26 GREENWAY RD - BUILDING INSPECTION :� --- I he C'omnwmsraliIs of Massachusclis
is ' hoard of Building Regulations and Standards CI'1'1'OF
'r NLIS.SUIR'setts State Building Code, 7SD CNIR SALEM
Building Permit Application TO Construct, Repair, Renovate Or mulish u
Ono-ur TIM4111nilr DIV,
—_ x n — -
Building Permit Number: This Section For iciu,UDo( Applic
Ilwidmy Otiicial(Print Mune)
gn uns Oulc
SECTION is SITE ORMATION
L I Property AJJr s+: 1.1 Assessors blap ti parcel Number
I.la Is this an acre tad street? 'a no hlap Number Purcel Nun R-r
1.3 Zoning Informatlont 1.4 Property Dimensions
Luring District Proposed uw Lill Ann Isy II) . Frontage 1 0
1.5 Building Setbecks(R)
Front Yard Side Yunis Near Yard
Required Provided Required Provided Reyuind Provided
1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Informatloni I.g Sewage DbpaSRI System:
Public❑ Private O Zone: _ Outside Flood'Lone?
CAeck if es❑ Municipal O On site disposal system ❑
SECTION I. PROPERTY OWNERSHIP'
2.1 Owner"o R c ds q--�
(11),Slue,ZIP
Nu.and Strcel telephone -1 Fmuil Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check al hat apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteratlon(s) ❑ Addition ❑
Densulition ❑ Accessory Bldg,❑ Number of Units_ Other O Speeily:
Brief Description of Proposed Work": /� I�i�rr rGr II I YY�fot-t
SECTION 4; ESTIMATED CONSTRVCTION,COSTS
liens Estimated Costs:
(Lahur and Materials OMCIAl Use Only
I. Building S I. Building Permit Fee: S Indicate how Fee is deternsined:
2. kleclrical S O Standard CityiTossn Application Fee
Piumhing S ❑Total Project Cost'1 hem 6).x multiplier
_. Other Fees: S_ - -
J. \Icch,usical ill\ W) S List:
i `u i ucssionl S rota \it Fees: S
I'otal I'rojcct Cust:. 3 ('hceA vu. _( heck:\mount . _.._._. l'•Ish \momt:
❑ Pail in Full O Outstanding Flal.uice Due:
SEC" ION S: C ONSI'RUCTION SFRVIC'ES
S.1 C'unstructiun Supeni. l.irenst(C'SI.) _
j�'f[�fJO/` J I ieenx untFar IvptI 11n 1 .neq
N,mle,dl/'.�Lll.,id.r IsIC\LI\IxlQU bell,
,sl.__.__ --
No. anJ Slrcet (I 14trestrided 111MIJin s ti pl)S,000 at. tier
R Rearicled Idh? f.anil 17u ellin
l'iNifaan�� .. -- KC K,Nlhm Cavedn
N'S Window.Uld Sidin
— - Sp Solid Fuel Iluming Appliances
I Insulation
1'c a bona Ismail eJdress
U Demolition ;
3.2 Registered Ilume ve t nt Cunt ctor(1. a/
IIIC liegistration Noon 1°. in ion I We
I lie C 1 91 1 n it alfl r .
Email address
No. mid Street rS-
cityrrown.State ZIP rele hone
SECTION 6:WORKERS'COMPENSATION INSU CE AFFIDAVIT(M.G.L.c. 132. 1 25CI
Workers Compensation Insurance aMdavit must be cc tied and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan f the building permit.
Signed Affidavit Attached? I es ..........
No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE CO�IPLETED WHEN
OWNER'S ACENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
loact on my behalf,in all matters relative to work authorized by this building permit application.
`t7
D to
1'rinl U�.ner's Nwne(Electronic Signature)
SECTION 7b:OWNERI OR AUTHOMED AGENT DECLARATION
By entering my name below, 1 hereby attest u the pains and penalties of perjury that all of the information
contained in this application is true and acc tot t to bed orm knowledge and understanding.
