEL. (978)745-9595 KIMBERLEYDRISGOLL FAX(978)740-9846 MAYOR THomm STTPIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING OOMNIISSIONER 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 c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) 1 The debris will be disposed of in: m-e (nameoff facility) IVO Aj©lt/ (address of facility) Sign ture of applicant /04 kr a(f e 44*NS1AtW1WffAW*N9 MWROVED BY 774E JIISPJ.L'=PWR TD A.PERMIT BEING GRAN'TkD CITY OF_SALEM No. 3� V� Dab ��5i wad zoNnq oiabm — Is P opwty LacaOW In Loeatio m of MN Hhdork Dbtrkt? Ym No_ Doildias11 Is Pia"ty Locded In f Sa ft A rrwvWon Ana? Yft No_ BUILDING PERMIT APPLICATION -� Permit to: --------- (Circle whichever apply) Roof, Reroof Install Siding, Construct Deck, Shed, Pool, Reps , Other. PLEASE RLL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned herby applies for a permit to build accordwig.to the following specifications: Ownees Name Address & Phone 0 EJeYtj er�u (sobl 878-�yG3 Architect's Name Address A Phone ( 1 Mechanics Name • Address & Phone ( 1 what Is VW purpose ci bWl W A WWW o1 twllerq? M a dwalkq,for how mmy WOW wa btfi rq calftn�tto law? Asbaalcs? ENInWa . " 1'7�fik.Od� (sty Lksm N ehb ucC 15 3s imrcv�t Lit. 1 layer pl�inaturorof plicarf SXWED UNDER THE PENALTY' OF PERJURY DESCRIPTION 99OF WORK TO BE DONE roo � MAIL PERMIT TO: ��� - � 5 ��' J�I3Iv5 f - � p BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 080145 Birthdate: 1026/1963 Expires: 10f2612 005 Tr. no. 80145 Restricted: 00 OOO GEORGE VALILIADES 4 LAKE ST PEABODY. MA 01960 Adminisnator r"- f/ie iJammwmwwa�(/i o`'✓uaaaac/+uaelta Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 124356 lug Expiration: 611212005 Type: Private Corporation Olympic Painting/George Co.,Inc George Vasiliado 515 Lowell at. .�—� �.✓ Peabody, MA 01960 Administrator' '' G, l...ontmoiuu�talG►� o a�.1at . Sods"- w..�teflas 3j,.d �a.wtcasa+ rn.....L.r.lb 02111 ca+rae.am/ Workers' ClIomperuadm Insurance Aftldayk I• �o � e, ass �a�l� . . whba principal place Iof basiswa asI I ��9 do hereby'certly under the pains and penaM" of perjery, chao / 0arwloysr Providing workers' cosrtpssswsien coverage for my siwp{oyoes waking on Insurance Compaq Poliq Number I am a Sole proprietor and have no one workbq fdr an In ca +� pedq►. . O i am a so'It proprietors general contractor or homeowner (drd n e es) sod have hied the centractors listed below who•hays thi following workers2 compensaahm poBdesr Convaetor Insurants Compasry/Popgr Numier Contractor Insurance Cosnparry/Po Nun*w Contractor Inssrancc Company/Policy Number () I am a homeowner performing all the work myself. • 1 rs.ons..act a C"Y sf.i wse.sw.a be f.rwwo.j a sa Olte.A is"'skno,e Of fur fs1A iv t...rapr.erlkoew me raw lirr�case ,onir.rs at,term saw Ssciw rlA of 1'iC, r t.n kN m e,r iraesfis of sedum s..ada..nssass Of Meo1 ss e-t 1.56l =calm eft rein, �o""a%uaa .eras ' ihs .Is STOP WORK ORDER was hr./ s1o0ACs .srssowssL signed this , day of - i--olf , :icerseei'Fcrmittee u ' ng Gepart ent -ccruing Eoard Selectmen Office =eslth Gepsrmer� �c � _ ece eQc f05, 17 /200,_ 10:04 FAX 19785322217 B K MCCARTHY 001/002 a 'l Client#:25567 NEWTO )CORD,. CERTIFICATE OF LIABILITY INSURANCE 101281M4 0/261oa IDOnT UCEP THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION . McCarthy Ins. Agcy. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE centennial Drive HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR body , MA 01960 ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW. 532-5445 INSURERS AFFORDING COVERAGE NAIC 0 RED INSUREaa Western World c/o Olytonmpic Property Services, Lin wsuRzRB: The Travelers Insurance Company c/o Olympic Street. u to 391 INsuacRc: Granite State Insurance Co 100 Andover Street,Suite 391 INSURER EX. Peabody , MA 0196D INSURER E: NERAGES TIE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING WY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICN THIS CERTIFICATE MAY BE ISSUED OR AAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HER@IN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH 'OUCIES_AGGREGATC LIMITS SHOWN MAY HAV=OEEN REDUCED BY PAID CLAIMS. NSROF INSURANCE [NPP859939 LICY NUMBER POLJCT EFFECTNE POLICVNIPPIY1 D MN LIMITBILITY 06177/04 06/17105 EAcnaCGURRENCE 57000000CIAL CENFRAL UAOL DAMAGE TO RENTED IMSMADE N CCC $5,0 0O0 MEO E%P IArc/olw 0amo,•1 [SOQQ Ded:500 PERSONALAAOVINJURY S1000000 GENERAL AGGREGATE s2000000 GAfE LIMIT APPUE9 PRODUCTS.COMPIOP AGG ,1000000 TEC LE LIABILITY 6AO371ND04 10/15/04 10/15/05 COMBINED SINGLE LIMIT tAWTO (Ea xuaml) $500,000 NED AUTOS BODILY INJURY .FOAUTO$UTOS BODILYINJVHY NEO ALITOi - IF-y .I) PROPERTY DAMAGC iVv amarnl) 5 GARAGE LIABILITY AVfOONLY- EAAGCIUENT S OTHERTWYA lO AUTOC IWN EA ACC 5 AUTO OHly: AGG 5 EACESSAJMBRELLA LIABILITY EACH OCCURRENCE 5 OCCUR ID CLAIMS MADE AGGREGATE i DEOUGTIeLC RETEMIONC WORKERS coMPENsAnoN AND WC4315629 041011 44 04101/05EMPLOYIERS•LIABILITY ANY PROPRIETOR/PARTTIER/EXECUTNE EL ENCH ACCIDENT OFFICER/MEMBER EXCLUDED? EL.(45EASE-EA EMROYE Ifyc drrnbeuMer SPECIAL PROVISIONS PIry OTHER EL DISEASE-POtIGYUMTi 'aSOO O00 OESCRIPRON OF OPERATIONS I LOCATIONS I VEHICLES,EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROV190nS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBEo POUCI ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 211 DAYS MITTEN NOTICE TO THE CERTIFICATE HOLDER HAMM TO THE LEFT,BUT FAILURE TO OD 50 SHALL IMPOSE NO OBLIGATION OR LIABIUTY OF ANY K WO UPON THE INSURER.ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESEMTATNE ACORD 25(2001100) 1 of 2 946256 DMN 0 ACORD CORPORATION 19B8 rumuc rwovowr pQAnn,. SO wO* sMpuma *d #P 07 M W STANLEV DR CMCWMUAYMAVU • 1a�aoadrr w!�ma paiior df1�.•I a�I �le��r a aaaiidoa=Z" r�IV SOLi+ a[!a apop�r lory • ct, Ge , ' �rald� Rox 'S57 �mtt� l�',�r n��f ![�l.T oaa�iMa baow hauls" R=�ar�a�rresaA�ta� . • 1�Lrdlla�tl��pll„t l �s •vn,n 1 L>�R i Vi, 7,n 0 °F�o t✓CRi 300 �n�[ oUey Ad&%OW 11 Mwabow amr tagatew dW dib&M �'��ro•'dba �4' tif' ��30�aai�abu0�y■,�ar lfoer��rd bamb da bow=dr hwk. -PL-* INWT-DE fWEB-A G APPROVED BY T44E ASPECTAR PWfl TPA_PERMIT 13EMO GRANTED \� CITY OF SALEM No. v v5 �" Date to-off Is Property Located In Location of the Historic District? Yes_No ✓ Building 10 Q V4IIs Property Located in � the Conservation Area? Yak_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shad, Pm- !, ­R­epair/Aepiace, ther: PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name Address & Phone 2a 1 j ',I S+rye _ jso8 ) �78- yyGz3 Architect's Name Address & Phone l ) Mechanics Name 4 Address & Phone L ) What Is the purpose of building? Mataft of building? If a dwelling,for how many families? will building conform to law? Asbestos? Estimated cost y, O o-o City License ar State U * a o s Noise 1:mprovewnt V trio. 1 Signature of App' nt SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE II DONE 11 r lhn 0.?lot MAIL PERMIT T0: No. APPLICATION FOR PERMIT TO LOCATION PER\M`IT,GRANTED APP OVFD L �08�CCTOR OF B LDINGS o CITY OF SALEM9 MASSACHUSETTS //. PUBLIC PROPERTY DEPARTMENT f I 120 WASH INGTON STREET, 3 R D FLOOR 1. SALEM, MA 01970 TEL. (978)745-9595 ExT. 380 FAX (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition --— - - - of Building Permit#--- —--- all-debris resulting-from the-construction-activit3 -- -- 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: T3 857 Lo h J a„,j e r r u IY Location of Facility Signature of Pemu.Appli.I t Date FULLY complete the following information: (PLEASE PRINTT CLEARLY) f o,.n y .IJ e3 Rcir Name of Permit Applicant 8I�Moi �0.144111n �-�or,t1 rl Firm Name, 'f any 44 JJ 30o RWbover 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. The Commonwealth of Massachusetts Department of Industrial Accidents \� = Otlleee/Itnrostlgatlo9s 600 Washington Street, 7rh Floor Boston,Mass. 02111 Workers'Com ensation Insurance Affidavit: Buildin lumbin lectrical Contractors mA ^�7 1 name: �✓ lwn� l)osho.,rA address, TJe11J S" raj city epstate )18 Q zip: 671115 phone 5'03- 8'�8- 9'}�a work site location(full address)' )0 2 SA. ❑ I am a homeowner performing all work myse . Project Type: ❑New Construction 5IRemodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition am an-employer providing workers'-compensation-for my-employees working on this'ob - - j FS �{� c •` U exiw. .tr ;rlx• -- �� a?`fir -r e rer ':o:,l'�;Y.*` § 'r.t. ,.� •.:a+ a^ >,j?y; address: 00 ttUOVeV �� dw 4��i } 5 �Fs 8 e ¢ 7,, city: _ I 1��n-dl i. ` I I . vt z�i" ' a insurance co. GRPnt�PrJ _�1�e... ig wig,N ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comoanv name: address: CItV' nhonef. ... t M _ a4 ygyr g3✓n�F@ x :1,r�as t' ,"�,� '",'a � "M' � J'°'p yyq -i. comnsav name:"` , addresses 1 p� r ue}tat �ai y'`ay�a#:i $ t ` , ^+' 1 rtYz yr.�_ 9y »'w 4z, m- 10 4.n 4 > �e Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition oteriminal peoaklas of a fine up to S1,500.00 and/or one years'imprisoo"ment as well w civil penald to the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to t Office of Investigations of the DIA for coverage verification. l do hereby certify a r the a p al' p ' ry that the information provided above is true and correct Signature I Date .2-/0-05 Print name r i I awl c Phone N `178-535- o Fcheckif nly do not write in this area to be completed by city or town official 7: permit/licenseq ❑Building Department ❑Licensing Board mmediate response Is required ❑Selectmen's ORice❑Health Departmenton: phone a; ❑Other0i l Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",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 e construction or repair work on such dwelling house or on the grounds another who employs per sons to do maintenance, P P or building appurtenant thereto shall not because of such employment be deemed to be an employer. MG chapter 152 section 25 also states that every state or Uo—caflicensmg agency sheltwithtrotd 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, 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. r Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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 a event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 hNstflatiels 600 Washington Street,7" Floor Boston,Ms. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 BOARD OF BUILDING REGULATIONS Licerue: CONSTRUCTION SUPERVISOR Number: CS OB0145 Birthdate: 1012611963 Expires: 10262005 Tr. no: 80145 Restricted: 00 E VAt.ILIADE6 4 LAKE 4 ST PEABEABODY, MA 01960 Admirtislra[oi Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 124356 Expiration: 611212005 Type: Private Corporation Olympic Painting/George Co..Inc George Vasiliado 515 Lowell sl. Peabody.MA 01960 Administrator' )0t !0:01 FAX 19785322217 B K MCCARTHY -00o1io02 ClientiF: 25567 NEWTO ORD- CERTIFICATE OF LIABILITY INSURANCE °ATE IMMI°Orc l 10/28104 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION =CarThy Ins. Agcy. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lennial Drive HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR iy , MA 01960 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 2-5445 INSURERS AFFORDING COVERAGE NAIC 0 INSURERk Western World c/o Olytonmpic Property Services,LLC INsuRERB: The Travelers Insurance.Company 30 Olympic Painting Roofing INSuHERc: Granite State Insurance CO D Andover Street_Su ite 391 Peabody , MA 01960 INSURER 6. INsvaeR E: RAGES POLICIES OF INSURANCE.LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PC RIOD INDICATED.NOT W LTHSTANOING REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR PERTAN T HE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE H TERMS.EXCLUSIONS AND CONDITIONS OF SUCH CIES.AGGREGATE LIMITS SHOWN MAY AVE OEEN REDUCED BY PAID CLAIMS. A TYPE OF INSURANCE POLICY NUMBER PDUGTEFFECTNE pOLIOYeZPIRATON iR D&1QxdMD8M— DATE MN LIMIT$ GENERAL LueILHv NPP899939 06M7/04 06/17/05 EA ER OCCUREENCE S1000000 X C°MMERCIALCENERALLIAIYDTY OAMAGEIORENTEO s70D000 CLAIMS MADE Roccua MED E%PIM�oPeP=.oA.-0 55000 X RUPD DId:500 PERSONAL A AOVItdIURY 51 000 COO GENERAL AGGREC,ITE S2 OOO O00 GENT PGGHEGnfE OMIT PPPUE9 PER: PRODUCTS-COMPIOPAGG a Don Ono POLICY LOG AOTOMONLE LIABILITY I61D4046AD371ND04 10f75104 10115106 ANY AUTOCOMBINED SINGLE OMIT I�x�lArnn SSOO,OOD IL OWNED AUTOS X SCHE°UEc AUTOS pODILIMIDRY 1 Y.ml S X HIREOAUTOS X BOOBY INIUHY uOwOvrtIEO AUTv; IF.. I) PROPERTY DAMAGE (Pn xnvml) S GARAGE LIABILITY AIROONLv.EAACCI°ErvT S ANv nuTO OTHER THAN En ACC S A RDOK AGG S EACESS ORELLA LTABIUTY EACHOCCURRENCE OCCUR CLAIMS MADE AGGREGATE S DEDUCTIBLE RELENT ION WORKERS DOMPENSATION AND WC4315629 04I07/04 04l07105 L^'GSTaiO' E)Tr* EMPLOYERS'LIABILITY ANY PHOPRIETOWPARTNERIEXECUTIVE EL EACH ACCIDENT 1 560000() OFFlCERIMEMB(Oi EXCLUDED? It UPaeT ELDISEASF-aiaAPLOY S500,000 SPECIAL PROv15IpN5 Alms EL OLSEg9E_pOULYUMIT SS OTHER OO OOO SCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES.QRVSIDNS RODEO BY EN°ORSEIAENTI sPEGIAL p,,,,SONS ERTIFICATE HOLDER CANCELLATION SKOULO ANY OF THE AaOYE DESGUIBED PODUES BE CANCELLED BEFORE YLE EXPIRADBN OATS THEREOF,THE ISSUING INSURER WILL FNDGAv0A TO MAIL _.ZD_ DAYS VrRfREN NOTICE TO THE CERTIFICATE HOLIER NAMED TO THE LEFT,BUT FAILURE To Do SO SRAIL IMPOSE NO OBLIGATION OR LIABILITY O F ANY` RO UPON THE INS URER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED wf9RFSENYAYIVE \ i ICORD 25 (2001108) 1 of 2 M6256 �I DMN 0 4CORD CORPORATInN tnRn