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3A HALSEY WAY - BUILDING INSPECTION 1 --- Phe C'omumonsveallh of Nlassachusctls Board of Building Regulations and Standards SAL Y OF B M Massachusetts S,\L1:\I Massachusetts State building CuJc. 73l) CM1IR L, .. Building Permit Application To Construct. Repair. Renovate Or Demoli One- or Trcu-Fuulrlr Dire/ling This Section For Otficiul Use ml Building Permit Number: Date Appl' INildina Olticial tllrint Nunc) Sitptalurc Data SECTION I:SITE INFORIIIATION 1.1 Property Add r 1.2 Assessors blap& Parcel Numbers I.1a Is this an acce led street?ves no 7— Map Number Parcel Nunotler 1.3 Zoning Information: 1.4 Property Dimensions: /oning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(R) Front Yard Side Yurds Rear Yard Required irovided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c. 40.§54) 1.7 Flood Zone Inrormaflon: 1.3 Sewage Disposal System: 'Lune? I'ubllc❑ Privau❑ Zone: Outside Flood— Check if yesO Municipal❑ On site disposals)stem ❑ SECTION3. PROPERTY OWNERSHIP' 2.1 Owner'of Rec t �a56 �� f� � Lo n N;unc(Prmtl City. T State.ZIP �4 r No.;mJ Street relephunle T Fmuil AJdress SECTION J: DESCRIPTION OF PROPOSED WORK'(check all !ftart apply) New Construction❑ Existing Building❑ Owner-Occupied O 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other .O ecily: Grief Description of Proposed Work': � YsC SECTION 4: ESTI;IIATED CONSTRUCTION COSTS Item Estintated Costs: OMclal Use Only Il.abor and Materials) 1. Building S I. Building Permit Fee: S Indicate how fee is determined: ❑Standard CityTusvn Application Fee _'. I(lectrical S ❑Tutal Project Cost'(Item 6).1 mulliplier 1 I'lunihiog S '. Other Fees: S J. MQ:h.lnic.d ill\ \('1 S List:._ Vech.utical rive S ----.--- -- \u geSi10o fUtaI \II Fc": S_.____—___ � ChaA \'u. __Chuck :\mount: l',i�h \imnunl: n ilrlul Project Cost: ) ❑ Reid in Full ❑Oulstanding llaLunce Due: SI:(1I0NS; CONS l'RUCTIONSFRVI('F:.S 5.1 Construction : isur l.tceu (C'St.) I inns¢ Nunthcr A16 .11/1 Nu. .nIJ�Ircet (i (glrcslricmJ I IhulJin s\i to 11.1100 al. It I It Tamil)Dncllin Cil,i loon.Slue.LII' rV M Mason RC' RINII"I C'userin µ'S µ'inJuu .mJ S;din — SF Soli)Fuel Ilurning Appliances I Demolition Wale hone Imall address D Dcnntilion S.2 Registered If le Imp ovement Cuntractor(HIC) IIIC Itegistrltiun Wun -r lie ink im I We Ai ' a c I ''I It Until No. , /�r�i'— � ''S Email address City/Town.State ZIP rele hung SECTION 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 atldavit will result in the denial of the Issuance a building permit. Signed Affidavit Attached? Yes .......... No...........O SECTION 7s:OWNER AUTHORIZATION TO BE CONIPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorizeP to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Nwne(Electrunic Signuture) t ar SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below. I hereby attest and t pains and penalties of perjury that all of the informatiun col in this cation is true and acuum to: st my knowledge and understanding. Print )e ncrle's or:\whonieJ Agant's NAIIIc Inflect uI l .'I III mu `I Ou NOTES: I. .\n Owner \chu obtains a building permit to do his.her own work,or an owner who hires in unregistered cuntractur I out registered in the Hume Improvement Cuntraciur(HICI Program),will nrf have access to the arbitration program or guaranty t'und under M.G.L. c. 142A. Other impunant inlurnlation on the HIC Program can be round at sss\a m.r•. ;01 .,\.I Information on the Cunstruction Supervisor License can be found at I%I%`s it 1,: 'z�:" ,IP` ? \\hen substantial \cork is planned, pros ide the infurnntiun below: Total (lour area(sq. R.) . __ I incluJ;ng garage. linished basement attics, decks or porch I (;fuss lie ing area 114. II.I Ilabilahle rouni count _ _. ... . .. � \unlhcroflircplaccs \'uulher kit hcdruunls _ . . \umber of