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179 FEDERAL ST - BUILDING INSPECTION The Commonwealth of Massachusetts Ulf Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 71h edition Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised J One- or Two-Family Dwelling Aril 15, 2009 This Section For Official Use Only „1 Building Permit Number: Date Applied: Signature: 0 , Building Commissioner/Inspe or of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Addres 1.2 Assessors Map &Parcel Numbers l.l a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54). 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes[] SECTION 2: PROPERTY OWNERSHIP' 2.1 'of Rq�ord• -f Vt9Y� t l�C �74 aj 5Ft54� Name(Punt) Address for Service: Signature Telephone SECTION 3:DESCRIPTION OF.PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) e Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work 2: eoliF [ INO (' G SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ' ❑Total Project Costa (Item 6)x multiplier x 3.Plumbing $ I Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount:• Cash Amount: 6. Total Project Cost: $ �� L 0 Paid in Full 0 Outstanding Balance Due: 'SECTION 5:;CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 9 Wtote ALicense Number Expi N of S -Ho de t List CSL Type(see below) - Addre s Type Description - U Unrestricted(up to 35,000 Cu. Ft. R Restricted 1&2 Family Dwelling Sign turg� M Mason Only 'yr- 10 � U/ � RC Residential Roofing Coverin ' Telephone WS Residential Window and Siding { _ SF Residential Solid Fuel Burning Appliance Installation ' D Residential Demolition 5.2 Registered Ho pr menttractor HIC) A^ HIC Co m n Name HIC Re stran Registration A umber Addre s _ `'—J qnf -,3 f' �� Expirati t �te S T , elephone ECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuanc of 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, e5�e C�I7-tr� 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. Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 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 ame S,4 i of Owner or Authorized Agent Dat,#� _ Si tied tider the pains and penalties of perjury) 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 and Construction Supervisor Licensing(CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, 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" The Commonwealth ofAlassachusetts Department of Lidustrial Accidents Office of Investigations Ur 600 Washington Street Boston, MA 02111 www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contraetors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: ��jt �� �i�fs Phone#: 4i1 waz Are y an employer'Check the appropriate box: Type of project(required): 1. I am a em toyer with 1 r 4. ❑ I am a general contractor and I p t� s have hired the sub-contractors 6. ❑ New construction employees(full and/or part-time). 2.El I am a soli proprietor or pa�aar- listed on the attached sheet. 7. ❑ Remodeling ship and have no e—""mp oI yees Thesc sub-contractors have S. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers'comp. insurance comp. insurance.t ` required.] 5. We are a corporation and its I0.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Pjl�pbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. oof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] 'My 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 must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. lain an employer that is providing workers'compensation insurance for my employees- Below is the policy and job site information. Insurance Company Name: M"l lce `7 - Policy#or Self-ins. Lic. #: �Q-/ �— Expiration Date: - Job Site Address: 9 FC�L(Zl J � City/State/Zip:_g.6�ya/ 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 Orrice of Investieations of theDIA for insurance coverage verification. I do hereby certify and r t e p*ns a penalties ofperiuty that the information provided above is it a and correct Signature: Date: hc 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. Plumbing Inspector 6. Other Contact Person: Phone#: 1 L.1T�' iNSUPANCE CERTIFICATEac��•zn C� �iF1CAT� Or LIAB _ ,' WCEH 1-404-5 93 }'33 ITOANLlT!S cV C R Ah�E'r!'.0 OJ ',. .t.cIL,_.;._ I ;IC -T, GP M'rsh USA. _'EL - :i.:medacot.ce_tr=_c¢co tbvtare:i,coM. s'_C - Y _ .� A1? an a - e-• .._ '.- '_' - .. .. � � CA I ' R cee Depor., 'L - _ i Ecae Depot U.S.A., <sav• n_RD 2d55 Paces F'_ry Road -� GV vi T CO 'I,SURER O_2 __ -rR YS--- - 1 Bu'_:3ta, CA 3 F-- — Z -0 I Ael onto. GA 30739- ; INSURER E. T_71 vro.a Vmor. Ins Co COVERAGES ED ANY REQUIREMENTS TERM OR ICONDIBTIONIOF ANYBCONTRACT OR OTHER DOCUMENT W TH RESPECT TO WHICH CHP HIS CERTIF GATE NDI IO ITS OV SUI(R MAY PERTAIN,THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIM _ __ -___ - -�— -'-"'-----��---�� POLICY EFFECTIVE POLICY E%PIRATIUNT LIMUB .. .__-._.-.. _.- r INS GR DL POLICY NUMBER A N YY ` l IM IYYYv I _ T 03/01/10 03/01/11 EACH OCcOaaENCE E 4, 000,000 GL04887714-00 DAMAG ol?ENTEO $ 1,00 0,ODO MISESl3_pcNlrenpa�_ .—.___.. - - X COMMERCIAL GENERAL LIABILITY MED EXP(Art,ena person S EXCLUDED. _CLAIMS MADE OCCUR - - PERSONALSADVINJURY E4_00_0,000 I - GENERAL AGGREGATE E 4_000,000 PRODUCTS-COMP/OP AGG E9,000,,000_. .. -, GEN%AGGREGATE LIMIT APPLIES PER: PRO X POLICY T LOC 03/01/11 BAP 2938863-07 03/01/10 COMBINED SINGLE LIMB E 1,000,000 B AUTOMOBILE LIABILITY (Ea attitlent) X ANY AUTO BODILY INJURY g ALL OWNED AUTOS (Per person) SCHEDULED AUTOS - - BODILY INJURY $ HIREDAUTOS - ( Per acNCenl) NON-OWNED AUTOS PROPERTY DAMAGE y % SELF INSURED AUTO ... (Per accident) PHYSICAL DAMAGE AUTO ONLY-EA'ACCIDENT GARAGE LIABILITY "' OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG S A EXCESSIUMBRELLA LIABILITY CL09887714-00 03/OJ/10 03/01/11- EACH OCCURRENCE S_5_000_000 AGGREGATE E 5_000,000 . X OCCUR EI CLAIMS MADE ----- S ------ --- DEDUCTIBLE WC STATU- OTH -9 WCO20342355 (AOS) 03/01/10 03/01/13 x_ RYSIMlIS_ . �. - - C AND EMPECOMPE LIABILITtONTY AND EMPLOYER5 PARTNHY YIN 03/01/11 E.L.EACH ACCIDENT D ANY PROPRIETORIPARTNERIEXECVTIVEO WCO20342356 (CA) 03/01/10 03/01/11 E.L.DISEASE-EA EMPLOYE E_1,000,000__ OFFICER EMBER EXCLUDED? WCO20342357 (FL) E (Mandatory in NH) E.I.DISEASE-POLICY LIMIT' S 1,000.000 II yes.dine be under _ SPECIAL PROVISIONS below 30M/2M OTHER TNSC46242373 -'(TX)--'^'- 03/01/10 03/01/11 Occurrence/SIR E TX Employers Exceee WC091OS66 (QSI) 03/01/10 03/01/11 D Workers Compensation WCO20342358(XY,MO,NY,WI, ) 03/01/10 03/01/11 C Workers Compensation DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOOR&EMENT I SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF TMEABOVE DESCRIBEOPOLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN THE HOME DEPOT, INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURETO DO SO SHALL HOME DEPOT U.S.A., INC. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR 2455 PACES PERRY ROAD NW REPRESENTATIVES. BUILDING C-20 AUTHORIZED REPRESENTATIVE ATLANTA, GA 30339 USA hts reserved. HH ©1488-2009 ACORD CORPORATION. All rig 4 a tee '[oomurno�u�rea.�/� o�✓�aeivaelk�`s { Board of Building Regulations and Standards Yt{ HOME IMPROVEMENT CONTRACTOR � t i Registration:,126893 v � . ExpiraGon =8%312010 _=Supplement Card r _ The Home Depot Aft Home Service S - RICHARD 2690-CUMBERLAND A't�l`At�`A GA 30339 pdmmistratot # 1 i tic.:;" '�• •. �«trtt.+e ta: RF,NlS.Dl6 - . .;t: :.'.;:'.J;i` �:��:�t_:y`.c_' _`. ti!i�ifC5t��7NNL'•.