17 GALLOWS HILL RD - BUILDING INSPECTION t
cK 103os IVED
The Commonwealth of Massachusett i
MCES
Board of Building Regulations and Standards Sciif EOF
QI. / Massachusetts State Building Code, 780 CNI015 APR 3U Ae�fr7d.Liur 20I1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only .
Building Permit Number: Date Appli
r � b —
M Building Official(Print Name). Signature Dat
..nnt SECTION 1:SITE INFORb1ATION'
U1.1 Property At Ire : I is j I ` 1.2 Assessors iNlap Sr Parcel Numbers
t W Ie
0 MapNumber Parcel Number
n I.1a Is this an accepted street?yes no
1.3 Zoning Information: Ld Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required F 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ al Check if es❑ P P y
SECTION2: PROPERTY OWNERSHIP!'
2.1 Owner'of R" } e I �I_p
City,State,ZIP�pe�fjin}),A.�It)U1J rJt11 � �7�� "1,S V
No.Iland
/Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs( Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief esc i tion Qt J'rQposed\V k
/7LL e � *A
SECTION 4: ESTIAIATED CONSTRUCTION COSTS
Itcin Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ . Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S P Other Fees: S
Lt.Slechanical (hIVAC) S List:
5. Mechanical (Fire 'rota)All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
G.TuCd Project Cost: p Paid in Full Cl Outstanding Balance Due:
,
SECTIONS: CONSTRUCTION SERVICES
5.1 pstructmn Supervisor License(CSL) 6 'I9 6 9C16 9 / L� (-
Kytyzi r�- O J License Number Expiration Uate
Name uCCSLaHolder List CSL'rype(see below)
y r5 -Type Description
No. and Street �
IQ �11 U Un d(Buildings tip to 35,000 u .
PI-e- A.l R Restricted l&2 Family Dwelling
Cilyrruwn,Sane,ZIP Ni Masonry
RC Roolin Coverin
WS Window and Siding
f n W� SF Solid Fuel Burning Appliances 1 Insulation
Tcle hone Email address U Dem/o'l_ition
5.2 Registered,Nome Improvement Contractor(HIC)
> me � )OOT - HIC Registration Number Expiration Date
{ �omy ' ne o 111C Re�istranLNnme r
yy t�7✓✓�� '��(0, n 1�l 1Z 2
N nd t Email address
X .6b%�/nnT jLl- ` Qu'
City/Town, State ZIP fete hone
SECTION 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 Issuance of the building permit.
Signed Affidavit Attached? Yes ........ . No...........❑
SECTION 7a:OWNE , RIZATION TO BE COMPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize (n t
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
F C D v-,,+ro"e,J- E' r— 5
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this ap iication is true and accurate to the best of my-knowledge and understanding.
r RAK )A p R
Print Owner's or Authorized %gent' amc(Eleebronic Signature) Date
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 nnf have access to the arbitration
program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
seww.mass."ov'oca Information on the Construction Supervisor License can be found at%y%vw.mass._ov/Jos
2. When substantial work is planned,provide the information below:
rotal fluor area(sq. ft.) '� ,(including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room coma
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ofcooling system Enclosed Open
1. `Total Project Square Footage"may be substituted fir"Total Project Cost"
The Cornmaonwea&k®fMgssackusetts
Deptartnteut ofiradrasdrW Accidents
Ogtce of lnvesdgadow
600 WasiahWen;Street
Bosdon,MA 02111
wwaaaaaaassgov1dM
Workers' Compensation Insurance Affidavit: Bunders/Contmetors/Eleetricians/Plumelaers
A-afdicant Information Please Print Leda
Name(Business/Organi7atioa/Iadividual): oinely
- o �g �
Address:
City/State/Zip: 6 v _ D ts'yS phone#: rO 8 -A
FOM
ployer?check the appropriate box:
to er with q. Pe of project(required):p y I aro a general contractor and I 6. New construction
s(full and/or parr time).* have hired the subcontractorsle proprietor or partner. listed on the attached sheet.x ?• ❑Rem�1inghave no employees These sub-contracting have 8. 0 Demolitionfor me in any capacity, workers'comp.insurance. 9, 0 Banding addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised thew IO.[l Electrical repairs or additions
3.[] 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers'' l]Other �� ���erh e✓� t
comp.insurance required.] 6
*Ant aMfia st m that checks box#1 mud also fill out the section below owmg theirworkets'wtnPereefion Policy he------
t Ilemeownas who submit this affidavh indicating they are dabs all work and Most hire outside contractors must submit a now atbdnit radiating such.