hathwumi — _ --- \umber of hall haths I)pe of healing sy aan _ \unlhcr of Jeeks, porches I 1 pe Jt �I`V IIIIs i\gdlll lllehhcJ 01\d11 t I' I,II rujecl \\hlarC IUOIdIe"111;1\ he it'hit 11 tit eJ tUf "1 UL11 PrPfdCl CPtf­ 06/12/2012 08:57 15088456076 HOME DEPOT PAGE 01/07 HOME IMPRO MDNI THIS pLF" Sold,Famished and.Installed by: '1'HD At-Home Services,hhc. Date: Ju✓G 3 ao I�. d/b/a The Home Depol At-HOme Services Branch Names Boston r 345A Cmeenwoud Street.Unit 2,Wmcester,MA 01607 Toll Ptee(WO)657-5182;Fax(509)756-8823 Federal ID is 75-2698460;ME Lie*C 4339;Ri Cr Reg.a 16427 Branch Number:31 Cr Lic#HIC.0565522;MA Home laRm tt Snstaliation Addr : 3 W City State 2•SP e� Pmeheser(s)- work J e: Rome Phone: CeR Phodr: (e-Fs [4/s7 7y 7gyS [779] 7" /353 � l [ 1 Home Address: City state Zip (If different from InataBatica Address) updates): E-ioa0 Address(to receive pM a communications and Home Depot ❑f DO NOT wish in receive any marketing emails from The Horne Depot s to bu CCnsmmer'�,the owrhery of the property located at the above installation address,agree. y, yrni.d 7njottnation- UndersignedHome� ,)agrees to fomish,deliver and arrange for the installation(ITnstallatiosi O Of and T'HD At-Home Services,Inc("Ilse Sheet(s), all of which ate incorporated C into this Contract by this all aua ials described on the below and S the referenced Spec U reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders.(collectively, "Contrail"); 5 Slhee s #: Amoum lob#: 'Products: J/`/3 -7/ $ 7 (^ hwfing Siding Windows inwladOn r/ 3J GXg0 G73 oGa,cs/C. OFany Dcors 0— fins idiog U Windows Insulation $ OGrhaess/Covers ❑Entry Doors 0 Roofing Siding 0 Windows Invdatim $ OGauers/Covers OE BUY Doors 0__- Roofing Siding Windows Insulation $ ❑Ohama/Covers OEntry Doors El pt®rhh®25%DepootdCbmrhat Amonmdae upon execution ofdais mmM& Tote)Contract Amount $ 5735 Menthe Pmda>naa slimy ma depedt mwe then hhhheddrd d tlm Cmnrad Ama®t Chrstorther agrees that, immediately upon corr�letiov Of the work for each Product,Customer will execute a (one for each Product as defined by an individual Sphx:Sheet)and pay any balance due. As applicabl Certificate e,each Customer under this Connect agrees to be jeinty and uverally obligated and liable herehrvder- The Home Depot reserves the right to issue a Cha°8e Order Or terminate this Connacl or soy individual Products)included herein,at its discretion,if The Home Depot m its ahuhorized service pn+vider determines thaz it cannot perform its obligations due in a structural problem with the home,environmental hasaNls such es mold,asbestos m lead paint,other safety conrxsus,pricing errors orb because work required to complete the job was no[included m dre Contract Payment Summary The Payment Summary# 'Y9R n9g 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-incupy of the C m ract at the tone you sign. Do not sign a Completion Cerliticate(rate: 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- e m pay The Home,Depot the costs of Lmterials,labors 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 low. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR 07'HER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. er Acceptance and Authorisation: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot with regard m the Products and Iostailation services and su s all rim discussions and agreements, oral or written,relating to said Products and installation.This Agreement cannot be assigned m amended except by a writing signed by Customer and The Home Depot Customer acknowledges and agrees that Cus amer has read,understands,voluntarily accepts the terms of and has mceivpd a copy of this Agreement. A , red b Sobtmqq��aa by: r. _,� �/�r,,e� 6�3�r2 mars r store Date Sales Cansultant's Signature O Dater N Telephone No- Customer's Signature Dare Sales Consultant License No. (as app8rablc) CANCELLATION: CUSTOMER MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION jut*0 6 Z412 BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE TIMID RUSIN:iH - - DAY AFTER SIGNING THIS AGREEMENT. T'HE STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL,TERMS AND CONDITIONS ARE STATED OIt TIE REVERSE SIDE AND ARE PART(W TMS CONTRACT 104 Il CSC white—faarrth Foe yeilow—Customer sN• ",•yi , ✓rze 1Jom�na�eurea�c a�✓�aaac�uiaelCa � Office of Consumer Affairs&Business Regulation !