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5 HARTFORD ST - BUILDING INSPECTION i13 �� — � Z �v1 t2y cK s� � The Commonwealth of Massachusetts: Board of Building Regulations and Standards RE EIVOF Massachusetts State Building Code,780 CMR INSPECTIOgalyt t Building Permit Application To Construct, Repair, Renovate Or Dett�j),gqlI'tsh a One-or Two-Family Dwelling IYIU JUL 22 A ep 51 This Section For Official;Use my Building Permit Number: Date Appli : ` /' Building Official(Print Name) - Signature Date - SECTION 1:SITE INFORMATION 1.1 Property A 1.2 Assessors Map& Parcel Numbers _ l 431 1.1 a Is this an accepted street9 yes_; no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area.(sy R) Frontage(R) 1.5 Building Setbacks(it) Front Yard - Side Yards -Rear Yard- ._ . .. . . _. Reyuin:d 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 Flogtl-Zone? Municipal❑ On site disposal system ❑ Check if y�s0_ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of ecoI ,. ,t / r- > Name(Print) - City,Stale Zw e- ` _';HE �— 7 0 No.and Street 'telephone Email Address SECTION 3DESCRIPTION:OF'PROPOSED WORK (check all that apply) New Construction❑ rAcc, ting Building❑ - owner-Occupied -❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition : - ❑ ssory-Bldg.❑ Number ofUnits Other-,-❑'_Specify: Brief Description of Proposed Work2`�> SECTION 4: ESTIMATED CONS? ON COSTS F2. Estimated Costs: Official Use Only Labor and Materials uilding $ 1: Building Permit Eee:S . indicate how fee is determined: ectrical $ �_'❑Standard Cityrrown App icat on Fee ❑Total Project Cost?(Item 6)x multiplier x umbing $ 2. Other Fees: S 4. Mechanical (HVAC) $ - List: 5. Mechanical (Fire _ Suppression) $ Total All Fees: Check No. Check Amount: Cash Amount: 6. Total Project Cast: $ ❑Paid in Tull ❑,Outstanding.Balance Due. f)P<1 LIED I aJ TNIza V_ O.1J C�(c) Wvopov::�s J � SECTION 5: CONSTRUCTION SERVICES 5.1 Constructi n ervrs r ens (.) LicensdNumber I Ex4r ,�,Vte Name of CSL Holder E� List CSL Type(see below) Description No.and Sttreti Type �1 t^ D Unrestricted 2 Famidinly s u el 35,O1R1 cu.ft. --- �_�„���p R Restricted I&2 Famil Dwelling Cityfrown,State. 1 M Masonry RC Roofin Covering WS Window and Siding SF Solid Fuel liuming Appliances 1 Insulation Tale one ' Email address D 4Rs lii 5.2 Registered Ira veme ntractorReg(stered Hl� HI Expan on e tI1C C e r s e No.an - - - Email address City/Town.State,ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:L.rc. 152.'§ 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 f the building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION 7a:OWNE AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLI S 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. Print Owner's Name(Electronic Signature) SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION Nentering my name below,)hereby art t and he pain and penalties of peedury that all of the information n thi of on is we and a curate t e o knowledge and understandingrs or Authorize Agent's Name(File nic Sign •) Dat 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 toot 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.massCov/oca Information on the Construction Supervisor License can be found at wvvw.mass �ov/dos/dos 2. When substantial work is plannedlrovide-the inforration b'eloW Total Floor area(sq. ft.) (inciuding`garage, finished basement/attics,decks or porch) Gross living area(sq. fL) 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 ofcooling system Enclosed Open 3: "Total Project-Square Footage"may be substituted for"Total Project Cost" 2014-06.17 12:26 EXPDTR 9787390618 » Home Depot AHS P 2/10 HOME IMPROVEMENT CONFRAC.