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8 GARDNER ST - BUILDING INSPECTION 'rhe Commonwealth of Massachusetts Llf� OF Board of Building Regulationsand Standards CITY M� Massachusetts State Building Code, 780 CMR $d,Uar; Revised,Llur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Us Only ' Building Permit Number: Date.App ed, Building official(Print Name). Signature Da e 1 I SECTION 1:SITE INFORMATION 1.1 Property Asll�ressy1 /f; LZ Assessors Alap&Parcel Numbers '-" 1.1 a Is this or)accepted street?yes no Map Number Parcel Number rn n j 1.3 Zoning Information: 1.4 Property Dimensions: 17 r I < m ` Zoning District Proposed Use Lot Area(sq It) Frontage(II) o r 1.5 Building Setbacks(ft) 4' I Front Yard Side Yams Rear Yard r 11 Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system I] Check if esCi SECTIONZ: PROPERTYOWNERSHIP'` 2.1 Owner d: thme(Printer City,State,ZI�P'�"'� — Y5 No.and Street _ Telephone Email Address SECTION 3. DESCRIPTION OF PROPOSED WORK'(check that apply) New Construction O 1 Existing Building o Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition O LAccessory Bldg.O Number of Units Other 9,Skccify, Brief Description of Proposed Work-: dr SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OfB Voly Labor and Materials I. Building 4. Building Permit Fee:$ fadicate how fee is determined: ❑Standard City,I own Application Fee 2. Electrical S 0 Total Project Cost'(item 6)x multiplier x 3.Plumbing S 2'�Other Fees: S d.klech:mtnical (FIVAC) S List: 5.IN (Fire Su ressiun) rotas All Fees:S Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S Paid in Full ❑Outstanding Balance Due: ( ( SECTION 5: CONSTRUCTION SERVICES 3 5.1 Cmtstructim Su Nis r iccnse( License Nu"�myer E.epir iu Date Name of CSL fl�ulJde List CSL Type(see below) Type' ._ Description No.,aid Sued U Unrestricted Buildin s tip to 35,000 cu. 11.) nj tic R Restricted 1&2 Family Dwelling Cily/ruwn,State,ZIP M Masonry RC Roolin Coverin WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Tc1e hone Ematladdress D Demolition— 5.2 Registered I mprov n eat Corttw or(HIC) HIC Re istration Number Espi lio , HI N r Reg to P No. an Sir Email address r City/Town, tate ZIP Tee hone ` SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 2SC(6)); t Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide t this affidavit will result in the denial of the Isivance of the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.WHEN.' OWNER'S AGENT OR CONTltACTORAPPLIES FORBUILDING PERMIT' 1,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) ate SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION Athis w,I ereby attest under the pains and penalties of perjury that all of the information on ' true and accurate to the best of my knowledge and understanding. \gcnt's Nano(Electronic Signalure) Dane NOTES: 1. An Owner who obtains a building permit to do his/her own work,or art 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. 1 d2A.Other important information on the HIC Program can be found at Nvww mas;eov'oca Information on the Construction Supervisor License can be round at tvww.mass. ov:'dos . 2. When substantial work is planned,provide the information below: rota) floor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. 11.) 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 of cooling system Enclused Open_ 3. Total Project Square Footage"may be substituted tar"'roCd Project Cost" i HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by: PLEASE READ THIS CONTRACT THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike Unit LShrewsbury,MA 01545 Toll Free 8779033768;Fax 8009863610 ' Branch Name: Boston North .Date:3/12/2015 ME Lie#C 02439 RI Cont.Lie#16427 CT Lie# Branch No: 33 HIC.0565522 MA Home Improvement Contractor r ! t ! Reg.# 126893 Federal ID#75-2698460 Installation Address: '8 Gardner St ' SALEM MA ' 01970 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: Mr.John Rioux (914)755-6532 Home Address: 8 Gardner St SALEM MA 01970 (If different from Installation Address) City State Zip JJJ 1 [q E-mail Address (to receive project communications and Home Depot updates):medrelijohnaa,gmail.cont Marketing emails will not be sent from The Home Depot. Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("lnstallati on")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(where applicable)attached hereto and any Change Orders(collectively,"Contract"): Job#:Paternal Reference) Products: Spec Sbeet(s): Project Amount 8099840 Windows 8099840 $4,484.78 Minimum 25 o Deposit of Contract Amount Total Contract Amount $4,484.78 due upon execution 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 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 concerns, ' pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary# 8099840 included as part of this Contract,sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). 06117114-SA Page 1 0l 13 HOME IMPROVEMENT CONTRACT PLEASE READ THIS CONTRACT NOTICE TO CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time of 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 Provider 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 RECOVER OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Contract is the entire agreement between Customer and The Home Depot with regard to the products and installation 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 read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. You are entitled to a paper copy of this Agreement if you choose. If you consent to an¢mailed copy,your consent applies only to this Agreement.By contacting sales office (R77)904-'i76x,you may update your email address,withdraw your consent,or obtain a paper copy of the Agreement at no charge. By signing below,you confirm the following: . • You consent to receive only an emailed copy of this Agreement • You have access to a computer that can receive and open emails and PDF(Adobe Reader Version 10.1.4 or later)formatted documents. • Your email address is correctly listed on the Home Improvement Contract Submitted by: Accepted by: Sales Consultant Jason Beisiegel Customer License Name. Signature: (877)903-3768 Customer -zx Telephone No. Signature: Sales Consultant License No. (as applicable) Mr. John Rioux (Mar 12, 2015, 4-13 PM) CANCELLATION:CUSTOMER MAY CANCEL THIS 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 IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE 06117114-SA Page 13 of 13 e r^�•✓jry'{ °�s /girl a�1��7�i�L i' l �✓����:�'�s 1.� r '�._ . .r•. 3.:Sa E- y spate l Boswn,Massachusetts 0- i6 Ho Ir prov nE C -ntra for Registredon Tye: S,pvlMo.,ica.:d THD AT HOT-SERVICES, INCI 29 AA�yy��0ppCl pp'�r�•��-�qq $//gvppryNg�t PA KNAY SUITE ZDO Update Addr=and pbianE Ura M42. reeaan for c;iaig.. ' AddrE j Srn al J Enpl ;r ani j Los'Cs; '-��e(�I-D.mf-rt++e:rl�Yl C�r•.I�K.;�I^/.•nXY✓+- p. (�ifl�v 755:OP "' : AseaSCanta?scsA tssP,er3veln�:Sd.�„u3a n� lx6ovethe wkra ndaa7;i'4ap 'gm5,aU. �' r •o F-PF99tti i9f L`�vr79aPL+ ➢'''9 ',£'.• ' '-r. yf `s*rr',,clo o TY�e AF4�mNlutwr*sd . .. , .' 5u ©Ie�nynFCaN �os`ns>k; + • a6' Tl? AY H(WE 'Y 1-li'HL1NhG REt�AT�19tJlE$ERVICEa i�;t;,HAYt17 FdlLONE •. '• , ?ugbdUnMB3 R D PARKWAY S s' otvali At?Ai9`A,fxA503� . 4 nf9er 1 i I i i ill The Commonwealth of Massachusetts . Print,Form' Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Q hone #: Q Are y an employer? Check th appropriate box: Type of project(required): ]. I am a employer with 4• ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 90 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. ❑Building addition required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ R repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 11[2rOther comp. insurance required.] Any 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. tContractors 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. t (�� `� / Insurance Company Name: 't[wJ [�J Policy#or Self-ins. Lic.#: 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 e A for insurance coverage verification. I do hereby cer un er e a sand enalties o er'u that the information provided above is true and correct. Si na Date Phone ======L 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: } CITY OF SALEM, MASSACHUSEM - BUIIDINGDEPARTM N-r 120 WASHNGTONSTREET,3"mFLOOR 7tL.(978)745-9595 KIA BERLEYDRIscoLL FAX(978)740-9846 MAYOR THOMAS ST132ME DIRECTOR OF PUBUCPROPERTY/BUn DM ppMDgSSIOMR 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 c40, 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: (name of hauler) The debris will be disposed of in: (name of facility)) (address of facility) i n ture of ap licant at i Bedard, Mike W From: ROBICCO INC<robiccoinc@gmail.com> Sent: Tuesday, February 11, 2014 2:05 PM To: Bedard, Mike W, Robert Poczobut Subject: ROBICCO INC/Robert Poczobut CSSL/CSL- 02/08/2016 i low I �5 'Massachusetts - Depart- e <b=ic Sa€ery Board of 3a43ain Regulations and'.StandaFos Construction Supen-isor Specialtl- License: CSSL4699699 ROBERT POC7O�IJT 172: , RrHAI.ERS I.�PTE`, _ Salem MA 01970 cmrr,,sionar 0210812016 1