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8 GARDNER ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only 1 Building Pe ' Number: Date lied- I © - / Building Official(Pnnt N a e) Signature Date SECTION 1:SITE INFORMATION 1.1 Property At(drj�s: /y� ^ i.l 1.2 Assessors Map&Parcel Numbers L l 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 R) Frontage(R) 1.5 Building Setbacks(B) 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Name(Print) 1, City,StateSZIP No.and Street Q 14 72h 2��2 Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)< Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work : n t o o SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Only (Labor and Materials 1.Building $ - I. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ —` 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Su ervisor Liiccen e CSL) e6.4 �� —s.lat License Number Expir io Name of CSL Holder �-b�� l List CSL Type(see below) LW4 4-7 No.and Street Type Description L _ T ���� U Unrestricted 2 Family u el ing cu.ft.) C1 R Restricted I&2 Famil Dwelling Erl / 'own, 4 zip M Masonry RC Roofing Covering WS Window and Siding { SF Solid Fuel Burning Appliances q� � I Insulation Tele hone Email address D Demolition 5.2 Registered Home Ira rovcm at Contractor( IC) HIC Re rshation Number im on ate HIC Co n o MC egia No.and S Email address CA A �01 ��� City/Town,State ZIP- Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be mpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issu a of the building permit. Signed Affidavit Attached? Yes..........❑ No...........❑ SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 43, /�&l fi to$ct on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest and the pains and penalties of perjury that all of the information contain this application is true and accurst to a st of y knowledge and understanding. Print Owners or Authorized Agent's Name(E ect n' ign Dat 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at Information on the Construction Supervisor License can be found at 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.,tL) 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 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents i 6P Office of Investigations :l 600 Washington Street Boston, MA 02111 = � i www.mass.gov/dia Workers' Compensation Insurance Affidavit: Buflders/Contractors/ElectricianslPlumbers _Amnlicant Information Please Print Legibly Narne (Business/Organization/Individual): Address: City/State/Zip: hone#: 1 —IJra�//j13 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/orpart-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole.proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling yip,,, ees These sub-contractors have v ❑ ri-mclition ' working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required] . 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I1.❑ Plumbing repairs or additions lf.In se o right of exemption per.MGL Y iN workers' comp.P 12.0 frepaa insurance required.]t c. ploy and we have no employees.ees. ([No workers' 13. Othzr �1 comp. insurance required] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 'Homeowilers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $contractors 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 must provide their workers'comp.policy number. Y am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: " 2ZZa r- — 14 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 IA for insurance coverage verification, d do hereby certi un r pa i and nalties of perjury that the information provided ab ve is true and correct. Signature: Date: Phone#: 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. Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: OF T'HIS CERTIFICATE IS ISSUE[) AS A SMATTER OF INFORMATION OrLY AND CO iFEP-5 NO Rlf3 FTS UPON THE CEFT:FIGATE HOLDER. Ttl-' CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TzR THE COVERAGE AFFORUEO E'f THE POLICIES BELOS11. TH15 CERTIFICATE OF INSURAIiCE DOE5 NOT CONSTITUTE A CONTRACT BETPiEEN THE ISSUING LNSURER(5�, AUTHORIZED E--PRESENTATIVE OR PRODUCER,.AND THE CERTIFICATE HOLDER- -le Fonc4ea)MUS, to endQrsed- If SURRCJCATI�DN IS WAIVED,subje�,t rFiO�T'M�l IT the certificate Felder IS an ADDITIONAL 1, SUFED�U— he terms and conditions of the policy,certain po;jcjaS r"'v requll e all A 5tatenient cf,U, 5 ce, if! at?diez To,-,_cncertificate holder in lieu of such erdors c right to fll� 'IARSH USA INC. NAME! TWO ALLIANCE CENTER I FAT 35K LENOXROAD,SUITE 2402 JA EMAJ- f ATLANTA CA 3025 ALD—DPE3� ION INSU9ERpjAF1-OFUNGC0VFl1ACE NAIL'S 92-HDnTlD-CAW-I3-14 3L, INSURER A: Sr�dt�.Hrrruianca CoTiliny 26 1 jj THE HOME DEPOT,INC. INSURER8,iPudchAralricaninsurarcaCo -E Ts 7 HOME,DEPOT U.S.Ap INC. jsjRER C:New H3anpStfire Ins Co 2455 PkiES FERRY ROAD,NW ------- BULDINGC-20 D- ";Ao'5 National InG Co Z3817 ATLANTA,GA 30339 INSURER E: INSURESEc COVERAGES CERTIFICATE'NUMBER: ATL-003159545-04�REVISION NUMBER:7 THIS 1-9 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ""A"IT NFl F THIS NOTWITHSTANDING ANY REQUIREMENT, TERM 18SUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THEJNSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU13JECT TO AI I_THE TERMS, I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED-BY PAID CLAIMS. Q I SURF LTR TYPEOFINSURANCE LICY ap POLICY NUK.BR 'YYY "'T 9-7 HSFaeD-aW"1I4 WVQ iM Mloor LIMITS Supe"THE HOME DEPOT, INC ,NOME DEPOT U S A_�INC 24 55 PACES FERRY CAD,NW 5,J.LOI NC;O_20 A GENERM�LIARIUFY (31-041387714-03 03MI2013 031DII2014 EACH OCCURRENCE S 9,000,000 X COMMERCIAL GENERAL LIABILITY -5��t�Gi: 1,000,000 PREMISES CLAIM3-MADE r-xlOCCUR UMHS OF POLICY XS EXCLUDED OFSIR SIMPER OCC PERSONAL&ADV JWURy S 9,000,000 GENERA,LAGGREGATE S 9,000,000 CI AQGREGATE LIMIT APPUES PER --------------- PRODUCTS-COMP)OP AGE -S .9,000,000 x .POLICY[---I Loc AUTO,MPSICE LIASILRY BAP 2938863-10 -50 MSINED SINGLE LIMIT U012013 0101/2014 X Ea accident ANY AUTO UO1)ILYINUURY(P.rp.,s.n) ALL OWNED i. SCHEDULED AUTOS SELF INSURED AUTO PHY ONG AUTOS BODILY.:WURY(Par kcId.nt) 5 4: NONOWNIa) IREDAUTOS AUTOS.* PROPER DAMAGE —7 UMBRELLA UAS OCCUR EACHOGCURRENCE --.ESCESS UAB CLAIMS WIDE AGGREGATE TIED RIEFENTIONS C WORKERS COMPE ION 030112013 50-1120114--)Xq g T AND EMPLOYERS'L;AUILITY — -T�--'--sTAkTlU _ftTH- C ANY PROPRIETOROPARTNEWENECILTRVE YIN WC033575315(AK,AZ) 031) LK-- Damry FN NIA .112013 WIDOW — 1,1100,000 OFFIcER)MElw LLEAaiAcciDENT 1 $ NHl WC033575316I1`0 0310112013 03ffl1/2014 ELOTSEASE-EAEMPLOYEE S e 1,000,000 'KSg�Rdl-PT'I'It-1,�OPERATIONS below1,000,D00 LLDISEASE-PDUCYUMn S W=3575317 V,RIC NH,VT) 14 (EL)LIMI I 1,000,DDO C WORKERS GOMPENSATION '31-Ul f'2013 OT101126 vvC'(I335753I8 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atl�dh EVIDENCE OF COVERAGE. ACOR.D 701,Addlli.naj Sth,,,J, CERTIFICATE HOLDER CANCELLATION THE RWr:DEPOT INC. HOME DEPOT M INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD,NW. THE EXPIRATION DATE THEREOF.-NOTICE WILL BE DELIVERED IN BUILDING C-20 ACCORDANCE WITH THE POLICY PROVISIONS.. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE ManashiMukherjee 0 1986-2010 ACORD,CORPORATION. All rights.reserved. ACORD 25(2010105) 'Tfie AQOPD name and logo.are registered marks Of ACORD N `P9,orno,w,e��f{a o�./��ewac.4usx7s • ' Oi6ce ql Conehm ��[air Riusmzss Rzguraton L;cans cx registration rafid inr lndivid�}w on'y µpMEIh1PEbVEMEN7GpTPACT;OR beforethee*.prgtjondnte. l[xonndretuinto Uff EC of Consm u €t Affairk as d$u>inessReuuThfiion , Rec�lst�ation���3,;; TYpe k0.1arYPlazaLSuRe5170' Explra suppleraertt and m Bosi6n,idktz116 The Nome peps RICHARO FALL �.. ..� � 2E90CWMBERLA3F , �"b••� - rF 41 - - h`�LAI t GA, ' vaLd 3 ithoutsigna use 3 f = CITY OF &U Emll �LaSS.�CHL'SETTS Bt.'ILDL\G DEPARTMENT \ � 120 WASHNGTON STREET, 31O FLOOR TEL (978)745-9595 F.jx(978) 740-9846 KIJiBERLF-Y DRISCOLL MAYOR THoi6w ST.P[ERRE DmECroR OF PIBLIC PROPERTY/Bt:tTMNG COSL\ISSSIONER 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 c 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposcd of in a properly licensed waste disposal facility as defincd by MGL c 111, S 150A. The debris will be transportcd by: Q WC7 7 (name of hauler) The debris will be disposed of in (name of facility) .._,._._.._._�l^ (address of facility) *gnature mit applicant da[ dcbtua dJ¢ Int Massachusetts-Department of Pvblic,Safety ' Board of Building Regulations and Standards License CSSL-099699: ROBERT POC2'ABUT 172 WHALENS LANEM,5• y: Salem MA 01970 !7121 Expiration Commissmner 02/08/2014 - 2013-09-03 08:54 2614READING 7819428601 >> Home Depot AHS P 1/6 nvmn rm rKOVEMKN'T CONTRACT PLEASE READ THIS R retch Name: Bruton Uule: Sold,Furnished and lnstathxl by: /� _ THD At-Ifonre Services,Inc, rphM. The Hume Depot At-Hume Services 908 Roston Turnpike,Unit 1,Shrewshury,MA 01545 Toll Free(8W)657-5182;pax(508)845-6017 Rranch Number:31 Federal ID a 73-2698460-,ME Lie It C 02139:RI Can?.Lic$16427 CT Iic 111 I IC 0565522:MA I Innc improvement C..ounnn for Reg.tt 126893 Installation Address: 8 _ (t(CA MI 70 City —State Zip Purchn"').