=:, ...U:::; v x� swnors.aaocs<c�m1.COUTRACTO'a NOMB WpKaJENMT .. K"Islimum� AS4737� TA 281257 .Type-. DBA Oi NCONTRACTOR ANGEL ORTTZ B12 NORTH MAIN ST A eLACWONE•Mn 01504 10-APR-26 04:32PM FROM-None Depot 2666 +0707401402 T-876 P.001/006 F-600 • PLEASE READ TH2S ------ .,,/ Sold,Fumished and Installed by: Bunch Name: Boston Date: �/2// �d THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 Branch Number:3Y Toll Free(800)657-5182; Fax(508)756-8823 Federal TD X 75-2698460;ME Lic X C 02439;RT ConL LIcX 16427 r-/ ✓f - �1 e^CT I.ic#565422;MA Home IT prov®snt Contractor Reg.X 126893 Installation Address: ��rE� '-�1 _�r11 J!Nl_ I1f 019-70` -- City State Zip — Purehaser(s): Work Phone: Home Phone: Can Phone: �i I�iCC l !qs r,4 A I s L 7 L°f7817Nc Z7f3 [7-7e]bz1 905I .L I L l Home Address: (If different from Installation Address) City State Zip m E- all Address(m receive project communications and Home Depm updates):-t'r� L$fz;r*72.t 5 @ UB IG Z-v4 ntET ❑I DO NOT wish to receive any marketing matis from The Home Depot of rm • Undersigned("Customer');the owners of the propetry,located at the above installanoa address,agrees to buy, anServices,Inc.("The Home Doper)agrees'to furnish,deliver and arrange for the installation('TnstaOatioa'�of Rll materials described on the below and on the referenced Spec Sheet(s), all ofwhich are incorporated into this Contract by this re&rence,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(colleetrvuly, "Contract': `1- Job X: n.u* aan;,aea Products: Spec Sbeetfal Xt ' ' PraleotAanaemt Woofing Siding Wind ows hisW=ion�9 ��+ ❑Gutless/Covers ❑Entry Dams ❑ a s a $ $ IQ If ps 0L'. a4ng Siding Windows ❑Insulation ❑Graters/Covers ❑Entry Doors ❑ $ Roofing Siding El Windows. Insulation - pOumers/Covens ❑Entry Doors❑ $ Roofing.❑Siding 0 Windows 3 lnsulaaon $ ❑Gutters/Covers 0Entry D ❑oors .. Minimum 25%Deposit ofCnmraet Amoumdueupao ereeution of this contract.; Moire Purchasers may not deposh more then one bud otter ConawrAmoant Total Contract Amount Maim Customeragraes•iLar:-umnediately-upoa.aampletian ofth work-for each Product,-ELsmmcr will execute-a Completion eertiGeate (one fin each Product as defined by an individual Spec Sheet)and pay any balance due, .As applicable, each Customer_undci this Contract apses to be jointly and savamllyobUpted and liable hemunder. The Home Depot reserves the right to issue a Change Order or terminate this'Comilact or any individual Product(s)included heroic.at Its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural probltar with the home,environmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because Work required to complete the job was not included in the Contract Payment Summary: The Payment Summary # a ( S-1 1 _ , included as prat of this Contract; seta forth the total Contract amount sod payments required for the deposits and final payments by-Prodobt(as applicable). - NOTICE TO CUSTOMER You are eatuled to a completely Shed-In copy of die Contract of the time you sign. Do not sign a Completion Certificate(note: there Is one Completion Certificate for each listed Product-as defined by individual Spec Sheats)before work an that Product Is cumptem. In the event of termination or this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the data of termination,plus any other amounts set forth in this Agreement or allowed under applicable taw. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Asceptanceon: Customer agrees and understands that this Agreement Is the entire agreement berwcen Customer and The Home Depot WItLI regard ro the Products and installation services and supersedes all prim discussions and agreements,either oral or written,misting to said Products and Installation.This Agreement cannot bemisigned or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Casco read, Inds,voluntarily accepts the reruns of and has received a copy of this Agreement_ Ac d by Submitted X a`f /0 O LfTtscc�e Cuat6humpis Signature Date Sales Consultant's Signatures Date X Telephone No. <00 Zy 3 -73` 6 . Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS .(to applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WR2TTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THUM BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW Ri CUSTOMER'S STATE. NOTICar ADDITIONAL,TEAMS AND CONDITIONS ARE STATED ON THE REVERSE SMS AND Mtn PART OF THIS CONTRACT 7.15-ne GSC White-lararxh: lia Yellow-Ctstomer. Pink-Sales Consultant