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310 HIGHLAND AVE - BUILDING INSPECTION (2) -- --------- �` :a The C'onmt)onwealII of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code. 780 C'NIR SALEM 1 '1'�.• rri.rrd.t lur_'till Building Permit Application 'ro Construct, Repair. Renovate Or Demolish (Arc-or Tuv,-funull-Du•e//in,K This Section For Official Use Onl Building Permit Number: Date Applied: / Building Olticial(Print N;ane) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.la Is this an accepted street?) no_ Map Number Parcel Number 1.3 Zoning information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area IN 11) Fmnlagc(11) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:( . I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check fifes❑ Municipal (3 On site disposal s)stem Cl SECTION2: PROPERTY OWNERSHIP' 2.1 Ow r Recor Nunn(Pont City.state.ZIP Nand street Tele�a� Email Addmss SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all pply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Numberof Units_ Other (3 Spccily: Brief Description of ProposedWork2: e—�> rrol SECTION {; ESTIMATED CONSTRU TION COSTS licit) Estimated Costs: (Labor and .\lalerials) Official Use Only I. Building S I. Building Permit Fee: E Indicate how fee is determined: 1 2. Electrical S ❑Standard City/Town Application Fee i. Plumbing ❑Total Project Cosh(Item 6)x multiplier _ _—x � S S - -- - J, Mechanical2. Other Fees: Mechanical nil\':\CI S List: . S. \Icch;wical Wire ------------ -- � .tiupiressionl S Tidal :\II Fees: 5 Check No. ('heck:lnumm: Cash :\niount: n. Total Project Cult: S � --- - --.---- 0 Paid in Full 0 Outstanding Balance Doc: C SE(:'1'ION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(C'SL) 1 ��y I Icense Number I v nr ton tie Nome of C'SI. I lolder List C'SI.1'ypc(see hela,vl .I.y Pe Description No. and Street -�0 - R l In tricte fed 12 I allin ti ti to 15,01111 eu. It �G�9LLrSr`LI/' R RcaricteJlR2Pamil 1twl11119 Cit_ei I'a„n. e.LI M Masonry RC' Rtwlin;Covering ._ W'S Window md sidinig SF Solid Fucl Ihtming Appliances tD1 G I Institution Tc lcyhanc I',mail address D Demolition 5.2 Registered Home Im rov ment Co rtract![!AH—(ICLr) lly= - �� IIIC Registration NC�m^nh 1IICTtrreC worIIIC' tgisI c Iff 2PJ Nu ' Emuil address City/Town. State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 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 Issuance 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 to act on my behalf, in all matters relative to work authorized by this building permit application Print Owner's Name(Electronic Signature) ute SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below. I hereby attest u the pains and penalties of perjury that all of the information containe this application is true and accu at o th bes f my knowledge and understanding. Print Owner's or Authori red Agent's N;unc I lilecuu Ic Slgmt trc) D4c NOTES* I. An Owner whu obtains a building permit o do his,her Own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contmctor(HIC) Program),will mr have access to the arbitration program or guaranty fund under M.G.L. c. I J_'A. Other impurtant information on the HIC Program can be found at ,u,,, mt,. ,, o, i Information on the Construction Supervisor License can be found at gn dp, 2. \%'lien substantial work is planned, provide the information below•. Total 11our area(sq. R.) _ (including garage, finished basement'attics,decks or porch) Grub living urea(sq. ft.) _-- ---------- -- Number of bedrooms Habitable room count \untber of fireplaces___. . ._ _.._ _.— Vuntherolhathrounu - .- _- - -. _ -I)pu of heating system Vumherol'decks, porches I'ypcofcoolingsystenl _ _ 1711closcd _. . . ---Opelt t. "Folal Project Square Footage" ntay he substituted for ,Total Project Cost" Fm:MyFax-David Barbetta To:THDIAHS Right Fax(18008883810) 21:501WWI IGMT-05 Pg 01-00 HOME IMPROVEMENT CONTRACT PLEASE READ THIS ` Sold,Furnished and Installed by: Branch Name: Boston Dale: /Q_-)".