- Wark Phone: Home Phone: VVII Phone: �� � f J fg141 g f I f l f l f l Lome Address: (Ifdifferenl tram Installation Adolressj City State Zip E-mail Address(w receive projLVL txrmmonicaLimin and Home Delnt urxiiii s): ❑I DO NOT wish u,receive any marketing emails from The Home lleput Eftt I Undersigned("Custumce'),the owners of the property located at the above installation address,agrees to buy. At- onle Services,Inc.("The Hume Depot")agrees to furnish,deliverand arrange for um installation("Distallallon')of all mamritds dewribnl on the Mow and nn the referenced Spec Sheel(s), all of which arc incorporated into this Cuntruct by this reference,along With wry applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Soh R: u..mm RarirarJ V educes: .. .S'pec Shsel(s)N: Protect Amount Roofing iding Windows [I Insulation ❑Oldtus/Covers rxary Dtxns ❑ 709 g665 Zy 4� Roanog ❑Siding ❑Windows ❑Imulmiun ❑(a in r Cavcxs ❑Entry nnom 171 ❑Roofing ❑Siding ❑Wndows Insubaiun ❑Cuucu, Coven ❑Pxnry Doors❑. ❑Roofing Sitling Windows lnsula6pn ❑r'.utnM Covers ❑Enury DRK" ❑- $ Mhantom25%DepxdidCm&w"xxml&mupmex=wnur"cunb-a& M�ePorrhmmertmy rDlr4paaft rooretlmn oraVNrO ufthe CmtrutAmnutl. Total Contract Amount Customer agrees that,immediately upon completion of Zile work For each Pmdnct,Custotucr will execute a Completion Certificate /r (one for each Product as defined by an individual Spec Shut)and pay any balance due. As applicable,each Customer order this rJ/ Contract agrees to he jointly and severally ohligawd and liable heremnicr. p� The Ilome Dgnt resR:mes the right W issue.a Change Order or terminate this Contract or any individual Pnuluct(s)included herein,at its discretion,if The Home Deem m its authorized service provider determines that it cannot perform its obligations due to a structural problem with the home,environmental haramis such as mold,adavun or lead paint,other safety euncerns,pricing errors or because work requinxl to complete the job was ma included in the Contract.Parre went Summate: The Paynent Summary#.qjQp(cq , included as pan of this Cuntr,cL sets forth the total Contract amount and payments required 0W the deposits and final payments by product(as applicable). NOTICK TO CUSTOMER You arc entitled toa osnrBlch196Ded•iu copy or the(contract at the time you sign. Du not sign u Completion Certificate(mite: there is one Completion Certificate for each listed Product xx defined by individual Spec Shuts)before work on that Product is Anmplete. In the event of termination or this Contract,Customer agrees to pay The Home Depot the coxes or materials,labor,expenses and services provided by The Humc Depot or Authorized Service Provider through the date or termination,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED I'O THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THK HOME DEPOT'S OTHER REMKDIBS FOR RECOVERY OF SUCH AMOUNTS. AggRlenre and Authorization: Cuslerner agrees and understands that this Agreement is the entire agreement betWEen Customer and The Homc Deport with regard to the Products and Installation services and supersedes all prior discussions and agreements,either ore err written,relating to Said Products and hislullalitrn.This Agreement cannot be assigned or anxnded except by a writing signed by Customer and 77re Hume Depot.Cusmmer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agaxment A y: sn(lrJ'�t / 13 Cusco lure hate s Cons.'Lia'x S rare 'I'dcphure Custonxr'x Signature Date _ Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THLS (m appticamc) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRr1TEN 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. NOTI(m:ADDITIONAL TERMSAND(DNDIIIONS ARE STATED ON THE REVERSE 5111E AND ARE,PART OF THIN CONIRACC 10.1142 White—Bmx:h File Yellow—Customer