11 CHURCH ST - BUILDING INSPECTION (9) The Commonwealth of Massachusetts Town of
v Board of Budding Regulations and Standards lowsopw
blassachuscns State Building Code. 780 CNIR. 7"edition Building Dept
` Budding Permit Application To Construct. Repair. Renovate Or Demolish a tlNwmodmm
One.or Tsso•FainilP Dwelling AMOK
This Section For OlTicial Use Onl
Building Permit Number! Date Applied:
Signature: ltz�- id l 9 ZZ
Building Commissioner/Ins ter of Buildings Base
SECTION 1:SITE INFORMATION
1.1 Property Addretls:f= Nu i 1.2 Assessors Map i Parcel Numbers
11 M Number Parcel Number
1.Is Is this an acce ted streetT yes no ap
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Am(sq III Frontage IRI
1.3 Building Setbacks(R)
From Yard Side Yards Rest Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Infermatlon: I.S Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal G On site disposal system C
Public O Private O Check if year] I
SECTION 2: PROPERTY OWNERSHIP' �+ 1 • I
2.1 Owners GAR u uf<<A.� �i12s+P'1`
Name(Print) �M r l V1stt l� Addreu for Service:
S1 issues Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(check aB lhot apply)
New Construction O 1 Existing Building O Owner-Occupied O Repain(a) Alterations) 17 Addition O
Demolition O 1 Accessory Bldg.O Number of Units_ Other O Speciry
Brief Description of Proposed Work': IA
fir
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllcial Use Only
Hem Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost(tterss 6)x multiplier a
J Plumbing S 2. Other Fees: S
a. Mechanical (HVAC) S List:
1' Mechanical (Fire S Total All Fees: S
Su resslon
Check No. _Check Amount: Cash Amounl:_
tt Total Project Cost S 0 Paid in Full 0 Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
S.t Licen d Construe lon Supervisor(CSL) )
,. C .
• s� ka L�reme NumEaf Etprt�••u,, O e
Hype tit " I r Ltvt CSL Type fx'e hcluw) W
A T e Description
►4" U Unrestricted u to 35.000 Ft
R Resin red Is:2 FamilyDwellin
.'Ju. re M Masonry Only
RC Residential flooriin Covering
I ciephone VS
Restdertttal Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
3.2 Rgbtered Home ement (HI
HI' ore tor HIC C ter Registration N m
A e
yQ) ?�aL,� Eapinti o a
Si Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 f the building permit.
Signed AMdavit Attached? Yes.......... No........... O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, sate— 65 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.
Si arum of Owner Date
SE ON 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate, to the best of my knowledge and
behalf.
Print Name
Signanueof or uthwi Agent Date
(Signed under the ains and penalties of r
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 2R have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and I WAS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenNanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half.Daths
Type ofheating system Number ordeckst porches
ry pt of cooling cyvtem Enclo%ed . Open
1 "Total Project Syuare Footage"may he wh.muied for 'Total Pro)cci Cost'•
, 3
14
.. � 6na3 di :f�widui Ri ul mn utif'�F1rui';~-d,
_. Licenser CSS SL 101227 .;,-
Y s.
_ ... Restricted to: WS ,an-. : -r :<" .
