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8 GARDNER ST - BUILDING INSPECTION (2) C t<` -5 2 ice_ I y , I'1'1 0 -T&j� t[7 © The Commomveulth of Massachusetts REOVY" Board of Building Regulations and Standards INSPE TIONi LEMRVI ES w/, Massachusetts State Building Code, 780 C(NR Revised Alur 2011 i' Building Permit Application To Construct, Repair, Renovate Or Demolis 0V 10 A 0 One-or Two-Family Dwelling u L This Section For Official.Use Only Building Permit Number: Date Applied: w C Building Otticial(Print Nume). .- Signature- - Data \ SECTION t:S TE INFORMATION 1.1 Property AJdreSsj r r t O$r r t /t 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?yes bt no tl' Map Number Parcel Number 1.3 Zoning Information: 1.4 Properly Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Requin:J 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 esO SECTION2: PROPERTYOWNERSHIP�' 2.1 Owner of Record: S Whme(Pon) `� City,State,ZIP S.3 I r-Jr,•Qf St 1+�Gt � � u SS ' No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Lowner.Occupied ❑ I Repairs(s) Altemtion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': f t rGl CQ z✓t u c SECTION 4: ESTIDIATED CONSTRUCTION COSTS Itcitt Estimated Costs: Official Use Only Labor and Materials) S 1 I• Building Permit F e:S Indicate how fee is determined: 1. Building Is—( ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cose(item 6)x multiplier x 3. Plumbing $ P Other Fees: .5 4.Mechmticel (HVAC) S List: 5. Mechanical (Fire ,� Total All Fees:S Suppression) Check No. Check Amount: Cash Amount: 6. Total Project cost: ❑ Paid in Full ❑Otustanding Balance Due: 2_ SECTION 5: CONSTRUCTION SERVICES U 5.1 Construction Supervisor License(CSL) a !q 6 / / J 1Z�beC� it Z License Number Expiration Date °N:une of CSE Elulde'r+ S List CSL Type(see below) �7a hc, lerS Type Description No. and Street s S R t C Y� v°` y '(� �" U Unrestricted& 2 Family s u el ing cu. tl. R Restricted I&2 Eamil Dwelling Cily/ruwn,State,ZIP M Nlisonry RC Rooting Covering WS Window and Siding b( r n S I Solid Fuel Burning Appliances "l a 1 IInsulation 'i'cle hone Email address D I Demolition v 5.2`pRgegistered Home Improvement Contractor(H1C) / 0 O 60 /v+ Pe )( /V 1 A J !I�A� PO VW, 1) r—ar, HIC Registration Number Expiration Date HIC4uLlory N,eor HIC C Regi;tr`tName IQ n� \ �nr�treet �, AA- _ U p l- � (�'(�_ a�� Email address s w b ul` / Ci /Town State ZIP Tele 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:OWNER AUTHORIZATIONNTo BE COMPLETED WHEN. :' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this application is true,and accurate to the best of my knowledge and understanding. f j Print Owner's or Authorize enP Name(Ele onic Signatu e) 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 Lint have access to the arbitration program or guaranty fund under M.G.L.c. 1 d2A. Other important information on the HIC Program can be found at www.rnass.1•uv'oca Information on the Construction Supervisor License can be found at wnw.�ns 2. When substantial work is planned, provide the information below: 'rota) floor area(sq. R.) " ,(including garage, finished basementlattics,decks or porch) Gross living area(sq. If.) 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 orcooling system Enclosed Open_ J. Total Project Square Footage"may be substituted f'or"rotal Project Cost" p� The Commonwealth ofMassaehusetts • \ Department of Industrial Accidents Office of Investigations 600 Washington Street 3 Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A (icant Information Please Print Legibly Name (Business/organizatiorAndividual):, i� /� ✓� "5 Address City/State/Zip: (t.rtjyQ . 3 0 3f Phone #: Are you an employer? Check the appropriate x: Type of project(required): 1.0 I am a employer with 4. I am a general contractor and I 6. ❑ New construction I employees(full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling vw_ ship and have no employees These sub-contractors have - g, 0 Demolition workingfor me in an capacity. employees and have workers' y p ty• 9. ❑ Building addition [No workers'comp. insurance comp. insurance.: required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions [No workers' comp. right of exemption per MGL f. insurance required.] 12.❑ Roof repairs myself t c. 152, §1(4),and we have no Other �,o 13.Q R employees. [No workers' f oL t A M� comp.insurance required.] la) a *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. tContmetors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. n Insurance Company Name: //�`/ew #� d tI-e- �TNY (—© , g 8 0� Expiration Date: 3 I s Policy#or Self-ins. Lic.