� - OME IMPROVkMENT CONTRACTOR �r r t `. Registration-`i126893 TYPMw E . f Expirr�ration =g/3/20T2-- Supplement - The Home Dep64�At'Hnme Serviees -� - RICHARD FALLONE s 2690 CUMBERLAND PARVJAY S � — A'fTL�,t3R`A,GA 30339-''' •�"• P k Undersecretary r `NaOdnaf FanesaaCQn a,. �. s .C Pis ;�N�+� TiNC Pia �N..RGY PFi VALUaelarioae=NalMtsrrrQE�ScIa Heat GainCae cient `i U-Facer edaadaft-mc. nanea de`._�ergiaSalar Factaru l:? 11 .'l L • a,•ldcusn:�'• ' Nsft m ADD M ONA VAkLUACIN S p M'FOR anun NGE�Ft�4 BINDS t a.. , Vi,le 1ioaedrlustWba --r—"' U . 4 tl 'Pcatle®FEtCpnaEur`for detecn :nq:utnk proQuct perfcrmance.nd R (I ManNacssret stlpuutai tllatNete nW9s conlarin to apP 4 ro nduetfarany speuGe use.Wesultn:cuh tire;Y Gtep yreUroC.er Prcductpe la maned tatln9s are determinedtoratlaed selat envlmnmenulconQldans aml upeG4c ,edud uae.NFPC QoesnY,recommeedanyP anddaesnctwananl0~e subaoE at anyp lnfortnaricn.wrra.nfn.crd J M Este bCdeanle esUpula Wssstasmlwueumptm eaclat Pmcedimlentcs ap7caNesde Ncnts andetert^lnar elmnd�Menlo total del uM no umtla Que el Pe Bode aadauado Pars unasoesped4o.tansutteoonet "- pro vatares usadospw NpAL son delemilnedos parun 'aeW G^de«ndidgnes ame1cn41esY uriVma^o de Dndueto" ' ' aspecako.NFaL no recamiVA11P un Pod Y 9 paaeto dd faodcank Pan el use ap!aAma Qeene prrEado.YmKrrc.crg - r uxli ds -1 R oc GVZiiGI G1'x3 a1v. . y :i d toyi: Norctaeen. Nacth t, . p r .ppsrhera.'• ,,.... .. s:±v.h Cn;;_t rat, Taw void+rl rw l.i[ira far+ Inl^� SAW. • ;:..e ryu:�:l ie:i...::•.. SL:C.• 't:u[co-c:aa.cal. Ghic L:anualL ` a li Lcosaldcl8-:c25 T;;acad 6i;a: ri'u" x Et.' t� aor-o ; IV i::cic 3.13 yJC: AoE 203.2 Cal Tasoar\o Pcoh ado; 124.9 cm - ... - �ip '.'-i r>h l )4t CM OF sm-Em, A%Ss,kc iL'SETTS JLLLDVG DEP.1ATtE,\T 110 W."NoiGTON Srxw. 164 FLOOA r EL k978) 741-9595 1UJ�ERLSY DItLSCO(1. Fut(973) 74&9844 .�UYolt Mowf ST.PMXU DlAticTolt aP vt.auc vRove�T�r/ec 2oorc co�nnurov Ett Construction Debris Disposal Alfidavit (required for all demolition and renovation work) rn accordance with the sixth editlon orthe State Building Cade, 180 CMR section I 11.3 Debris, and the provisions of MGL a 40, 9 54, Building Permit v is issued with the condition that the debris resulting from Ihis work shall be disposed of in a properly licensed waste disposal facility as defined by ,&ICL c 111, 3 130A. rho debris will be transported by: �f— L� (none act hauler) rho debris will be disposed aria : (name m. ar ru,luy) r,Jdreuor•r,,,l„y 'f rut „ m,tipphc�n 'pia DATE(MMIDOMW) A CERTIFICATE OF LIABILITY INSURANCE 02/27/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-866-966-4664 CONTACT NAME _ Marsh USA Inc. PHONE FAX Exti, (AIC Nol' _ homedepot.cartrequeet®marsh.com ADORIESS: _ Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURERS AFFORDING COVERAGE NAICN Atlanta, GA 30326 _ Fax (212) 948-0902 INSURER A: Steadfast Ins Cc 26387 INSURED INSURER B: Zurich American Ins Co 16535 The Home Depot, Inc. New Hampshire Ina Co 23841 Home Depot U.S.A., Inc. INSURERC: P _ 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Cc 23817 Building C-20 INSURER E: NATIONAL UNION PIRE INS CO OP PITTS 19445 Atlanta, GA 30339 Illinois Union Ins -Co 27960 INSURER F: COVERAGES 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. INSR EXP TYPE OF INSURANCE AODL SUER POLICY NUMBER POLICY MMIDDVIYYVY LIMITS LTR