-!( THD At-Hume Services,Inc. —/—/— d/b/a The Home Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 Toil Free(800)657-5182;Fax(508)756-8823 Branch Number:31 Federal ID#75-269MW,ME Lic 4 C 02439;RI Coot Lic#16427 CT Lic#HIC056552�2:-MBA�Hoosme,buiptuvement Comr actor Reg.4 126893 Installation Address. -3/0 H �- city State Zip pwvhase(s): Weirs Phone: Home Phone: Cell Phone: Home Address: (IfdiHeaent£tarn Installation Address) City State Zip E-ming Address(m receive project cvmmnnirations and Home Depot updates): ❑I DO NOT wish to receive any marketing emails from The Home Depot Project Information: Undersigned('Customer-).the owners of the property located at the above installation address,agrees to buy, and THD Al-Home Services,Inc.(-1Le Howse Depot-)agrees W 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 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#: <s....+admmr Products: Saco Sheens)It: Project Amount Roofing ❑Siding indows Insulation ec $ a- (� ❑Guuers/Covers Dam ❑ /9s-/ l C� LIRcorug siding Wadoon, Insulation $ ❑C../Covers ❑Bray Dual ❑ Ring LISiding El Wirdowz ❑hisdauon ❑Cmt rs/Covers ❑F1my Dams $ Roofmg idmg ❑Window; 0 Insulation $ ❑Gauss/covers ❑Entry Doors ❑ Mmimona25%DepasitdCmhadA Trial Contract Ammint $ Maine Purchases;may mtdepaft moretlmamedsvd ofOnCaonadAmo®r. Customer agrees that,immediately upon completion of the work for each Product,Customer will execare 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 be jointly 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 was not included in the Contract. Payment Summary: The Payment Summary# �/ (f,1� included as pan of this Contract, sets forth the.total Contract amount and payments required for the deposrTts and fund 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 defsned 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 rovided by The Home Depot or Authorized Service Provider through the date of termination,phis emy other amrounts set forth in this AgreermenYor allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMRNTS MAD$ WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Ac ntence and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home pot with regard to the Produce;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 has read,understands,voluntarily accepts the terms of and has received a copy of this Agreement.Acreprra hest i(Of X _ so Ctimances Signature ° ID& Sa�s _�l's Sigtainne Date X Telephone No. Custonner's Sigrramm Date Sales Consultant license No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as amucabk) AGREEMENT WITHOUT PENALTY OR OBLIGATION / BY DELIVERING WRITTEN NOTICE TO THE HOME /oZ ((.COhAYM S /UCi /P/TC2W—, - y r DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREEMENT. THE OM r)7) CC- STATE SUPPLEMENT ATTACHED HERETO M(yl�t-I S -t CONTAINS A FORM TO USE IF ONE IS A QlcrrJ i9�/trryYJ SPECIFICALLY PRESCRIBED BY TAW IN CUSTOMER'S STATE. NOTICE:ADDITIONALTERMS ANDCONDDIOM ARE SEAT®ON THE REVERSE SME AND ARE PARTOFTHIS CON Cr 10.1&10 C-SC WNpa-8ninch 3a Yellow-Castomer The Commonwealth of Massachusetts ,Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 e www.mass.gov/dia Norkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers dicant Information Please Print Leeibly le (Business/Organization/Individual): ress: awUo,j�l/+'1�/1° �I /State/Zip: Phone #: C;�Co Slap gu an employer? Check the appropriate box: Type of project(required): I am a employer with L7 4. ❑ I am a general contractor and I " 6. El New construction employees(full and/or part-time).* have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11.0 Plumbing repairs or additions I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. 12,❑ Ro repairs c. ploy insurance required.]t and have no employeees.es. [[No workers' 13. ther comp. insurance required.] plicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have es. If the sub-contractors have employees,they must provide their workers'comp.policy number. n employer that is providing workers'compensation insurance for my employees. Below is the policy and job site ation. �—ice Company Name: — # or Self-ins.Lic. #: Expiration Date:— e Address: ] /� �G �_City/State/Zip: i a copy of the workers' compensation policYideclaration page(showing the policy number and expiration date). to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a r 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 o$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of gatiors of the DIA for insurance coverage verification. ?reby certify under th pai s d p alties ofperjury that the information provided above is true and correct. ure: Date ] )'/ #: Mal use only. Do not write in this area, to be completed by city or town official y or Town: Permit/License# wing Authority(circle one): 3oard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector )ther ntact Person: Phone#: t e Office of Consumer Affairs&.Business Regulation v UIV ..OME IMPROVEMENT CONTRACTOR . Registration S#26893 Type '',Expiration f/3120.-,, Supplement: - Th`e Home Depo� ...... e`s a� RICHARD FALL�NU-1 .�---G. . 2690;CUMBERLAND PARKWAY S "g `-- A .'NQ`Ai:GA 30339 .{ ';Undersecretary 9 'Natlonal Fanestradan yu ti� s �,iaz .� •- - r .-.;eo:' . Sam cmmdm ENERGY PERFORMANCE OR9LNANCEENDIMEWOER�CCNGS { U-Factor Solar Heat in CaeF ci Factor•U Caefidente:Gananan da de:nergiaSol Sol ar '.-•NShT paeuke/f0 ADDITIONAL PERFORMANCE RATINGS EVALUACION SUPLEMENTARIA DE RENDIMI M Urans ii to debalance Tremmision deLvzWble 0 . 44 Mmulecemer stlpulass that Umse mVngs cvh"to apP�CIe NFRC pocedums ter dekmdmn9 whole Product Pedormanca.NFAC . ratings are determined for a Axed setof em mnmenW coaftm and a WHIC pmductsize.NMC does not recommend any WOW end does nutwartaatihe sulsaaftolam/productfor anany speemcme. uracroier'sFiterature foraUerpmductpedafmance _ Eatsfahncante UttPula cps estuvalores cumplen comas par rofeV��li aRC l IensalesY untvnanode pmducto _. produeto.Los valares umdas porNFRCson deteminatlas pa espedAro.NFRCmrecomlendaNnAm yadudoYno garmtlzaque el poduclo spadeouado pare un use espedAro.Cann+Aecan el , folew del fabdome para el use aproPladade arre producW.Wmul C-org _ w. _ _U;i &42iLGx STAR i�• regionfal: Nortborn, North - antr.At, soerch C4ntra4 °enth�r^.`IK jd - :?rt^rR7�u.R - T.a unidwd MlaPirn rarA 1AW R'IC: 29 •° t'sUwrr;esS-£-4"i STAR $urtu, . + a NOLL, control, Luc Caatcai, SUZ. • f 1.'40; Rain GO/Gla., 1%Lf" pro$Oiar/S-LC2S •� Tooted Size: 4U" x au" f • R:aYvor:o JGIV i.dric 3.13 fma/R-1.C25 DP ;-+2! /— .J 5 Taman* probado: 121.9 Gm Is 203,2 cm - _a LPPiieal2le Tusc 'atandardier) A.4SLAAMA/NW DA'101/I.8.2-97,LL ' NAi 6Y/:LL{CSLI01/Z-6.2/Lg40-OS,A ' LPILia,PIL/csaiol/i.s.2/La,c-Ga, , 7605i00/02 glesa Rs aurnatr. 5319696 ' ..kepddsland!:rpCs!cERGS`Si•:'.b••es'.:M wom:isammfrer9'hRc�r+ _ .. - :�;.;:..,:_' . . attrxa de esro,riPte mwrmergystocgw. . .. 9) J ,ERTIFIC.A7E IS ISSUED AS A MATTER OF INFORMATION ONLY X'TFY�rIOR ALTERS R THE COVERAGc AFFOP,D UD 'a THE POLICIES FICA7E DOES NOT AFF!RMATIVEL`! OR NEGATIVELY AMEND, N. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE71IVEEN THE ISSUIMG INSURER(S), AUiHORIZEU _SEN7ATIVE OR?ROOUCER,AND THE CERTIFICATE HOLDER- tTANT: B the certificate holder is an AODl710NAL INSURED, the pnlicy(!esJ must be endorsed. If. SUBROG,AT!ODI iS h9AiVEDi rights tot to ms and conditions of the policy, certain policies may esquire an endcrsemani. A Statamant on this certificate does not conger rights to the . -ate holder in lieu of such endor3ement(s)' �pNTACT 1-404-995-3000 NAME: _ _—_— __.