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1A HALSEY WAY - BUILDING INSPECTION It The Commonwealth of Massachusetts �. Board of Building Regulations and Standards Town of ZP �yj; Massachusetts State Building Code, 780 CMR, 7'"edition Building riii, ept Building Permit Application To Construct, Repair, Renovate Or Demolish a d MOne-or Two-Family Dwelling �• k1 �' This Section For Official Use Only Building Permit Number: Date Applied: �/I,• Signature: 6 ( fl ' 0 Building Co missioner/Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Property Rddr s: 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?ye 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(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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owners o�;;1 D— U • e Name(Print) 4 Address for Service: C f)VU4 5 SQL Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) - Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Pthq ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost (Item 6)x multiplier x 1 Plumbing $ 2. Other Fees: $ _ 4. Mechanical (HVAC) $ List: 5 Mechanical (Fire $ Su ression Total All bees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ CQ� rnW'�— 0 Paid in Full 13 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) '7L4-)= ' :• {mil l nt� �� ..LIB License Number Expimti n l6atc Name of CSL-Holder VVV ��66 List CSL Type(see below) y r ©1 T Description Ft Udd4st Unrestricted(u l0 35,000 Cu. Ft.) R Restricted 1&2 Family Dwelling Signatur gyp, M Mason Onl 40L<�{. ti�p�(Aw RC Residential Roofing Covering Telephone wS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered HomeAIMWove en Contrac (HIC) �6o HIC Com N or HIC R ist Registratioatio r Address rJ Expiration Date Si ature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be eprnpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuanc of the building permit. Signed Affidavit Attached? Yes .......... V 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 SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION 1, 1?1/1 K 6�1 lcow— ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print 1 Signature of(Tiner or Authorized Agent Date Si ned under the pains and penalties of perjury 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 1 IO.RS, respectively. 2. When substantial work is planned,provide the information below: Total Floors area(Sq. FL) (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" CITY OF SALEM PUBLIC PROPRERTY DE PAR"I'vtENT !1N V . I '.I .. I_.. \\ .i l:\ . .".l:illr � \\11 \L \I\..V •. 1 . • .II - construction Debris Disposal Affidavit (rc(luired for all dcntulition .u'J rcnuaation work) In accordance ww ith the six Eli edition of the State Building Code, 750 C'A1R section I 1 1 .5 Dcbris, and the provisions of A1GL e 40, S 54; Building Permit it is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 111. S 150A. The debris \%'ill be transported by: Q• t I^tidtlC'�o I name of hauler) he debris will be disposed of in I namr ul ta.11 ') IadJrc+� r 1]clhlvl .1e1 we 1 p:nult ehph<aul N$y-01-2006 06:15PM FROM-HOVE DEPOT 6176736117 T-262 P.002/005 F-152 • ■� w•W PLFASEREAD THIS ---'-- l"'r R !� �� Sold,Furnished and Installed by: Branch Name: Boston Date: !/ / TIID At-Home Services,Inc. d/b/a The Home Depot At-Home Services Branch Number: 345A Greenwood Street,Unit 2,Worcester,MA 01607 North 33 ❑South 37 Toll Free(800)657-5182; Fax(508)756-8823 Federal ID#75-2698460;ME Lie#C 02439;RI Cont.Lie#16427 CT Lic#565522;MA Home lmproveracm Contractor Reg.#126993 Installation Address: Or �Ql Q" (n lit4u +��2- mom' O19__g-�-o ity State Zip Purchaser(s); Work Phone: Home Phone. Cell Phone: yo 7 Home Address: (If different from Installation Address) City Slate Zip Vail Address(to receive project communications and Home Depot updates): O NOT wish to receive any marketing entails from The Home Depot Project information: Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy, and rJID At-Home Services,Inc. ("The Home Depot'l agrees to famish,deliver and arrange for the insmllation("Installation")of all materials described on the below and on the referenced Spec Sheei(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 Orders(collectively, "Contract"): Job#: ou...