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2 HARTFORD ST - BUILDING INSPECTION Tom- IS-70 c < -7 2zZ DSO,° ( Z t �j The Commonwealth of Massachusetts ECEI Board of Building Regulations and Standards INSPECT ONA&FICES Massachusetts State Building Code,780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or DemoW SO' 2 S A I k 0 q One-or Two-Family Dwelling This Section For Offici ,Use Only Building Permit Number: Day Applied: Building Official(Print Name) Signature ty Date SECTION 1:SITE INFORMATION 1.1 Property Address: n) i 1.2 Assessors Map&Parcel Numbers L In 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(ft) 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' s _ 2.1 Owner cadV r i� Name(Print) ,� Citye ZIPS at o Jt No.and ree Telephone Email Address >, SECTION 3:DESCRIPTION OF PROPOSED WORW(check all at apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 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 O (Labor and Materials 1.Building $ 1. Building Pemri Fee: $ (Indic a how fee is determined:2.Electrical $ ❑Standard Cityrr Application e . ❑Total Project Cost'(Ile ' ier x 3.Plumbing $ 2.`Other Fees: $ 4.Mechanical (HVAC) $ List:'` 5.Mechanical (Fire $ Su cession Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ l r 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) L(��d �C`l� C�r�nyf 5 License Number Expira' n at Name of CSL Holder �f ,-tt 1©' il � List CSL Type(see below) No.and StreeW&,t .Type v Description U Unrestricted Buildin u to 35,000 cu.R Restricted 1&2 Famil DwellinCity/To",S M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances �owj5� ?y 1 Insulation Telephone ' " Email address D Demolition 5.2 Registered Home Im grove e t Contractor C) HICW" L _ HIC Registrafi n Number ion Date �s - 's t Name ej No. e t i Email address Ci /Town,State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c152 § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance a building permit. Signed Affidavit Attached? Yes ......... No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT" I,as Owner of the subject property,hereby authorize l lHW�/� to act on my behalf,in all matters relative to work authorized by this building permit appli ation. Print Owner's Name(Electronic Signature) I Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby a under the pains and penalties of perjury that all of the information contained in this a lication is true an ac to a best of my knowledge and understanding. t Print Owner's or Authdillied Agent's Name lectroni Signature) ate 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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 haWbaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by: PLEASE READ THIS CONTRACT THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike Unit 1,Shrewsbury,MA 01545 Branch Name: Boston North Date:9/2/2014 Toll Free 8779033768;Fax 8009863610 ME Lie#C 02439 RI Cont.Lie#16427 CT Lie# Branch No: 33 HIC.0565522 MA Home Improvement Contractor Reg.# 126893 Federal ID#75-2698460 Installation Address: 2 Hanford sT SALEM MA 01970 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: M/M Dan Richmond 978)854-3109 Home Address: 2 Harford sT SALEM MA 01970 (If different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates):dan24Ogmail.com Marketing emails will not be sent from The Home Depot. Project 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("Installati on")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(where applicable)attached hereto and any Change Orders(collectively,"Contract'): Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount 7758485 Windows 7758485 $1,702.68 „ Minimum 25% Deposit of Contract Amount Total Contract Amount $1,702.68 due upon execution of this contract 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 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# 7758485 ,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). 0710911"A P 0 of 7 1 The Commonwealth of Massachusetts s Department of Industrial Accidents Office of Investigations 600 Washington Street v .� Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): — Address: City/State/Zip: Phone #: Are an employer?Check the appropriate box: Type of project(required): 1. 1 aim a employer with �_ 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ l am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition and have workers' working forme in any capacity. employees9. ❑ Building addition [No workers' comp. insurance comp. insurance? required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their L'1k2. R ing repairs or additions myself [No workers' comp. right of exemption per MGL epairs insurance required.1 c. I52, ees. [ and or have no L, employees. [No workers' comp. insurance required.] *Any applicant that checks box NI must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an aipional sheet showing the name of the sub-contractors and state whether or not dense entities have employees. If the sub-contractors 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: , y Policy#or Self-ins. Lic. #: ��F�LIJ� Expiration Date: Job Site Address: DC / Jd !!F_ __City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy oum t' ate). 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$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 ' surance coverage verification. I do hereby certify under t e pa s d p alties of perjury that the information provided a ove is true and correct. Si nature: Dater Phone 4-- Official use only. Do not write in this area,to be completed by city 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 Contact Person: Phone#: �991/1;Zdfil.Z(J� 1uan.�'.Zfl�•Pic�:.J Office of Consumer Affairs'and Business Regulation 10 Park PIaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplement Card THD AT HOME SERVICES, INC. �� sr3rzats CHARD 2690 CUMBIrRLAND PARKWAY SUITE 300 - ATLANTA;GA 30339 _... Update Address and return card.Mark reason for ebangc. Alt a zmaosm J Address _I Renewal D Employment J Lost Card Sof rIce of consoaur Affairs&Noilam ulatioa Reg Licenseor reistraSioo valid for individai use only MEIMPROVEiF.WCONTRACTOR before the expiration datafffoundreturnto: Office ofCensumer Affairs and Business Regulation stratich: ;26F93_ Type: tOParkPi'ara-Site5176 Eipiraiion:i:BWO16 Supplement Card Boston,' Y u T H D AT HOME SERVICES.INIY 1 HE HOME DEPOT AT HOME SERVICES RICHARb FkLONE -. ?6w CUMB9kWgD'PARKWAY S 4 r-:..� - ' l;ndersrveury of va w -51 Y A� ,� GATE(MMiGOfY'fY'j �. CERTIFICATE OF LIABILITY INSURANCE 92J,91201i 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 _BELbw. THIS CERTIFICATE_OF_INSURANCE DOES'.NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE`OR PRODUCER,AND THE CERTIFICATE HOLDER. - - -!MPO�TA�1T; M_lhq,certl8wte holder Is an.ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS'NAIVED,subject to .the ions terms.and condit of the pollcy,certain policies may require BIT endorsement. A statement on this certificate does not confer rights to the certlflaate holder in lieu of such endcrsement(s). C T P0.000CER.. . _ - - NAME: FAX MARSI USA,INC - PHONE AIC No: TWO ALLIANCE CENTER EMAIL 3560 LENOX ROAD,SUITE 24CO ADORE S:_____ ATLANTA,GA.30326 INSURER S AFFORDING COVERAGE NAIL 0 INSURER A: Steadfast Insurance Company 26287 700492-HomeaGAW-1415 ._ . .....___._ . . - Zurich American Insurance Co 166a5 INSURED INSURER S. _ D13ATH HOMSERMCEATINC, INSURER C: New Hampshire Ins Co 23841 DBA THE DEPOT AT-HOME SERVICES Illinois National Insurance Company 22817 '�245&PACESFERRY ROAD - INSURER D: ... ATLANTA,GA-30339'-_ .' - - .._Z" - INSURER E: INSURER P: COVERAGES CERTIFICATE NUMBER: - ATL-003242685-01 REVISION NUMBER:3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEDBELOW 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. ILTR TYPE OF INSURANCE DD POLICY EFF POLICY EXP LIMITS POLICY NUMBER MMIDOM'VY MMIDONYYY 9,000,000 A GENERALLIASILITY GL048BT714.04 0310112014 0310112015 EACH OCCURRENCE 8 PRE cc n e $ 1,000,000 X-'COMMERCIAL GENERAL LIABILITY EXCLUDED CLAIMS-MADE M OCCUR LIMITS OF POLICY XS MED EXP AnY one arsan) $ OF SIR:$1M PER OCC PERSONAL a ADV INJURY $ 9,OOD,OOp GENERAL AGGREGATE $ 9,000,000 PRODUCTS-COMPIOP AGG $ 9,000,000 GEHL AGGREGATE LIMIT APPLIES PER: $ X. POLICY PRO- LOC 0 310 7 2 01 4 C3101I2015 COMBINED SINGLE LIMIT 1,000,000 B AUTOMOBILE LIABILITY BAP 2938863-11 Ea acndent X ANY AUTO BODILY INJURY(Per person) $ .ALL OWNED SCHEDULED SELF INSURED AUTO PHY OMG BODILY INJURY(Parattldent) 8 AUTOS AUTOS NON-OWNED PROPERTY DAMAGE § n Hill D Al1TOS AUTOS It UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB. CLAIMS-MADE AGGREGATE $ DED' RETENTION$ WC STATU- OTH- C WORKERS COMPENSATION WC 910188 (AOS) 0310172014 010112015 - - ....... ._ 1,000,000 AND EMPcoYERs•cfnealTr - WC0491D1884(AK,AZ,VA) 031012014 0310112015 E.L.EACH ACCIDENT s i ANY PROPRIETORlPARR�ER/EXEOUTIVE V�. NIA - 1,000,000 OFFICEPIMEMBER EXCWOEDT WC04910483(FLI 031OU2014 03/012015 E.L.DISEASE-EAEMPLOYE $ (Mandatory In NH) 1,000,000 It yes,tlescdbe under E.I DISEAGE-POLICY LIMIT s DESCRIPTION OF OPERATIONS bar. 1,000,000 C WORKERS COMPENSATION WC049101885(KY,NC,NH,VT) 03/012014 0310112045 (EL)LIMIT C WC049101886(NJ) 031012014 031012015 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addldonal Remarks Schedule.If momspacelsrequlretl) EVIDENCE OF INSURANCE - CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE -DM THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN �2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhedee 01988-2010 ACORD CORPORATION. All rights reserved. ACORD25(2010105) The ACORD name and logo are registered marks of ACORD I k 4 5 gg r S "�t��~+'3�-'eg �'aP,� N.u4rT�"�� a $ •'�u �„�i b„� `'�r..a "Tv su.+ . v� 3 Y1 v ° k N5't .4 - �3.' .. &�' .�,_• �d�J fc/y �Sa `�z�, ''��: ii�x�.,. 4j�.f"a, 3 ��'�k � h'xn ^� $r S' <v b� 'k ,i n.k-yiE kfir ,z3'w ,o- s $ rot uix d e 'v �v��"0W"Ib .PP' � j}q}�p�py x• '' LAM g' v � �"a{�t?�5£x� Txi x*�s° �' e, rah < � rescv 'nr,x t•�/ .x m � a .�xd s r'x 4.4 , s t a i CITY OF S.ULE:�I, NLkssAcHUSETTS • 3U11M1NG DEP�Rnt&NT 130 W ASHINGTON STREET,3tD FLOOR TEL (978)745-9595 FAX(978) 740-9846 KI\tBE u-EY DRISCOLL MAYOR THomAs ST.PIERRa DIRECTOR OF PUBLIC PROPERTY/BUILDING COWMSSIONER 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 i 11, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in K�4e q4T (name of c li y) 1 Cd4 of (address of facility) m: of permit applicant �L to a.ti,airauc