18 CLIFTON AVE - BUILDING INSPECTION 4
fhe Commonwealth of Massachusetts - - —
u CITY OF
Board of Building Regulations and Standards SALEM
a Massachusetts State Building Code. 780 CMR Reri,sed.11ur 2011
L.,
Building Permit Application To Construct, Repair, Renovate polish a
One-or Two-FumilP Duelling
This Section For Official Use O
Building Permit Number: Da Applied: —
( y/
Building Official(Print Name) Signature ` Date
SECTION 1: SITE INFORM TION
1.1 Property Ad ess/• +� 1.2 Assessors 8 Parc Numbers
S._61�Dn_� — —
L I 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(sy Il) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Reyuircd Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.a0.§SJ) 1.7 Flood Zone Information: 1.8 Sewage.Disposal System:
Zone: _ Outside Flood"Zone?
Public[I Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner ord:
Name(Print) — I , C'ity.State,ZIP _
No.and Street CCC..../---1111 `�{1,�1-LQ�i� —mot Telleepphhoonnne��1��d" Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check"at apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repaus(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Nun er of Units_ I Other ❑ Specify:
\ es ript'on of Pr sed Work-
I
TINIA ED CONSTRUCTI N COSTS
Item Estimate Costs: Official Use Only
Labor and \laterials)
I. Building $ ' I. Bung Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
i, Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
t. ,Ale ',anieal (fire S 'Total :\II Fees: S
Sum cession)
Check No. _Check Amount: ---_Cash ,\moune__ _
6. Total Project Cost: S 13 Paid in Full ❑Outstanding Balance Due: .__._ _
r
SECTION 5: CONSTRUCTION SERVICES
5.1 C'onstruction Supervisor License(CSL?
I� License Num- her li.�pirali n Da
Name of:SI. IIuIJer
List CJL 1)pc(xc below)
Iype Description
U Unrestricted(Buildings uti,to 35, 000 Co. 11,
C'ilyill»tn,State,ZIP - R Restricted 1&2 Fw»il Dwelling
M Mason
RC Roolin,C'uverin
W'S Window and Sidin
SF Solid fuel Burning Appliances
1 Insulation
Tcic hone Email address D Demolition
.5.2 Registered Home Improvement Contractort(HIC)
I IIC'Con N uc or I IIC'I �— I IIC Registration umber 1&pira on ate
tf>�y- 'gistrm l N� n
No. and Stree —.
c . � Email address
Ci /Town, State, IP
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 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
I, as Owner of the subject property, hereby authorize_ �� e- 6-A 4-r
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner s Name(Electronic Signature) ate
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I here a a by attest r the pains and penalties of perjury that all of the information
contained in this application is true and orate t th est f my knowledge and understanding.
Print Owne 's or Authorized Agent's N;u a(IIIccUud Signat vc) - a
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.c. 142A.Other important information on the HIC Program can be found at
ty g,„circa Information on the Construction Supervisor License can be found at2. t�wtv.ma,:. ut:Jp_
When substantial work is planned, provide the information below:
Total flour area(sq. ft.) (including garage, finished basentent'attics,decks t
Gross living area(sq. It.)_ -- or porch)
Habitable room count
Number of t _------___ Nunberof'bed rounns ---
-----------
NumberuPbathroonts _____-------_---__ Numberufhalf'baths
"I)pe of healing system _-- Number ol'decks, porches
--------------
lNpeofcoolingscstcnt
- .-._. .. - ----------- Enclosed
Enclosed .-_----
3. "Total Project Square Footage"may be SL1bS(iJaICd for"Kraal Project Cost"
HOME IMPROVEMENT CONTRACTOR -
Registration 160616 Type:
%WjExpiration: 8/8812012 Ltd Liability Corpoi _
B BUILT ENTERPR)SEst:LG:
c �
EVANGELOS
27 WATER STREET,?
WAKEFIELD. MA 0188Q.k�. a-
- Undersecretary
y
room. Massachusetts- Department of Public Safet% .