D to
Print Utt reef!tit:\tit orinJ Ageln's Name 'ti% lic Signa tire)
NOTES:
i. .�n Owner slhu obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
I not registered in the Hume Inlprovemeol Contractor t HIC) Program).will i have access to the arbitration
program of guar111) fund under M.G.L. c. I4?A. other important information on the HIC Prugrmn can be ti,wld at
information on the Construction Supervisor License can be round at„1%^ M-II,'
\1 hsu
en bslanlial %%ork is pleutned, pro,ide the infurnin ion below:
_ ____.._1 including garage, linished bascntent attics.decks arelu
ks or p
rolal flour area uy fl.l
Habitable room count
Groii living area uy. lt.t _-_._, _. . - Number of hedroanls
\untFeroftireplaees ... .._ ._. .. -- \unlberofliallbaths .. . . . .
\unlherol'Fathrrwns , , - . . N,,nlbcral'J%I parches
I'�pe of hcating i)+too 1'1161ied ..lti,cn
I1pe, fe,ading ;�slem
1. "I.ual I'n,jecl .ti,111:1rC I'o.H.tge"n1a) be uF.11it1wd tl,r..fatal PnQeet Call'. �
10/26/2012 07:13 17818940331 TODD RIDEMAN PAGE 01
` HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
7I 11 / ),., / Sold,Furnished and Installed by:
Branch Nam: Boston Date: 1 D/ 1b 1 4/ THU At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
145A Greenwood Street,Unit 2,Worcester,MA 01607
Toil Free(800)657-5192;Pax(509)756-8823
Branch Number:31 Federal ID#75-2698460;ME Lie#C 02439;RI Cant.Licit 16427
CT Lic#HIC-056552Z MA Hnme Improvement Contractor Reg.#126893
/1/97n
Installation Address: ►z�
Cittyy State Zip
6e5K"(' GALL - aND
p h+mr(s): Work Phone: fry�,yHe Phone: r�C 1 Phone:
Home Address:
(If differem from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
❑1 DO NOT wish to receive any marketing email.from The Home Depol -
Proiert Information: Undersigned("Customer),the owners of the property located at the above installation address,agrees to buy,
and THD At-I lone Services. Inc.("The Home Depot")agrees to furnish,deliver and arrange for the Installation("Installation")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 attached hereto and any Change Orden(collectively,
"Contract'): -
Job#: n.ar.tit a.4..eRr Products: Sae Sheet(s)#: P.roimt Amount
❑Romig Siding P9 Window. LJ Insulation �
❑Guners/Covers ❑Entry Doors ❑ 6-3 z16-7 $ 13 d y jr/., 06
Roofing MSidmg Windows insaladon $
❑Goners/Covers ❑Entry Doors ❑ _ I
❑Roorng Siding D Windows LJ Insulation $
_. ❑Gutter,/Coves ❑Fury Drxas❑
❑RrwHng LJSjding Ll Windows Ll Insulation $
❑Gutters/Covers []Entry floors ❑
Muwmrm 25%Deposit ufGenrartAmount due upon execatiwl oflhn tmbaA, Total Contract Amount $
MainsPmdlasns may rlott/eptaed mme d.vr ale-third of the Ccmtrud,km aml. J06
,^J
Customer agrees that, immediately upon completion of the work for each Product,Customer will execute a Completion Certiftcalc
(one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, cash 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(.)included herein.at
ilA discretion,if The Hume Depot or its authorized service provider determines that it cannot perliorrn its obligations due to a structural
problem with the home,environmental huzards such as mold,asbestos or lead paint,other safety contents, pricing errors or because
work required to complete the job was not included in/the Contract.
Payment Summary: The Payment Summary # b5�59 1 1 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 cornpj1letcly'filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Cumplchon f cr(ificate for each listed Product as defined by individual Spec Sheets,)before work on that Product
is complete.
In the event of termination or 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,ROMP,DEPOT MAY WITHHOLD AMCSUNTS
OWED TO THE HOME DEPOT FROM THE, DEPOSIT PAYMENT OR OTHER PAYMENT'S MADE, WITHOUT
LIMITING:THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
Acceptance anduth Aorization: Customer agrees and understands re that this Agreement is the entire agreement between Customer
and The HMne Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either
oral or written.rcluliug to said Products and Installation.This Agreement cannot he 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
terns of and has received a copy of this Agreement.
Aceyg/� by: 5ubmttl /�Jj
X �(j/ �7
Gusto A Signatur Date Salac Consultant's Signature Datc
X -_-_-_ Telephone No.
Customer's Signature Date Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL. THIS to Appac.btro
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE.TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD HUSINESS
DAY AFTER SIGNING THIS AGREEMENT- THE
STATE, SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
SPECIFICALLY pRpSCRIBRID BY LAW IN
CUSTOMER'S STATE;.
Nt/'1'ICHe:ADDITIONA1.Ti' KM. %AND CONDITIONS ARE,STATED ON THE REVERSE.SIDE AND ARE PART OE roll CON'I'HAC'I
10. 11 GSC White—Branch Foe velimw—Cu6tomer
it
60Y)
02
workers Conipeusation Insurance Affidavit; s
nplicant Information
Please triDtjegibly
Name ()3tisiness/Organization/Individual):
Address:.
City/State/Zip:
Art. �ek 2:employer? Check the appropriate box:
in & Type of project(required):
I am employer with 4. ❑ 1 am a general contractor and I I
employees(fill and/or jTart:itinae). have hired the sub-contractors 6. E] New construction
2.[] 1 am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling
ship and have no employees These sub-contractors have 8. E)Demolition
working
B me in any capacity. employees and have workers' -1 Building addition
0 "Ing or, comp. insurance.T 9. F addition
[No workers comp. insurance
required.] 5, E] We are a corporation and its 10.E3 Electrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.[]Ro repairs
insurance required_] t c. 152, §1(4),and we have no
employees.[No workers' 13.
Other
comp. insurance required.] I ,
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit this affidavit indicating they we doing all work and then him outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the subeontrectars and state whether or not those entities have
employees. If the sub-contactors have employees,they most provide their workets'comp.policy number,
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 1,
Policy#or Self-ins, Lic. #-. Expiration.Date:
Job Site Address: 04o Gmll A-_-N i 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 MOL 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
InvestiLratidns A44he DIA for *insurance coverage verification.
[dahereby ertijyu d the sins and penalties ofperjury that the information Provided above . true and correct.
7)
S,ionatur Date:
Phone#,
Official use only. Donot write in this area, to be completed by c!ty or tolvil officlat
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- Z
Contact Person: Phone
CITY OF SALEM, - ASSACHUSETTS
Bu=LNG DEPARM&NIT
120 WASHIIINGTON STREET, 3''FLOOR.
T 1- (978) 745-9595
FAx(978) 740-9846
KIILBERL F-Y DRISCOLL
T
MAYOR HOxtAS ST.F�IERRs
DIRECTOR OF PUBLIC PROPERTY/Buu.DD;G=W IISSIONER
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 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 to facility)
(address of facility)
J A �A
signature permit applicant
1
d e
Jcbriu 17.d.x
t�q Massachusetts -Department of pubIIC Safety
'-- Board of Building Regulations and Standards
License. CSSL-099699 = a
ROBERT POCZOBUT
172 WHALENS LANE
Salem MA 4970
Expiration
Cnma�issianer 02/06/2014
i
weaN
Office of Consumer Affair/ and Business Regulation
10 Park Plaza - Suite 5170
Boston, IVdassachusetts 02116
Home Improve m. 6-06Contractor Registration
r -T Registration: 126893 -
_ Type: Supplement Card
c
;.v
Expiration: 8/3/2014
The Home Depot At-Home Services :
-
RICHARD "FALLONE
2690 CUMBERLAND PARKWAY
�S�UITE30 '
ATLANTA, GA 30339 "° ._ -'C .`_--
Update Address and return card.Mark reason for change.
�---' ❑ Address ❑ Renewal ❑ Employment Lost Card
oPS-GA1 0 5610-04/64-G161216
r
y3 ;gymCERTIFICATE OF LIABILATY INSURANCE'
THIS CaRr;FICATIE 13 ISSUED AS A MATTER CF INFORNIATION ONLY AND OCNFER0 No RIGHTS UP'Ori TiIE" U-.- '.it. cE-,
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE TOVER,,\GE AFFORDED BY THE PCI ICIEn
BELCIIIJ. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETTJEEN THE SSUI MC INSUPER(S), (AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSI th< policy(les) must be endorsed. H SUBROGAF10H IS
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this'C'lificate doer no>
certificate holder in lieu of such endorsement(s).
RODUCER -FO—NTAT CONTA
NAME:
arah USA Inc. PHONEC I FAX
AJC NQ,
omedepot.certreclue.st@mars�.com E-MAIL
ADDRESS:
.o Alliance Center, 3560 Lenox Road, Suite 2400 tlanta, GA 30326 INSURERS)AFFORDING COVERAGE NAIC If
-
ax (212) 948-0902 INSURER A: Steadfast ins Co 26387
JSUREO INSURER B: Zurich American ins Co_ 16535
he Home Depot, Inc. ampshire Ins Co 23841
ame Depot U.S.A., Inc. INSURER C: New 11
455 Paces Ferry Road NW INSURERD: Illinois watl ins Cc 23817
uilding C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445
.tlanta; GA 30339
INSURER F: Illinois union Ins Co 127960
;OVERAGES `CERTIFICATE NUMBER: 25776028 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ADOLSUBR POLICY EFF POLICY
P
SR JMMIODWWI LIMITS
TR TYPE OF INSURANCE ihm Awk POLICY NUMBER IMMIDDMWI
A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $.9,000,000
X DAMAGE O(Eia`oNTED ccurrenc.) 5 "0 0 0'0 0 0
COMMERCIAL GENERAL LIABILITY PREMISES
= CLAIMS-MADE I I OCCUR MED EXP(My one person) $ EXCLUDED
LIMITS OF POLICY XS PERSONAL&ADV INJURY S 9,000,000
X OF SIR: $1M PER OCC GENERAL AGGREGATE S 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 9,000,000
JECT--il POLICY LOC F-] PRO- [ $
B AUTOMOBILE LIABILITY HAP 2938863-09 03/01/1; 03/0l/13 COMBINED SINGLE LIMIT
Ea accident) $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Pe,acci ant I
IXSELF INSUR D PHY DMG $
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LAB HCLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
* WORKERS COMPENSATION WC019736915 1 0 3 01/1: 0 3/01./13 X I TCCSrAM`,%I I OETgH
AND EMPLOYERS'LIABILITY YIN
* ANY PROPRIETOWPARTNER/EXECUnVE WC019736917 (FL) 03/01/1: 03/01/13 E.L.EACH ACCIDENT $ 1.000,000
OFFICER/MEMBER EXC 5-1 N/A
* (Mandatory In NH) WC019736916 (CA) 03/01/1: 03/01/13 E.L.DISEASE-EA EMPLOYEE S 11000,000
If Kes,describe under
D S RIPTION OF OPERATIONS below E.L.DISEASE-POLICY POLICY LIMIT $ 11000,000
* Workers Compensation WC1192494 tUSI) --6'3—/01/1,--C3101113 SIR (AOS)/SIR (GA) IM/750,000
* Workers Compensation WC019736918 (WI) 03/01/1: 03/01/13
* TX Employers XS Indemnity TNSC46566397 1 03/01/1: 03/01/13 Occurrence/SIR 30M/lM
,ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
E: EVIDENCE OF COVERAGE
;ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ONE DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS.
455 PACES PERRY ROAD NW AUTHORIZED REPRESENTATIVE
UILDING C-20
TLANTA, GA 30339 11
USA
@ 198§-2610 AqORP CORPORATION. All rights reserved.
716- Af`nnn 1--- —6. "f Ann-