The URL can be used to link to this page

64 HIGHLAND AVE - BUILDING INSPECTION 6-" The Commonwealth of Massachusetts �§ Board of Building Regulations and Standards Ct I'Y O � E, Massachusetts State Building Code, 780 CMR fI C (911 L SERVICE Revised i ar 2l!-1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling M 2 A pt 2L This Section For Official Use Only Building Permit Number: Date Appl' d: � � -Building Official(Print Nume) Signature Date SECTION 1:SITE INFORMATION r1.3Zoning operty Add ss• 1.2 Assessors iYlap 3r Parcel Numbers this an accepted s ?yes_ no - Map Number Parcel number Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(s-q fit Frontage(It) — 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided 12aluired Provided 1.6 Water Supply:(M.G.L c.,10,§5,I) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Check ifyes❑ Municipal ❑ On site disposal system ❑ SECTION2: PROPERTYOWNERSHIPt 2.1 Owt erl or 1 cc rth Name(Print) , f City.St.ue.Z11 — No. and Slrc 'fc aplh wnA "Email Addres SECTION 3: DESCRIPTION OF PROPOSED WORKr (check all t tappply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory.Bldg. El I Number of Units Other ❑ Specifyk-_ Brief Description of Proposed \York'-: _ ' SECrION 4: ESTIm1ATED CONSTRUCTION COSTS Item i i , Estimated Costs: (Labor and Materials). Official Use Only I. Building $ r-- I. Bdilding 1'ertnil Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard 'City/town Application Fee ❑Total Project Cost'(Item 6)x multiplier x_ 3. Plumbing .S 2. Other Fees: $ 4. Mechanical (I IVAC) ,$ List: _ 5. Mechanical (Fire Su res'sion) $ Total All Fees: $ _ Check No. __Check Amount: Cash Amount: C. Total PrJM Cost: $ ,r El Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Constructi pervt icense(CSL) A'• tpr, T1a4= t Lic'C'R umber Ex rat nDatc Namern {� of CS1 liulde--�� —� List CSL.Type(see below) �d.andSt et� Type Description U Unrestricted Buildin s Lip to 35,000 cu. tl.) R Restricted 1&2 Family Dwelling CitylTown,State,ZIP M Mason RC Roofing Covering WS Window and Siding D SF Solid Fuel Burning Appliances I Insulation Te le hone Email address D Demolition 5.2 Registere to Imp rtjet ontrator(IIIC) r HIC Registration Nam •r Ev ra on ate IIIC Co m a or - I • 'etry t ante No. (reel ID Email address City/Town, State,ZIP "fele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.G.L.c. 152. 1 25C(6)) Workers Compensation Insurance affidavit must be • pfeted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issu a of the building permit. Signed Affidavit Attached? Yes .........ro No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES BUIL INGPP/ERMIT 1, as Owner of the subject property,hereby authorize -� !Gi to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) 0 Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby at st on er the pains and penalties of perjury that all of the information cunt in Vntr i- lion is true an accur. a the s[o y knowledge and understanding. r� Print Owner's or Authorized Age 's N c s edre uc Si nature) p; 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 Florae 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 www.ntass.gov/oca Information on the Construction Supervisor License can be farad at www.mass.flov/dns 2. When substantial work is planned,provide the information below: Total floor area(sq. If) (including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.) 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 L_ _ Enclosed _Open__ — 3. `Total Project Square Footage" may be substituted for"Total Project Cost' F4:)- C�WN�iL Cou it: cxery` 2014-05-30 12:47 2686RTV 9787401417 >> Home Depot AHS P 2/11 HOME IMPROYF.MF,NT CONTRACT d PLEASE READ THIS Sold,Furnished and Installed by: Branch Name:Boston North&South THD At-Hmnc Services,Inc. d/b/a The Home Depot At•Home Services Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free 877-903-3768 Federal ID A 75-269MI);MF I to 8 C 02439;RI Cunt,Lic#16427 ' Ln. (1 CT Ii�c#A HIC.056�55r22;MA Barre�Impro¢nor t Cro'�nneect Reg.#126893 Installation Address: �{17( „ Hkq(�A�Ct�{'y_Rtlf-L �riJtPitn fl`,LA V ' 1 /y UU City Stair Zip Purchaserls)): Work Phone: Home Phone: ♦�, Can Phone: It J Home A dress: 1l C) (Ir(Iiffercn urn Installation Addreww) City State Zip Email Address(to roceivr.prajc4l wnm ti IH D ,,,.I,.sea __ ___ ❑1 DO NOT wish to receive any marketing mails from The Hearne Depot Protect Information: Undersigned("Customer"),the owners of the property located at the above installation address,xgrccs to buy, and THD At-Hnmc Service:, Inc.("The Home Deport")agrees to famish,deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Sheet(s), all of which arc incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attamled hereto and any Change Orders(collectively, "Contract"). Produces: Sec Means)#: Proem Amount Rwfmg Sidi mdows all ❑tuners/Covers❑Entry Doors ❑ ]naubmao 3 Roofing Siding Windows U meuladon - $ ©GUIMM/Covers ❑Paluv Dorms ❑ �oot7ng Siding windows Elinsulation - C 01GuLtCrs/Co"n, �Enay Doms Fl $ Rwfmg Siding LJWindows Ll msula urn Q(iummiCovers ❑bntrylMnrs ❑ $ Minimum 35%Depend of Contact Amount due ulmn exeeution of this Contract. Tnml Contract Amount $ Maine Pumhasem may not deposit more than oneihird ofthe Contract Amount Customer agrees(hat,uninedia(ely upon cmnple(iou of the work for each Product,Customer will tacecum a Completion(7Cltilieatr, (one for each Product as defined by an individual Spec Sheet)and pay any balance duc. As applicable.curb Costumer under this ,•1r— Contract agrees to bejointly and severally obligated and liable hereunder. W' ` The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at its h.crctio n,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a sinictural Pico].with the hnmc,environmental hazanb,am:h as mold,asbestos err lead paint,Mhcr safbty concerns,Pricing ermrs or hecause work required m complete thejoh\vas not included in�jthe Contract. m Payent Summary: The Payment Summary 9 _f 14.5__1 1 included as part of this Contract, acts tenth the total • 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 Cmtract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product m defined by individual Spec Sheets)before work im that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Elastic Depot the costs of materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus on other amounts set forth in this Agreement or allowed under applicable law- '111E HOME DEPOT MAY WI'1'1lIlOLb AMOUNTS OWED TO THE HOME DEPOT FROM THR DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER RF.MF.DIF9 FOR RRCOVRRY OF SUCH AMOUNTS. et'cglane¢end Aulhnriratiom Customer agrees and undomiumbi that this Agreement is the entire agreement between Customer and a omeTh IF Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements,either oral or written,relating to said Products and Instillation.This Agrcement cannot be assigned or amended except Jaya writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Customer has read,undersmnds,voluntarily accepts the terms of and has received a copy of this Agreement. Accepted by: Sub 't Cuero r'x Signature Date• sakiijunmltanM i mur!u Date x Telephone No. 910 Customer's Signature Date Sales Cnnsullant Geensc No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as avafiu,blrj 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 IIERETO CONTAINS A FORM TO USE IF ONE. IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S SPATE • NO'1'UX ADINFI1NA1.'I ERMS AND C01,111 'IONS AR4S1'A'I'an(1N'1'l1E REVERSE SIDE AND ARE PART OF T1415 CONTRAS i CITY UE S;IL E;1 [, A-1SS.ICHUSETTS k7CILI=NGDEP.IRTUE`1T YF� 120 WASHLYGTON S-MFET, 3'0 FLOOR ~; [�L (973) 745-9595 K1NIBUf FY DaISCOLL FAX(973) 740-99M T'riOSL�$ST.PIe^,gr;$ DI:iECTOR OF PLBLIC PROP ERTY/aE:MnCVG COJLAIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) rn accordance with the sixth edition of the State Building Cod Debris, wid the provisions of tMCIL e 40, S 54; a, 730 CD.IR section l l I.5 Building permit tt is issued with the condition this work shall be disposed of in a prope that the debris resulting Cram l 11, S I SOA. rly licensed waste disposal facility as dcBncd by bIGL c The debris will be transported by: y � (name ut'hauivr) The dahris will be disposed of in (nantc u(tacPlay) -_— � \ .ram (:IdJrassof'fileili(/ .) — 49 YIS aru rC U(}) rml(dI1(7hl'alit The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Api3licant Information Please Print Le ibl Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: L Are you employer?Check the ppropriate box: Type of project(required): �, 4. I am a general contractor and I 6. ❑ New construction 1.