11 GALLOWS HILL RD - BUILDING INSPECTION (3) The Commonwealth Of Massachusetts
t Board of Building Regulations and Standards CITY
OF SALF'M
Massachusetts State Building Code, 780 CMR, 7i°edition
'w Revised Jmnu.rr•
Building Permit Application To Construct, Repair, Renovate Or Demolish a /. MAY
iOne-or Two-Family Dwelling
This Section For OfTtcial Use Only
Building Permit Number: Date Applied:
Signature: �/7 f l
Building Commissioner/Inspecr6ptif Buildings Date
SECTION 1:SITE INFORMATION
1.1 Prop Ad ss: 1.2 Assessors Map rk Parcel Numbers
1.1 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 11) Frontage(11)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTI N2: PROPERTY OWNERSHIP'2.I n t of R d• 1 I
Name( rin Address r Service `E3�
t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKr(cbeck all t t apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMclal Use Only
Labor and Materials
I. Building S _ I. Building Permit Fee:S Indicate how tee is delermined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (NVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: E
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Llcens nstructlon rvlsor(CSL) _
/ ' b�
fi
License Number I:xptra wn ute
Aol*C' l r List C'SL Type(see below)r-U llnrestriR Restricted IB2 Famil Uwellin�• �_ M M Only
`/ri��'�'' RC Residemial Roulin Covering
fctephone WS Residential Window and Siding
SF I Residential Solid Fuel Burming Appliance Installation
D I Residential Demolition
5.2 Registere srre Ira v eot u e HIC)
f I Nam r f C e e 7 Registration No er
a 7
d rein /.
r- Expiration gore i
SI t re Telephone
SECTION 6: WORKERS'COMPENSATIO NSURANCE AFFIDAVIT(M.G.L.c. 152. 1 2SC(6))
Workers Compensation Insurance affidavit must b9ecompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuag6e of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
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 to act on my behalf, in all matters
relative to work authorized by this building permit application. 15
Si mature of Owner Dale 4 XL
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATI N
as Owner or Authorized Agent hereby declare
that the s ents and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Pr' e
St a re of honer or Aut orized gent Dote
;,XL
i ed on
r the sins and rallies of 'u
NOTES:
I. 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 01 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
_'. When substial work is planned,provide the information below:
Total floor area(tanSq. 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
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
yr ,
PUBLIC PROPRERTY
DEPARTMENT
�wK\
\I `J �If I '�\C.\il IIV .,�\}lit II T • $.\I I'M. \I.\ii.\t !I; q I
lTl: 97S-74;.9;95 # 1: 5:7'8J4„9846
Construction Debris Disposal Affidavit
(required lbr 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 it 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
I 11. S 150A.
The debris will be transported by:
(name of
hauler)-
I'he debris will be disposed of in
name ul Ihcilit )
(address of facilav)
kj__�
--_—sig slur ufpennitapplicant —
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y..\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Regis tra_LQd , 126893 -
- EXe1Fa[fan_@] f2010
p�ementCard
1 -EMi,,
The Home Depot--' i0¢>j%SSery
_, -
RICHARD r•ALLONEe-���, ,;%
3200 COBB GALLERI;gK7N,.?;�#20
X
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7 ......
city/stateizip-
-kre yqd-n employer?Check the 2pprop-Mte DOX:
am a employer-,Alh I LA--; 4. I am a ea elal coitracter and 1 6� Fj-NzelvLonsITUCTS-021
�ave hh-ed the sub-coollmdOts
eniployces(full and/or past-firnc)-* listed on the anachrd she--L 7-
2�El I am a sole proprietor or Paz--cr- These sub-cor&aCtors have S. F1 Demolition
ship and have no employees
employees and have workers' 9. []Building addition
working for me in any capacity-
comp.insurance-,
(No workers'comp.insurance io-
5- El ire are a corporation and its E]Electrical reams or additions
required.] officers;have exercised their I I.[]Phunbing repairs or additions
3.0 1 am a homeowner dGin,'all work �of exemption per IVIGL 12-[] us
myself.[No workers'comp- 152,§1(4),and we have as
insurance required.] l3-ff&hcr--�Aj1)jj01 lb
employees.[No workers'
comp-insurance revir-C&] I
; MrV,,,Lon cy
67 xwk .' [ POE i-ro�IiW=sid assnum brii ancwaUidzvitinffimfi—MXh-
f Hnn�,"m who subrnit this affidavit indicating d"YaM doing A lark mail thm him W1 c—tr--
icon uw,that ctwk this box nost aumimd m2mdasaj sb=t slowing the now:untie sub-zavntton and state wbcae W not fix=catiLics luwc
=,play=s. Wokm CU"V pohcywI am an �
employer that is providing mOj*M,conapmsmavir&surancefor eey employees Below is the police and foh site
infornza6on. .11 -
Insurance Company Name: -------lwqlw. -
Policy#or Self-ins.Lic-8- \1 Expiration Date:
GtWState/Zip:7�st
Job Site Address
IMET a"copy"o7-tlie—vr;i-rlEiW-compensation-iisUcY fle 4 claration page(sumnug trff POUCYROM OFF- U V.W11 AUUM UA,,j-
criminal penalties Of a
fine up to S 1500.00 and/or one-year imprisonn=34 as well as civil penalties in the form of a STOPVVORK ORDER and a fine
of up to S-750.00 a day against the violator. Be advised that a copy of ibis statement maybe forwarded to the Of&e of
Investigations of the DIA for insurance coverage verification.
Ida hereby certify and I ep7a penalties ofpedury that the informadonpyro7videdaboie Is eff"add rra%
Signature: Wa M41 9,
Phone 0:
Oflicialrise Wn—tF—Do not write in this area,to be evnWleted by ciT or town official
City or Town: Permit/License 9
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
TYINSURANCE
��.. « - 1-?7'!-9_� 3•]^.,T TS CERTIFICATE IS L€D AS ?TTc
ONLY AN-) CONFERS PdD RIG P ME
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USA, n HOLDER, 73i1S CERTIFIGAlE DOE ;d T / v:::a'+iD E,Yf f'J Ct 1
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axlaata OVERAGE 3032E INS LIFERS A�ORDNG C r1r r.f -
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COVERAGES ,�
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AAW MAY PcRTNN,1T?4=OdSURANCECCAFF +aFCS�J BY THE FGL'+C1ES DESCRMEL')ir'9tECtx9 i5 SLS_aECT TO P.L�1.1HE TERMS. XL'LUSSI 5,17 II L DII"S L"Ur-"'
FOUCIES.AGGREGATE LMTS SHOWN MAY HAVE BEEN RE?DLACEDSY PAID C A4AS. --
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MAM OccR PERSONALAAMWAM s4,000,000000_
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-CLAIM GENERAL AGE_ 34000,000 _
GENLAGGRESATELWTAYPUES POt - PROOYfCIS-CfOYP,VPAC-G 84,ODO_m00-_--
E POLICY PRo- LOC . .
H AUTONC®aELN0p3IY BAP 29383S3-07 03/01/10 03/02121 COUNNEDSM4GLELUST 31.000.000
E ANY AUTO --
ALLOWNSDAUrO°S BCOBY Ri.'APRY s - ..
SCNEDUL®AMOS - -- _—
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E SEr.F iNSUBEO AUTO � � . --.--.. S. .,_.:.
PHYSICAL DAMAGE- -
- AUTD�Y-EA ACC�F.NL 3 _
GARAOELVUSO - EAAOC S _
AMAULO - OTHAO� AGG S
--A- -�^- EKt1•SSI11fIRHLAl1A0LiiY -- - G7p4887714-00 --- -- . ---__. - - -03/Ol/10 _....._03/01/11 - EACH O S 5,000,000_,_ -
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- 1,000.000
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D Workers Coopemati1M HCO910566 (0SI) - --03/01/10 03/01/12
C Norkera Campaneation NCO20342358(KT.MO,NV,Wl, 03/01/10 03/O1/11
_oEs�NOFaPe+AroxsnounoxsrveeaEsiE]xLus�orasAoo®arENoo�FnsPEaAL _:.... ._.:-_.._.�....�..,;,,�;;., '
RE: EVIDENCE OF COVERAGE - - .'.>,•,-.....-.._._.:. - .
CERTIFICATE HOLDER CANCELLATION '
SNpLaDANYOFTHEAOOYEUESCROEDPOLKJESOECAIWSLEDB9O0EDffE WM1RSJ
M FETMkMFl IS5UaGRaSifO:PPwa1e1 VOR70eMa 30 M
rRE uONE DEPOl, INC.
KRIE DEPOT D.S.A., SAC. - _ NOII�IO TEE CERHHCATE NOIDEA NNN:OIOTHE LEii.OULFAO.NETO0DSO5HALL
_._. - - No OnnATKPi ON LJ OY OF ANY LPON THE OmrtOL n5 ASSAM OR
1455 PACES PERRY ROAD HN - REPRCSENTATIVES.-- - -
mlLDING C-20 AUDORODDRUMM RfATPIE
LiLANl'A, GA 30339
USA
4CORD 25(2009101)Jthomton_),d - _ ®JSW2009 ACORD CORPORATION. Ali FightS reserved_
24482689 The ACORD name and logo are registered marks of ACORD
06/02/2010 10:13 15087568823 THD AT HOME SERVICES PAGE 01/07
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Furnished end Installed by:
Brach Name: Bastion Date:-- �� THD At-Horne Services,Inc.
d/b/a The Home Depot At-Horne Services
345A Greenwood Street,Unit 2,Worcester,MA 01607
Brach Number:31 Toll Free(800)657.5182; Fax(508)756-OM
Federal ID At 75-2699460'.M6 Lic#C 02439;Rl Cont.Itc#16427
CT Lic#565522;MA Home Improvement Contractor Reg.#126M
Installation Address: G/�LLOLAIS 141 f t" !20 S,-LEYtg b let 76
City State Zip
Pumbaser(a)r Work Phoney Home I'bouse Ce11 Phone:
Rt14 � I y .cg-too [ l [q-tb] S9'i S32b [9�g7 7rb 98s
f ) [ 1 [ l
Horne Address.: �'yfYYt@_,. V/0
different
n[from Ins[etladoo Address) City State Zip
+-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marinating amalls from The Home Depot
Prnl¢et Information: Undersigned("Costumer'),the owners of the property located at the above installation address,agrees to buy,
and T€fU t- one ervices,Inc.("The Home Depot")agrees to famish,deliver and mrange for the installation(`Trtctallation")of ^�
all materials described on the below and on the referenced Spec Sheet(,), all of which are incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary eKached hereto and any Change Orders(collectively,
'Contract"):
Ioh#t aet 5 Sh s #: Pat' Amnunl O(
_ ❑Roofing Siding endows ❑insulation a"50 4 9 4 -7 q ❑Gutters r Covers ❑Pmtry Oorx, [I3 o i t4 8 $ 1 �5'1
❑R Siding wrmdows El ter. $
tiers/Covers ❑nanny Doors fl
Roofing USIdung ❑Windows Insulation $
❑Gu"I Covers []Entry Doors❑
Roofing Siding ❑Windows Insllation
❑Gauers t Covers ❑F..nwy Doors ❑ $
Miodrmn 25%Depositor Contract Amrrurt doe upon execution dthis oantivel. $ rF Qd�
Tool Contract Amount 7
Maine Purchasers; tatdtpsaltnraethan arotktrd aftiR ConlractAmnnrL
it
Customer agrees that, immediately upon completion of the wink for each Product,Customer will execute a Completion Certificate
to
(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 Home Depot reserves the right to Issue a Change Order Or terminate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot Or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paint,Other safety concems,pricing Orion Or because
work required to complete thejob was not included in the Contract.
fATRrent Summarv: The Payment Summary # , included as part of this Contract, sets forth the total
Contract amount and payments required for the delimits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You arc entitled to a completely fined-)n copy of the Contract at the time you sign. Do not sign a Completion Certificate(Rote:
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 terminatirm of this Contract,Customer agrees to pay The Hattie Depot the casts of materials,labor,expenses
and se"kee Provided by The Home Depot or Authorized Service Provider through the date of termination,plus ay other
amsubta,mt forth in this Agreement or allowed under applicable law. THE HOMF,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.
Acoeotan and Authotdzation: CMMMW agrees and tmderstundc that this Agreement is the entire agreement between Customer
and The 210me 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 Agreemew cannot be apignicil or amended except by a writing signed
by Customer and The Home Depot.Customer acknowledge.,and agrees that Cuslome Tharead,Sonde ds,vnluntarily accepts the
terms of and has received a copy of this Agreeritent.
Accepted hy�- N Submitted by:
�c oo �� ✓�al�ls� x
Customer'SSignamre Date Sales Consultant's Signature DateV
Customer's Signature: Date Telephone No, 50 8
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS N.-pplksble)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DEI.fvERDVG 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 TISE Hr ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
N(MCN:ADDITIONAL TERMS AND CONDMONS ARK VATM ON Txm REVF.RRE SIDE AND ARE PART OF"is CONTRACT
11-3609 GSC Whoa-BMnch File Vellow-tbretiarw ph*-Sales Cormoaam
.�L is f�huaait Dcpaivncnt of public tYi•[_� ,'
4 B,,a d of Sui(dio F2._ui fnum vindt�c uuEArd"
:r ,,.e::on _uue isnr or -ciaRq L'.CerSe
License: CS SL 99699 _
Restricted io: WS,
ROBERT POCZOBUT
1'.7 BEACH ROAD APT. 45
LYNN, MA 01902
EXpinCion: 2/81.2012
99699
l