—__ FAX TSA, Inc. PMONE�=x{v._--_— _. _ AI Nei__ _._.. E-MAIL pot.certrequestdmarsh.corn ADDRESS: —'---"""'- Liance Canter, 3560 Lenox Road, Suite 2400 tNSURER(S)AFFORDING COVERAGE %, GA 3032E INSURER P Steadfast ins Cc 26387 : — 12) 948-0903 INSURER 8: Zurich American Ins Co 16535 '--------"'-' me Depot" Inc. _23841 INSURER C: New Hampshire Ins CO ___-_ ' spot U.S.A., Inc. Illinois Natl Ins CO 23817_ . aces Ferry Road NW INSURER O: ng C-20 - _ INSURER E: NATIONAL iNION FIRE INS CO OF PLTTS 19445 a, GA 30339 Illinois Union Ins Cc 27960 . INSURER F GES CERTIFICATE NUMBER: 1983468z REVISION NUMBER: CA IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS IFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. USIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN EDUCCED BY PAID EFF CLAIMS. 0 EIMS LIMITS ADDL SUBft POLICY NUMBE0. MMIDDIY'YVV MMIOD/YYY TYPE OF INSURANCE 03/O1/12 9,000,COD NERAL LIABILITY GL04887714-01 0]/O1/1 EACH OCCURRENCE 4 DAMAGE O NT D S 1,000,000 R COMMERCIAL GENERAL LIABILITY P VISE (EaoccurrenMED EXP(Ani one person) S EXCLUDED CLAIMS-MADE X OCCUR 9,000,000 LIMITS OF POLICY XS PERSONAIb AOV INJURY S GENERAL AGGREGATE SS 9000,000- OF SIR: $1M PER OCC 5 9,000,000 PRODUCTS-COMP/OP AGO E --------- TL AGGREGATE UMIT APPLIES PER: E - >POLICY pRa LOG BAP 2938863-OB 3 01 1 3 0 2 COMBINED SINGLE LIMIT 1,000,OOD Ea den ._..._ JTOMOBILE LIABILITY BODILY INJURY(Per person) E ANY AUTO BODILY INJURY(Per accident) S - ALLOWNEcD SCHEDULED PROPERTY DAMAGE _ AUTO AUTOS NON-OWNED P r a 'd nt E HIRED AUTOS AUTOS S SIR AUTO P Y UMBRELLA LIAR OCCUR ---_---- AGGREGATE S _._._._._--.._..... EXCESS DAB CLAI0.15-MADE ' f DED RETENTIONS WC STATU- OTH- /ORKERSCOMPENSATION WC061967752 (A051 07/OS/1 03/O7/12 X __---- .NO EMPLOYERS'LIABILITY YIN WC061967354 (FL) 0]/01/1 03/01/12 E.L.EA CH ACCIDENT 51,000,000 N E Y PROPRIETOWPARTNERIE%ECUTIVE IFFICEWMEMBER EXCLUDED? N NIA WC061967353 (CA) 07/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE S 1,000,000 _ Mandatory In Hill sC It come under E.L.DISEASE-POLICY LIMIT 31,000,000 ESRIP_ N OF OPERATIONS oelaw 'ozkers Compensation 4WCD 6196735S(XY,MO,NY,WI, 3)3/Ol/1 03/01/12 'X Employers XS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/1M WC1192378 (QSI) 07/01/1 —1—112 SIR 1M Porkers Compensation . :IPTION OF OPERADON9l LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule.it morespaca la re9ulred) EVIDENCE OF COVERAGE \ TIFICATE HOLDER CANCELLATION . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT, INC. ACCORDANCE WITH THE POLICY PROVISIONS. DEPOT U.S.A., INC. i PACES PERRY ROAD INN - AUTHORIZED REPRESENTATIVE .➢ING C-20 LN'1'A, GA 30339 USA ©1988-2010 ACORD CORPORATION. All rights reserved. BRD 25(2010105) The ACORD name and logo are registered marks of ACORD ;� f3uai-yi of $uiltliny HE "Oatinn, .tud �i.Wdal Construction 5uper;isor Specialty License , License: GS SL 99364 estricted to: WS AERTE TORRES 6 FELTOM STREET AARLBOROUGH, MA 01752 r�- may Expiration: 316/2012 Tr#: 99364 Restricted to: WS i IA.- Masonry only RF Roof Covering WS-Windows and Siding SF- Solid Fuel Burning Devices DM-Demolition only Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. _ Referto: WWW.Mass.Gov/DPS CITY OF SAL&NI, , kss.ICHL'SETI'S 9LtLDLNG 0eP.1RT-.%jLNT 120 W.tSHLNGTON STRW, 1'e FtooR t!f. (978) 745-9595 K15CEIERLFY ORLSCOLL FAX(978) 740.9846 MAYOR Noma ST.P'MRM DlucroR op pLauC PROPERTY/aL MDLNG CONp11SStONEAL 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 MCL o 40, S 54; Building permit M is issued with the condition that the debris resulting from INS work shall be disposed of in a properly licemed waste disposal facility as defined by MCL c 111, S 130A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name or fact ity) �— liddrsir orCtcduy) ay +ture o(permrr Jppl innt PD ��te