`f PLEASE READ'fH1S _ 6 Sold,Furnished and Installed by: h Nm Ilraneae:lki un Ntath& uuln S Date:&io/-Af 17fU At-Home Services,Inc. d/Ua The Hume Depot Al-Home Saviucs Branch Number:91 and 33 908 Wislla,Turnpike,Unit 1,Shrewsnury,MA 01545 1'011 1'1ee 877-903-3765 recieral II)»75-2698460;Mh Lic#C 02439!,RI Cent 11c#16427 rr CT Lic#HIC.0565522;MA Hum;hnpr0 serum Coolzaclot Reg.#126b97 Installation Address: •5 4QP}7orq sT Sgl4M Mf3 _ d1 9"1(:)-- City Slate Zip Purch'wrRs): Work Phone: Hume Phone: Cell Phone: 140n o In _on [so8] 3b4-Z4%ly [ ] h41]aIS-2d 1 e obtnsaN�_. � L J f 1 r Home Address; (If different from Installation Address) City may,, State n 'Lip Addreaa(lo rwctvc project communications and Home Depot updates): grl'�'plf�Lll� 19(c( C•�y4`1QD.�1K f ll0 NOT wish to receive any marketing emails from The Home Depot 'ce Info ntl ' Undersigned("Carillonneur"),the owners of the property located at the above Installation address,agrees to hay, an At-Home,Services,Inc.("'1'he Home Depot")agrees to furnish,deliver and arrange for the installation("Installafiort of all materials described on the below And on the referenced Spec Sheet(s),all of which are incorpnmted into this Cnmtruut bay this reference,along with any applicable State Supplement and Payment Summary attached herein and any Change Orders(collectively, "Contract"): Tub#: aeamml PSadurta.. Spec Sheet(A)#: Pngect Amuum I 1 Rtnti ng Siding, Windows 1]Insulation u W_73{�A"_�)� $ 59 s50� [3Gutwrs/Covers ❑paeyDoors O 7�t1/lVl ORooliug Siding ❑Windows Ll tnsulalra $ /'� []Gutters/Covers C]EmyI) [I ._oos —1 -- 1 /N - Roofing Siding❑Windows ❑insulation 1p�lUV ❑Churn/Comm ❑f Ary rxdrt� $ _ ❑hoofing Siding LJ Windows U Inadboon $ 0Gattlas/Coven ❑Hnuyunam ❑ 1,11idnmm25%IkErn*ofCllumat Amwmtdueupunewatianoft is contract. Mahnel'ur<baxu may nor depushmm than onstNmorlhe f:mmactAmount Total Contract Amount $ ��)f Custoner ugrmb dud, immediately upon completion of the work few cash Product,Customer will necure a Completion Cerlibcale (one for each T4nxluel as derriod by An individual SFxe Sheet)and pay any balance due. As applicable,well Customer under'this Conu'act agrees to bejolmly and severally obligated and liable hereunder. Thu Hume Depot reserves the right to issue a Change Order or termin;dc this Contract or any individual Product(s)included herein,at. i1.n discnairm,it line Huns;Dolan or Its autlicel2M service provider determines that u.cannot perks in iLs obligations due in,a structural problem with the home,envin insui al hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because work requital to eompldc the jobr was non included in the Contract. O ECe p Payment Summary. The Payincnt Summary# e5l�- —, included as part of this Court= sees botch the total Contract amount and paymerns required for the delxxsies and lined payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a eumplelely filled-in mpy of the Contract at the time you sign. Ike not sign a Completion CertlScate(note: there is one Completion f erliHeate for each listed Product as defined by hie lAdual Spec Sheet%)before work on that PrWmt is complete. In the event of termination or this Contract,Customer agrees to pay The Home Depol the ants or materials,labor,expenses and services provided by The Home Depot or AulhortRd Service lrrovider the date of termination,plus any other amounts set forth in this Agreement or allowed under applicable law. "I'IIE HDEPOT MAY WITHHOLD AMOt1N'I'S OWED TO THE IIOM, DEPOT FROM THE: IMPOSIT PAYMENT OR OTHER PAVMHN'1$ MADE, WITHOUT LIMI'fDNG TILE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acce lance and l 111145 zat�fOn: Customer agrees and understands that this Agreement is the entire agreement herwa:n Cuslumer an f to 1 urns Depot wltn regard to Inc.PrpW;Lti laid Installation services and superstdc all prior rii.,ii ohms and Agreements,either oral a written,relating to,suid produces and Insudlaliou.This Agreement cannot he assigned or cnnaded except by a writing signed by Customer and The Horn Depot.Customer acknowledges and airaa that Customer has read•understands,voluntarily awepls is terms of and has received it copy of this Abmemcnl. Ac peer Soh by: Si,manux: LY,ue Sales onsnitan's 5i itur�eyT Harr: Telcphtac Nrs �� a {� •CC73� .. ustomer's Sign fire Sales Consultant Liumnc No. CANCELLATION: CUSTOMER MAY CANCEL THIS meappunMd AGREEMENT WITHOUT PENALIN OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE 'THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT A7•I'AC'HED HERETO I CONTAINS A FORM TO USE Ip ONE IS SPECIFICALLY PRM:AIRED BY LAW IN CUSTOMER'S STATE- No I MR%ADDITIONAL TERMS AND(R)NDITIONS ARE SrA'1'Fal ON THE REVERSE SIIIk1 AND ARK PART OF TIDS CONTRACT' _- p ;I nse or se g'stiation vai;d£ot mtlrvadu]vse anly L4ce r 3�ftiice of Cya.„xsaoier Ai't's�rs&Business gegiilahoa� 6efo.# the expiration date. IS found return to e`=- ''' ridBnsiaess;tegulataon.., :l QME IRdEH �dF'CONTRACTOR.YF m„ pfi of Consumer Affairs:. Tq yQp ikPlaza SUhe5170 RegutratfoF% 93 MA 02116 f d Snlfiy�emeht. and $ostdn, he Nome pep s .,—.�—� otvaLd ithovisigluature f' ` p G�13033 ,� - Uadeneare 6k� a 3�:. } The Commonwealth of Massachusetts Department of lndusdrialAccedenes Orke of 1ntKstigadions I Congress Street,Suite 100 Boston,MA 02114-2017 wwmmtss.gov/dia Workers'Compensation Instimuce Affidavit:BnilderstContma ors0ectricians/Plumbers Alpylicant Information Please Print Lnibly Name olustrmeuJOrgeakraoouftdividual): _ . - -- Address: — -. _ . _ .. .. -- I Ci /state/Zi : Phone#: CIA Are "a amployer?'Chick. the appropriate box: Type of project(required): 1.lJ✓ I am a employer with nc` 4• C] l am a general omtractor and I ,_.__.._. ._-_.employees(full.andlorpet-tie).•. _. 6ere,bued tiro ab�o�haclors_ 6. Q New construction 2.❑ I am a sole proprietor or partner. listed on the attached sheet 7. ®Remodeling -ship and have no employees Then s coma have 8. Demolition working for me in any capacity. employees and have waders' 9. ❑Building addition (No worimrs' comp.mnuance comp.mammae.t required,) 5. p we are a corporation and its 10.0 Electrical repairs or additions 3.[1 1 am a homeowner doing all work ofhcu s have exorcised their I LC]Phunbing repairs or additions myself,[No workers' comp, right of exemption per MGL 12.0 R96rrepairs insurance required.]t e.15$41(4),and we have no employees [No workers' 13. ' Other msmmoe ) ;Any 4P1�thatcircle buta1 actwhoaV satire melonbdow e' ' rhaiwtabae'eompmeedm Vdh' meson• t EtamaOlPeate woo adtmltthit atrmdmhhdiot0eathey as dmoa dI watt tsdtltm hheeawlde aeatramo ant mbmh a eew&Mdavn hdtamna such. tLaOaa@ew dire da#thY ba eat eanerhedt addllloml lBfR hK(blameotdon64muemteoddmwhaha tsotthemmntimhave mpbyaea. rasabombamebumeeeplelna,WryemetPtwede�,t'o®Rpdarmusb¢ lam an®nployer akm tr proMdbra workers'coarpmmaebn knrronce for sey mpleyesz Below tr she policy and fob stre inforneadom Insurance Company Name: Policy#or Self-ins.Lie. till n('M (,Expiration Date: Job Site Address:. rnd� �cvLLy�/S •—• Attach a copy of the workers'oneepeuntion policy declaration page(showing the policy number and expiration date). Failure to aecu a coverage as required under Section 25A of MGL b. 152 can lead to the imposition of criminal penalties of a free up to S 1,500.00 soNor one-year tmptiso as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator, Be advised that a copy of this may be forwarded to the Office of Investigations of the D m nmmcc coverage verification. .l do hereby, er d of psr"neat Lie Mformatloa'rovMedebove sad correct official use only. Do not write in thk area,Po be compkied by city or scam official. City or Town: Permit/Liecose# dssuing Authority(circle one): L Board of Health 2.Building Department J.CltylTown Clerk 4.Electrical inspector 5.IPlumbiog laspector 6.Other Contact Person: Phone It: J Mass Ls -Department of Public Safety Board of Building Regulations and Standards Constructim,Supen'isnr SpecialtY License: CSSLtM9 .I I% p, F ROBERT POC7POUT 172 W Salem,M ;S7,0 F g ¢ ' 'ram Expiration d., 0210D12OIZ .Commissioner acoR CERTIFICATE OF LIABILITY INSURANCE °ATE 02/19/2014 Y' /2014 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(les)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 endorsements. PRODUCER CON A T MARSH USA,INC. NAME: TWO ALLIANCE CENTER PHONE FqX 3560 LENOX ROAD,SUITE 2400 A/t No ATLANTA,GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIC N 100492-Hom D-GAW-14.15 INSURER A: Steadfast Insurance Company 26387 INSURED Zurich American Insurance Co 16535 iH0 A7-HOME SERVICES,INC. INSURER e DBA THE HOME DEPOT AT-HOME SERVICES INSURER c:New Hampshire Ins Co 23841 2455 PACES FERRY ROAD ATLANTA,GA 30339 INSURER D: Illinois National Insurance Company 23817 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-00324268501 REVISION NUMBER:3 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. III SR A OL SUBR LTR TYPE OF INSURANCE POLICY NUMBER MMILDIDY/YYYY MM EFF AIDY EXy "LIIIT �, IMITS A GENERAL LIABILITY GL04887714-04 03/012014 G31012015 EACH OCCUR $ 9,000,000 X COMMERCIAL GENERAL LIABILITY D A ETO 1000000 REVISES E $ CLAIMS-MADE OCCUR LIMITS OF POLICY XS MEDEXP(Any $ - EXCLUDED OF SIR:$1M PER OCC PERSONAL B A $ 9000,000 GENERAL AGG $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-CGG $ 9,000,0W X POLICY PRO- 1-1 LOC $ B AUTOMOBILE LIABILITY BAP 2938863-11 03/012014 03/01/2015 Eo a&tleD SIN1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG AUTOS AUTOS BODILY INJURY(Per acc,l $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS $ Pere cident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CWMS-MADE AGGREGATE $ OED RETENTION$ C WORKERS COMPENSATION WC049101 2(AOS) 03N112014 03/01/2015 WC Srg7u- $ AND EMPLOYERS'LIABILITY OTH- C ANY PROPRIETORIPARTNER/EXECUTIVE YIN WC049101884(At,AZ,VA) 03Nif2014 0310112015 1000000 D OFFICEPoMEMBER EXCLUDED? ❑N NIA E.L.EACH ACCIDENT $ (Mandatory In NH) WC049101883(FL) 03/0112014 03/01/2016 E.L.DISEASE- 1,000,000 If yyeess describe under EA EMPLOYE $ 1,000.000 FINSURANCE CF OPERATIONS below E.L.DISEASE-POLICY LI MIT $ PENSATION WC049101885(KY,NC,NH,VT) 03/012014 03101/2015 (EL)LIMIT ip00,000 WC049101886(NJ) 0310112014 03/0112015 - ATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarke Schedule,if more Space Is requlredl CE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC.DBAT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PAACESCES FERRY ROAD ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee _I+diAwaoH,: .�4nAfLS�A/ -(t, ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD -i5rr' '- r CITY VFS, E,Yf, UJ LL J /�' �L•tLDL�IGDEP.1RTlC.`:7 ,♦ t ?ri•'r 120 1V.1SHLNGTON 3-MEET, 310 FtCo It fts (973) 7 a5-9595 lQMJE1UEY 01USCOLL FAA(973) 7.10-93-S L"LAY02 I c{OSL13 ST.PI^e.RRL{ DI:tECTGR OF Pt:BLIC PR0PERTy/8C(LOLNG CawassrONER Construction Debris Disposal AftIdavit(required for all demolition +md renovation work) In accordance with the sixdi edition Of the State Building Coda, 730 C fR Dcbris, and the provisions of MGL c 40, S 54; section l l 1.5 Building permit k this work shall be is issued with the condition that the debris resulting from l l 1, S ISOA. disposed of in a properly licensed waste disposal facility as defined by b9GL c The debris will be transported by: y (nan,c of hauler) The dchris will be disposed of in *.wie,"Cral lily sign n,tr u(j;rrmi(.i , !PG�•,,nt