69 HATHORNE ST - BUILDING INSPECTION GK 1050B
The Commonwealth of Massac Shusetts R\/ICES
IMPECTION1-
9 IT OF
Board of Building Regulations and Standards M SALE
q't Massachusetts State Building Code, 780 CMR ALEDI
e I ,Dl i
' ' 3
n Building Permit Application To Construct, Repair, Renovate Or DI015olls mR'a
One-or Two-Family Dwelling
I� This Section For OfTcial Use Only
(� Building Permit Number: Date plied:
Building Otllcial(Pont Name) Signaluro Date
SECTION 1:SITE INFORMATION'
I.I Property Address:/_q / ,1 o �v ro t..�i'�.y� 1.2 Assessors blop&Parcel Numbers
71,Is this an acce ted street?yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(R)
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 Cl On site disposal system ❑
Check if yesO
SECTION2. PROPERTY OWNERSHIP,` ct
2.1 Ownertof I cq r)� r+ � � Z '� Le M (n "r 1 1 7D
Rjtme(Print)& / State, _ r `
- b(`rt o` I ,V�J � V
No.and Strut Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s Alteration(s) ❑ Addition ❑
Demolition ❑ I Acc ry Bldg.❑ Number of UnitsI Other ❑ Specify:
Brief Des fr ption of Propo l\ rk'
xVtf 7A I Ce Rai )OOl
U L av✓1
SECTION a: ESTIMATED CONSTRUCTION COSTSJ
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building `,�, 89`-a $ I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard CitylTown Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S P Qther Fees: S
4.Mechanical (11VAC) S List:
5.Mechanical (Fire S Total All Fees:$
Suppression)
Check No._Check Amount: Cash Amount:
6. Total Project Cast: S 5 C) ❑Paid in Full ❑Outstnnding Balance Due:
IQ At
SECTION 5: CONSTRUCTION SERVICES
5.1 �unstructio1n Supe isor License(CSL) O C19 6 9 q Ti i 6
(I/\�bT' oez b� r License NumberExpiration Date
Noma ol'CSL Huller
IT-4 �1Lf S n List CS
(see b";
No. td Sued Type. Description
1N R- U UnrestriilJin a loiiwif
R Restricted 112 family Dwelling
Cityfrown,State,ZIP VRCR,ofin
Masonry
Coverin and SiJinlel Duming Appliances
nTele hone Email adJresa 5.2 RegisteredHomeImprovement Contractor(HIC)
�4 M 4Z p r HIC Registration Number Expiration Date
III t y orfll Registm t�,ne
K..Q
N IIhTC odk. r p T 1 f D 1. q _ � ?3e1 Email address
Ci frown State ZIP! Tele hone I
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G,L:c.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 Is4uance 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`
I,as Owner of the subject property,hereby authorize O-DMt DC t37 -
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
5 t E C 0(N4r-D,c i- �— I - l
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
M � 2I( Pro
Print Owner's or uthorizW Agent's ante(Eltdronic Signauue) Dale
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 LiI t have access to the arbitration
program or guaranty rund under I.G.L.c. 1 J2A.Other important information on the HIC Program can be found at
www mass.cov'oca Information on the Construction Supervisor License can be found at wtrw.mass.�_o��'dus
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number or bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Typeofcoolingsystem Enclosed Open
3. `Total Project Square Footage"may be substiuucd 1'or"Total Project Cost"
The Cemnwnweaft ofMassacftasee&
IDepadMent of dndtastrta/Accedetets
®,Free of lfives*adoas
600 Waskingon Seed
BOSIW4 MA 02111
ivwstsM=&gotr/dda
Workers' COMPensation Insurance Affldavit:Bu lder&tContractors/Eleetddans/Plumhe>rs
AnDlicant Informatfion y Please Print I eatbl
Name(Business/Organization/individual): (016i2
Address:
City/State/Zip: Phone#: 'rO 9-
Fama
ployer?Check the appropriate box:
Type of project(required):
ployer with 4. [9 1 am a general contractor and I
s(full and/or 6. ❑New construction
part-time).o have hired the sub contractorsle proprietor or partner- listed on the attached sheet.1 1• ❑Remodeling
have no employees These sub-contractors have 8. ❑Demolition
for me in any capacity. workers'comp.insurance.
9. Q Building addition
[No workers' comp.insurance 5. ❑ We are 2 corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 Ln Plumbing repairs or additions
myself.]No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.fNo workers' 13er �176�y�ICI)
romp.insurance required.]
*Any applicant that cheeks box#]most also fill out the section blow showingtheir µ�orttrts'
t Homeowners who submit this affidavit iodiptin mg C0m�1on polite'mfoonatiou.
g they are do" all work and then hire outside extntracmm must submit a oaw affidavit indicating such.
tContractors that check this box must aloud m additional shed showing*a name of the sub•wpuactms and their wodm,cow•policy iaracaration.
/arm an evriplayer that iv providing workers,comperasorion inmrnucefor my eanfaloyee� Below is the po/%y end job site
ImformwPpom /1
Insurance Company Name: �/y'/QiDfj Jj rrE. -11J 5 . (�O ,
C
Policy#or Self-ins.Lic.#:� O ? .3 Expiration Date: 3 o?a/6
' L D y
Job Site Address: l/ T 0q �/ f �Qf n-e tad S 1 e W ✓�1 A-
City/State:/Zip: a
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 a 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby t the me and pe noWn ofpe1*;ythat the information provided above is true and correct
i nature: ��
Date S
Phone#: J 916 -
00leial rase only Do not write in this evco to be contp/dexJby cify or town o0 iredai
City or Town Permit/License#
Issuing Authority(circle one):
I.Board of Hemlth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person Phone#•
I
A CERTIFICATE OF LIABILITY INSURANCE 0224201501
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 terns 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 CONTACT
MARSH USA,INC. NAME:
TWO ALLIANCE CENTER PHONE FAX
3560 LENOX ROAD,SUITE 2400 W.
END, JAIC NO'
ATLANTA,GA 30326 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC0
100492-HMGD-GAW-15-16 INSURER A:Sleadfast Ire'uarm Carl 26387
INSURED THD AT-HOME SERVICES,INC. INSURER B:Zmdl Amencan InEuverm CO 16535
DBA THE HOME DEPOT AT-HOME SERVICES INSURER C:New Hampshire Ins GO 23B41
2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D;Illinois Ndwd Insurance Cwrpalry 23817
ATLANTA,GA 30339
INSUER E
NSURRER F::
COVERAGES CERTIFICATE NUMBER: ATLM4268509 REVISION NUMBER:7
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANDING 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,
INSP S POLICYEFF POUCYEXP
LTR TYPE OF INSURANCE POLICY NUMBER MMR)DA-fM lNumnoryyyyj LIMITS
A GENERALLIABILITY GLO488771405 0WQW5 03N12016 EACH OCCURRENCE $ 9.000.ODO
X COMMERCIAL GENERAL LIABILITY PREMISES Ee oa hence $ 1,000,000
CLAIMS-MADE OCCUR UMITSOFPOLICYXS Mm EXP(Any one person) $ EXCLUDED
OF SIR$1 M PER OCC PERSONAL S ADV INJURY $ 9,000,000
GENERAL AGGREGATE $ 9.000,000
GENT AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMPIOPAGG S 9,WD,000
IECTX POLICY P" LOC
B AUTOMOBILE LIABILITY BAP 293886312 ONI12015 03I012016 �aIEDSINGLEUMIT $ 1000000
X ANY AUTO BODILY INJURY(Per Person) $
R
SCHEDULED SELF INSURED AUTO PHY DMG
AUTOS BODILY INJURY(Peraccident) $
NON-OWNED PROPERTY DAMAGE
AUTOS Per accident)
$
R OCCUR EACH OCCURRENCE $
CLAIMS-MADE AGGREGATE $
TENTION$ $
C WORKERS COMPENSATION WC017731493 (AOS) 03N1I2015 ON112016 X I WC STATLL 07Ti-
AND EMPLOYERS'LIABILITY O (MIT 1
G ANY PROPRIETORIPARTNERIEXECUTIVE YIN WC017731495(AK,KY,NH,NJ,VT) 03NI2Di5 OW1201fi E.L.EACH ACCIDENT $D OFFICERIMEMBER IXCLUDED? N NIA
(Mandatory In NH) W0017731494(FL) 03MI2015 0310120% ELDISEASE-EAEMPLOY $ 1.000,000
UW.describe under CDminued on ADdgidrrel e DESCRIPTION OF OPERATIONS balm Page EL.DISEASE-POLICY LIMIT S I.ODD 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AHxeh ACORD 101,Addillonal Remark.Sehed^K mom space is nn u1nm)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD AT-HOME SERVICES,INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
DBA THE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2456 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS.
ATLANTA,GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee _.�lcLumor: rsua<,1.
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
q
/J'I,<'." 'll 'l�r'd2"1'J'J.'t2JG'l,V��Ct%G�.�7� ��/ �✓ N d.CLJ'�ddYl%✓�L'Ld;1�'/f�'
' 01lice of Consumer Affairs said Business Regulation
LL;
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Ianproveaa� ; t,,Contractor Registration
Registration: 126893
Type: Supplement Card
Expiration: 8/3/2016
THD AT HOME SERVICES, !SIC.
MARK NIADNA
2690 CUMBERLAND PARKWAY
ATLANTA, GA 30339
Update Address and return card.Mark reason for change
scA i ., 2UM.a5n1 �] Address (_j Renewal (� Employment Lost Cards
(':%/r Yfnurrrauunavr///r�(`.f�nuur•/rn�r/1.r
0'7�-'dy
Office ofConsumer Affnirs tl<Business Regulation License or registration valid for individul use only
before the expiration date. If found return to:OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
Registration:. 126893'- Type: 10 Park Plaza-Suite 5170
Supplement Card Boston,MA 02116
THD AT HOME S$RV.ICfi$;,INOi
THE HOME DEPOT.AT,64�ME`SERVICES
MARK NIADNA
2690 CUMBERLAND PAgKWAY S
Xff-'AM.GA 30339 —0in., -
Undersecretary Notvalid wilhou signature
i
` i
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supeniaur Specialty ELI,.
License:CSS l-0 MM
ROBIRT FOCUOUT "' `�
172 WHALERS
QIv -
sateen its steno
J'4 .1& „nrta Expiration
Commissioner 02f0 MIS
QTY OF SALEM, MASSAaiUSE M
BUILDING DEPARTMENT'
_ 120 WAsmNGTON STREET,YO ROOR
nL(978)745-9595
KAMERLEYDRISoc)LL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BuRDING 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 c40, S 54; Building Permit#
z 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 150A.
The debris will be transported by: DOQ �lbVCIC
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
4Signure of applicant
Date
I
• �, '"� IIOMF:IhIPHOYHAtHNT(Y1NfRACT
IOLFASE READ THIS
'
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l�f e— ��^ Slid;FamishedIllld installed by.
Pronrh Namet Pailml Ntwlh A Snllth Date:�l,-/_�,,. 1110 At-tlimce Servim.Irlc.
dd✓a Ilse Innis Ikp(k A1.1"ac Sce"res
ttraneh Number:11 and91 yllµ Iluslon 1`umluke,Unit 1.Shrcu.bury,MA It I'W5
'roll Free 877-CM30764
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/^ L' .(,.� Cr IJc I,111'.l1}a}IJ_;N A IInns:In ,ro maVt qvcnvni CtID Reg.II 12003 1.
hkcbdlulho Address: Get I?�11'16 1LA !"'I'
City Slade Lip
IVI •nnv-n.s: ,,��l Work Phone, Nolan Ylrwre: CNI pMulr: i
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Hone Acklmm:
(lt'dulercnt Inun la ndlulion Aridness) City State Zap
K-mull Addles+(in mcht project cvsmmunicatio,nml Mane Ik{mt ulxbmes):
�i (]1 t)l)NOT eid)Iu nxCive arty mnrkoing rn)uils I'mm The lions lklxa .
I'r e•1 1 o I t of: Undersigned 1"C'uctpmer").the osvltem of the pnq+erty Ircalni at the above initallothpl adttrrss agrees to bug.
aud'f I ),V•I Innte 1rn•icC,.Inc I"'1'hr Ilunse Hepll")agars it,I'nmtdt,delhrr and:mmge(Iu the installation MMIA11911ce1 of
all materials dcv'tihd au the Ixh,W l lal tin the Wlersmc,xl slice Shpsls), all of ulliell tar imvalxxatwl inn thi.Cmv.ict by this
wForcnet%altatg with nay applicable State Supplcmcvu laid payment Sutlumay ,,,Kited hcrrtu and any Change Ovelm loillwvrely,
"Contruel"):
Jnb a: lt.wllleuw.i Irntut•Is: spry sbrtt s)I: IVnJtel AalWn1
/ kl 1711--I'
a tyu Ill nklws Insulation
._I g r � �Ilnurh l C,wrrs
amainµ aawg ❑N'imkta� In,ulaa,al $
Ofiatlrmf(lnrn[]fnay'111an [I _
aluglnµ�5idinq 11''in+krwe Ummunn $
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(one for each Nrsluct it,delia"J by an nafiv dam SIAN Shtct)and rya'any Ixdmlce title. As alTheublw etwh Castotner undo this
C'onuaei agn•rs I„IV!,,Italy cold sr,crally+ahhgnlcxl and liutar hereundts.
The Ibanr 1101xa rest• %v,tile•.light In Ismw a Chnnge O rder ur lemtinale this Cetunuk IV my Individual lInxtuct(s)incllxlal herein,in
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MQTIi`F 111(11 ati 1'1UI F;R
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lilacs is our Calapledtat t'crlllfrulr lilt r11rh listed I'ruduct a*drlharl by Intthhhml Slier Shrvas)helorrr wllrk an tMt 1laatat
Is cnmplelo.
j In the event of terntlnulltm of this Co lml"Cu,amner aar*ws b,Ims I'll,-ll,m*Ile{.a the ecM,of rlmleNn1%Int.w.e,prnw•s
and,er,lee,praslded by The Ilona•Delon tm Audl-airtsl serd,v PrIl,hter Ibn.Wh the,hdr It Imul Mira, plus arty labor
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Marcia Kirkpatrick
From: Mike <mike@permitservicesne.com>
Sent: Wednesday, January 27, 2016 3:47 PM
To: Marcia Kirkpatrick
Subject: Permit Cancellation
Attachments: Follow up letter HD.docx
Please see attached letter in reference to Building Permit #B-15-376. Thank you.
Mike Bedard
Permit Services
Cell: 508 962-6942
Fax: 401 246-2868
Email: mike(@i)ermitservicesne.com
t
Permit Services L ^Phone: (508) 962-6942
303 Narragansett Avenue Fax: (401) 246-2868
Barrington, RI 02806 Email::mike@ permitservicesne.com
' Professional Permit Services
January 27, 2016
City of Salem, MA
Building Department
This is a follow up letter for a cancellation request for Building Permit #B-15-
376 issued on May 6, 2015. The address is 69 Hathorne Blvd.
Would you please let me know if this permit has been cancelled.
Thank you for your attention to this matter.
If you have any questions, please call me at 508-962-6942.
Thank you,
Mike Bedard
Permit Coordinator