29 GREEN ST - BUILDING INSPECTION (3) I
V1 fhe Commonwealth ol'Massachusetts
((( Board of Building Regulations and Standards EoFSALEM
Massachusetts State Building Code, 780 CMR, 7ib edition ry
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-ur -Family Dwelling
T s Secti n For Officia Use Only
Building Permit Number: Date pplied: Z r C
I
Signature: r 2 L J
Building Commissionoq Inspector ol'1t it rags Date
SECT N 1:SITE INFORMATION
1.1 Property Addr 1.2 Assessors Map& Parcel Numbers
'mot �r�or( S6
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 11) Frontage(11)
1.5 Building Setbacks(ft)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 n r of cord:le n'�
Name(Print) Address for Service:tz� 2�7
1 ! Q-L--4 ('
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK Z(check al that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building S I. 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 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 0 0 Paid in Full 0 Outstanding Balance Due:
I ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
e� � .-,n/'I L•) n License Number Fsptm ion I ate
Nana of "1.- I IulJer ` � 't./
rNll List CSL I}Ipe(see below) 5
Ad J •ss fc I)escri tion
it l InreuricteJ u l0 35,OW C'u. PI.
It Restrict . ... .. Uwellin
S ur M 'vlasonry Only
RC I Residential Routing Covering
Telephone WS Residemial Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
5.2 Registere4J4 teI roveme Cont tor(HIC) !�[I�p+q!��.
IiIC C t a+ datI ur HI 'Re�i RegistrationNumber
AJJr
Expiration to
Sib u Telephone
S CTION 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 Issuan of the building permit.
Signed Affidavit Attached? Yes ..........<f No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT '
1, ( 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.
—Signature of Owner Date ftliD
S TION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, VQE, ,as Owner or Authorized Agent hereby declare
information on the fore foregoing application are true and accurate to the best of m knowledge and
that the statements andg g pp y g
behalf
Prin a
Sig a ure w er or utho r. J Agent Date
Signed un er the pains and penalties of perjury
NOTES:
I. An Owner who obtains a building permit to Jo 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. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. 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
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
\la..achu�ett�- Department ul'public Galen
1 Beard of Buildim, Rc^_ul:uiun>and tt:uulanl.
I Construction Supervisor Specialty License
License: CS SL 99693 .. .
Restricted to: RF,WS- - - J.
JOHN PERRINO
17 STONEHEDGE DRIVE
WILMINGTON, MA 01887 -
� l_y Expiration: 8122/2011
Tr: 99693 _
l inumj..nnu• - - _ ..-�
I
10-NOV-13 11:25AM FROM-Home Depot 2886 +978T401402 T-059 P.001/007 F-836
HOME IMPROVEMk1VT CONTRAC E
PLEASE READ THIS
j. Sold,Furnished and installed by-
THD At-Home Services,Inc.
Branch Name: Boston Date: ��J�—Qn d/b/a The Horne Depot At-Home Services
\� 345A Greenwood Street,Unit 2,Worcester,MA 01607
Toll Free(SOO) 657-5182; Fax(508)756-8823
Branch Number:31. Federal ID#75-2696460;.ME Lie#C 02439;RI Cant,Lie# 16427
CT Lie#0565522f;�M�A Home Improvement Contractor Reg.#126893
o
Installation Address: eat bVLrlr City Suite 'Lip
rr4s 44-- Coll
Porchaser(s); awm—l'Pho S1 Home Phone,iI 8 a Phone:����
utVN; o6r"W, ik �r7� 7�1y 7 rrrC'
L
Home Address: City . State 2rp
(If different from Installation Address) ;n /
E-mailAddress(to receive project communications and Home Depot updates): `�
❑ I DO NOT wish to receive any marketing emails from The Home Depot
for th
Pro ectorrmauon: Undersigned("Customer"),the owners of the property located at the above installation address, agrees to bu of
y,
all materials described bzd on thetbelow and n t1teDepot")
zferoneedees to 5pec Sh tt(s)aall of whicliver and h are incorporated installation
Contract bythis
reference, along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively,
"Contract'):
Job#: uwr.�i tier••"a1 Pr. uctF: Snec Sheets #: Protect Amount
❑Siding /Windows ❑Insulation @ $
rJtRou,fn'
ers/Covers QEntryDoor•sfing ❑Siding Windows Insulation
