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57 FORRESTER ST - BUILDING INSPECTION I'Ile Commonwealth of blasia:huscus Ihtard of Building Regulations and Standards CI VY OF Massachusetts State Building Cude.-M CNIR s.\Lli\I Building Permit Application To Construct, Repair. Renovate Or Demolish u one or Tlru-Pinnil: Dwelling This Section For 011icial Use Onl Building Permit Number. Date App 'c c tZv. f IludJiny Ullieial(prim N:unc) Siyoature ate SECTION 1:SITE INFORMATION 1.1 Propert r '`- 1.2 Assessors,flap ft Parcel Numbers — 1r I.la Is[his an acre leas!'es no Nlnp Nunlher I'urccl Number I.J Zoning Information: 1.4 Property Dimensions: /oaring District I'mpascJ liar Los Area(sy R) Pmnlayu(1l1 1.5 Building Setbacks(R) Front Yard Side Yards Rcar Yard Reyuired Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40.154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: 141bllc❑ Privuse❑ Zone: _ Outside Flood'Lune? Check il' G❑ Municipal❑ On site disposal s)atcm ❑ SECTION2. PROPERTY OWNERSHIP' 2.I owner en 41g jirJ N,une(Print) C t).Slate.ZIP Nu.and St n t rel �S F.muil AJdrcss SECTION J: DESCRIPTION OF PROPOSED WORK'(check all at apply) New Construction❑ Existitlg Building❑ Osvner•Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Denwlition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ .Spccily: Brief Description of Proposed Work': SE TION d: ESTIMATED CONSTRUCTION COSTS hvm Estimated Costs: (Labor and.Materials) Official Use Only I. Building S _ I. Building permit Fee: S Indicate how fee is determined: '. Llccuical S ❑Standard Ciry.Tossn Application Fee ! I'lumh;ng S O Total Project Cost'(hem 6).1 multiplier _. Other Fees: S J - J. \Icat.ulic.d ill\ \(': S List:-_ \k:h.miad i Fire I �u +res5ionl 5 foul .\II --�.-- -•- -- - _ .-.. ._ n Futal (inject Cnq: S Check Vu. _.. (fleck:\mount. . Cash \mount. ❑Paid in Full ❑Outstanding Ilal.tnce Due: SE("110N5: ('0NSfRU(-rI0NSERVI('ES i.l C'unstructionSupervis�rLirenselCSL1 I tD n� .._ f\', p will) e ic !ihar N,unc al'l'SI I alder ---- I Ill 01. I''pe Isee helotvl _ .I.+Pe Ucscriplion No. and Street - -- --_ (I I Inrestricicd I lluildin� to tS,IIIItl nl. Il.l it lic,Irictcd Idl'21 an1i1) D++cllinit \I \lason l it) aen,Slate. J R(' N,nllin C,ncrin ,otd Sidin "'— SF Solid Fuel Ourniny Appliances /^� I Insdution IFS FJll;lll;IJJre�s D Dcnwli tian c c bane 4.2 R Islered I me [nil) s st Cunt nctar IHIC) Till:Itcgislrotiun Nmnlwr IScplr lion ale I IIC C N 1 •ar 'Itagi na 3 1anail address No. an 'In Ln IG� L— fell:hone Ci elTown.State ZIP � SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52.1 25C(6)) tried with this application. failure to provide Workers Compensation Insurance affidavit must be completed btn this affidavit will result in the denial of the Issuance of t 1 ding permit. Signed Affidavit Attached? Yes .......... No••• •••• I] SECTION 72: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT t I,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" Pate print O'vner's Nwne(Elcctrunie Signature) SECTION 76:OWNERt OR A HORIZED AGENT DECLARATION By enteri fly name below.I hereby attest under t p as and p allies of perjury that all of the information contai dint is al) cation i true and accurate to th est m n ]edge and understanding. nit I'rinl IA'ner s ur:\uthari ,\•�u s Nnnw(liicctr a Ai wall VOTES: I. .\n Owner who obtains a building permit to do s.her own work.or an owner who hires an unregistered contractor I not registered in the Home Improvement Contrnclur(HIC) Program),will nu have access to the arbitration program or guaranty fund under\I.G.L.c. I41A. Other imponant information on the HIC Program can be round at tt tt't IP.1" '�0t ''.I Inronntion on the Construction Supervisor License can be round at ttt"t M3,; 2. \\'hen substantial work is planned, provide the information below:including foryc. ri fished basement attics,decks or porch) a. --.._t total tl'wr area Is 4 ft I -- lbil.lble room.oust Cirosshitingarealsy. 11.l ----. Nunlher tit'bedruonls \unlbcn>I'lireplaccs .. .. —_ \lunbcruf hall,hwhs .. . \Inuhcrol'hadvoonts - \umhcrol'Jccks. porches I\pc of he.lting s)'tell 1,116",:J ..Open I'\po '1 C,•, Illlg '\'ICIII .. �d.11 pfUie❑ 1squareI'o,nale Itl;l) IN'II I,Nlhll cd Iirt" ,ual projeO COA" I The Commonwealth of Massachusetts Department oflndustrialAccidents �u fix Office of Investigations 600 Washington Street Boston,MA 02111 d ' i www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual)):,� �-�,_� �,,/ [1�, /)(�� Address: ;CCU ^�_ F7.X11�n-'- Y!( AIS/ City/s /zip: a' Phone#: f10 t 7`�7h5 Are y an employer?Check the.appropriate boa: Type-of project{required): 1. I am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors -6. ❑New construction 2.❑ I am a sole proprietoror partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 51 ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑PI bing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. oof repa' s insurance required.]t c. 152, §1(4),and we have no �' employees. [No workers' 13.E timer comp. insurance required.] *Any applicant that checks box 111 trust 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 sub-contractors;and state whether or not those entities have ' employees. If the sub-contractors have employees,they most provide their workers'comp,policy number. ' lam an employer that is providing workers'compensation insurance for my employees. Below Is the poUcy and job site information. ,� 1_ Insurance Company-Name: p 1 1LAMAIP I M I b Policy#or Self-ins.Lic.#: 7 (��i'7 Expiration Date: Job Site Address: _ 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for it coverage verification, I do hereby certify u der t e pains d naUies ojperjury that the Information provided above ' hue d correct S' afar : /jt Date: l� j Phon #: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other - Contact Person: Phone#: CITY OF S'V-F—Nf, NEUSACHUSETTS 3LLLOLVG CEP.IATNM%T I-'0 ',n.liFILYGTON 3rXM, Jw FtCC)t R+1. �97f� 74�.9S9S KI MAr Y OXISCOLL F.lx(97� 1#784d tiUYORt MO.%W ST PMXA,$ D rMUTC ti OP PL SIX PROPERTY/st:MDprG CO3 LNtSSION E A Construction Debris Disposal At't?davit (required for 211 demolition and renovation work) In accordance with the sixth edition of the State Building Code, 190 CrjvfR section Debris, and the provisions of MCL c 40, S 34; I I I.S Building permit al ibis work shall be is issued with the condition that the debris resulting from disposed of in I, S 1 JOA. a property licensed wrote disposal facility as defined by I�ICL e I I The debris will be transported by: (name utYhauler)' no debris will be disposed orin : (namne of foci iy) (rJdreu ar f�,dqy) ynaruro or�ermif ippLcmf �.id6G� ` off o eauand Busuiess Regulattoii 10 Park Plaza - Suite 5.170 Boston,=�_ sach>a etEs:02116 Home Improveontractor'Aegistration _.•�� .._ Regletratlon: ' 128893 c— — Type: . suppiement Cafrl Eiplraflon: 8l31201d The Home Depot At-Home Servi T _ RICHARD FALLONE inl _ a 269D CUMBERLAND PARKWAY 39 ATLAT\ITA; GA 303 i W 9 . nr`- �y4� Update Address end return cat d Mark reason for change. Address Renewet .[]1 mployment Lost Cnrd . . be 3-ant sord-omoq-uioizte- 07130amc»wot«e? sue\ Office of Consumer Affnirs&'Businass Regulation License or registration valid.for Indlyidul use only before the expiration dn4e. If found return tv OME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Business Regulntion t Typo: 10ParkPlaza-Suite5170 Regls[ratlon ,126093 Expimtlon '0f3 [}D4�y Supplement Card Boston,MA02116 ' The HomeDepoliAIHtmdn { 'tvlhles ':, .. J !1 l RICHARD 2690 CUMBERIA�I4.,PA�iFr(r��A S � _.' . • of valid with ut A nature - A`}j-rF1ry9`a,'GA 30339"''!`,.;,'=° Undcrsecretnrg ... .... DATE MMIDDIY V' CERTIFICATE OF LIABILiTY INSURANCE -(H' S 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), AIUTHOR!ZEO REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. iMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(!es) 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 to the certificate holder in lieu of such endorsement(s). 1-866-966-4664 CONTACT PRODUCER NAME: --------- Mzrsh USA InC. PHONE FAX o (A/C,No: E-MAIL homedepot.certrequestOmarsh.com ADDRESS: --Two Alliance Center, 3560 Lenox Road, Suite 2400 - INSURERS AFFORDING COVERAGE NAICN _ Atlanta, GA. 30326 Fax (212) 948-0902 INSURERA: Steadfast Ins Cc 26387 INSURED INSURERS: Zurich American Ins CO 16535 The Home Depot, Inc. INSURER C: New Hampshire Ins Co 23841-- Rome Depot U.S.A., Inc. 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Co 23817 1 Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER F: Iliinois Union Ins Co 127960 COVERAGES CERTIFICATE NUMBER: 25776028 REVISION NUMBER: THIS IS TO CERTIFY THAT THE ROLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY,.REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE LTR POLICY NUMBER MMIDDIYYYY MM/DDIYYY'I A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 A Al ORENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S CLAIMS-MADE O OCCUR MED EXP(Any one person) S EXCLUDED - X LIMITS OF POLICY XS PERSONAL S ADV INJURY $ 9,000,000 X OF SIR: $1M PER OCC GENERAL AGGREGATE S 9,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG S9,000,000 X POLICY PRO- .,LOC $ B AUTOMOBILE LIABILITY HAP 2938063-09 0 EeacccdeOtSINGLE