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401 HIGHLAND AVE - BUILDING INSPECTION I'he C'onunonweallh ul•Massachuseus Board or Building Regulations and Standards CI 11,OF Massachusetts State Building Code, 780 LAIR RevileSAL Ili\I Building Permit Application 'ro Construct, Repair, Renovate Or Dem fish a One-or rlvu-PiuniA, Dtrel/in.4 This Section For Official Use OolyZ building Permit Number: to Applied; Building 011icial(Print Mune) Signat Dale SECTION I: SITE INFOR TION 1.1 Property, jd 1�. �� n A 1.2 Assessurs Slap& Parcel Numbers 1.la Is this an acre teal erect?yes_/� no iMaitNumber Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arco(sy 11) Frontage(11) 1.5 Building Setbacks(() Front Yurd Side Yards Rcar Yard Rcyuimd Provided Required Provided Reyuircd Provided 1.6 WANT Supply:(M.G.I.c.40.§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Ihablle❑ Pdvute❑ zone: _ Outside Flood Luna? Municipal❑ On site disposal s).rtum ❑ Check if cs❑ SECTION3. PROPERTY OWNERSHIP' 2.1 Own of Recall 11(J'd' aU� N;inu(Print) City,Stale,ZIP No.and Street rcleQ ophu� Emuil Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check II apply) New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) IlrJ Alterations) ❑ I Addition O Demolition ❑ I Accessory Bldg.❑ Number of Units Ot ❑ Spccily: Brief Description of Proposed Work% i SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor:rod .Materials) 1. building S 7. �- 1.:Building Permit Fee: S Indicate how tree is determined: '. S ❑Standard City!TunnApplicationFee l:'lectmal ❑Tuml Project Cost't Item 6).x multiplier ). 1'huuhimg S ?. Usher Fens: S- J. \lechanical ill\ \('1 S �List: 5 \Icdianical IFm \uppruismnl S r+tat ,\IIFas: S_,.------- ('hccA Nu. _Chuck:\mauuC l'.uh \m,wnt: I. 1'utul Project CuvL S J ❑ Paid in Full Q Outsemding bal.uicc Oue: SE( I'10N S; ('ONSI'R1 ("fION tiF.RVI('F.0 / $.i C'onstrucIion Supers isur License(C'SI.) -- I icatae anther Pynr unu )ale N,uncul'l'SLILddcr II,tCSI. I)pelsechelu,sl.._._ _.._ � (hvcstriovd Illuddin's Ii it) 15,11111)cu. Il.l PC �� �. . It Re,trivwd l&.11nil Dwdlin Cit)%f,re n,Slate.LIP %I NhIsun RC Rnntin Cuwrin %AS R'indow.wd Siding �I SF Solid Fuel Burning Appliances [- I�t'3��ft� 7 1 Insulutiun t'Y ]I ` Finail addruvi U Demolition 'frlc hone I 5.2 Registered llama In pru 'ement Contractor(HIC) IIIC Reglitr;niun Nuntl,er liq uli n Dwc I IL' ' t t ; n•nr c nw Nu. tJ •et Email address -Cityrrown.State ZIP Tc a hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.c. 152.1 2SC(6)) Worker Compensation Insurance affidavit must be c eted and submitted wish this application. Failure to provide this atRdavit will result in the denial of the issuan of the building permit. Signed Affidavit Attached? Yes .......... No...........O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorize ! DEL to act on my behalf,in all matters relative to work authorized by this building permit application. Print Uwncr's Nwne(Electronic Signature) to SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering Iny name below, I hereby aft under the pains and penalties of perjury that all of the information coma' in this application is true and cc ate to he b t of my knowledge and understanding. 11611 Owllef d or.\111hori/eJ Agelp•..4, Mile 'IeelrUI11V.............. ) Date NOTES: I. .\n Owner who obtains a building permit to do his.her own work,or an owner who hires an Intregisterrd contractor (not registered in the Home Improvement Contractor(H ICI Program).will nu have access to the arbitration Program or guaranty fund under M.G.L.e. 142.4. Other intpurmnt information on the HIC Program can be round at ,,,,,, nit„ �; " .