A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 X DAMAGE TORENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ _ CLAIMS-MADE O OCCUR MED EXP(Anyone person) $ EXCLUDED X LIMITS OF POLICY XS PERSONAL B ADV INJURY $ 9,000,000 X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 9,000,000 JE X POLICY PRO- LOC $ B AUTOMOBILELIABILITY BAP 2938863-09 COMBINED SINGLE LIMIT 1,000,000 Ea amitlent X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PR der DAMAGE $ HIRED AUTOS AUTOS _ Perre ccitlent X SELP INSURED PHY DMG $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY YIN IMT D ANY PROPRIETORIPARTNEWEXECUTIVE —1 NIA WC019 7 3 6 917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? Lyj E (Mandatory In NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 1,000,D00- Ifyes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Workers Compensation WC1192494 (QSI) 03/01/1 03/01/13 SIR (AOS)/SIR (GA) 1M/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 p TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/lM DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20r-- ATLANTA, GA 30339 USA ©198§-2010 AGORD CORPORATION: All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORW Jthornton hd J j 1 1,1,7' 2 L r 1 7 J. JI -H. lunl).MiI7 work-r3, C c r-!-Ap-,32 -n r L:su 1.2 3] e Aff-; brit, Bi-! c i ri c!2E,5,P1 u i3abt:r± 131foriflatio- L-QsE Print L,,eRiM� "Iddress: "City/State�/7ip: Id = Priolic Are yolu an Employer ChLch- the appropriale box! Type Of pruj2ut (ray-1;3Jrz.(l)'. 1. -j I am a employer with C�r 4. 1 111] 8:-tmeFal Colluduor -cim'! I employees (fulfaiid/orparlt-iiine).* have hired Liu sub-contractors .-J listed on die atlacbcd . 7. [] Remodeling 2.❑ 1 am I sole proprietor or partner.- sheet. I I ship and have no employees 'fliese sub-contractors have 8, E] Demolition working for me in any.cipacily. workers' COMP. i-11SUMFIC'e. 9. E] Building 2ddiilon- [No workers' comp. insurance 5. ❑ We are 2 COrPOTaliOD and its - 0. required.] officers have exercised their 1 0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I I El Plumbing repairs or addition: myself. [No workers' comp. c. 152, §1(4),and we have no 12-El Roof repairs insurance required.] t employees. [No workers' 13 Other insurance required.] [tr Any applicant that checks box fit must also fill out the section below showing their workers'compensation policyiorbmation:. Ilonnowncrs who sulurnit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indi,,tj (Contractors that check this box must attached an additional sheet showing the ti me of the sub� and their workers'comp.policy info� onlmctors ng such. tion. I am an employer that is providing workers'compensation insuraaree for my employees. Below is the policy and job site Insurance Company Name: 12 Policy V Or Self-hrs. Lie. 4: �fj 7-72 Expiration Date Job Site Address:--._,_.___-___ City/State/zip.: Min I ch ,I copy of the workers' compells.Ption poll y declar-110" page (shONving the policy number and expiration date). Failure to secure coverage as required undet Section 25A of MGL c. 152 can lead to the imposition of cfijjunaj penalties Ora fine up to $1,500.00 and/or one-year iniprisOnoleDt, 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 st2tellicul may be forwarded to the Office of I invcsfigitions of the DIA fi insurance coverage verification. �sLtt�"Llu"� or Luc t coverage verification. � hereby Idoceltifyund f eFaAsan pena ies oflieijury that the information provided above is, rue and correct Si nW Signature: Dzi[C7 .Phone#: Ojjic I ial,use on I 1y. Do not write in this area, to be completed by cityor town official. City or Town: Perinit/Liceirse # Issuing Authority (circle one): I. Board o.f Ilealth 2.Building Department 3. Cityrrown Clerk 4. Electrical Inspector 5..Plutubing Inspector 6.-0 tit cr Contact Person: Phone H: