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39 1-2 HARBOR ST - BUILDING INSPECTION ' The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY�l M Massachusetts State Building Code, 780 CMR SdMar/ Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a p One-or Two-Family Dwelling '11 This Section For Official Use Only Building Permit Number: Date App ' d: el ( I Build ng OffeiiiI(Print ame) Signature Dateate SECTION 1:SITE INFORMATION 1.I Property Add s 1.2 Assessors Map& Parcel Numbers 1.1 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 ft) 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes[] SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: tt�nw� 7elAV112,Pr 1�1� nlgz Nwne(Print) City, —taate, IP / No.andrS`lreet a hone 9~ Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ 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: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ GUI7 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction�}pervisor License(CSL) License Number Expi a Uate Name of CSL Holder List CSL Type(see below) No. 1 Street "�fT" Type Description � U Unrestricted2 Family (Buildings u el 35_.000 cu. tt.) 7-/I/P�1�� `—� �J R Restricted I&2 Famil Dwelling City/fown,S ie. . M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Ho mprplv¢ment C etor(HIC) HIC Registration Number Ex irat on ale H e or HIC Re i NJ,. S eet //J Email address City/Town,$tale,ZIP ` Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuer a of the building permit. Signed Affidavit Attached? Yes .......... 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 perms application. L } Print Owner's Name(Electronic Signature) Dole SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby att under the pains and penalties of perjury that all of the information cont ai in this a lication is true and ccu at o t est of my knowledge and understanding. Print Owner's or Authorized Agent's Nafne( ctronic. ignature) Date 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 can be found at www.mass.eov.oca Information on the Construction Supervisor License can be found at vt_ww.mass.eov/dns 2. When substantial work is planned, provide the information below: Total Floor 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" Apr 1011 10:44p Kowalczik 9789362838 p.1 HOME IMPROVEMENT CC NTRACT PLEASE READ TH ( f ��� Sold,Famished and Installed by: Branch Name: Boston Date:"1 /Jt//_U_ THE,At-Homc Services,Inc. dfbia The Home Depot At-Home Services SA Greenwood Street,Unit 2,Worcester,MA 01607 Branch Number:31 Toll Free(800)657-5182; Fax(508)756-8S23 Fade I ID#75-2698460;ME Lie#C 02439:RI Cont.Lie#16427 +� CI'Lie g 565522:MA Hamc impm�•vtee.,.Jt Coninctor Reg_9 126893 Installation Address: �,�,)q ___ 1�YXJ✓ SLI c..-. /'V) 1 r t K Citv State O f Zdr•�Q t'urchaser(s): Work Phone: Home Phone: /Cell Phisma: Home Address:_.._— _. - — _....._..._..... -._----- (IfditTerembom Installation AddresS) City State Zip E,cn ddmss(to receive project canummications and Home Depot upda[ ): 5 �_ C)_�Cc�� •lXJ t7� [} NOT wish to receive any nwrketing emails from The Home Depot Protect information: Undersigned(`Customer'),the owners of Die proper y located at the above installation address,agrees+to bay, and THD At-Horne Services.Inc.