�, I Information on the Construction Supervisor License can be round at \\'hen substantial,wrk is planned, provide the inibrination below: rota) hour area 114. R.) . ____.._1 including garage, finished basement attics.decks or porch) Cross h%ing area l sq. It.) Habilable roost count \anther al lircplacci .... -... . Number of bedruvoli _ . . \uulherothothreunn — \umherofhall'hathi 1'.po othcming i)heal Number ol'daki, porches cn )I, I)pu„I':o„hng :)SteinSteinI!nda,cd .I t. "I t.11 I'rnjcd Square FootaLte"ma) k,e,uh,tiuncd tort"f,n.d Prujcct COAL CITY OF S.u.E.N1, AUSACHUSETTS 13 azoiG Dmm-mm'sr I '0 IO-UNLNGTON SntM, 1"EtOOlI KIMSFAr Y OUXICLL FAX(97J) 14O.9i14d MAYOI! 1}to.+w ST.PMUS D11tECT011 Of A SLIC PROPlBTY/Stanva cmallsito.%ER Construction Debris Disposal Affidavit (required for all demolition and renovation, work) fn accordance with the sixth edition orthe State Building Code, 190 C,UR section 1 11,J Debris, and the provisions oil a 40, S 54; Building Permit 11 is issued with the condition that the debris resulting from ihis work shall be disposed of d-in a properly lice¢sed waste disposal facility as defined by NIGL c 111, S 1 JOA. The debris,{willlbe transported by: i 1 I yice 1/f'\ I /C (nano ul'Aaul�r) The debris will be disposed of in : —_ (name�afrac,,JIOL— Wl orrjohly) r y +Nro urpermif ipph<inf The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 -UV. www.massgov/dia Workers' Compensation Insurance Affidavits Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): IJ D ll'(ei I/ Address: ea e 5 Ee rr y ED A-b City/State/Zip: Q,N 3 0-5 3 L Phone#: Are you an employer? Check the Appropriate box: Type of project(required): 1.® I am a employer with_ol 0 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 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 employeesv w rkin f and have workers' working or c in any capacity. 9. ❑Building addition cbm . insurance. t [No workers comp. insurance P 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.❑ R pairs insurance required.] t c. 152, §1(4),and we have no 13. Other �C employees. [No workers' 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 new affidavit indicating such. tContraetors 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 subcontractors 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: /V�W l�Llm p5 k riie, 73j_Q s /�, 1 o . 2 Policy#or Self-ins.Lic.M W C O 1 g 7 3 6 1p 15 Expiration Date: 3 � Job Site Address: g n� ak LJ City/State/Zip: (c; Attach a copy of the workers'compensatio-4 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 D r insurance coverage verification. I do 6d ,15 an penalties ofperjury that the information provided above Is a and correct. S' Date: Phone M Official use only. Do not write In this area,to be completed by city or town officld 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 s. Contact Person: Phone#: r G _ _ CERTIFICATE F LIABILITY" INSURANCE � on z7; r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER IBIS 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 1 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). _v PRODUCER 1-866-966-4664 CONTACT NAME: Marsh USA Inc. --- ---PHONE FAX homedepot.certrequest@marsh.com E-MAIL 5: Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 INSURERS AFFORDING COVERAGE NAIC Fax (222) 948-0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURER B: Zurich American Ins Co _ 16535 The Home Depot, Inc. Home Depot U,S.A., Inc. INSURER C: New Hampshire Ina Co 23841 - 2455 Paces Ferry Road NW - INSURER D: Illinois Natl Ins Co 23817 Building C-20 NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER E: INSURER F: Illinois Union InB CO 27960 COVERAGES CERTIFICATE NUMBER: 25776028 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. _ ILTR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY E%P POLICY NUMBER MM/DDIYYYY) iMIWDD1YYYYI LIMITS A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 X DAMAGE 10 RENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S - CLAIMS-MADE F11 