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20 HAZEL ST - BUILDING INSPECTION r 13 The Commonwealth of Massachusetts r OF Board of Building Regulations and Standards CITY� M assacuse 1 Mhtts State Building Code, 780 C^VIR SdMar Revised Mar 2011 J Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two Family avelling This Section For Official Use Only, Building Peermit Number: D to ppl' d. tGh T L Building Official(.rint Name) `. Signature Date SECTION 1: SITE INF T O 1.1 Property Add j; 1.2 Asses r a & Parcel Numbers 7 `7� 1.1 a Is this an accepted street? yes_ no Map NurrVer 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❑ SECTION2: PROPERTY'OWNERSHIPl- ' 2.1 O%nerl,111 ecord: (9y � Name(Pont) —� City,State,ZIP CX2 No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK"(check alj txat, apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': � — t ,n o (b•Z SECTION 4: ESTIMATED CONSTRUCTION COSTS Rem Estimated Costs: Official Use 1.Only'. Labor and Materials 1. Building S _ 1 Building,Permit Fees$ Indicate how fee is determined: ❑:Standard City/Town Application Fee, Cl2. Electrical S § Total Plolect Coss[,,(Item.6)x multiplier x 3. Plumbing 2.. Other Fees: $ 1. Mechanical (ffvAC) S List:- - �)f!�6__ 5. Mechanical (Fire $ 5n ression Total All Fees: ,S Check No, Check Amount: Cash Amount: G. 'I'ntal Project Cost: S ❑ Paid in Full Cl Outstanding Balance Due: /� SECTION 5: CONSTRUcTION SERVICES 5.1 Construction Supervisor License (CSL) e� — ��.A vkf t,io License Number E.ept tion ate Name ofCSL I-(older 11---JI C� List CSL Type(see below) No. and Street Type Description U Unrestricted Buildin s up to 35,000 cu" tt. R Restricted 1&2 Family Dwelling City/rows, State, ZI b( Masonry RC Rooting Covering. WS Window and Siding Sr Solid Fuel Burning Appliances G)t ��>���'7J I Insulation relz hone Email address - U Demolition 5.2 Registered Ho m�e Im ro^ve ent Contr�actor.(IIIC) 1 V ' \.ZV IIIC Registrati��aon Number E.ep r do Uate I- y at or 'strant Name G No. and r- Email address Ci /Town, State, ZIP Tzle�hoiw ��' 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 Issuan of the building permit. III' Signed Affidavit Attached? Yes ..........Zr 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 ���G�. relative to work authorized b this building ermit a application to act on my behalf, in all matters r Y P pP l� Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and YCL-191te to th best of my knowledge and understanding. Print Owner's or Authorized Agent's Nai ie( E •ctron is 9 ignatu re) ate NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (tot 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 w ww.muss. oyr5)cu Information on the Construction Supervisor License can be Found at www.mass._uv dL 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) _(including garage, tinislied basement/attics, decks or porch) Gross living:tea(Sq. ft.) -- Habitable room count Number of fireplaces_ . Number of bedrooms -- --- _ Number of bathrooms Number of half/baths _ rype of heating system ------ Number of decks/ porclies ---_ 1'ype orcooling sy;lem-- —. -- Enclosed -Open -- ]. "I'Ootl Projec[ Square Footage" may be s'Ubvtittned tor';T,r ctl Proicct Cost" 12/01/2012 02:18 17819940331 TODD RIDEMAN PAGE 01 y ' IIOMEIMPROVEMENTCONTRACP PLEASE READ THIS Branch Name: Boston Date: Sold,���'� Sold,Furnished and Installed by: _!J� THD At-Home Services,lne. d/b/a The Home Depot At-Hume Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Branch Number:31 Toll Free(800)657-5182;Fax(508)945-6017 Federal ID#75-269g460;ME Lic N C 02439;RI Con,I,ic#16427 CT Lic# IC.0565522;MA Home Improvement Connector Reg.#126893 Installation Address:, U Ada S) -. State Zip .p. City ' Parcha"s): Work Phone: rQ7 t'omr ph o�y� r Cell Phone: V Nr axp [ ] 1 L J [ ] [ ] [ l Home Address: (Ifdifferentfrom lnsle0ation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive any marketing emails from The Home Depot ro'e 1 ormat : 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 f'or the installation(`Installation")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 attached hereto and any Change Orders(collectively, "Contract"): Job#: 'I.. 1 Products: Spec Sheets M P.o ect Amount Roofing ❑Siding Windows Insulatioh / �/ �] jt ❑Grote s l covers ❑Entry Dons ❑ !