LIMIT 1,000,000 NX ANV AUTOBODILY INJURY(Per person)AU OS SCHEDULED PBODILYROPS INJURY(Per accitlenq S AUTOS AUTOSPROPERTY DAMAGENON-OWNED Peraccident S HIREDAUTOS AUTOS S SELF INSUR D PRY DMG UMBRELLALIAB OCCUR - EACH OCCURRENCE $ - EXCESS LIAR CLAIMS-MADE AGGREGATE S S DED- RETENTION$ TATU WORKERS COMPENSATION WC019736915 (ADS) 03/01/1: 03/01/13 X WC S"MT OTH- C AND EMPLOYERS'LIABILITY YIN WC019736917 (FL) 03/Ol/1 03/01/13 E.L.EACH ACCIDENT S 1,000,000 D ANY PROPRIETOR/PARTNEIUEXECUTIVE NIA OFFICERIMEMBER EXCLUDED'+ WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 1,000,000 I E (Mandatory In NH) - Iiyendes bbBldu 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ E Workers Compensation WC1192494 (QSI)- 03/01/1 03/01/13 SIR (ADS)/SIR (GA) 1M/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD 101,Additional Remarks Schedule,II more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING GA 3 ATLANTA, GA 0339 I USA ©'198 -120'10 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Jthornton hd .............. ....................... IS CS-101433 ...........- SERGIO A SANTOS ::'.... . 11 HAWKINS STREE-r-A &imen ille NIA 011431, 0813012014 09/03/2012 20:11 17819940331 TODD RIDEMAN PAGE 01 �- HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Famished and Installed by: Branch Name: Boston Date: 9/3 ,11- THD At-Home Services,Inc. "a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free.(900)657-5182;Fax(508)845-6017 Branch Number.31 Federal ID#75-2699460;ME Lie#C D2439;RI Cont.Lie#16427 --1 � CT Lic#HIIC.05 5522;MA Home Improvement Contractor Reg.#126893 . Installation Address: 5 / C 'fir " ��Q ST SA 1,019 01117 0 City State Zip �t Purchaserye): ^ , [ jerk Pboce: [ Home Phone: r^HC]aI1 Pho Home Address: (If different from Installation Address) City Stine Zip E-ma"Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing emails from The Home Depot Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, L•/-� and THD At-Home Services,Inc.("The Home Depot")agrees to furnish deliver and arrange for the installation("Installation")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 Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): I Job#: nna..aniaremi prishm": Spec SM1 s #: Praiser Amount �7 Roofing Siding Windows Insulation ) 6y5!--7-/�T Guttars/Covers []Envy Doors ❑ / $ / /p 7, Q O Roofing Siding Widows Insulation $ inWartars/Covers []Envy Doms ❑ y ❑Roofing LISiding Windows Insulation Gy4� yy ❑Gamas/Cover. ❑Entry Doors❑,._ 133 3)1 y $ 75, 0 0 Rmfng LISiding Windows ❑Insulation $ ❑Gutters/Covers ❑Envy Doors ❑ Minima.25%Deposit of Contract Amount due upon execution ofdris molract Total Contact Amount $ Maine Purchasers may not deposit more than one-mad of the Contract Amount. r O O Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to bejointly and severally obligated and liable hereunder. The I lume Depot reserves the right to issue a Change Order or terminate this Contract or any individual ProducUs)included herein,at its discretion,if The Nome Depot or its authorized service provider determines that it cannot perfi nn its obligations due to a structural problem 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 Contract7c Payment Summary: The Payment Summary # F,%p!`(f included as part of this Contract, sets forth the total Commu;I arrroum and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled4m copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each*led Product as defined by individual Spec Sheers)before work on that Product Is complete. In the event of termination of 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 date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. 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. Acceptance and Authorization: Custom"agrees and understands that this Agreement is the entire agicemern between Customer and The Hnmu Depot with regard to the products and Installation services and supersedes all prior discussions and agreements,either oral or written,minting to said Products and Installation.This Agreement cannot he assigned or amended except by a writing signed by Cusmmet and The Horn:Deem-Customer acknowledges and agrees that Customer has nderslands,voluntarily accepts the terms of and has received a copy of this Agreement A t y: �/ Submitted by: l � �fr3/1 Z X .tot er's Signaum - Date Sales nsultant's Signature Date XL-- Telephone No. Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicabl.) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOl'ICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE.PART OP THIS CONTRACT as-10-12 Whae-Brmch vlile yellow-Customer