OCCUR MED EXP(Any one person) $ EXCLUDED X LIMITS OF POLICY XS PERSONAL B ADV INJURY S 9,000,000 X OF SIR: $iM PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 9.000,000 - -XI POLICY PRO- LOC $ -- B AUTOMOBILE LIABILITY BAP 2938863-09' 0 0 COMBINED SINGLE LIMIT 1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ _ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED Perr PERT cd entOAMAGE $ AUTOS X SELF INS UR D PHY DMG $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 X WC STATU- OTM-AND EMPLOYERS'LIABIL TY D ANY PROPRIETORIPARTNERIEXECUTIVE YIN NIA WC019736917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICEWMEMBER E%CLUOEDt a E (Mandatory in NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYEE S 1,000,000 Ifyes,describe under DE SCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Workers Compensation WC1192434 (QSI) 03/0l/1 03/01/13 SIR (AOS)/SIR (GA) 1M/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Atmch ACORD 101.Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW _ AUTHORIZED REPRESENTATIVE BUILDING C-20 ^ — ATLANTA, GA 30339 USA ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks.of ACORD ' Jthornton hd 11 C /7 pp ���,,``/ ✓lZUddUGLUQC�d �\ '.office of Consumer Affairs&Business Regulation i4, 0VOMEIMPROVEMENT CONTRACTOR � . .. t� TyPC; - Registratiom. 26693 _ Expira �n:- f2012 7n : Supplement The Home DepoAf No'meryicesIiWM _ RICHARD 2690 CUMBERLAD - r GA 30339'`''� Undersecretary 2012-03-29 00:04 2686PRODESK 9787401417 » Home Depot AHS P 1/6 HOME IMPROVEMENT CONTRACT PLEASE RRAD'/'HIS Nana:: Beaton Dale: 3 Sold,Furnished and Installed by: Bianch �, I�� 'fHD At-Home Services,Inc. d/b/a The Home Depor At-Home Services 345A Greenwood Stree4 Unit 1 Worcester,MA 01607 Toll Prey:(800)657-5192;flax(511E)756-8823 Branch Number:31 Federal ID#75 269k4k);ME Lic A C 02439;R1 Cont.Lic#16427 CT Lic#NIC1.115655221 MA Hume hnprovemenl.Contractor Reg.#126893 Installation Address: 401 4i(=)Wukr-r0 AV6 SAI-C-1 rM8 OI e9-7Q - City State Lip (—P urvlm.(s)' Work Phone: Home Phone: CAI Phone: vt1MI CC—tLAl z< l`hb] 853 8 i l Home Address: t5 (If different Item installation Address) City State Tip E-mail Address(to receive project communications and home Ik:put updates):S C-90 2 _ I &D b' ..4,1 ❑I DO NOT wish to receive any marketing entails from The Home Depot Project Inforldxtionc Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy, and THD Ai-Home Services,Inc.("The Home Depot")agrees m furnish,deliver and arrange for the installation("Installutimf of all materials described on the below and en the referenced Spa: Sheet(s), all of which arc 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#. oa..mt vdt.eiW uG ds: S c Sh.t s If: Pro' Amount koofiog QSidiog RrVrd. 0Insulmion ��py�r�t ry J q ❑cutters 1 CRvas ❑retry nags ❑ I C ( &f-X $ ( 3 V-S cm ^ J/q ❑Ruufing Siding W.mlows hmlation - ❑Ruufng Siding❑Wmvluws hmlation I $ dieters 1 Cnveta ❑Entry Dotes fl Roofing ❑Siding ❑Windows hsaladrn ❑Gu(rrslCovas ❑Entry n<oro ❑- $ Minimm25%Depma ofCmWactAm Amman due up.amcudan of this contract 11DiuePd�aamny not dlcpamtmwe dhmorayryrW dNeCoatrxtAmnme Total Contract Amount $ r 3 0§- Customer agrees Ihat,immediately upon completion of the work for each Protect,Ctstorax will execute a Completion Certificatet (one for each Product a%defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to he jointly add severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Pruduct(s)included herald,at its discretion,it The Home Depot or its authorized service pnnvider determines that it cannot perform its obligations due to a structural problem with the home,environmental hazards such a.mold,asbestos or lend paint,other safety amccros,pricing errors or becauau work required to complete the lob was not included in theContract. Payment Summary The Payment Summary #J / l 