tConrrectots that check this box must attached an additionet showing the MM of&a strb.wntrpaors and their wogs'comp.policy inibrmation.
lo'nanmPit7jwtkatisprovidingworkmlcompemadombuarmceformyejWloyeem Below is Ikepoliey end fobsire
dnfornredon. /I
Insurance Company Name; '�� rf�'/Q�J f/trC, i115 (lO
Policy#or Self-ins.Liic/.#:/— iC O / 7.3 f y 23 j Expiration Date: 3 aOf6 nn,,
Job Site Address: I / 020; , I 0 c)S , l city/State/zip: (50 R- 4--, -
Attach a copy of the workers'e»mpenmtion Policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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 insurance coverage verification.
I do hereby thepa is paL dp� s,tolds of perjury Mat theinforinadon provided above Is fte and&naturel rnrrect
=C-7 Date:
Phone#: —
QakW use only. Do not serke ka*6 area,to be cw* ted by city or town offid i
City or Town: Permit/Licease#
fssuiug Authority(circle one):
I.Board of Health 2.Building Department 3.CRY/Town Clerk q.Electrical Inspector 5.Plumbing Insptctor
6.Other
COntaM Person• Phone#:
AID O�® CERTIFICATE OF LIABILITY INSURANCE 44(/l0W15DD"Y"'
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 to the
Certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
MARSH USA,INC. NAME:
TWO ALLIANCE CENTER PHONE AX _
356D LENOX ROAD,SUITE 2400 ffi No),
ATLANTA,GA 30326 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC6
103492-Home)-GAW-15-16 INSURER A:Steadfast'M lane COMM 26387
INSURED THD AT-HOME SERVICES,INC. INSURER B..Zurich American Imurance CD 16535
DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:Nm HarlpsNre Ins CO 23841
269D CUMBERLAND PARKWAY,SUITE 3DD INSURER D:Illinois National Insurance Conparry 23817
ATLANTA.CA 30339
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-OM242685-09 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. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MATH 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 7UUPOUCY EFF POLICY EXP
LTR TYPE OF INSURANCEINSIR POLICVNUMBER MMIODf/YYY NMMO LIMITS
A GENERAL LIABILITY` GLO48877144D5 034)12015 03/0112016 EACH OCCURRENCE $ 9,000,0D0
X COMMERCIAL GENERAL UABIUTY PREMSES aocunance $ 1,000,000
CLAIMSMADE OCCUR UMITSOFPOUCYX$
MED EJ(P(Any one person) S EXCLUDED
OFSIR:$iM PEROCC PERSONAL a ACV INJURY S 9.000,000
GENERAL AGGREGATE S 9,000.000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPADP AGG S 9,00D,000
X POLICY P CT LOC
B AUTOMOBILE LIABILITY BAP 2938B6312 03MI 015 03,012016 COMBINED SINGLE LIMIT 1�,�
Ea accicbd S
X ANY AUTO BODILY INJURY(Per person) S
A O SCHEDULED SELF INSURED AUTO PHY OMG
AUTOS
AUTOS BODILY INJURY(Peracc'rJenO $
HIREDAUTOS NON-OWNED PROPERTY DAMAGE
AUTOS Peractidem S
$
UMBRELLA UAB BUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DEDI RETENTIONS $
G WORKERS COMPENSATION W0017731493(ADS) 0310112015 031012016 XWC STAN- OTH.
AND EMPLOYERS'LIABRnY I R
G ANY PROPRIETORIPARTNEWEXECUTIVE YIN W(D77731495(AK,KY,NH,NJ, 031012015 U31012016 1,00D,OW
D OFFICERIMEMBER IXCLUDED? F-N� NIA EL.EACH ACCIDENT $
(Mandatory In NH) W0017731494(FL) 031012015 031312016 EL DISEASE-EA EMPLOYEE $ 1•000.000
Urs,descn6e under Confined on Additional Page DE SCRIPTION OF OPERATIONS oalow EL.DISEASE-POLICY LIMIT $ I'0OD,000
1 ---7
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Aflaeh ACORD 1D1,Addhimal RemarMs SchWuN,K mom space Is required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee -„r•�ytpyMv1uuw�c�
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
nXX jaKci"Jj a,e e
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 170
Boston, Massachusetts 02116
Home Improvelnpot;Contractor Registration
Registration: 126893
Type: Supplement Card
::: ::dt:';' :•ri' r Expiration: 8/3/2016
THD AT HOME SERVICES, !NC.. ::
MARK NIADNA.