-W—) Products: See Sheets #: Pro eet Amount ❑Rcoftag []Sidmg.9LWirdDW9 0 Insulation /�q ❑Guars/Covens ❑Envy Doors ❑ I I $ V Roofing ]Sidig Windows ❑Insulation $ ❑Gurters/Covers ❑Entry Doors ❑ ROofmg ❑Sid,.8 0 Windows 0IDsulnh0- $ ❑Guacn/Covers ❑Entry Doors❑ _ Roofing ❑Siding Windows ❑Insulation $ ❑Guars/Covers []Entry Doors ❑ Minimum25%DepositofContr tAmoantdunaponemeutiuRofthisw.b el. Total Contract Amount $ Maine Pureleasers may not deposit more than one-third ofthe ContractAmoun[ I 'S 00 ,OQ 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 Crammer or any individual Products(s)included herein,at is 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 # 674-Lf g td , included as pan 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 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 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 RECOVERY OF SUCH AMOUNTS. Aeceotance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot wilt regard to rite Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agmcment 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. / Submitt X s�e try: 16b0/0� x l0�30(0� r's Signature �� Da�— Mes Cornsfutairt's Signature: �j Date Telephone No. 4el :Z!j �Rq Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS , (I--poksb1c) 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. NOTICE!AD➢ITIONALTERMS AND CONDMONS ARE STATED ON TWi REVERSE SME AND nAE PART OF THIS CONTRACT a-0S-08 CSC White-Branch File Volknv-Customer Pink-Sales Consultant �U /^ �' ,' C �. 4-4 45' 5 American Properties Team, Inc. TO: Paul Dube — I Halsey Way FROM: Jennifer Pappas, Property Manager RE: Window Replacement DATE: . October21, 2008 Please be advised that the Board of Trustees for Pickman Park has approved replacement windows for the above referenced unit. This approval is contingent upon them matching the existing windows and that they fit in the existing opening. They must be the same in appearance from the exterior. The Board will not allow windows with grids, crank outs, etc. We also require that permits be pulled in advance (regardless of what your contractor may tell you), and then a copy of the final approved permit once completed must be sent to APT for the unit file as well. We also recommend that owners obtain a certificate of insurance from the licensed contractor. You will need to bring a copy of this letter to the Salem Building Department in order to receive your permit. Should you have any questions or require additional information, please feel free to call me directly at(781)932-9229 x675. cc: Unit File 500 WEST CUMMINGS PARK SUITE 6050• WOBURN •MA 01801.781-932-9229 •FAX 781-9354289 /�cnuuuoaeucv(!� r./'. �l»yir�rau!!a Board of Building Hegulatioas and Scaodards H� OME IMPROVEMENT CONTRACTOR �5 � Registration: 129206 Expiration: 7/22/2009 Trp 131960 "- Type: Individual _ AEGEAN CONSTRUCTION Kostantinos Vaitis - 16 Hanson Road Saugus. MA 01905 Administrator Board of Building Regulations and Siandurds Construction Supervisor License License: CS 74722 Birthdate: 7/5/1972 Expiration: 7/5/2009 Trm 36 Restriction: 00 KOSTANTINOSS VAITIS 18 HANSON ROAD SAUGUS.MA 01905 Commissioner DATe jNRUDarYYYI .Ac RD CERTIFICATE OF LIABILITY INSURANCE 1-4G�-995-1GD9. THIS CERTI7. FICATE 13 ISSUED AS A MATTER OF INFORMATION :ocucER - - - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ash USA, Inc. - - HOLDER. THIS CERTIFICATE DOES NOT AMENO, EXTEND OR ALTER THE COVERAGE AFFCRCEO BY THE. POLICIES BELOW. Can mad e?a0.eat =lSt3R9 ammar9 n. 3 1:3dmonG Ad YZ, Suia9 5100 - _ia]a. GA 7.a305 - INSU REASAFFCRCING COVERAGE INAIC9 _ 9A3-090: IG! „ 3!1d3d330 CoCtr 3 !l?:�-! ]a'c: U.S.A.. :..c - :NSCSE93::___ch Aite•__3r. I'a Ca 3 3.ae 3e 4 . r^C. N9v�E.?::• Sa,! saiCt I39Annew ^ i37�7 i 73C3! 1CL:/ �1dL:g C-3 - iNSURER]:Amaaean Home Assur Ca 13710 Laaoi, CA: 70339 . - _ •,,.'• - INSURER New Hant"h1r3 Is! Ca 117141 7VERAGE3 LHY CLIC REMENTSTERAI THE INSU CE CONDITION mAvEF ANY CONTRSSuACT OROOTNER DOCUMENT RESPECT TO WHICH THIS CERTIFICATE MAYE ISSUED IOR ,IAy PERTAIN,THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH. IOUCIES.AGGREGATE LIMBS SHOWN MAY HAVE BEEN REDUCED BYPAIOC aucvvracTIV1 POucr/XPIMTIOY UNITS POLICY NUYa ER . . �, f. SPA 37S7. E09-03 03/01/0S 03/01/09 EACH OCcuaaENCE 34,000,000 GENeMLUAaOJTY - A COMMERCIAL OEME R 191UTV LINIT9 OF POLICY ARE ESC 39 _ PR E r. $ SXCLutO CLAIMSMAOE�/fl/jJI OCCUR -OF 9IA: $1.000,coo PER Cca MEO UP(Any me Pon fEXCLODED . - "A30NALBACVMJURY -$4,090,000 i, '. . . - GENERAL GGREWTE 34,000,000 ' PRODUCTS-COMPIOPAGG f4,000,000 -.OENL AGOREGATEUWTAPPLIE3 PER:. x POLICY . PRO? LCC 07/01/09 HAP 39311E7-05 03/01/08 COMBINED SINGLE LIMIT 11,000,000 .AUTOMOBILE LIABILITY - (E AcNerU) x ANY AUTO LYW IOOI - ALLCWNEDAUTOS - _ - - - ) f (Pr LYINJ SCHEOULEDAUT09 - - BOOILYINJURy - 3 HIREOAVTOS (Pr eatleenl) - NON4TWNEOAUT09 PG X SELF ITT9URZD AUTO Per lociR TYDAMAGE f - PI9;LIICAL DAMAGE AUTO ONLY•EAACCIOENT ! OARAGELutrurrY - O7MER THAN EAACC S ANYAUTO AUTOONLY: AGO S IPA7757 601-07 03/01/0S 03/01/09 EACHOCCURRENCE S5,000,000 lxCBSSNMEW LIABILITY Y AGGREGATE - 55,000,000 X OCCUR ❑CLAIMS MADE _ S f DEDUCTIBLE - ' . ., S RETENUON S. O3/Ol/01 03/01/09 X WC9 A WORKERS COMPENSATION AND 1933737 (PL) 1;000,000 fiNPIpYBRS'W�IUTY TS 193175E (CA) 03/01/04 03/01/09 ILL EACH ACCIDENT I ANY PROPRIETORNARTNEtNXECUTNE 03/01/08 03/01/09 B.L.DISEASE-EA EMPLOYEE I1,000-,000 OFR M FA CERUMER EXCLUOT 1938755(AGS) _ E.L.DISEASE.POLICY UNIT $1,000,000- IIyn.MIelMur9w SPECIAL PROVI9N)wst, w OTHER TN9•CI51l7967 (T7q 03/01/01 03/01/09 Crurrenne/9IA 35N/3N - TX ShP1°yers Execs '19317l9.(G9I) 03/01/00 03/01/09 workers Compensation - orkere Co"eneAtLan 1920758 (ICY, No, NY, NI) 0][O1/01 O3/O1/0! ICRIPUON Of OPERATIONS ILOCATIONS IVEHICLE3IEXCLUSION5 Ao0lO By ENDORSEMENTNPECUI}fROVOlONS _ IS MDENCZ ONLY RTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCHES BE CANCELLED BEFORE THE EXPIRATION _ DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DATE WRRTW HONE DEPOT, INC. NOTICE TO THE CERTIFICATE.HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 90 SHALL IMPOSE No OBLIGATION OR LL"ILRT OF ANY KIND UPON THE INSURER.IT3 AGENTS OR. II. i5 PJ10E3 PSRRT RO.), N.N. BUILDING C-1 pEFREfFMATNEi AUTHOAUJO REPRESENTATIVE .MIA, GA. 30339 zAvule&a USA ... _-__ 0ACORDCORPORATION1958 ,.' I - -,1-173 . e3-Os D6 .. 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Board of Building Reguladoni and Standards HOME IMPROVEMENT CONTRACTOR Regist4 126893 — 12010 e Ug ement Card The Home DepoAG �y RICHARD FALCON, 3200 COBB GALL Eif ,:���0 �� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations - 600 Washington Street Boston, 314 02111 www.niass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 11 Please Print Le¢ibly Tiallie (Business/Organizationrindividual):_�y� Address: ✓al� — P 1 sry� ►►► VVV���►►► �tt���— Et 'ei City/State/Zip:_ �d � �%y 0'3 666 Phone #:_ !!900 L 7 914?a Are yoy an employer?Check the appropriate box: Type of project (required): 1. am a employer with�_ 4. ❑ 1 am a general contractor and I 6. 0 New construction employees(full and/or part-time).• have hired the sub-contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet. % 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required:] t employees. (No workers' comp. insurance required.] 13.0-cCer 'Any applicant that cheeks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavitindicating they ate doing all work and than 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 subcontractors and their workers'comp.policy information. I am an employer that is providlirg workers'compensation Insurance for my employees. Below is the polky and job ske information. Insurance Company Name:__ 1�t tl ,lvv✓1�,, w1S Policy#or Self-ins. Lic. #:_ �9 � t ] y� Expiration Date: Job Site Address: — A—t�� City/State/Zip: Attach a copy of the workers' compensation po c1P y declar tion page age(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 S 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 the DIA for insurance coverage verification. 71ido hereby c if un er t e pa' s andpenalties ofperjun,that the information provided above 's true and correct. a ure: �f Date: uD Phone#: Official use onlr. Do not write in this area,to be completed by clty 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