17 ,included as pan of this Comma, sets faih tire wtal Contract amount and payments required lira the depasits and final payments by Product(as applicable). NOTICE TO CUSTOMER You are entitled to a eotrgdetcly(Bled-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion CertiBwte for each listed Product as defined by individual Spec Sheets)before work an that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of a atmiNs,tabu,,expenses and services provided by The Home Depot or Authorized Service Provider through the date or termination,plm 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 'JAMMING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization; Customer agrees and undeismads that this Agmaxot is the entire agreement between Customer and The Home Depot with regard to the Products and Installation services and supersedes all pnor discussions and agreements,either oral or written,relating to said Products and Installation.This Agreement tans assigned or amended except by a writing signed by Costumer and The Home MINA-Cmtomer acknowledges and agrees that Cu,to r has read,uod2e ixnds,voluntarily accepts the term of and has received a copy of Ins Agreement, ZSubmitt by: Cr x fter's igmtme f/Dale Sales Consultant's Si�". ore - date �! x Teleptwr c Nn. mar 3 7 3 i Customer's Signature Date Sales Consultant license No. _ CANCELLATION: CUSTOMER MAY CANCEL THIS (a:eppacaede) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO TI/E HOME DEPOT BY MIDNIGHT ON THE TFmtll IUSI]NuS.N DAY AF9'h:R SIGNING THIS AGREEMENT. THE SLATE SUPPLEMENT ATfACFFF.D HERETO CONTAINS A FORM '170 USF. TF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADI1rr1ONAL TRIVO AND CONDMIOM ARE STATED ON THE REVERSE SIDE AND ARP'PAlrr OF Tills CON'1'RAr7r 7618.10 C-8C While.-Brandt FBe Yellow-Cusaxnar `Nadanal FenesYadan �a.. r ,-_... Rom caufdre vWmjUw ' ENERGY PERT flRMANGE RATINGS EyplY PEIGN DE RENCIM;NTOENERGEnCO . U-Factor Solar Heat Gain Coeffident Uall I'mcanancia de E`etSul Solar VOJTA t . AD��OIANPER YCaaRRt+�oMCE IRAToINGS ' Trannsm8wn deta sib e . 0 . 44 r i p D rmaz¢e.NFAC I mductilu.NFRC aces Ad(ecomnund any Product Manulacarer sdpulales that glass raVngs conform to appDcaateNFRCprocedures tardelermlNn whole rodxt pads Manut era determined tar a dead set enulsanmenlzlcsndldons aiMasOn D enddiesnittenantaxsu�adRYof anYP lar any zpeafic use.Wnndt ma_whcttirel's traose for aNerPm�ctPedarmance I _ Inlarmamn.wvxsnhc.mg Este ra rIM1e GeV WaesmsvWC turnd emblas Plu un=l FAanafa d,em11did0rurSen Cenll ustri lamanadepmdacto l' ' praducto.lns'a+IaarasusadaapmNFPCsandelermin guant tquo atun W especramNFRC rm recamrendanmprm 0rodrrdaYna 9°r nSuedDramxaadecuada Par un usdesPe •�n��can al nda d0 este Product°. ra'°fF toaeto del laMcante panel use apmp _r;yy;;�quati2ie3 2or FNZita f3TAR tagiantsl: Nocthern. at 1,66 .. ent r.at, South twntrsst, .g^srh"cn.'• y _ i ,�ct'.Cycu«4 f.w �rni.�arl raliElrq �w[w ler4? FjrZ: 29 Esc-iGZ u:\a: 9•Nctar ..q rtl�ivni . 'Nucta-Cant Cal, $ur CanCCai, • rcuSolacj8-:.C25 . •,- ].Yu; Ruin GOiGI�+ Ilf,' la„ y Tented Size: 4 x s �► yyy; R;; ooeeo cotVidrie 3.Ia snstl R-7;c2S ` r TalaaAo pcohado: ]'t-1.9 czd x 209.2 On - .. ._ .. .. x1D ; +>h�—J�i , eralis yvsilasxa/Nrrw-,aiu1/=.s._Z-��,u � '' ania Tact atanacd isl: .1� .w CSliOil,Ll,�-sd•2J ayJ—Oi•� - .. Sr•IL'w1lMa1 C+a103iR.b'.i a94L-08, r"T-?7a<,ashis�:ctt+- CJelturtrncn't o1'Puhiir;ti.t(t(y $ S3n;ard nt' Bu'slden_Rc�:BILLti6i19:md stand:tnls CorsiiuCtion Supa.visor License Licensz: CS 9-671 MtCHAEL DEFELIOE JR 21 SPRiNG,,ROAD DRACUT,MA01826 Expiration: 6r2g=12 Trx: 18228 � dlar/ . '^. Olfiea�Coasu,cr I-Rain do B4mo Regu .. GOA7E IPAPROVEMENT CONTRACTOR gays: ., 1peglstratlat: 161579 InCWWu&1 2' y29f20t2 " iy Expiratimn: ., 'AEL A DEFEUCE MICHAEL.DEFELICE 21 SPRING RD. . . DRACUT,MA 01826 Dodcn«ntaT7 - i x yr -