ers/Covers [EntryDoorsfing ❑Siding Windowsers t Covers ❑Entry Doorsfing Siding ❑Windows ❑lnsnladon❑Gtters/Covers []Entry Doors ❑
.1tTidmtlm 25%n Deposit pf CenlruM Amount due upon ameenlion OF this cmrn'act. 'Total Contract Amount $ (' /
Maine Pnrchasets may riot deposit more than one-third of the Contract Ammmf. 1
—sue eust6mer agrecs-that;immediately upon completiuu of-the-work-for each-Product�trstomer will execut" G'ompiction Certificate
(one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this
Contrdct a.grecs to be jointly and severally obligated and liable hereunder -"
The Home Depot reserves the right to issue s 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 oblig acing eons rrors or to a because
tural
problem with the home, environmental hazards such as mold, asbestos or lead paint, other safety concerns,p
work required to complete the job was not included in the Contract-
Payment Summate The Payment Summary #
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).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you 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 throufilt the date of termination, plus any other
amounts set forth iu this Agreement or allowed under applicable law. THE HOME DEPOT MAY WTI HHOLD AMOUNTS
OWCD TO THE HOME DEPOT FROM TDEPOSITFOR RECOVERY R OTHER
f AMOUNTS TS MADE, WITHOUT
LIMITING THE HOME DEPOTS OTHER
Acceutancc and Authorirntion: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The Home Depot wimt regard to the Products and Installation services and scdes all prior discussions and agreements,gseitledr
am] or written, relating to said Products and Installation. This Agreement can t be signed or amended exec t by signed
by Customer and The Home Depot. Customer acknowledges and agrees that tome 11as re erstandS, voluntarily accepts the
.,f nnri h"s received a conv of this Agreement.
ri_a { ?La Liu
ENERGY PERFORMANCE RATINGS
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U-Factor Solar Heat Gain Caeffident
•F+cmrU CaA�rri¢G.naudadaErecgoSolar.
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_
ADDMONAL,PERFORMANCE RATINGS
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Office or Consumer Affairs&Business Regulationlow
-
i
OME IMPROVEMENT CONTRACTOR
Registration ' 6'893 . TYpj .
Expiration 8f3(2Ot�-2-- Supp!ement -
The Horne DeRaE fHorne.Services
aN
RICHARD FALLONE_ -'�
KWAY S
2690 CUMBERLANFI.PAR
CITY OF SALEM, iNLkSSACHUSETI'S
• BI;UMLNG DEP ARTMEINT
• 130 WASHLNGTON STREET, 3w FLOOR
T L (978) 745-9595
FAX(978) 740-9846
Kl3jBFRr RY DR SCOLL
MAYOR 'hioM.+s ST.P>3;RR8
DIRECTOR OF PUBLIC PROPERTY/BUILIMNG COMMISSIONER
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 It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condiiiori thaf the debris resulting from
this work shall be disposed of in a properly licensed waste disposal 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)
si na a of permit applicant
. to
• .� ® DArE(MMIDDN'1Y')
�cofzo CERTIFICATE OF LIABILITY INSURANCE__ 72,19,10
700 THIS CERTIFICATE IS ISSUED AS A MATTER OF IN,
PRODUCER 1-404-995-3 ORMATION_
Marsh USA, Inc.
ONLY AND CONFERS NO RIGHTS LFON "IF C RTIFlr �r
HCL r. R THIS rERT''-RC L70FS Nr .'o,.c Ir ('.o_VL ,:�Al :
4cce Ue Jc c _ a sh.Com
o Allia.:-._. r r -:SG Lenox Road, S. ce 2400
h. _ _
'ice:.
.2 1. _ .. .
j
Hon. 'le Y . a _ hd
2455 Paces Ferry Road NW "SI;RERC New Hampshire Ins Co I23?#'.
Building C-20 INSURER D NATIONAL UNION FIRE INS CO OF PITTS 134i_5
Atlanta, GA 30333 .__. _._-..
INSURER Illinois Union Ins Co 27960
COVERAGES -
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED it)THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ __ ___ _—___._,_ --_.—_- -
INSR DO'RorL PpIICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
q MM N V T M I IYY V
GENERAL LIABILITY GL04887714-00 03/01/10 03107/ll EACH OCCURRENCE S 4,000,000
uAMAGE TOR N ED E 1,000,000
% COMMERCIAL GENERAL LIABILITY PREMISES EaocunanceL
CLAIMS MADE ❑% OCCUR MED EXP(Any one Person) S EXCLUDED
PERSONALSADV INJURY S4,000,000
GENERAL AGGREGATE S 4_000,000_
GENT AGGREGATE LIMIT APPLIES PER: - PRODUCTS=COMPIOP AGG S 4,000,000_ _
% POLICY PR6 LOC
H AUTOMOBILE LIABILITY- BAP 2938863-07 03/01/10 03/Ol/11 COMBINED SINGLE LIMIT $ 11000,000
(Ea acodent)
X ANY AUTO - --'--- -.