#: W Ci O y-t p f O � � Exp Job Site Address: �7a t ��^S �' City/State/Zip: 37a I Cum 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$1,5 00.00 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 certifyyuunder /�the pa'i/ns and penalties oofpeerjury that the information provided above is true and correct. Signature' V V I�`I� IV\ C�. Date: I l r O `It/ _ Phone#: -7 ? 075 — ;—) 139 Official use only. Do not write in this area,to be completed by city or town official City or Town: Pertrtit/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#: I Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction5upenisorSpecialty v �A T License: CSSL-099699 ROBERT POCZO�IJT ;: 172 WHALERS LAM Salem MA 01970= � 5 tJ Commissioner - 02/08/2016 1 i 1-10 JF VVY PROVL-7,,IEN T CONJ'I .3CT Ps _ Sold,Fumished and Installed by: '�1SF�E�I�D I HIPS CON `RAC f THDAl-Home Services,Inc. d./b%a The Home Depot AUriome Services 908 Boston Turnpike Unit I,Shrcwsbury,MA 01545 Branch Name: Boston North Date:9/27/2014 Toll Free 8779033768;Fax 8009863610 ME Lic ti C 02439 Rt Cunt,Lic*16427 CT Lic 4 Branch No: 33 HIC,0565522 MA Hoioe Improvement Contractor Reg.Y, 126893 Federal IDS 7i-2698460 i Installation Address: 8 Gardner Street Apt IL Salem MA 01970 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: Mr.John Rioux (914)755-6532 Home Address: 8 Gardner Sweet Salem MA 01970 (If different from Installation Address) City State Zip T mail Address (to receive project communications and Home Depot updates):na(Zlna.com Marketing entails wilt not be sent from Pile Home Depot. i Project Information: Undersigned("Customer"),the owl crs of the property located at the above installation address,agrees to buy,and TI-ID At-Home Services, Lic. ("The Home Depot[")agrees to furnish,deliver and arrange for the installation(`Instxllati on")of all materials described on the below and on the ref- iced Spec Sheet(s),till of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary(where applicable)attached hereto and any Change Orders(collectively, "Contract"): - Job#:(1e0m:d R Terence) Products: Spec Sheet(s): Project Amount 1250444 (Windows 7250444 $2 45] 6R 14Lm+num 25% p Pwitof Contract Amount Total Contract Amount $2,451.6R due upon ezecu tlon of this contract 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 be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contractor anv 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 concerns, Pricing errors or because work required to complete thejob was not included in the Contract, Payment Summarv: The payment Summary 4 72504 4 included as pan of this Contract,sets forth the total Contract amount and payments required for the deposits and final pa}lmenls by Product(as applicable), 07109/14 A Page t IN 10 b'd 999Z9bZ L0b SaoiAAS;iwJed ' O;vSE i '[PIIOYEMEN''C.'ONTRACC P' FASE;,EAD THIS t-ONTRjILCT I NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contrl ct at the time of sign.Do not sign a Completion Certificate(note: them is one Completion Certificate for each listed Prnduct,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 Provider through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law.THE HOME DEPOT MAY WITHROLD AMOUNTS OWED TO THE HOME DEPOT FROMTHE DEPOSIT PAYMENT OR OTHER PAYMENT'S MADE, WTTHOUT LIMITING TIIE HOME DEPOT'S OTHER REMEDIES FOR RECOVER OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Contract is Er the entire agreement behaecn Customer and The Home Depot with regard to the products and installatilon services and supersedes all prior discussions and agreements, either oral or written,relating to said products and installation.This Contract cannot be assigned or amended except by a writing signed by Customer and The Home Depot. Customer acknowledges and agrees that Customer has avail,understands,voluntarily accepts the terms of and has received a copy of this Agreement. I I I You are entitled to a paper copy of this Agreement if you choose. If you consent to an emalled copy,your consent applies only to this Agreement. By contacting sales office TR 7T 90i:768,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement at no ehaixe. By signing below,you confirm the following: • You consent to receive only an emailed coplive of this Agreement • You have access to a computer that can rec and open cmails and PDF(Adobe Render Version 10.1.4 or later)formatted documents. • Your email address is correctly listed an the;Home Improvement Contract Submitted by: Accepted by Jason Betsie el Cusiomer Sales Consultant g _ License Name. Signature: — 'K7)903-3768 Customer Telephone Na. sigr,' mre: Sales Consultant License No. (as applicable) CAN CUSTOMER MAY CANCEL THIS AGRE�MENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPgl'BY MIDNIGHT ON THE THIRD BUSINESS DAY \1'1'F.R SiGNLVG THIS AGREEMENT.THE STATE SUPPLE 1ENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW 1- CUSTOMER'S STATE 0749M"A Page 10 of 10 S'd 999Z 9bZ lob seolmes I!Wjed