Board of Buildin" Realulations and Standards
f Construction Supervisor License
License: CS 84795
EVANGELOS LIAPIS
12 STONE STREET
DANVERS, NIA 01923
Expiration: 5/13/2013
('onunissioner Tr#: 15961 -
ss
iV11E i'-')N fi SPECTICNAL
SERVICES
. HOME IMPROVEMENT CONTRACT '
PLEASE READ THIS
Sold,Furnished and InstaAed by:
Branch Name: Boston hate: -r--5- ( THD At-Home,Services,Inc-
J—/ - _ dib/a The Home Depot At Home Services
345A Greenwood Street,Unit 2,Worcester,MA 01607
Tod Free(800)657-5182;Fax(508)7W8823
Branch Number:31 - PedenlID#75-2698460;ME Lic#C 02439;RI Coat tact 16427
- CT Ti.d H1G0565522;MA Home hminovemem CoomicmiReg.4126893
Installation Address: CL 1Tr) City sale -Z+p
Petri (sk Workphone Home Phase: �� Cell Phone:
�A SarJ ItilFarS L E
[g7g17�5 97 L [ ] L .l
Home Address S / -rate - zip(IfdOeumt from Installation Address) LK➢ N .
E-much Address(to receive project communications and Home Depot updates): . .
❑I DO NOT wisb to receive any mukedng mails from The HomeDepoc .
1?mieet iuformtiou: Undersigned("Cashunce7,the owaaa of the property located at din above installation addicts,agrees to buy,
and TH ARRHome Servces,Inc(•"Ihe Hone Depon agrces to furnish,deliver and arrange for the installation C-105181111110111 Of
all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this
reference,along with any applicable State Supplemeat and Payment Summary attached hereto and any Change Orders(collectively,
"Contraet"): -
Job#: WrnNhlemml - Protests: s #' - Amount
❑yr��lnw,adw f`}Sas $
5 -7 r.sot �.
fm6❑Slamg wallows ❑Unsuladun I
57,140. oo E-ft Doors fl $ L i
Routing.QBidmg ❑windows. taadadon
[]antes/tom ❑FWYDo nfl. .
- ❑Roofing WmdowS O lnsulatiun _ $
Q('xhnersYCrrvtrs finny Dams fl
pTimmun 2B96 D¢pasha[CasnxutAmoomdrcenprw unof@Acouhaa.u . Total Contract Ammaut $ L / �"7-7
M®aAmeb�smignotdepasrtmraemnnaedeNdmeOohmadAm®t v fVl
---- emt,mar-gi—ffiytm000�on'wrople4iar:bhtRe-wrnic fn�e�b'Pmdac�6astome-wit•wrecute-sEbmpiadoa rectificatc
(tare for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this
Comma agrees to be jmndy and severally obligated and liable hereunder-The Home Depot tesuves the right to issun a Change Oidar or terminate this Contract or toy individual Product(s)included herein,at
As discretion,if The Home Depot or its audroozed service provider determines that it cannot perform its obligations due to a ructioal
problem with the borhe,euvironmeural hazards such as mold,asbesms or lead palm,other safety conoems,pricing errors Or because
wont requited to complete the job was nottWu ided in Conhaa.
Pavia, Soummrs: The Payment Summary# _Wf S 3 , included as put of this Contract, sets forth the total
Contract amount and payments required for the deposits and&A payments by Product(as applicable).
NOTICE TO CUSTOMER
You are enlftkd boa ttely Slled-fa copy of the Contrad at the flint yin slop, Its not sign a Completion CettwxCate(toto:
there is one Completion Certificate for each Bated Product as defined by mbvidual Spec Sheets)before work an that Product
is complete.
in the event of termination of this Contract,Customer agrees to pay The Home Depot the coals of materials,labor,expenses
and services provided by The Home De t or Authorized Service Provider tbrou the date of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. THE ROMLDEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTTD;R PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Aocettwice and AmhorQation: Customer agrees and undestaods that Ws Agreement is the entire agteemem between Customer
tad The Home Depot with rogard to the Products and TustallaiMu services and supersedes.all prior discussions and agreements,either
Oral or written,relating to said Products and Iota ahma This Agreement cacao[be assigned or amended except by a writing signed
by Customer and The Home Depot CastomD[aclaowledges and agrees that Customer has read,understands,voluntarily accepts the
terms of and has received a copy of this Agreement.