ALL OWNED AUTOS BODILY INJURY E
(Per Person)
SCHEDULED AUTOS - -- -----
HIRED AUTOS - BODILY INJURY S
(Peracciden0
NON-OWNED AUTOS —
X SELF INSURED AUTO PROPERTY DAMAGE - $
(Per accident)
PHYSICAL DAMAGE
GARAGELIABILITY _ AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EAACC
AUTO ONLY: AGG 6
A EXCESS/UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE S 5,000,000_
X OCCUR a CLAIMU,MADE AGGREGATE _ 1 :,000,000_.....
E
DEDUCTIBLE ..__—___-- __._.__.___________
RETENTION S S
WORKERS COMPENSATION WCO20342355 (ADS) 03/01/10 03/01/7EACH
TATU OTH-
C AND EMPLOYERS'LIAa1LITY
YIN 1,000_000
D ANYPROPRIETDRIPARTNERIE%ECUTIVEQ WCO20742356 (CA) 03/01/10 03/Ol/ CCIDENT S OFFIOEtoryin NH)EXCLUDED)E (Mandatory in NH) WCO20342357 (FL) 03/Ol/10 03/O1/ E-En EMPLOYE S 1,000,000Ilyes,describe under SE.POLICY LIMIT E 1,000,00SPECIAL PROVISIONS belowOTHERE TX Employers Excess TNSC46242373 (TX) 03/O1/10 03/O1/ nce/SIR 30M/2M
D Workers Compensation WC0910566 (QSI) 0.7/01/10 03/01/C Workers Compensation WCO20342358(XY,MO,NY,WI, ) 03/01/10 03/01/
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
RE: EVIDENCE OF COVERAGE .. -
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE AB GIVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
THE HOME DEPOT, INC. -
HOME DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURETO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
2455 PACES FERRY ROAD NW - R;iPRLSENTATIVES.
BUILDING C-20
AUTHORIZED REPRESENTATIVE
ATLANTA,� GA 30339
USA
ACORD 25(2009101)Jthornton_hd - ®1988-2009 ACORD CORPORATION. All rights reserved.
14481889 The ACORD name and logo are registered marks of ACORD
•
Office oflnvestigations
jS o Washington Street
Boston,MA 02111
r wivw.mussgov/din
1�%orkers' Compensation Insurance Affidavit: Ba�tders/ContrartarslEleztrirsans/Pln�hbers
A hcant Information Please Print Letribiv
Name(gtduess/Orgaaizatioa/indiv1&m1):
Address:
City/statemp i 4 af, C6 Phone#:
Are yo `°an employer"!Checkthe apProPtiate box: 7 ype of project(required):
t.ld I am a employer with 4. 0 :am a general contractor and I 6. 0 New Construction . . ,
employees(hU aud/orpad-time)' r. havehirodthe sob cantrac�ts s.7,_ : temodebng -
] }oiralt
2: Iama-solepmp ororpa - —These sub-conuacam have 8_ Demolitmn
ship and have no any ny YCM
capacity. workers' comP.msuzanee. 9. 0 Barldiog addition
working'for me in . 5' ❑ We are a corporation and its
C vvorkcts'Comp-insurance 10.0 Electrical repass or additions
otEcecs have exercised the
regnued 7 11.E PlumbingrePaies or additions
3.01amahomeownerdcimgallwork 5tofexempt>oaPebavc
em ploy ers-U9ndwehavetro 12Q Rgefiepa� "
myself[No workers Come• rL��/
insurance required-)f !employers-
taPtired] 13. Other
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infonv4Woa.
Insurance CbmPanY Name Ot n U1�I( I
Policy#or Self-iIIs Ur-# Expiration Daft-- / .
Job Site Address:
Attach a Copy of the workers'compensation Policy declaration Page(showing the policy number and expiration date)
mem
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I do Ireceby eerdfy arrder ofper}wq that the biformafioaprevlded above is*we and correct
Phone#-
Of Wd use only. Do not write in dds area,to be complded by city or MOM OhMaL
Catty or Town - Permitl73cense#
Issuing Authority(drde one):
1_Board of HeaHh.2-Building Department 3.CtlylTown Cterk 4.Rleetrirel Inspector 5_Plumbing Inspector
6.other
_ Phone#