("The Home Depot")agrcat to foriiish, liver and arrange for the installation C'Installatio»')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 Sunune ry attached hereto and any Change Orders(collectively, "Contract"): Job#: .,.,te.urt a P_ ws t_insu� m ts: S ce Shmus it: Project.Amount_ ❑Rixating OSidine indo _ i (]Gone„C.vers btintry Dlwrs ORooting OSiding 0 windmvs O Insulation $ OGmtcrs/Cbvus OEnuy Doors Q _,_,_. _ I _ i ORnpfing 1]Siding Windows ❑Insulation I _ _ _ _ 1 �_.. OGdticr -,,rs OE W Doors O_ ---]-OR oniing 0 Sid;'ng O inEous O atsulaunn ( S i ❑Guttcrsr Cavcrs ❑Gmry Doors ❑ i Minimum 25 .Deposit or Contract Amount due upon astrution of this to ffrom Total Contract Amount .s, Maine Porckaurs may m4depnsi[rrsarcl.,n tore-third of[he Cwmtrac[.Ammmt tJ C_O . Customer rureeS that, immediately upon completion of the work for each roduct, Customer will execute it Completion Certificate lone for each Product as defined by an individual Spec Sheet) and pay an balance duc. 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 dui Contract or any individual Product(s)included herein,at its discretion,if The Home Depot or its authorized service provider delennin s that it cannot perform its obligations due to a structural problem with the home,environmental hazards such as could,asbestos or 1 d paint,other sat'cty concerns,pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary # Z . included as part of this Contract, sees forth the total Contract amount and payments required for the deposits and final payments I y Product(as applicable). NOTICE TO CUSTO R You are entitled to a completely filled-in copy of the Contract at the tim you sign. Do not sign a Completion Certificate(note: them is one Completion Certificate for each listed Product as defined ky individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay a Home Depot the costs of materials,labor,expenses and services provided by The Hoax Depot or Authorizod Service Pro 'der through the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. IIIE 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 RECO ERY OF SUCH AMOUNTS. Acceptance and Autb crizatione Customer agrees and understands that tl is Agreement is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services a rd superscdcs all prior discussions and agrccntems,either oral a written, relating to said Products and Installation.This Agreement ennot be assigmed or amended except by a writing signed by Customer mid The Home Depot Customer acknowledges and agrees tba Customer has read,undu'smnds,voiuntnrily ncccpts the terms ��lo�,ffa and �has received a copy of this.}gncmcnL Xcce"'ram-oF/ ktJrct.- (r �i j Sub i by: 'T- �U'- f 1 x Customer's Sigrufrftm - Date Sir es Con sultant"s Sig(g��(tunee Date X Tcicphon No. l X 2); X InWC Customer's Signature Dare Sales Cor sultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (a'n°pli.biel 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:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE EVERSF.SIDE AND ARE PART OF THIS CONTRACT 9-7-10 GSc white-Braxfi File Yellow- ustomer 3 ' - - Li.L" �C'.N::?ti SU.iti4` �r..,ArTw• U-�adcr SdarNe GainCf�',c.act •Fec- U - G,rrs�C�naCadai.•z.•tiicLit •• _ /Q . 32 A,DDMONALPERF.tiHMAr10ERATlNGS . -. psi lyerfnN YUPi.F7fET(fANA _ ' tirihctrr seµlabe tm?++i rApos�mtoalotli HPL R?�•aaMrtl+n,Lldivm►,a vt'tr^'.�:jsi'c.. `••rmfa n berRN,aa tr akoa rt l.xlvm:Mr males u+s t aad,s r �![ a �ecm+tra.t7 t' rd da a y yR.Q a'a�GIQ f rig kr nY VKIlc iQ+aRrtaz edaat b ws kr?laPRld 'Km mtrtsm Ada a.a eme,esaa air�ial an beR¢mcrkYa !IlY Pn m'aml�ra tvmrbl7 ix •.