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12 HARTFORD ST - BUILDING INSPECTION (10)
l�- �� -i� � 3 The Commonwealth of Nlassachuset SEQT(QNAL CITY OF Board of Building Regulations and Stan arils (j ALENI Massachusetts State Building Code, 780 CM SEP 11 A. RNYed a/ur 2011 A1�t Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date pplied: /9 y Building Official(Print Nmne). Signature- Date rn ECTION 1:SITE INFORSIATION 1.1 Property A re 1.2 Assessors blap& Parcel Numbers I.I a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: `Coning District Proposed Use Lot Area(sq III Frontage(It) 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 yesO SECTION2: PROPERTY OWNERSHIP", 2.1 Owner of ecor x 7� - tine(Print) City,State,ZIP - No. and gtrwt Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK°(check al hat apply) r New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work t"—"' SECTION a: ESTI SIATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1. Building S I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 21 Other Fees: S d.Nlcchmtical (NV;\C) S List: 5. Mechanical (Fire S Total All Fees:S Suppression) �M Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S COD ❑ 'aid in Full ❑Outstanding Balance Due: ,5(-DJ-r" To 1A, D, A 1 I C 1 . SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor 'ecuse(CSL) License Wtimber Esp tit' n at Name of CS Hotdbr List CSL'rype(see below)—_ Ne.and S; ectr Type - . ` - Description ---awl`c, p'/ U Unrestricted(Buildings u to 35,000 cu. It.) R Restricted 1&2 FamilyDwelling Cilyfl'uwn,State,ZIP �— ibt Nlasonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Tcle hone Email address D Demolition 4. S gistered Home Im rovement Co rtractor(H1 ) I Qom HIC Registration Number x it on D.ae t � n. f % tr•at Name cet Email address Cit /Town,State ZIP ele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 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 IsSuanc f 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 I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized ifding permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION — By enteri g m name b low,I hereby attest under the pains and penalties of perjury that all of the information containe in t s ppl' ation is true and accurate to the best of my knowledge and understanding. Pn wner' or Auth razed Agent's Name(Electronic Signature) Vale NOTES: I. 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 liol 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.m:tss.eov'oca Information on the Construction Supervisor License can be found at www.mass._ov!d s 2. When substantial work is planned,provide the information below: rotal fluor area(sq. R.) '� ,(including garage,finished basementlattics,decks or porch) Gross living area(sq. 11.) 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 coolingsysteiu Enclosed Open_ 3. "fotal Project Square Foota,e"may be substituted fur"'rota) Project Cost" r QTY OF SALEM, MASSACI-IUSEM a� BUILDING DEPARTMENT HI 120 WASNGTON STREET,3" FLOOR '` yam ,✓ +� n TEL. (978)745-9595 FAX(978)740-9846 KIMBERLEYDI�IS�L3.1,•. "+'?i MAYOR THomA.S ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING GONMSSIONER 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 c40, 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 deposit facility as defined by MGL c 111, S 1SOA. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Si nature of applicant D e M U.y, zto c MP e-US or. �Msux�_,nc-, C PTJ'at Legibj I-P-2 it Infor-Laa-tiori oplicaut 1i N=C �Bos=es3jU71.=!zazGIL-r- Pho-ne r Cityl St ate/zil): project required): Are youAn ernolover? Check the appropriate box. Type Of J ., -acter. uctic` 2 4. ❑ 1 am a genera;con� S. L! New' connstr I [2fam a employer wit have hired the sub-cortracto-s employees (foll aadYor pari-time) i j sted on the attached shcet. .7., 7, Remodeling moLition 4 a sole proprietor or Paltrler- These sub-contraelan ha vc 8 F-1. De ship and have no emplOYres 9 71 bauaiag ad±, oil - 6,Viig iuf ILI' y cuyactty. comp, inswTancp.� i No workers' comp,insurance Wa.are a corporation and its I I jo.Dj Elec ca'l repa rs or additions required.] cf[icer-,have exercised the 11 ❑Plumbing repairs or additions ir 3 1 am a OnleoeT dO1',UaE Work r,6t of exemption per IvIGL workers'myself. [rdo ,--mo c. 15Z, §IM, and We have no insurance required.1 employees. [No workers' comp.insurancered.] 19 their compensation policy information- tAny,pplic,mt that ciiacks bcx#3 must also fill out the sectionbelow showing the most ,lo,,it anew affidavit indicating such- t Homeowners who submit this affidavit indicating they us doing aU*workQd the,bite outside contractors - th entities have taiit,actors that cbeck this box must attached an additional sheet showing the.name of the sub-contractors and statI5 whether ci not 05" employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees.. Betow is tAepoftcy and job site information. 62 Insurance Company Name:_ xpi ration I policy#or Self-ins.Lic.#:_ En a;31: 4 -) Ala" -71 City/State/zip: Sob Site Addiess: li declaration page (showing the policy number and expiration date). Attach a copy of the workers' compensation policy d M Failure to secure coverage as required under Section 25A of MUL r. 152 can lead to the imposition of criminal penalties of a - i fine UP to$1,500.00 and/or one-year impis6nment,as well as civil penalties in the form of a STOP WORK ORDER and a f ne 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 insurance coverage verification. —flue and correct perjury that the information provided above is h Ida hereby certify under pa a pe alties of --jDate: -----. afore: Phone do here ___'Date! -- SiSj P One h , Official use only. Do not write in this area, to be completed by City Or town QJJ'c'aL EVERETT . Permit/License 4--------- City or Town: )W]Issuing Authority(circle one): �7eltc)r nt 1.Board of Health 2.Building Department 3. City/Towncierk 4.Electrical. Inspector 5.Plumbing Inspector 9 K nthPr ni-hpr CZ I 7-qQA- / ' 8 DATE(MMIDDIY'frf) p CERTIFICATE OF LIABILITY INSURANCE QZOV2011 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 BELdW.:_TkUS_CERTIFtCATE,.OF_INSURANCE.DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED, REPRESEPtfATNE OR PRODUCER,AND THE CERTIFICATE HOLDER. - .'MPORTA�I, If'tNe,certiflcate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS`NAIVED,subject to the berms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certifleate holder in IieU of sdeh endorsement(s). CON T PRODUCER - - NAME:MAR FAX TWO ALLIANCE � PHONE AIC No TWO ALLIANCEROAD,SUITE IAIC 3560'LENOX ROAD,SUITE 24C0 E-MAIL ADDRESS: ATLANTA,GA 30326 !INSURER(S)AFFORDING COVERAGEANAIC100492-HOmeD-GAW-14.15 INSURER A: Steurance CompanyINSUREo ' - INSURER e: Zutican Insurance CoTHDAT-HOME SERVICES,INC. - Nehire ins Co DBATHEHOME DEPOT AT-HOME SERVICES INSURER C2455PACESFERRY ROAD INSURER D: IIIinnal Insurance Company ' -ATLANTA,GA-30339 : .INSURER E: -. :. INSURER F: - - COVERAGES - CERTIFICATE NUMBER: - ATL.00324268Rl 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. "SR I - AO R POLICY EFF POLICY EXP LIMITS LTRTYPE OF INSURANCE POLICY NUMBER MMMDrfYYY MMMD1YYYY 9,000,000 A'. DENERAL LIABILITY GL04887714.04_ 031OV2014 03/0112015 EACH OCCURRENCE 8 ,X -' PRE I O Rc me c 8 1,WO,000 COMMERCIAL GENERAL WBILITY EXCLUDED CLAIMS-MADE M OCCUR LIMITS OF POLICY XS MED EXP(An' one ersonl E OF SIR:$1M PER OCC PERSONAL a ACV INJuftv S 9,W0,000 - GENERAL AGGREGATE $ 9,000,000 GEHL AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ 9,000,000 X POLICY PRO- LOC $ BAP 2938883.11 0310112014 ------2015 COMBINED SINGLE uMIT 1,000,000 B AUTOMOBILE LIABILITY Ea acdtlent X A BODILY INJURY person) $ ANYUTO ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accfdent) $ AUTOS. AUTOS - PROPERTY DAMAGE $ NON-OWNED eld n HIREDAUTOS AUTOS _ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ $ DED- RETEMICNE WC BTATU- DTH- _. --D WORKERS.COMPENSATION2IAOS) 03,011201 0310112015 , AND EMPLOYERS'LIABILITY WC049101884 AK,AZ,VA 0310112014 0310112015 1,000,000 O ANY PROPRIETOR/PARTNERJEXECUTIVE YIN ( ) E.L.EACH ACCIDENT E OFFICEROAEMBER EXCLUDED? O NIA WC049101883(R) -0310112014 0310V2015 ,000,000 D (Mandatory In NH) - E.L.E DISEASE-EA EMPLOYE E 1,000,000 If yyes,descdba under E.L.DISEASE-POLICY OMIT ItDESCRIPTION OF OPERATIONS below C WORKERS COMPENSATION WC049101885(KY,NO,NH,VT) 0310112014 030112015 (EL)LIMIT 1,000,000 C WC049101886(NJ) 03XV2014 03,01/2015 _ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more apace Is required) EVIDENCE OF INSURANCE - C ERTIFICATE HOLDER CANCELLATION THD AT-HOME SERVICES,INC. L OULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE OBA THE HOME DEPOT AT-HOME SERVICES - EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD CORDANCE WITH THE POLICY PROVISIONS. ATIANTA,GA 30339 - ORIZED 0.EPRESENTATIVEsh USA Inc. shi Mukhedee ©J988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD = ( Office of Consumer A airstyy r d Business Zegulatior. 10 Park Plaza - Suite 5 170 Boston, Massachusetts 02 116 Home Improvement Contractor Registration _ Registration: 112785 - Type: Supplement Card HOME DEPOT USA INC Expiration: 4/23/2015 RICHARD FALLONE — ----— —_--- - 2690 CUMBERLAND PKWY STE300 HM;SV,< = -- ATLANTIC, GA 30339 Y Update Address and return card.Mark reason for change. SCAT Co 20M-05111 �] Address ❑ Renewal ❑ Employment Lost Card C1711riuirriuuuoeal(�c f'G�CruJc�c�toctG segistration: ice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR Fd before the expiration date. if found return to: lOffice of Consumer Affairs and Business Regula4ion YPe 10 Park Plaza-Suite 5170 112785 T , Expirahon 4/2312015,:(; Supplement,and Boston,MA 116 HOME DEPOT USA INC •i; s RICHARD FALL NE: 2690 CUMBERLAND PKWY STE30 At{s�N�ICeV`Q'��339 Undersecretary of v ith t signatr re j P Supenivm DONALD L BURjNtTT. 31 MARION ROAD MARBLEHEAD MA 120612014