2690 CUMBERLAND PARKWAY S6IjE:.30.0 ::: ': --------------- '•__.......
ATLANTA, GA 30339
Update Address and return card.Mark reason for change.
SCn 1 tl 2UM-05/11
Address (J Renewal ❑ Employment Lost Card
r:/�r'((rvrruruiuncrll/�r/r.��aJJnr�rNr.•//:
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
before the expiration date. 1f found return to:
OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
� �¢ Registration::.:126893•• Type: 10 Park Plaza-Suite 5170
Expiratiph;;i;$/9(2gi.6.., Supplement Card Boston,MA 02116
THD AT HOME S�RV1Cfc$;.!NC:
THE HOME DEPOT.AT,,HOME`,SERVICES
MARK NIADNA • ''=iii''
2690 CUMBERLAND PARl(WV Y S
Aal lAM,GA 30339 Undersecretary &Pt valid withou signature
' I
i
,
a
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialty
Ucense:CSS 4)99699a
,%'}
ROBIMTIW7,01 tiT "-
5atem MA 0197U'
.�! ' ii Expiration
-
commissioner Q?/61112016
G
CITY OF SALEM, MASSAaRISE TTS
Bu!LDINGDEPARTA ENT
120 WAsnNGToN SmOET,310 FLOOR
TEL(978)745-9595
FAX(978)740-9846
KIIvIBERLEYDRISOOLL
MAYOR THomm ST.PIERRE
DIRECTOR OF PuBLicPROPERTY/Bu[I DING GDmusslomR
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 111.5 Debris,
and the provisions of MGL 00, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by: D A `��JL IC
(name of hauler)
The debris will be disposed of in:
Aht��
(name of facility)
_ N- i [\aofz'r
(address of facility)
Signa ure of plicant
_ ,5 ( — I
Date
Simonton Windows
6100 VantagePointe
' R%, Hopper-Vinyl 3132"Glass Argon Low-E No Laminated G-lass No
Grids
ava^.a+perosi�arw- Ventana de proyeccion superior Vinilo 2.38 mm Vidrio Argon Lori-E
Ral Cu.miI Sin vidric laminado S'in rejlllas
CPD:SBP-A-62-10840-00001 08-09 HP
ENERGY PERFORMANCE RATINGS
EVALUACION DE RENDIMIENTO ENERGETICO
U-Factor i Solar Heat Gain Coefficient
Factor a CQ,, .lame Ganenoia is Energla Solar
0.26 1 .48 0.22
(I,S'li-P) (Metnco/oi)
ADDITIONAL PERFORMANCE RATINGS
EVALUACION SUPLEMENTARIA DE RENDIMIENTO
Visible.Transmittance
I
Transmision de Luz Visible
0.37
Manufacturer stipulates that these ratings conform tp applicable rlF6:C procedures for determining whole praauct poronnance.
PffP.0 ratngs are determined for a fixed sat of emxica,,enal oendimons ane a Specifie nrocuetsize-:4l does mtrecommend
- any produce and does not warrant the sueab@ty of any product for specific use.Consul[manufacturer's fiteratu,re or other
Este fabdeante esfipula due valares cumplen con de proceNmlePtos aplicales dv NFRC Para determine ei vndlmarno total dal
groducto-Losyeores usados do.of son aeterminados por un oJn,unt)fii e eond c cees eim:shtess y un tomano de
product especlfce t4f no recomanda ithqun product no jard.,za que el pnoductsea adacuado pare on use especifiac-
Consulte con el folleto not more cane Para el use aw'cpiada de age proIL-t rttvw.rohe.org
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Unit qualifies for ENERGY
STARS region(s):Northern, � .,•
North Central,South Central. ,
®�
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Southern.
s STC: NIA"
r.
;. OoErfled
IND:Rein in 00/Glass ProSolal9AP-R25
Tested Size:48"x 32"
Applicable Test Standard(s): ANSI/AAMA/NVWVDA 101/LS.2-97,AAMANVDMA/CSA
101/I.S.2/A440-05,AAMANVDMA/CSA 101/I.S.2/A440-08
r
8871207/01 J0025 FS Morrissey 6584565
Keep this label for possible ENERGY STARa rebates.To learn more visa w .energystar.gov.
Guarde esta etioll posibles reembolsos ENERGY STARS. Para conocer mas acerca de esto,visite
_ Dow I\If RUlM!HI.1N`I'cOVTRAer
PLEASE READ THIS
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