• pbdmtd v.la.aum o wpcmdw 4wda perueca"A,hadlld p"'; p1vfOmuta npaim' ,[far.9�j(ALm�vmfrdit�V�P�Y!ei�Y��*°d��dsiaft.Pramup a�Gi•Ya @ate-ra.l: . .Mkt!4i ldtti�Y Wt 1 Asa aim h ui(Padc4a�'`'udca7.:'''-• '. �} ' UALC Clot LCLi> roc•CNERCY SWL .•,n r[q Len(aI' Ne c[Ri cA, HocCR • - cr C.At.l L,-10,lh CSAte>L" So+thl.n.• . ... ShC Aaf LfAR Li, m10.aQ a�LLfLm P>.> In iej .• ' 1- ;� _ .;� cis�LGn lull ;l'/NBftOT ]Tlil,•,afocla. , Sac CaA Coal, Sae. ' ..a-��. •- ' `LNO: ti+le a0/Cliaa 3/IS'!if-Ri]:. ' • 'D ' Listed Slat: 1C' M 61' • Igo; saf.Acco 00/Yld<Lo 2.16 Ha/R-Ri3 - J_�C / -A Tuu fo pcobtdo: 91-1 cx n ls6a cam: • 40111 . .•..Hs. raLiu.In :a9sttta. E�9se9Ffe1. - - • . .. . . . Cnp9a66etktpaktllac(_svr�kJwlm�a'Al ar.:nep�ALOa. . G,d[[iwm ijtiwp w9 naarbcbss aunt SUC ha nro v aam di a t:v6Ci mlmeq>�aa� �••� -Office or Con A(fairs&Business Rcgulalion 0ME IMPROVEMENT CONTRACTOR Registration 426893 TYP4 EzpiraUon_ 813f26t2_ '•'-SuPPlement� The,;Home DePoC'Af-hbmeSet+nces RICHARD FALLONE ., 2690 CUMBERLAND PARKWAY S g -47134� r-> an¢to n_A—tecrelary ® DATE IMMIDDIYTYY) a�ub CERTIFICATE OF LIABILITY INSURANCE 02/21/2011 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 1-404-995-3000 CONTACT NAME: Marsh USA, Ins. PHONE II g' FAX No: homecienot.c er treques t@lt lar.h.com ADDRESS'. Two Alliance Center, 3560 Lenox Road, Suite 240E Atlanta, CA 30326 INSURERS AFFORDING COVERAGE NAIL# Fax (212) 948-0902 INSURER A: Stead East Ins Co _ 26387 INSURED INSURER 8: Zurich American Ins- Co_ 16535 --_ The Home Depot, Inc- ew N Hampshire Ins Co 23891 Home Depot U.S.A., Inc. INSURER C: P 2455 Paces Ferry Road N4I INSURER D: Illinois Matt Ins Co _ 23617 Buildin_ C-20 NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER E: INSURER F: Illinois Union Ins Cc 27960 COVERAGES CERTIFICATE NUMBER: 19834682 - 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.'NCI.91THSTANDING ANY REQUIREMENT, TERIA 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. LTINSR ADOL SUOR TT POLICY EFF POLICY EXP LIMITS . TYPE OF INSURANCE r, POLICY NUMBER MMIOOIYYYY AWDDNYYY _ A GENERAL LIABILITY GL04887714-01 03/01/1] 03/01/12 EACH OCCURRENCE S 9,000,000 CAMAGE'fO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea Kounencel- E 1_000,900 CLAIMS-MADE, OCCUR M E D EXP(Any one person) S EXCLUDED - X LIMITS OF POLICY XS - PERSONAL S A_DV INJURY $ 9,000,000 X OF SIR: $IN PER OCC GENERAL AGGREGATE S 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 9,000,000 X POLICY PRO- LOG S B AUTOMOBILE LIAR I LITY BAP- 2938963-08 03 O11 03/01/12 COMBINED SINGLE LIMIT l,OD0,000 _ Ea.cadent X ANY AUTO- BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - -- NON-OWNED - PROPERTY DAMAGE S __ ---- - HIRED AUTOS AUTOS Per,accident X SIR AUTO P Y S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE _ CEO 1 1 RETENTIONS E C WORKERS COMPENSATION WC061967352 (ADS) 03/01/1 03/01/12 X J CO VLAM OTH- AND EMPLOYERS'LIABILITY D ANY PROPRIETOR/PAft71NER1E%ECUTIVE YIN WC061967354 (FL) 03/01/1 03/01/12 El,EACH ACCIDENT E 11000,000 OFFICEPIMEMBER EXCLUDED? O NIA '"'-"� E (Mandatoryin Nil) WC061967353 (CA) 03/Ol/1 03/01/12 E.L.DISEASE.EA EMPLOYEE E 1,000,00E If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 C Workers Compensation WC061967355(KY;MO,NY,WI, 113/01/1 03/01/12 F TX Employers XS Inden¢iity TNSC46244151 IT 03/01/1 03/01/12 Occurrence/SIR 30M/1M E Workers Compensation WC1192378 (QSI) 03/01/1 03/01/12 SIR 3M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addllional Remarks Scbedule,it more apace 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-20 -- �— ATLANTA, GA 30333 USA 11 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name.and logo are registered marks of ACORD jtiero End nR YS 9,-.,s� 16 1 A'vo irAl 0"4' L!f;C lif+y tfii l��r,, St. ( 1'�;'�19.C6?k�t�(�91.1"i9yCTYLI�.'''�.1'� 1rE�i !1'k1�. Y�FkYYF9. :u t11,61,11191 1i+11 Z1 1` � 1 ✓ 1 [la uas j$ti1;I'z' IrnpP"ol+olll+ Itfl �;nntnacA`M1-I' irl 'Llr111 1APi_Cls4 J Y 1 r 13o%C-11 RM. Ao.;IP T`anYaIC IA•u�f.crss ssp9 rslncrl ttrrtf tsI!['l:is rt :l i..ir'+s"'if•`' T ,4 hIL"i r Ikl'Ids +"l l f F.�9s(il4la+i;'GVIY LAW 7,nu•i4 t nia+A f,,D 4Afd 1•t'anvy;:.iui"r:;S . 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(978) 745-9595 FAX(978) 740-9846 KIJ®FRr FY DRISCOII. MAYOR THo.+us StPt�as DIRECTOR OF PLBLiC PROPERTY/BUMDLNG 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 111.5 Debris,and the provisions of MGL c 40, S 54; Building Permit Al 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 of facile )' 6- (address of facility) GQO—L 1'r'1411 sig tune of per applican 7 ate debnvif d•e: 1he Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations - 600 Washington Street - Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: BuEders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgmizgiitin/Individual): Address: rS7 e U CC251 Q152 I City/State/Zip: �I Are y an employer? Check the appropriate bom Type of project(required): IIIIII 1. I am a employer with__ 4• ❑ I am a general contractor and I 6 El Now construction he hued the sub-contractors employees(full and/or part-time).- have listed on the attached sheet 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- These sob-contractor have $ ❑Demolition . ship and have no employees working for me in any capacity. employees and have workers' 9 Building addition comp.insurance. [No workers' comp.inc�*,-once ip.❑Electrical repass or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their I1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roo repairs insurance required]t - c. 152, §1(4), and we have no 13. -J�1) 1 IJA'f)� — employees. [No workers' comp.insurance required.], . -Any applicant that ebwlo box#1 must also fiU out the section below showing their workers'eompeosation policy information. t Homeawoers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. 7Contrs Wn that cbeck this box must attacbed on additional sheet showing the name of the sub-aont=tors and south whether nrDOt those entities have employees. if the subcontractors have employees,they mustl3 f ide their workers'comp.policy number- I am an enloyer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. r'-- Insurance company Name: PoLcy#or Self-ins, Lic.#: ('0 1 q4/i �r Expiration Date: R.b S dd 'Z.i_ 5 1(- � Ci y/State/lip: ST eo r Attach a copy of the workers' compensation policy declaration page (showing the policy number and erpiratioa date). Faiure to seaLrc coverage as required under Section 25A of MGL c. 152.can lead to the imposition of criminal penalties of a fine up to 31,500.00 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 Invest lions of the D r insurance coverage,verification I do hereby certi un a he ins d e alties afperjury that the information provided ab ire is rue and correct Si atur:: Phone# Official use only. Do not write in this area, to be completed by city or town cffrcial. 7ung City or Town: Permit/l.icense#Issuing Authority(circle one):1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5Inspector 6. Other Contact Person: Phone#: