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15 HERSEY ST - BUILDING INSPECTION
The Commonwealth of Massachusetts Town of s Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept U\ Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tiro-Family Dwelling AMMUL 1�J This Section For Official Use Only Building Permit Number: Date Applied: Z b tta/,t Signature: I—�— Building Co issioner/Inspector of Buildings Dam — �— SECTION 1:SITE INFORMATION 1.1 Property Ad're : 1.2 Assessors Map& Parcel Numbers l.l a 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 R) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided ?tEpff Required Provided I . EE 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Own f Record: .— , 11 J Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': %CONS SECTION 4: ESTIMATCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Su ression , J_ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ `f� 0 Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) i77� License Number Expir do ute Npmc of CSL-fluld72 List CSL Type(sec below) 7 Addre Type Description U Unrestricted(up to 35,000 Cu. Ft.) R Restricted 1&2 FamilyDwelling Signat q� / �j�� / M Mason Only Yn1 !-6=�'�/ RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Ltonwirn a rac (HIC) HIC C n qr IC Registrant Registration N in d ss �)�/r�yy''J r� / I! CJ Expiratip e a e Telephone �� 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 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 as Owner of the subject property hereby authorize v to act on my behalf, in all matters relative to work authorized by this building permit application. -�q Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, jz� ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. •P Fri Signat of ner or Authorized Agent Date _Signed undeFfthe pains and penalties of perjury 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 not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HICProgram and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.RS, respectively. 2. When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) Grass living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms LNumber of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost' CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 11,t 1.1-i # 1'\I I \I, \1 1 . .I I _ Construction Debris Disposal- Affidavit (rc\luiied for all demolition and renovation work) In accordance wth the sixth edition of the State Building Code, 780 CNIR section If 1.5 Dcbris, and the provisions of:bMGL c 40, S 54; Building Permit k is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be transported by: (name of hauler 'Ilse debris will be disposed of in (name of facility) -- (address u( tacdily) - \ enaturc >t permit applicant 1 date 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naine (Business/Organization/Individual): Address: City/State/Zip: Phone Are you a mployer? Check the appropriate box: Type of project (required): 1. am a employer with ` I 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # 7 ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL l l.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12 .Roo its insurance required.] t employees. [No workers' I er COMP. insurance required.] Any applicant that checks box#1 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 most submit a new affidavit indicating such tContracton that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the.polity and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: ��t i` Expiration Date: i Job Site Address: City/State/Zip:_ &+ 1&l 97D Attach a copy of the workers' compensatioi policy declaration page (showing the policy number and expiration date). 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 insurance coveragC verification. I do hereby certify and th ins d pe ialties ofperjury that the information provided above is tru and correct t Si ature: Date: Phone#: 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#: a ..,, .—. ✓/ee "tJo�rrmw,wiv,¢(�/i o�,/l�aooa�/uwctls Y ' ' ,. ' - .. -Board of Building Regulations and Standards 1 UV, HOME IMPROVEa� NT !, License or registration valid for i CONTRAC70R ndividul use only , ' bcfore til tile expiration expiration date. If found return to: Reljistra 10.6� 126893 ij Board of Building Regulations and Standards Exptrafton _8f3/26i0 One Ashburton Place Rna 1301 �' Type $upp)eme❑t C2rd - ;! `Boston,Ma:02108 The Home Depot Af yoine;ServirR RICHARD FALLON� '� 3200 COBB, Y GALLER F�V�#20 ` TLANTA, GA 30339 Administrator Not vah without signature I I ACORUN CERTIFICATE OF LIABILITY INSURANCE DATE 02/26 IYYYY, 6/08/08 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR hcmedepo t.ceztrequestOmarsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE ' NAIL# INSURED INSURERA:Steadfast Ins Co 26387 Home Depot U.S.A., Inc. The Hose Depot, Inc. WSURERB:Zurich American Ins Co 16535 2453 Paces Ferry Road .Illinois Hatl Ins Co INSURER C. 23817 Building C.8 Atlanta, GA 30339 INBURER D..American Home Assuz Co 19380 INSURERE:New Hampshire Ins Cc 23841 COVERAGES - 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOA POLICY EFFECTIVE POLICY EXPIRATION TR NSRc WPEOFINSURANCE POLICY-NUMBER DATE MWDO1YYIAT YY LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE 54,000,000_UANTAGE TO RENTED X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXC SS PREMISES Eaoccurence $ 1,000,000 - CLAIMS MAOE OCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Anyone person) SEXCLUDED _ 1 PERSONAL S ADV INJURY S4,000,000 GENERAL AGGREGATE S 4.000,000 GEN'L AGGREGATE LIMITAPPLIES PER. PRODUCTS-COMPIOP AGG $4,000,000 X POLICY PRO- LOC B AUTOMOBILE LIABILITY BAP 2938853-05 03/01/08 03/01/09 COMBINED SINGLE LIMIT g1,000,000 X ANY AUTO (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS (Per person) HIRED AUTOS. BODILY INJURY $ NON-OWNEDAUTOS (Peraccident) X SELF INSURED AUTO - . - - -- - PROPERTY DAMAGE PHYSICAL DAMAGE (Per acnden0 $ - - GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $ ANYAUTO - OTHERTHAN EAACC S AUTO ONLY: ` AGG $ A EXCESS/UMBRELLA LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $ 5,000,000 X I OCCUR CLAIMS MADE - AGGREGATE $ 5,000,000 $ DEDUCTIBLE - S RETENTION $ $ G WORKERS COMPENSATION AND 1928757 (FL) 03/01/08 03/01/09 X STATLIMIT- DTR� WC D EMPLOYERS'LIABILITY 1928756 (CA) 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 ANY PROPRIETOR/PARTNERAEXEOUTIVE E OFFICERUEMBER EXCLUDED? 1928755(AOS) 03/01/08 03/01/09 E.L.DISEASE-EA EMPLOYEE S1,000,000 If yes,describe under SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT S1,000,000 OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 acurrence/SIR 25M/2M D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers, Compensation 1928758 (KY, NO, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS _ -FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2455 PACES FERRY RD., N.W. BUILDING C-8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)datkinson ©ACORD CORPORATION 1988 8213215 ' FES-02-2009 09:54AM FRDM-HOME DEPOT 3401 +603-437-4212 T-023 P.001 F-877 CL6AJb i{beiu iazi� Sold,Famished and installed by: Branch Name Boston Dace: ?/ 1 / 2Cb9' THD At-home Services,Inc. dWa The Home Depot At-Home Services Branch Number. aoath 31 345A Greenwood Street,Unit 2,Worcester,MA 01607 Toll Free(800)657-5182; Fax(508)756-9823 []North 33 [gS Federal ID fi 75-2699460;ME Lie 9 C 02439;Rl Cont Lid#16427 ` CT Lic it 565522;MA Home Improvement Contractor Reg.A 1126893 Installation Address: I S HIRSly SlR✓�7-� 5AIF/? 144 0)970- 01ir City State Zip Pumbesar(s), Work Phone: Home Phone: Cell Phone: 007MOM) ft-SCOD [ l [97g')710-0 [Wirl76f-7o Home Addresa: SAME '1� n 14 f4 (If different front Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): FD _LWQfI2 YAMX.CG" ❑I DO NOT wish to receive any marketing emails from The Horne Depot Pro'ect lnformwtion: Undersigned("Crutomer'),the owners of the property located at the above installation address,agmcs to buy, a AI-Home Services,Inc.("The Home Depot'l agrees to famish,deliver and arrange for the installation(`'Installation")of all materials described on the below and an the refierenced Spec Shoet(s). all of which are incorporated into this Contract by this refarmec,along with any applicable State Supplement and Payment Summary attached hero and any Change Orders(collectively, "Contract,'): Job#: a.wr.) Products soft Shw s M. Project Amount Woofino❑Siding Windows LJ insulation +2_21"3 MEntry Doom ❑ 071 s $ 11' 667, 60 Roofing LISidins ❑Windows 0 insulation 4 82 i Grate s�❑ ay Doors ❑ 5 5 ZS6 $ 1, 05 s.40 Root) ❑Siding windows insuladon $ ❑Canters I Covers ❑Entry Doors❑ Roofing ElSiding ❑Windows Insulation $ C]Goners/Covers ❑Envy Doors ❑ hflnma,25"i6 Deposit arCuntracrArmett dun upon exeeudna of this contract. Total Contract Amount $ I I, Mahn purchasers may not deposit amre man ace durd of toe CantmaAmonnL Customer agrees that,immediaiely 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 arty balance due. As applicable, each Customer under this Contract agrees to bejoimly and severally obligated and liable hereunder. The Home Dcpm reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at is discretion,if The Home Depot or its authorized service provider detetmims that it cannot perform its obligations due to a structural pmbkm with the home,environmental hazards such as mold,asbesms or lead paint,other safely concerns,pricing error or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary 0 130091 _ . included as pan of this Contract, sets forth the total Contract amount and payments required for the deposits mid final payments by Product(as applicable). . NOTICE TO CUSTOMER You an 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 Tinder applicable law. THE HOME DEPOT MAY Wr=OLD 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. i Acceptance and Author izati n: Customer agrees and understands that this Agreement is the entire agreement between Customer and The llama Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or writtm relating to said Products and Installation.This Agreement cannot be assigned or attended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Accepted by: Submitted by: li -2oo x/VSCKPAtczDN ^ 2-I-Zm4 Custwn'er' Date Sales Consulianl•s Signazrae Date 7I 2_-I-zC0q Telephone No.iM co-oir iumar's Signature Date Sales Consultant License No. FA CANCELLA7ION: CUSTOMER MAY CANCEL. THIS (as uppl!cabte) !I AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME j 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 CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 10.1-011 my 6415416 CSC white-Branch Ffle Vallow-Customer Pink-Sales Consultant - J