�'I am a employer witti_ ❑ _ employees (full and/or part-time).' have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ J ant a proprietor partner- These sub-contractors have ship andd have no'employees 8. ❑ Demolition working for me in any capacity. employees and have workers' q ❑ Building addition [No workers' comp.insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roo airs insurance required.]t C. 152, §1(4),and we have no 11 employees. [No workers' 13. ther 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 must submit anew affidavit indicating such. [Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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 insurance for my employees. Below is the policy and job site information. Insurance Company Name: P Policy#or Self-ins. Lic. #: Expiration Date: -ob ---- ��.: t Job Site Address: =City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure cover ttige 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 oft for insurance covera a verification. I do hereby cer fy u der a ins and penalties of perjury that the information provided above true a d correct. Si nature: Date: — _ .. Phone#: Official use only. Do not write in this area, rob-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 i Contact Person: Phone#: i ` erase of xegastra4aon valid, andWIM use only q RA f Utfice of Cyer� � $ $ 51°essegulauon y befoi the expsrataon date If found return Yo ofConSuiiierA.ffaar��iadBusinessReQulatfon ! , 1Qpk$laza-5ua4c517O. d. . Re9Fstra Ion.. 93 I '-- Supplerrtenf atll $dstcjn,iVYA f The Home,gepo, s. 4 I 1 G RICN� � �I g lea �Fs valid Rhout sad`nature i ' ® DATE(MMIDDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 921912014 ii 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. CONTACT PRODUCER : NAME: MARSH USA,INC. PHONE N FAXAIC TWO ALLIANCE CENTER AID. No 3560 LENOX ROAD,SUITE 2400 E-MAIL ADORE59: ATLANTA,GA 30326 INSURER S AFA;INAGE 100492-HomeD-GAW-14-15 INSURER A:Steadfast Insurance Co INSURED INSURER B:Zurich American Insuran THD AT-HOME SERVICES,INC. New Ham shire Ins Cc DBATHE HOME DEPOT AT-HOME SERVICES INSURER C: p2455 PACES FERRY ROAD INSURER D:Illinois National Insuran ATLANTA,GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-003242685-01 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. INSR rypE OF INSURANCEFF E ADDL UBR POLICY NUMBER MMNDYIYYVY M EFF MR)DM'YY LICY EXP LIMITS LTR A GENERAL LIABILITY (3L04887714-04 0310112014 03101/2015 EACH OCCURRENCE $ 9,000,000 X PREM SEDAMAGE T EaExc RENTED "co $ 1,000,000 COMMERCIAL GENERAL LIABILITY CLAIMS-MADE X OCCVR LIMITS OF POLICY XS MED EXP(Any one person) $ EXCLUDED OF SIR:$1 M PER OCC PERSONAL a ADV INJURY $ 9,000,000 GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS AGG $ 9,000,000 X POLICY Fj PRO- LOC $ B AUTOMOBILE LIABILITY BAP 2938863-11 03MV2014 0310112015 COMBINED ISINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) $ AUTOS AUTN-0WNED OS PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accitleni UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEO' RETEMION$ $ O WORKERS COMPENSATION WC049101882(ADS) 0310112014 0310112015 X WC BTATu- oTH- ANDEMPLOYERS'LIABILITY WC049101884 AK,AZ,VA 0310112014 0310112015 1.000.000 G ANY PROPRIETORIPARTNEWEXECUTIVE YIN ( ) E.L.EACH ACCIDENT $ D OFFICERWEMBER EXCLUDED? NIA WC049101883(FL) 03/0112014 0310112015 E.L.DISEASE-EA EMPLOYE $ 1,000,000 (Mandatory In NH)' 1,000,000 If yes,describe undo' E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C WORKERS COMPENSATION WC049101885!KY,NC,NH,VT) 03101�014 0310112015 (EL)LIMIT 1,000,000 C WC049101886(NJ) 0310112014 03/0112015. DESCRIPTION OF OPERATIONS ILOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule.If more space is required) 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 2455 PACES FERRY ROAD ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee m 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD s?a sachusakis - apartment c3 Public Safety Board 07 Building Regulations and standards - - Consh•riction Snpen isnr Spccizltc `* . License: ROElRRT POCZO$U"f J S 172 W1IAI SaHEm h'1A 01970- n ,t, Expiratian