�3Y V% Z $ / 9/ ❑Roofing Siding ❑Windows Insulation ❑Gulturs/Covers ❑Entry Doors ❑ $ ❑Roofing LJSiding Windows LJ Insulation ❑Gutters/Covers ❑Entry Doors❑ Roofimg ❑Siding ❑Windows U insulation ❑Gutters/Covers ❑Entry Doors ❑ $ / Minimum 25%Deposit ofContrm Amount due upon gmrgoo of"wnfracL Maau Purebasg yaotdgp** wre.d..elbirdofdn:Ca b-ACtAmovM. Total Contract Amount $ �-�C?�O O 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 bejointly 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 wan not included in the Contract- Payment Summary: The Payment Summary # 7/h. 6+ , included as part of this Contract, sets lonb the tow] Contract amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO CUSTOMER � You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE 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 RECOVERY OF SUCH AMOUNTS- Aceeotanee and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Dcprit with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement cannot be assigned or amended except by a writing signed by Customer and The Home Depot-Customer acknowledges and agrees that Customer h as d,understands, voluntarily accepts the terms of and has received a copy of this Agreement. Acce t by: Submitted by: x P ' Customer's Signature Date I Sales Consultant's Signature Date x Telephone No. Customer's Signature Dare Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS Ia�aPPLwnlel 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 CUSTOM F.R'S STATE. NOTICE:ADDITIONAL.TERMS AND CONDITIONS ARE STATED ON THE RF V F.RSE SmE.AND ARE PART OF'I'HIS CONTRACT 05,10-12 White—Drench File Yellow—CuStarrier 09/29/2011 20: 37 9786949533 LAHEY WILMINGTON PAGE 01/01 Cc. �Le� j Ma.,wt ""setts- Ucpartmenl of Public 5afet, Board If Building Regulations and Standard Constr ion Supervisors ciat l� ty Licen*c License. CS SL 99td93 Restricted to. RF,WS JOHN PEM INO I 17 STONEtf 0GE DRIVE WILMING , MA01887 i Expiration; d/22J2o13 ('.rmmiyelu r TrS. 6378 i ti t II I r r i r/GY'lu.tivs` �.! �� i -7 15 i�17-.J•.`;All.dzo/ll:, Pli 'C 93'_. 4-V 4.3_ �9f1 City/E;i:lcip: Are yo employer?Check the appropriate box: Type of project(required): l. I am a employer with _ 4. Q I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor-or partner- . listed on the attached sheet. 7. ❑ Remodeling ship and have do employees These sub-contractors have 8. Q Demolition working for me in any capacity. : employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp.insurance.t required.] 5. Q We are a corporation and its ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions right of exemption per MGL myself, e r workers'comp. 13.❑ Ro /( I pairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13. Other comp.insurance required.] 'Any applicant that checks box H I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those 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 insurancefor my employees. Below Is the policy and job site information. Insurance Company Name: g . ��� _ Policy#or Self-ins.Lic.#: �L7 Expiration Date: Job Site Address: 4:6 ze zl City/State/Zip: 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 MOL 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 D1A for insurance coverage verification. I do hereby certi a de the ins and penalties ofperjury that tite information provided ab a is tr and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Wuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: ,r. CITY OF SALEM, ,NAxSSACHUSETTS BuILONG DEPARTNMUNT 3 r+ 120%V.,ksHINGTON STREET, 3"a FLOOR T EL (978) 745-9595 F.tx(978) 740-9846 KINIBERLSY DRISCOLL MAYOR THo.%w ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUMJ:)DJG COSLMISSIONER 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 1 11.5 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 111, S 150A. The debris will be transported by: (nave of hauler) The debris will be disposed of in : (name 6f'ff acihiy (address of facility) Fa a t -r C of permit applicant SIC JcbnselCJ•a: t OfajVa;rdegiatioi FeCsum ;.;. F rj 10 Park Plaza - Suite 5.170 „ ; Boston, Assa6husetts.02116 Hoizie Ii31rovea t ontractor RCgistlation ReAietratlon: 126593 . Type: Supplement Card .. g t z ter_ r ExplraUon:' 8l312014 • a The Home'Depot At-Horne Servi , _ RICHARD .FALLONE M r i _ a 2690 CUMOERLAND PARKWAY . ATLANTA, GA 303.39 . . Up nr�- e�°vvC' date Address en'd return card.Mnrkrenson for ehnnge. Address Renmval' ,[] Bsuployment 1J Lost Cncd OP SUiIi.OGI04•G7rn/ 0121fi., ✓!te l anN)taauuEaL!/L 0�✓lacfi7I, License or registration d.for Ind idul ^uif ce of Consumer Atrnirs Ro-Busancss Regulnhon: before tlse expirationd te.,if foundrrcturn to0n!y '. 111 C)MEIMPRO/,.�ENT NTRACTOR office of Consumer Affairs and Business Regurntion ' I t :Typo: 16ParkPlnzn-Suila5170 T Re�g„lapllrruff6fi,rr:.1�B236 6aJ'4 supplement Card Boston,MA02116 ' „ L,e HOmtl Depolcl1;. trie 3eNles .. ,JOHARD -PALLfSN .n tit 60 CUML'CRIA�II)P%4I'ZI'lVd 5 �•�%'-•>� � L4 _ . i. r �� ''✓y/,tid' —'—��'' of valid ivlth ut sl nature n, I Ilt`Iq I\,`G.4 3n339".;.::,- Undersecretary. : " . .. / ::c _•�' /� ® CERTIFICATE OF LIABILITY INSURANCE D11/15/2012m 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 1-866-966-4664 CONTACT NAME: Marsh USA Inc. PHONE FAX AIC No: homedepot.certrequest®marah.com E-MAIL ADDRESS: Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 INSURER(S)AFFORDING COVERAGE NAIL# Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURER B: Zurich American Ins Co 16535 The Home Depot, Inc. New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. INSURER C: P 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co 23817 Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER F: Illinois Union Ins CO 27960 COVERAGES CERTIFICATE NUMBER: 30289573 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. 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. _ INSR AOOL SUER POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDO/YYYV MM/DD A GENERAL LIABILITY GLO4887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 _..... _ ..X OA AGETO REN - 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ _ CLAIMS-MADE � OCCUR MED EXP(Arry one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL B AOV INJURY $ 9,000,000 X OF SIR: $1M PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 9,000,000 X POLICY 7 PRO- LOG $ B AUTOMOBILE LIABILITY BAP 2938863 09- 3 Ol 03/01/13 COMBINED SINGLE LIMIT Ea 1,000,000 accdent X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED - PROPERTY DAMAGE $ XHIRED AUTOS AUTOS PeracddenHt SELF INSURED PHY DMG - $ UMBRELLA LIAR OCCUR - EACH OCCURRENCE S EXCESS NAB CLAIMS-MADE AGGREGATE $ OED I I RETENTION$ $ C WORKERS COMPENSATION WC019736915 (ADS) 03/Ol/1 03/01/13 X WC SRV IAAIT OTH-AND EMPLOYERS'LIABILITY D ANY PROPRIETORIPARTNERIEXECUTiVE Y/N NIA WC0197 36917 (FL) 03/01/1 03/01/13 GLFACHACCIDEN'( $1,000,000 OFFlCEtoryin ER H)EXCLUDED'/ WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 11000,000 E (Mandatory in NH) If yes,describe under 1,000.000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICV LIMIT $ E Workers Compensation WC1192494 (gS2) 03/01/1 03/01/13 SIR (AOS)/SIR (GA) 1M/750,000 C Workers Compensation WC0197369: (WI) 03/O1/1 03/01/13 P TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Anach ACORD 101,Addidonal Remarks Schedule,If more space Is required) RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. HOME DEPOT U.S.A., INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES PERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 mJ ATLANTA, GA 30339 — �A aN.c�o h.i �1"V��I"` k' USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Jthornton_hd 30289573