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40 HANSON ST - BPA B-13-95 C'onununwvallh of,klassachusells Board o1 Building Regulations and Standards CI I OF sl , \Ltssachuselts State Building Code. 780 CAIR Building Permit ,application ro Construct, Repair. Renovate Or Demolish a Otte-or riso4li n h, Vite/1111 This Section For 011ilviorUse Onl i Building Permit Number. Date ppli• : IhrilJiny 011ieial 11'rint N;uhe) tiignalurc Ualc SECTION I:SITE INFORAI TIO I.I Property A90, 1.2 assessurs blap fi reel Numbers I.la Is this an acce ted streel? ,es no Map Nunther tiered Number 1.3 Zoning Information: 1.4 Properly Dimensions: Lnniny District I'mposd lhu Lol Amu(sy 11) Frontuya ill) 1.1 Building Setbacks(R) Front Yard Side Yards Hoar Yard Required PNYWed Required Provided Required Providd 1.6 Water Supply:(M.G.I.c.J0.§54) 1.7 Flood Zone Informallon: 1.1 Sewage Disposal System: Public❑ Priv ale❑ Zone: _ Outside Flood Zuni? Municipal❑ On site dig sal f Sion ❑ Check if cs❑ P Du ) SECTION ]: PROPERTY OWNERSHIP' 2.1 Owners gGgecord: City.Slate Y15�t 7.4225� Nu.;wJ Streot rolephune Email Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteratfonts) ❑ Addition CO) Otnwlilion ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ .Spocisy: Brief Description of Proposed Work':. '- SECTION 4: ESTIJIATED CONSTRUCTION COSTS hail. Estimated Costs: ILahur;md Materials) Official Use Only I. Duilding S I. Building Permit Fee: S Indicate how fee is delernsined: 2. Flecuical S ❑Standard City'russn Application Fee ❑Total Project Costs I Item 6)a multiplier _ _ x 3 I'luwhing S — ..__ ._ _. Usher Fees: S J. \IKhJnIi.II rll\- \( 1 S List: 9 \Iccli.utiad iRre \nrfelS Wnl S rolal \11 Fees: S tr Pohl l'rnject Cos: S /^� Chvvk \u. _. .__ChccA :\nunurt: . . ._. ('.r>h \mrnuu: v 0 Rrid in Full 0 Oulscmding B.11.ulve Due: SE( IION 4: ('ONS I RIICI-ION SFNN'1('FA S•1 Cbnslrucliun : enisurl.iC e(CSL) I ICen>e Nunlher I Ipvaul a Ile Name ,,..o��lC,,.111 "JJer I ist('St. I\pu l•ec hdall).__._ 1 11 Jr�\ 0 PC Ikiaripliun It I nrcftrteled lllm Idill Es'In to 14,111111.n. I11 ry Ih?I.unit Dlt cilia Cil)/rolw..\Idle.LI FFF-----fff'441 -'—�-•t-t \I Masonry NC Nlatin Cln Grin Jutr.utd SiJin SF Solid Ivc1 litiming Appliances /ram I Insulaociliun ICle hun (mail:IJJrma l) Drnnuoliliun 4.2 Registered Ilume In vent 1 t Cunt r or(fI1C ` aG IIIC• Itcgivuutiun NPItlber li pir, um Date IIIC Cone t •or I unm Nu. alu S •el �I��� r )GV fGX3F 3 Email uJJn+s Ci lfown, State IP ( / fe1c bane SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G,L C. 152. 1 25C(6)) Workers Compensation Insurance affidavit must be co eted and submitted with this application. Failure to provide this atttdavit will result in the denial of the issuance the building permit. Signed Affidavit Attached? Yes .......... No ...........O SECTION 7 W a:ONER AUTHORIZATION TO BE CO�IPLE I WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit applicat on. ate IMnt O%%ner's Nwnc(Clcctmaic Signature) SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below. I hereby attest under e p ins and enalties of perjury that all of the information contains • this application is true and accurate o th of y owledge and understanding. d�7 . �, e Ffllll OI1llef•i a1:\II(bllrl/l'J r\gelll•i Nllllpt Wieclranic s- nature VOTES: I. .\n Owner who obtains a building permit to do his.her awn work,or an owner who hires an unregistered contractur tout registered in the Hunter Improvement Contractor(HIC) Program),will nu have access to the arbitration program of guarmt) I•und under M.G.L. c. 142.>. Other impurtant information on the HIC Program can be Iuund at "\"% nl.1" .I .. I information on the Construction Super%isor License can be found at III,H n1.1•2. "d:•` 111� \\hen substantial Iwrk is planned, pruvide the infurnmliun below: rota) tlour area I sy. It.) . ____.._I Including garage, Poislwd basement arks.Jocks or perdu ,1rea 1 iy. It 1 Habilable foul"count Cirnislisiog - _ Number tit'hcdruools \In tl her of llre111.tees t .. \unlbvrul'hal(halhs I \umber of hadvlwnls . I\pc of henrng i)Ilrm \anther III Jecki porches I)pc,lfc..oliny .)uem 1 "I,d.111'rolcd sylldry 1:ool.lec" 1113) hl• .IIh1111111eJ ha "total Project(•o%C BOB DANGELO 9785157765 p.1 HOME IMPROVEMENT CONTRACT ' PLEASE READ THIS J �� � < Sold,Furnished and Installed by: Branch Name: Boston Date: Jr!✓n 1 0 O f-, THD At-Home Services,Inc. / d/b/a The Home Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 Toll Free(800)657-5182;Fax(508)756-8823 Branch Number.31 Federal ID#75-2698460;ME Lic#C 02439;RI Cons-Lic# 16427 CT Lic#HIC.0565522;;MA Home Improvement Contractor Reg.#126893 Installation Address: yo &afnM 10 0/970 City State Zip Purcd.aser(s): Work Phone: Home Phone: Celt Phone: Orr A)sJe N [ ] [97s]P4Y 76a 5 [ ] Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any ma keting entails from The Home Depot Proieet 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 ("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 Orders(collectively, "Contract"): Job#: n—.rwx,.".vr Products; Spec Sheets #: Project Amount ❑Roofing Siding Windows ❑Insulation 6�9 /p&6 TY ❑Graters/Covers ❑Entry Doors ❑ s/,3$6 $ C, 7 10 — ❑Rooting ❑siding ❑Windows Insulation ❑Gutters/Covers ❑Entry Doors ❑ $ Roofing ❑Siding ❑Windows Mrisulation ❑Gutters I Covers []Entry Doors❑ $ Roofing iding Windows El Insulation $ ❑Gutters/Covers ❑Erdry Doors ❑ Nr®mmn 25Y.Deposit of Contract Amount doe upon execution of the contract Tots Make Purchasers may notdepask more than onothed of the ContrartAmount l Contract Amount $ 6 7 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 severalty 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 # , 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 Tilled-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 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 LLNHTING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization: Customer agrees and understands that this Agreement 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 Agreement 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. Accepted by: Submitted by: x (��ir,�n�jf uoe. 400/&-teii Z x Customer's Signature Dade Sales Consultant's Signaturca Dale The Cormnanwealth ofMasstach isetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/fndividual): 1� Qf/' 1�t•7��� 'Address:- City/State/Zip: ��,�Q� Phone.#: . _7�L _ Are yo employer? Check the appropriate box: Type of project(required) t. I am, employer with_ [2 4. 0 I am a general contractor and I employees (fill and/or part-time).* have hired the sub-contractors 6. ❑ Now construction 2.0 I:im a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship and have no employees These sub-contractors have S, 0 Demolition working for me in any capacity. employees and have workers' insurance.( 9• ❑Building addition [No workers' comp. insurance comp. required.] 5. 0 We are-acorporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 1 LQ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roo airs insurance required.]t C. 152, §1(4),and we have no employees. [No workers' 13. Cher 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 subcontractors and state whether or not those entities have employees. If the subcontractors 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. Insurance Company Name: Policy#or Self-ins. Lic.#: Exp ration Date: Job Site Address: _`' � �_City/State/Zip: Tl �1 �� 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 £me 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 if up to$250.0 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestgatiog of the IA for insurance coverage verification. I do hereb certify er t e pai sand penalties ofperjuty that the information provided above 's true nd correct. Si nature. Date: Phone #: F l use only. Do not write in this area, to be completed by city or town ofjlciaL Town: PermiMeense Authority(circle one): d of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector r Person: Phone#: CITY OF S.V-&Nf, Aus.kCHE:SETTS JL'tLDLVG OEP.%An1F.\T I _'0 J7.liHLVGTON ST7lH8'I', Yo ROOA rEL. k973) 141-9595 130FRLAY 01=OLL FAX(913) 749g.W tiUYolt ntou r,Sr.pmxxs Ormcrox OP pL aUc PRO PERTY/at;MDLNG CO,101f311O.%E4 Constructlola Debris Dlsp0s31 Affidavit (required ror ill demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 C/bfR section 111.S Debris, and the provisions of MGL a 40, S 34; Building permit M this work shall be " issued with the condition that the debris resulting from disposed of in a properly $ I JOA. licensed waste disposal facility as daBncd by NICE a III, The debris will be transported by: name of'haulvr) rho debris wi It be disposed orin : (name a/facdr y) f iddreis at rjal,(y) In+ s o(pe U ipphcrnt J� DATE(MI11DYl !! , ) aa yyqy�ap�TE 77 ,,tqqq y)pp Y INSURANCE � qI� ��q N!� � 02/27/2 CERTHOLDER.. THIS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORM T AION ONLY AIVD CONFERS NO RIGHTS UPON THE CERTIFICATE POI CERTIFICATE DOES NOT AFFIRMATIVELY ZED BELOW NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THEE POLICIES THIS CERTIFICATE OF 1NSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IPISURER(S), A� REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED the poilcy(les) must be endorsed if SUBROGATION IS WAIVED 'he e the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not can er rlgfit certificate holder in Lieu of such endorsement(s1. CONTACT - -- 1-866-966-9663 NAME: Fax RODUCER PHONE -- arah USA Inc. AI Et: E-MAIL -- ADDRESS: NAIC N wo Alliance 3560s Lenox INSURERS AFFORDING COVERAGE --- wo Alliance Center, 3560 Lenox Road, Suite 2400 26387 .tlanta, GA 30326 - INSURERA: Steadfast Ins Co -- 'aic '(212) 948-0902 Zurich American Ins Co 384 INSURERS: 1 NSURED - 23841 New Hampshire Ins Co :he Home Depot, Inc. -.. INSURERC: Inc. 23817 come.Depot U.S.A., INSURER D: Illinois Natl Ins Co — 1455 Paces Ferry Road NW - NATIONAL UNION FIRE INS CO OF PITTS 19445 3uilding C-20 INSURER E: %tlanta, GA 30339 INSURER F: Illinois Union Ins Co REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: 25776028 NE BEIEN 0 THE INSURED 7THIS IS THIS INDICATED.CNOTWITHSTANDING NOTWITHSTANDING. ES Ql-.IINSLU�RANCE LISTED REQUIREMENT, TERM OR CONDITION OF ANY CONTRA DCES DESCRIBED OTHER DOCUMENT WITH REC TECT LL T HICHBOVE FOR HE POLICY RMS. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES ID CLIMS. HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES:LIMITS SHOWN MAY HAVE BEEN REDUCE[)CV BY PAID lcv ExaS um1T$: iNSR ADOLSUBR POLICY NUM BER MM too IYYVY MM/DDIYYYY INR TYPE OF INSURANCE 03/01/1 03/01/13 EACH OCCURRENCE $.9,000,000 GL04887714-02 DAMAGE TOR NTED nce $ 11000,000 A GENERAL LIABILITY pftEMISES Ea occurrence)) -- X COMMERCIAL GENERAL LIABILITY MED EXP(Any one person) $ EXCLVDED - CLAIMS-MADEff]OCCUR 9,000,000 PERSONAL 8 ADV INJURV $ X LIMITS OF POLICY XS GENERAL AGGREGATE $ 9,000,000 X OF SIR: $IN PER OCC PRODUCTS-COMP/OP AGG $ 9/000/000 - GENT AGGREGATE LIMIT APPLIES PER: $ " 11000,000 X POLICY PRO- LOC 3 01 3 01 13 COMBINED SINGLE LIMIT HAP 2938863-09 Ea accident H AUTOMOBILE LIABILITY BODILY INJURY(Per person) $ X ANY AUTO BODILY INJURY(Per accident) $ ALLOWNED SCHEDULED PROPERTY DAMAGE $ AUTOS AUTOS -Per accident NON-OWNED $ HIRED AUTOS AUTOS X SELF INSUR D PHY DMG EACH OCCURRENCE $ UMBRELLA LIAO OCCUR AGGREGATE $ EXCESS UAB CLAIMS-MADE $ DED RETENTION$ 03/01/13 X WC STATT- OTH- WORKERSCOMPENSATION WC019736915 (AOS) 03/01/1 C YIN 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 ANY EMPLOYERS' WC019736917 (FL) 03/01/1 D ANY OFFCEWMEMBER EXCLUDEDP ECUTIVE� NIA 03/O1/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 1,000,000 E (Mandatory in NH) WC019736916 (CA) 1,000,000 E.L.DISEASE-POLIGV LIMIT $ If yes,describe under 03/O1/1 03/Ol/13 SIR (AOS)/SIR (GA) 1M/750,000 DESCRIPTION OF OPERATIONS be low WC1192494 (QSI)' E Workers Compensation 03/01/1 03/01/13 C Workers Compensation TNSC46566 9 (WI) 30M/1M F TX Employers XS Indemnity TNSC46566397 (TX), 03/O1/1 03/O1/13 Occurrence/SIR DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if ore space i m s required) RE: EVIDENCE OF COVERAGE CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THE HOME DEPOT, INC. ACCORDANCE WITH THE POLICY PROVISIONS. HOME DEPOT,U.S.A., INC. - - 2455 PACES PERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 111 " ' ATLANTA, GA 30339 USA. ©198q,2010 ACORD CORPORATION; All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACOR6�= ✓ we '. , OfticeoEConsufier m Af(airs&Busess:Regulahou ,II lWIRR.OVFVIENT-CONTRACTOR �. ?Yp . Re9isRat:.ton-s�#Q6893:. Supplement Expi1re' . fkj4 HARP FEAR 26 (J-CIM'e�BEjt ':.SI 1.4 " ipw30339� �iJud'ers'eccetary 4 rr f _nard or Bul ling R gnlationn Ind CSSL-099699 _1 d ROBLRT POCZOBUT - =- -+ 172 WHAL6NS LANE,' -- Salem MA 01970 i JX Ex; rao<;a 02/08/2014