RICHARD DIFRA,- E CO
7 PINE BLUFF,.�YENUE_,
MERRIMAC, MA 01460
=x'iranon: 1/15/2012 -
( : olmi�.ILnn' Tr 101227 .. . . _
11-23-2009 14:16 FROM-THD AT HOW SERVICES +508 T56 8823 T-202 P.004/004 F-166
sold f,,r bhnd andn DIb-o7
T, D As o
Dnc: drom HemDeotA[Home Setvioe
7s
Branch Name* Booan 3'SAOr S.a ta,Wa�Q.�
Talk Free(800)65'7..51 pax 0 956-8823
14C' -
FCderal lb A 75-209s'ado;ME i ie anat ConQmalpr Re1-.a 126893
D.-..cm Rumba-r::11
Lie p 565522:MA Home ImproveO l�f Z b
_—C`= � � I�►�. �,s a —
Inata6at)Oal Addro � zip
['ity
_ a.ae tee a n ba
>!wrs-tv"�(m)' L�y'•�b7$Y 3 GS 3 L � L��� Le. 6531►
Smtc zip
City
cg f_ainomm lrorrt Ineralletion Address) catios and a Depot Updates):
COman Address•(lo receive FroJ�rq�mnnl emaUa iroru .Tim Hem=Vopot t0 buy
]1 no NOT v i h to reoeive any marketing ,ty lot:tied se the ab wo i nstanarlan address,agree_
y,r - [ go 1(rta= Undm*aiJ'Pned(( Customer•),mo owners of the px'o�ea. eodfor d inn this Conareot by
•I-fD A3--natne oervic,s,Inc. (a'TItY Fame DePOt a d S ao titeeo do� of which areeincWPornro Nation('lastaBado.t 7 of
ccd 9 a 9h¢C1Gs�, ed hereto and anyGltanga Orders (eollootiveiy-
all mnte.Ws described on the below and on die rtdbceaa P
reference.alQuZ with any applicable Sres= 9urpta m-ant and Payment Stm entry attsclt
'Coantracl"): Shah #t Pro at Am [
$ <C �l O wa
]nh M= nsotto na+wM ...datrs auladon ���..' ��� $ oC -7 I
r�r Rom S M.
d1.• !7 S OCrotoxs!Covers bam noers 0
01W.Knts frig W s lasuhmon $
CJT3e, ra/C.. []Entry boon 'ua
tea S
mab= W-a— t.taWa S
[]6trtteaa/Cwm nwo.s❑_ S
a ss Siding w Wm eves Insulation
�Gtutots r co.M1 Orally ncora O
'no289.ptposit arconuatt Amoumdve trOnn tntazatton dVtis sootraca Total ConrrneCAmount
Maatne rnashama ta.tp not dRaWa.ewa Wnra anamtrd orthe Cm.Irsc[Ama.mt'.
Gtaswa.a�agrees bus. immedietmly Upon comylation of the work d each Product, due-
d
use a Cotrtpicddn CtycteaR
Spec
9htxt add P`-d attY balaue due. AS applieebW, cx6 �^"tomzr ,snd'.s r1•is
(o.ac for cmoh Product as defined by an btdividtlal Sp )
Contract agrees to be)ointij.and severally Obligated sad liable hoteunder_ Product(S)included hcrciU.at
ten obligations auc ro a stNctural
The Home Depot tesertte9 the right tp�rssu r o6c W p� � Cs riles i�cannot x or any tnperfernt 1 ticie errors or ba cause
Its disc^=don,Ir The Xtemc Depot or: mold, asbestos or lead paint, other sAkktY concama<, P 8
paoblcm whit;be home, anvfronnmontal Jaaretds such as _
tyotic required to eOmp wag not the lob w not included in time C=%rUeT- q _ yacl utod as part of this Ctmota= sew forth the total
P,XRBt % mar+:ilh The Paym
eni Summary W�l a=�` Product(ea applicable)-
Con�aSM aRtouat and payments required Ibr the deposits and onal Payn•a.,t=by
NOTICE TO CUSTOMER
. Do not si a Completion Ger[hfitase(roue%
You urn Ono co [o u completely Gllad-:a COPouch
l etch¢Can'""at the time loans
Spec Sheets) before work,on that Product
spores is ono CotoPlaaion c rate for each listed Prodna;t as defined by adivtduwl
Fs cumPllte labar,'ex eases
r.M a by at or Aurhorkm Servlee rovtd¢r rnt-on h the dart of ta�...:ta,tdon, lea any other
In she eons of earminaattam or this Can[rnct,Cttammor actors m pa.y The Home Depot she amasta of tnat¢rials,
and smrvieami P The Humo Dep ppppd P wITHOUT
ptirs
sic ¢re r.,p' 9Yr PAV;;F StT CM OTHER TAYA�NTS MADE.
OWED TO fTHEIoU[OME DEPo�'i Rxo ir3F.dD licabAc law. THE HOT DEPOT MAY WfTH11O AMOU
TS-
LIDy,(T(NG THE HOME DEPOT'S OTHER 1tEMSd'VS Fsnnd9 that AY cOemen Cs thiR e etm�aS mmcnt better, Customerier
for discussions and agre
m tad At tkaorizatlun- Customer agxe a amend c t by a venting sign
c auto DsP�tit To ae the products and lasallntial suNieas and suPc*s lunraattY accepts The
an old Produe¢ a taaatsllation. This A eem,at ontmot be y1 ro .models
oral or imam, retau'Dg w a er aclmowlcdgcs Bud agrees rl'at caste
by Customer and The Homc-Depot Oustam opt
Tethts q£ hens received a copy eE dt:s Asrocra p
Submitted W- o/],.t♦b L -i E
watts = t.( [t
Dare
cueIto acCs siso;%mr:
Date sales consultant's Sis-amm
Telephone Nc.
l'}astOonrr'a Signattue Dnw Sales Consult--¢License No•
ten uppaeaola)
C t,tCgLt,ATrotV: C(IS'roWWVL 1yIfAY C.aNC)EX. THIS
nRCPMENT Vtr(TFOUT PSNAI,TY OR OBL(CATION
SY rt1E,X,XVERING Wlti'PPBN NOHto 8 mown
DF,FOT BY lvyMMGHT ON THE T
TNESS
DA3( AFTER SIGNING TMS TTQ"EMKNX-TT' T O
STATE 91JPP1EMENT ONE IS
SONG: CA , ]FORM TO USE BY LAW IN
SP8CI8ICALI.X PRESCRIRFT
CUSTOMER'S PART OF rota CONTRA
.010MC -
R
pOTICR:ADDrrIOAi i'SlthtS AND CprtDlTONa ARa!r!'nTao ON T1tg RF.V i;RSII 5[bn6YltHn[/UxII
T.�a-nP csc
vw,Aa-9.e..or,cvw vulbt, -Ca.atantar p-tnk-531ea
The Commonwealth of Massachusetts
Department oflndustrialAccidents
m - 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 Legibly
Name (Business/Organization/Individuall)).:,
Address:
City/State/Zip: Al C:6 ' Phone #:
Are you an ployer? Check the appropriate box: Type of project(required):
1.❑ a employer with � 4. ❑ 1 am a general contractor and I 6. ❑ New construction
have hued the sub-contractors
employees (full and/or part-time)-*
2.El I am a sole proprietor or partner- listed on the attached sheet. T ❑ Remodeling
ship sole pr employees These sub-contractors have g. ❑Demolition
employees and have workers'
working for me in any capacity. comp. insurance.l 9. El Building addition
[No workers' comp.insurance 10.❑ Electrical repairs or additions
u
required.] 5. ❑ We are a corporation and its
3.❑ I a homeowner do ng all work. officers have exercised their I I. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' er__ n __
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 most submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-wntractors have employees,they Must provide their workers'comp_policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: �1��� d Gf j lr Expiration Date:
Job Site Address: City/State/Zip: Yr H!1
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
Investigations of the DIA for insurance coverage verification.
I do hereby certify der h in nd enalfies afperjury that the information provided above is true nd correct.
S' afore:
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 2, Building Department 3. City/Town Clerk 4.Electrical Inspector 5.EInspector
6. Other
Contact Person: Phone#:
a
ACORD CERTIFICATE OF LIABILITY INSURANCE ' D 2 120 ,DO 3IYYYY,.
00/0
PRODUDER 1-aos-995-1Do0 'THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
9;T USA, I'!?. ONLY AM) CONFFRS NI-) F?!'•:H�i.i UPON THE CER"rIFiral'E
HOLDER. THIS CERTI
FICATE DOES NOT AMEND. E:TEI;Q GR
L ALTER CC'i_:'.:10° "'';�.]'=0 - TY_
TE
'•got._=.:r=_meal-ina_Oh.rom T .1.r �• - _y•L,
'"nta, CA 3131L J � I NSURERS AFF(JR'OIDIO COW=RAG� It
I' UL:
At..
❑ TD �, Tw . _c,.n JZu Co 16515
Il.lfl $L�. __
�'390 Cmlu`_r1a.Id P.Iti}.:any wS!NLit C:N:.1"a0ii UNLOt? 2'IT.F: IiiS CZ) OF PI'L1": 13415
i- Iite 300 IN - --___ 23841
\tlanta , CA 30339
EINSURER O:Nx1Y Ham shire Ins Co
IN SU0.ERE'.I111no i0 Natl Ins Co 2781?
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.CONOITION 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 PAIO CLAIMS.
INSR 00' - POLICY EFFECTIVE 7ATMMIDD]NO
LIMITS
TR N R POUCYNVMBEfl D i M 0 GENERAL UABILITY IPA 3757608-02 .03/01/09OCCURRENCE S<,000,000-N $11000,000X CON.MERCIALGENEMLLIABILIN LIMITS OF POLICY ARE EXC SS CSES asccurenceaOCCUR "OF SIR: $1,000,000 PER CC" %P(Any one parson) II IE OEpNAL 6 AOV INJURY $ /,000,000RAL AGGREGATE S 4,000,000UCTS.COMP/OP AGO 54,000,000
GEN'LAGGREGATE LIMIT APPLIES PER:
X POLICY PRO LOC. .
H ECj
AUTOMOBREUABIUTY HAP 2938863-06 03/O1/09 03/01/10 COMBINED SINGLE LIMIT
(Ea acddcn0 $1,000,000
X ANYAUTO
ALL OWNEOAUTOS BODILYINJURY $
SCHEOULEOAUTOS
HIR50 AUTOS BOOILYINJURY $
(PeratcidenQ
NON-OWNEO AUTOS
% SELF INSURED AUTO PROPERTYOAMAGE $
(PeFatcihmQ
PHYSICAL DAMAGE
AUTO ONLY-EAACCIOENT f
G4flAGE LIABILITY
ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG S
p LPR.]l57 608-02 O]/0 L/09 03/01/10 EACHOCCURRENCE f5,000,000
E%CESSIVMBItnLLA LIABILITY
AAGGREGATE f 5,000,000
X
OCCUR ❑CUIMB MADE
S
DEDUCTIBLE '
i
RETENTION S WC STAru_ OTH.
C WORKERS COMPEHSATIONAND 3566916 (CA) 03/01/09 D)/01/10 % T RY MIT
D
EMPLOYERS'LIABILITY 3566915(ADS) 03/01/09 01/01/10 E.L.EACHACCIOENT i1,000,000.
nNYPROPRINISEREXCLUOUEXEcuTrvE 03/01/09 03/01/10 E.L.OISEASE-EAENIPLOYEE S1,000'000
g, OFFICERIMEmOER EXCLUOEO2 ]56691T (FL)
Vyet PRO under - E.L.DISEASE-POLICY OMIT f1,000,000
SPECIAL PROVISIONS below
OTHER
0 Workers Compensation 3566918 (KY, MO, NY, wI, ) 03/01/09 OJ/O1/10
F TX Etnp loye rs Excess TNSCG5695522 (TX) 13/01/09 03/01/10 ccurrence/SIR 25H/2H
C workers Compensation 9001323(OSI) 0)/01/09 11/01/10
DES DRIP TION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADO ED BY EHDORSEMENrI SPECIAL PROVISIONS -
RE: EVIDENCE OF INSURANCE -
CERTIFICATEHOL DER CANCELLATION
SHOULD ANY OF THE ABOVE OESCRIBEO POLICIES BE CANCELLED BEFORE THE E%PIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAR 30 DAYS WRITTEN
THO AT-HOME SERVICES, INC.
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL
IMPOSE NO OB LIOATIOH OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
2690 CU ERLAND PARKWAY REPRESENTATIVES,
SULTE ]00
ATLANTA, GA 30339 aUTHCR12EO REPRESENTATIVE
USA
n nrnon rnR PnR 4TION 1988
f
I
��zikH°aY fie;%
U-taaor —�� — SofarHeat Gain Coefficient
" • .yc-,�,.0 .CaeAr�eCw�m'�da d¢Eraryia`vur
/0 . 32 1 . 6 0 : 29
P.DOMONAL FERFORN"CE RATINGS
C421J1 C0N 9 ptj:),E AAA De PJD40UE VM
Visible Tran s.�itmnce
hancriilan dt taa Wm4 -
0 . 52 _
uo„ka,r ,ava d,e.r"madam m wpAmbk W c RoMi+ kr d.wM+v vtvw wade wftm Kpt
nmrrp v h®rmh�ha a Azad aal d a�'aaurarrol ozsD0r>t a'd s Wil:&P�lint lFc dm rot ntmM4d.arf aradLt
ad dm re rarr"Tv aJSNRy of n1 proCG,tr m Td4 �R mtnAa9r'a'7 lrann,4 oew Pmct pr>D.rtrvry
-- --==- -= - - --=--- --- ------- --...
Eft�Lutsv.V,"Qa a®a�•`��^�^'@, irk d-W"bi-da 16PL I"ditm at VW dal.
pod.ffi La Ktra u "as RW m d.an,t�A in aryr+t Jude mti4.w arbitnt"y u;WMM da aaLce
..aerd¢y 1FPG io rrerda,da n}Va+ ID t ry 9v�ca Y 41 orwi�a Z—u on un uc UvKIlm CLraA
tam,"]tltsi Gaa d-av vl:p t do du P-W=iiii cal ..'
"UaLG cr,11-1-fLax focc�9N.CRCY 3rkR
- c¢gLoaQl �n cCn¢cn, No.Cn .
C. fo..[h.,
. ckF tS!SfAA
C�. un 1C�d onL111ca .ps.a L (.) .
ca?lOn(.�1 uwca q2 3rAA: Noce_
NocCt Can C<a1, '9•.c Can Gcal, 9uc_ '
' I40: fttLn. 60/CLaas J/Jl"/N-RIJ
`? C¢nGtd 9Lat 3G'
�. INe: Rnf..toro e0/YLQ<10 2 .31 atn/H-.R47
tta Ad pcobado: IIA cu . 190 cti
EC9:.CgCJ Q� 40-773 . Hs Kof fun 293L 124. ._ r,.......,.._
„„�»............... L,p Me tnW f(9=6910M SUR 4a*.To 6mn mon•hh ww.mtigtttQlm_ ..
Camd..im.kuAo paa Fa tin rMmDohat 0067 MC Iva owu nib mro br afi,LNIs Wk mirytrl vt --
-\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
} I '
Registration 126893
Expiration -:=gl3l2010
Type..-Supplement Card
The Home Depot Al Home Service
RICHARD FALLONE _ .F
2690 CUMBERLAND PARKWAY S (�-L•„Q,�„•."
XYLNM, GA 30339 Administrator
,S CITY OF SALEM
; i PUBLIC PROPRERTY
T' DEPARTMENT
I'O;t PI KN,'lI
.p 12C A'.\i1II..m..oN S I'$LET #SAI I M. MA+i.0
Trl: 478.743-9395 • 1`.%X:7711•743-9946
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
1 11, S 150A.
The debris will be transported by:
bmrT�r~s11
(name of hauler)
The debris will be disposed of in
�)�%lam
1 (na�meut7aal
+t.t '
(address ullacthty)
Sign re of permit applicant
/n
,Fate