Ater by: �yp Sbtd ay &�' ®►�d1D lPfg �t
's Sipiatfire, Date Sales Coosnitam's Signature Date
f= ,e Telgftm No. .7�� a y? 7 3 y b
Crumomer's Signature Date Saks Consultant License No-, ..
CANCELLATION: CUSTOMER MAY CANCEL THIS (ss applimbk)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING TKM AGREEMPIT. -THE
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A. FORM TO USE IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE
NOTICE:AnDMONAL TERMS AND CONDITIONS ARESTATED ON THE REVE M SWE AND ARE PART OFTHIS CONTRACT
1b-18-10 C-Sc - Whim-Branch He Yenaw-❑»ma .,
g� The Commonwealth of Alassachusetts
` Department of Industrial Accidents
�Of
fce of investigations
I Congress`Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information i to Please Print Legibly
Name(Business/Organization/lndividual):
Address:
City/St te/Zip: G< 1 Phone
Are u an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 4. Q I am a general contractor and I 6 Q New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a sole proprietor orpartfier- These sub-contractors have g, .Q Demolition
ship and have no employees ees and have workers'lo mpy
working for me in any capacity. e comp. iasurance.t 9. ❑Building addition
[No workersl comp. assurance 10.❑ Elec ioaI repairs or additions
required.] 5. ❑ We are a corporation and its
3.Q I required-]
a homeowner doing all work officers have exercised their I I.Q P mg repairs or additions
right of exemption per MGL 12. of repairs
myself. [No workers' comp.
c. 152, §1(4),and we have no 13. ther
insurance required.]t employees.[No workers'
comp.insurance required.]
-Any applicant that checks box#1 must also flit odt 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 am affidavit indicating such.
tCoatractws thatcheck this box must attached an additional sheet showing the name of the sub-contractors and state whethef or tat those entities have
employees. If the sub-contractors have employees,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Expiration Date: I
Policy#or Self-ins.Lic.#:
Job Site Address: I 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 its 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 urc er the ins d enalties of er'ury that the information provided above ' due Is correct
_. Date:
Signature:
Phone#:
ofjcial use only. Do not write in this area, to be completed by city or town offtciaL
City or Town: Permit/License #
Issuing Authority(circle one): p Inspector
a__-, r rx. lit. i Ruildine Deoartment 3.City/Town Clerk 4. Electrical Ins ector 5. Plumbing Insp
J
CITY OF S.ULE.Nt, ��L�SS.ICHL'SETTS
BCILOLNG DEPARTMENT
120 W.+.smLYGTON STREsT,3 °FLOOR
TEL (978) 743-959S
FAX(978) 740-9846
KI\BERLEY DRLSCOLL
MAYOR THo.+w ST.PIERRti
DIRECTOR OF FLOLIC PROPERTY/HLaDLYG COMMISSIONER
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 l t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit All 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:
(name of hauler)
The debris will be disposed of in
(namef facility)
(adds! O facility)
signutu of per it applicant 4Jate T
I.M1rr vl(.Lw
� ® G I�TI
r+ FICATE OF LIABILITY INSURANCE Dal 02/21/21 pOn/2011
�/ �
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS -
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES -
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
'IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights l0 the
certificate holder in lieu of such endorsement(s). -PRODUCER 1-40 i-995-3000 COp
NTACT
NA
Marsh USA, Inc. PHONE e FAX
E-MAIL
homedepot-.certrequestCatnarsh.com ADDRESS
_55
- ---
00RE :
Two Alliance Center, 3560 Lenox Road, Suite 2400
INSURERISI AFFORDING COVERAGE ____ - NAIL 9
Atlanta, GA 30326 _
FBX (212) 948-0902 INSURERA: Steadfast Ins CO 26387 -_
INSURED INSURER B: Zurich American Ins Co� 16535
The Home Depot, Inc. INsuRERC: New Hampshire Ins Co 23841
Home Depot V.S.A., Inc. """
2455 Paces Ferry Road NW INSURER o: Illinois Nab) Ins Cc _ - _ 23817 -
Buildin^ C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445
Atlanta, GA 30339
IN.SURERF: 111"C i9 Union Ins CO 27960
COVERAGES CERTIFICATE NUMBER: 19834682 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.'-NCT7lITHSTANDING ANY.REOUIREMENT, 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
•L�LSR , -AOOL 5U0R T POLICY EFF POLICYEXP
. TYPE OF INSURANCE _. _ IN. POLICY NUMBER 1 MMIDOIYTYY NMIDOttYYY LIMITS
A GENERAL LIABILITY - GLO4887714-01 03/01/1 03/01/12 EACH OCCURRENCE S 9,000,000
-X - -bnMAG- 7ORENTEo 1,000,000
r ,
COMMERCIAL GENERAL LIABILITY PR MIBE a cc rrence S
CLAIMS MADE.u OCCUR M_ED EXP(An one penpn) S EXCLUDED
X LIMITS OF POLICY XS - PERSONAL A AOV INJURY S 9,000,000
X OF SIR: $IN PER OCC- GENERAL AGGREGATE 53,000,000 _
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPKIP AGO S 9,000,000 -
-q POLICY PRO- LOC _ .S.
B AUTOMOBILE LIABILITY BAP, 2938863-08 03/01/11 07 Ol 11 COaBIINEDI SINGLE LIMIT ,1,000,000
X ANYAUTC- BODILY INJURY(Per Person) 7 --_�
ALL OWNED SCHEDULED BODILY INJURY accident) S
AUTOS AUTOS _ --_-----• -
NON-OWNED POPE rYDAMAGE 3
HIRED AUTOS AUTOS - (Par accidtf,,I ---
X SIR AUTO P Y S
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR CU .MADE AGGREGATE S -_- -
OEO RETENTIONS S
WORXER9COMPENSATION WC061967352 (NOS) 03/01/1 03/01/12 X WC STAID- DTH.
C TDRY IIMITS
AND EMPLOYERS'LIABI
0 ANY PROPRIETORIPARtNEN EXECUTIVEOYIN ---- -
NIA NC061967759 (FL) 03/01/1 03/0 1/12 E.L.EACH ACCIDENT f 1.000_000 —_
OFFICEPUMEMSER EXCLUOED! N WC061967357 (CA) O7 _
E (Mandatary in NH) ( 03/O1/1 /01/12 E.L.DISEASE-EA EMPLOYE S 1.000,000
If yyea Adsorbs Under
OESC PTION OF OPERATIONS below - E.L.DISEASE•POLICY LIMIT S 1,000,000
C Workers Compensation WC061967355(KY,MO,NY,WI, )03/01/1 03/01/11
F TX Employers XS Indemnity TZJSC46244151 (TX) 03/01/1 03/01/11 Occurrence/SIR 30M/1M .
E I9oc Y.ers Compensation WC1192379 (BSI) 03/01/1 03/01/12 SIR 1N
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD to.Additional RemaAs S[Iudul,,it more span is required)
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE'
THE NOHE DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVEREO IN
HOME DEPOT U.S.A., INC. _ ACCORDANCE WITH THE POLICY PROVISIONS.
2455 PACES FERRY ROAD NW AUTHORILED REPRESENTATNE
U �arcr Scar HerCarCcczot "
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-0(fseeorconiumer Affairs&Business Regulation
i,
OME IMPROVEMENT CONTRACTOR
- i
Regtstratson 12689] TYPO
Intiois...-tiWQ12_ ':::;Supplementi
rr�
Ttre..}tome DePO 'At ms, ces i
_ - - -RICHARD FAU-61N � -
2690 CUMBERLA4N0.PARKWAY 5 _