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12 FOWLER ST - BUILDING INSPECTION The Commonwealth of Massachuscus Town of \� Board of Budding Regulations and Standards Y1 � Nassachuscits State Building Code. 780 CMR. 7'"edition Budding Dept Budding Permit Application To,Cunstruct. Repair. Renovate Or Demolish a One. or Two•Funuf►•Dise/fmg This Section For Official Use Only Building Permit Numbe . Date Applied: t ` 6 11 O Signature. 8uildi CamritissioneN In f dines Date S TION 1:SITE INFORMATION 1.1 Property A�r . l f�l _r :1 1.2 Assesson Map i Forest Numbers mber Parcel Number I.I a Is this an ace ted strew'!yea no Map Nu IJ Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq n) Frontage IR) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: I.S Sewage Disposal System: Zone: _ Outside Flood Zane? Municipal 0 On site disposal system C Public 0 Private 0 Check i- sO SECTION 2: PROPERTY OWNERSHIP' 2.1 Owoe f Reeo 70 � .� . rA 1' Name(Print) � , Address for Service: Signature Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check a hat apply) New Construction 0 Existing Building O Owner-Occupied O Repairs(s) Altention(a) O Addition O Demolition 0 Aecesaory Bldg. O Number of UniU_ Other 0 Specify: Brief Description of Proposed Work': •�� SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials ,� I. Budding Permit Fee: f Indicate how fee is determined: I. Building f O Standard CiryrTown Application Fee 2 Elecincal S O Total Project Cost'(Item 6)x multiplier x J Plumbing S 2. Other Fees: f i. Mechanical IHVAC) S Lisr t Mechanical (Fire S Total All Fees. f Su remote eck Vo. _Check Amount: Cash Amount: et Total Project Cost S 0 Paid in Full 0 Outstanding Balance Due SECTION !: CONSTRUCTION SERVICES 5.1 Licensed Constructlon S rsisor(CSL) ,, 1 ► 1P �C� ��i Liceroe Number —f Espuauon Date N.(roe ul CS 1491 , L,.t('SL Type 1><Y Aluwl A s T Descn ton u unrestricted u to JS,000 Cu. Fl R Restricted 162 Famd Orrltin na re ! N Ma Onl (y./ RC Residential Roofin Covenn Telephone ;S Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D f Residential Demolition 3.2 Registered Home rov e t C for ) � HIC C or H ik tstr t Registration Number Adtlreta ��� Eapiranon tie Sigtu Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L-e. IS2.12!C(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 IssuancSpMe building permit. Signed Affidavit Attached? Yes.......... No........... O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. lf7�r Si attire of Owner Date I r' SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION 1, f WV 1 GOW` , 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 Name ------------- Signature or Authorized Agent Dal (Started under the sins and penalties of 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 g&have access to the arbitration program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I0,R6 and 110 R3, respectively. 2. When substantial work is planned•provide the information below: Total floors area(Sq. Ff.) (including garage. finished basementlanics.decks or porch) Gross living area ISq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half baths Tvpe of heating system Number of decks/porches Type u(cooling eystern Enclosed Open t "Tool Project Syuare Footage"may he suhstituted for-'Total Project Cost" Thz Corramo:awealt, of ljassack�Szits � 7'er�r n zit' cf��t�usirtal �ccid�n;S , ii...., `7 oj, ,tC I ,;.- ..�- 1\Talne, ($usmoss/organization/Individuat):— Address: City/State/Zip: 11Ty., �it�7i��y Phone.#: n I mployer? Check the appropriate bos: Type of project(required):. mployer with (Z 4. ❑ I am a general contractor and I 6 ❑New constructiones (full andlorpxrt-tune).* have h red the sub-contractors7. Remodelinglisted on the attached sheet. ❑ole proprietor or partner- These sub-contractors have g. ❑ Demolition have no employees for me in any capacity. employees and have workers' 9 ❑Building additioncomp. msurance.tkers' comp. insurance 10.❑Electtical repairs or addi ons' required.] 5_ ❑.We area corporation and its officers have exercised their 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work of right exem tion per MGL myself. (No workers' comp. g p - 12.❑ Roof repairs _ c. 152, §1(4), and we have no �{ insurance required.] t - employees. [No workers' 13. Iher ,,��Y-Af�1 comp.insurance required.] applicant thatchecks box Nl must.also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hits outside contractors must submit anew affidavit indicating such. nh'actors and state whether or not those entities have tContractom thatcheck this box must attached an additional sheet showing the name of the sub-eo employees. Lf the subcontractors have employees,they must provide their workers' comp.policy number. I am an employer that is providing workers'compensation insurance fo r my employees. Below is the policy aln dd job site informati0n. - +y �- Insurance Company Name: Policy # or Self-ins.Lio #::� �/'�� f ( " [ -.Expiration Date: 1 Y a"� _ City/State/Zip: t Job Sits Address: \ FIN 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 psnalties'of a . fine up to $:1.,500.00 and/or one-year imprisonmenea��as-�of up to 1250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. t in ormation rovided above is true and correct. I do hereby certi un r e p s an penalties ojperjury that the j p .. Si ature: / Date: — Phone# OjficiaL use only. Do not write in this area, to be completed by city or town ojficiaL City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspect7EF�lumbingInspector 6. Other 'Ph nne #: ATE CERTIFICATE OF LIABILITY INSURANCE D 02/20/09/20 PRODUCER 1-a0a-995-3000 `fH15 CERTIFICATE IS ISSUED AS A ^HATTER OF INFORMATION -rsh USA, Inc. ONLY AND CONFERS N•") F?!:3H'iS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR madewt =_a�zs:3ma_sh.com j ALTER Trio CC'i E:7.AI= -"Ru EO S" THE PCL 3C - - r i ?i t T Slit_- 1290 i '_7 ants CA 3.3 T. (212) 940, 0912 Tic.. - 112IIPE t8 t iCn A.0 - L n In Co _ 1.65 IS I2a:90 CwmS...1„a` I'.r.-ray INSL,HIII G.PAT_O'.-`.7 i3N 1:01, b'iP,f I i, <13 OF nIl 17415 - 1 cite 3U0 Atlanta , CA 30339 INSURERD:New Hampshire Ins Co 23841 INSURERE:Illincis Natl Ins Co 23817 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.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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 013'1. POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR 14 R POLICYNUMBER OAT M DO ATE MMIOO A GENERAL LIABILITY IPR 3757 608-02 .03/01/09 03/01/10 EACH OCCURRENCE S4,000,000 X COM.MERCIALGENERALLIABILITY LIMITS OF POLICY ARE EXC SS PREMISES Ea occurenca $ 1,000,000 CLAIMSMADE aOCCUR "OF SIR: $1,000,000 PER CC" - MEO EXP(Any one person) SEXCLVDED PERSONAL$AOV INJURY $ 4,000,000 GENERALAGGREGATE S 4,000,000 GE N'L AGGREGATE LIMIT APPLI ES PER: PRODUCTS-COMP/OP AGG $4,000,000 X I POUCV PE� LOG B AUTOMOBILE UAB ILITY BAP 2938963-06 03/01/09 03/01/10 COMBINED S INGL E LIMIT X (Ea accident) S 1,000,000 ANYAUTO ALL OWNED AUTOS BOOILYINJURY S (Perperson) SCHEOULEDAUTOS HIREDAUTOS BODILYINJURY S (Perilmdenl) NON O WNEO AUTOS X SELF INSURED AUTO PROPERTY DAMAGE PHYSICAL DAMAGE (Perattn0 $ ide GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANY AUTO - OTHERTHAN . _ EAACC S AUTOONLY. AGO S A E%CESSIVMBRn LLA LIABILITY IPR 3757 608-02 03/01/09 . 03/01/10 EACHOCCURRENCE y5,000,000 %I OCCUR ❑CLA.IMS MADE - AGGREGATE S5,000,000 S _ DEDUCTIBLE S RETENTION $ S C WORKERS COMPENSATION ANO 3566916 (CA) 03/01/09 03/01/10 % 1 qy TI nTIT- GTR D EMPLOYERS'UABILITY 3566915(AOS). 03/01/09 03/01/10 E L.EACH AOCIOEHT $1,000,000 ANY PROPRIETONPARTNENEXeCUTIV F. E OFFICERIMEMBERE%CLUOEO? 3566917 (FL) 03/01/09 03/01/10 E.L.DISEASE-EAEMPLOYEE S1,000,000 If yes describe under - 000,000 SPECIAL PROVISIONS below E.I.DISEASE-POLICY LIMIT "S 1, OTHER D WOrkers Compensation 3566918 (KY, NO, NY, WI, ) 03/01/09 03/01/10 F TX EYnployers Excess TNSC45694422 (TX) 03/01/09 02/01/10 cc Urrence/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDOR$EMENTI SPECIAL PROVISIONS RE: EVIDENCE-OF INSURANCE - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, INC. DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2690.CUMBERLAND PARKWAY SUITE 300 REPRESENTATIVES. ATLANTA, GA 30,33.9 AUTHORIZEOREPRESENTATIVE USA ACORD 25(2001/08)ckomraus_hd _ ©ACORD CORPORATION 1988 �� Boar ofu ln � lat�ons antanr(s g g One Ashburton Place - Room 1301 .77,� y Boston. Massachusetts 02108 Home Improvement Contractor Registration i Registration: 153418 Type: Private Corporation ' Expiration: 11/30/2010 Tr# 280810 BUILDER SERVICES GROUP INC. THEODORE PLONA -- ------------ --__. 2339 BEVILLE RD ----- -- -- - - DAYTONABEACH, FL 32119 - -=---- -- --- - - --- - - . Update Address and return card.Mark reason for change. j Address ❑ Renewal [— Employment J Lost Card nPS-CAI 0 40(A-08109-0aSUFORMCA108212008 .1/l4 V'(:II/•I)[4111[4.'IS�Ji ll.;�(✓:iJILIJI.UAP.�: Board of Building Regulations and Standards License or registration valid for individul use only kit HOME IMPROVEMENT CONTRACTOR � before the expiration date. If Found return to: i+ r. Board of Building Regulations and Standards a �J Registration: 153418 - !% One Ashburton Place Rat 1301 - -�-/� Expiration: 11/30/2010 7r# 280810 Boston,Ma.02108 ar+v., Type: Private Corporation BUILDER SERVICES GROUP INC. / THEODORE PLONA 2 INDUSTRIAL RD. t a.L.` .._. ._-.....11"1..+' ✓.--_.._ ---._-------__. MILFORD, MA 01757 Administrator ilNot valid without signature 'Va.sachuscrts - Department of Public safct% ,`w.. \I t..arhunctt. ilcparnncot 'It politic tiaf�n Board of Buildim;, Rc!'nlalitln. u1tl St:uul,tr'd. B'u rd of Builibn" Re•!ul triun. :md �tandani Construction Supervisor Specialty License Construction Supervisor Specialty License License: CS SL 100189 License: CS SL 100189 Restricledto: RF,WS,SF,IC Restricted to: RF,WS,SF :✓F THEODORE PLONA THEODORE PLONA 18 THAYER AVE 18 THAYER AVE AUBURN, MA 01501 AUBURN, MA 01501 Expiration: 9/13/2012 �!�L 'y E`pneoun: 9113t2011 Tm, 100189 : .nuuri�.i..,u r ?r 100189 ( �unmi.•i,nmr 11-17-2009 10:44 FROWTHO AT HOW SERVICES +508 756 8823 T-128 P.001/003 F-020 HUME IMPROVEMENT CONTRACT PLEASE MEAD THIS . Sold Furnished and Installed by; BYaneh Name: Boston Date: �/�)�_ THD At-Hone:Services,Inc. ' d/b/a The Home:Depot At-home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 Branch Number:31 Toll Free(800)657-5182; Fax(508)756-8823 Federal M#75-2698460;ME lac#C OM39;RI Cont.Lint 16427 Cr Lie#565522;MA Home Improvement Comraemr Reg.#126893 Installation Address: �. FOWL _S'T _ [_F-M�___Z c"LTZlJ q City State Zip Purehaser(s): - Work Phone: Home Phone: Cell Phone: C—F [(indigo—(.wT- [ehidL7yi—i4clig [ ] Home Address: ' (If different from Tnstagatron Address) Crry Stale Zip E-mail Address(to receive project communications and Home Depot updates):_ 1 DO NOT wish to receive any marketing emails from The Home Depot '— rd Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and ITID pt-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 allacbed.hereto and any Change Orders(collectively, Contract"): Job#: a..a,ra...,l Products: Sec Sheens)#: Project Amount //- /(��( Roofing ❑Siding Windows nsulafM V�"'t/`�" ❑Guters/Covers ❑Entry Doors ❑ I I S�-1 $ j. I V - Roofmg ElSiding ❑Windows Insuladon ❑Gutters/Covers ❑Easy Dion ❑ S ❑Roofing Siding ❑Windows insulation ❑Guners/Covers ❑Entry Dotes❑ $ ❑Roefing ❑Siding 0 Windows ❑insulation - ❑Outters/Covers [3any Doors El _ $ Minimum 25%Deposlrof Contract Amount due opee emmtion ofthis motract Total Contract Amount S Maine Purchasers may,notdeposit mom than one-third of Me CoMmetAmmut. Customer agtees-tfiat,ir>msctiiamip npoii arompleGau of the Work Ytir each-Produc4'Ctist6r�r�vitl execvts=a Completion CerdfikMe (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable, each Customer under thin Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or.any.iodividual Products)included herein,m its discretion,if The Home Depot or its authorized service provider detmmmes that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold, asbestos or lead paint,ocher safety concerns,pricing errors or because work required to complete the job was not included in the Contract, . Payment Se t�.Gmmary: The Payment Summary # ��� / I , included as part of-this Contract, sus forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at 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 Sheets)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 Provid"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. 7nD nce and Authorti7stion: Customer agrees and understands Mat this Agreemcrrt is the entire agreement between Customer Home If A wide regard to the Prodons and agreements,tither ritten,relating to said Products and Iru�itation.Tlus Agreement cannot be e v or amended except by a writing signed mer and The Home DepotCustomes,volunmrily accepts the and hag received a copy ofthis Agrcenrent.d bY:on �w . L�r's Sigoarore DateData �/-737C r's Signanae Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (asapplicnbl.) 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 1S SPECIFICALLY PRESCRDIED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF TRIS CONTRACT 7.15-09 C-SC Whke-Branch File Yellow-Customer Pink-Salsa Consultant , it -Sol s CITY OF SALEM 3,t l PUBLIC PROPRERTY �� .-' / DEPARTMENT O*s KN -n I'Q V('.\;I I��c:uNSrBeeT •S.\I r%t, bt.\.:.0 'fFt:108-.743•9595 1°.\3:978•7444846 Construction Debris Disposal Affidavit (required fur 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 c 40, S 54; Building Permit M 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 111. S 150A. The debris will be transported by: (name of Iwuler) The debris will ,be disposed ofin _.__.. - (name ul'^Facility) (address of facility) alg tm re of4mitpe cant ! DC date Jrbi i v!I'Cac