2 HOLLY ST - BUILDING INSPECTION (4) - - 6— the Commomvealthaf Massachusetts w CITY OF y
Board of Building Regulations and Standards SAKI ✓ i
4 Massachusetts State Building Code, 730 CMR RevisedA ' 201
Building Permit Application To Construct,Repair, Renovate Or Demolish a p
-" One-or Two-Family Dwelling
This Section For OfficiAl Use Oni
LI , Building Perm it Number. Do Applied-
Building Official(Pont Name) x Signature• '.. ,- .. Date Ln
SECTION 1.SITE INFORMATION' '
_ 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers`
14o!!� ST Map
II.1 In Is this an accepted street9 yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
a
Zoning District' Proposed Use Lot Area(sy R) Frontage(R) -
1.5 Building Setbacks(ft)
Front Yard Z +.Side Yards _ f Rear.Yard
Required Provided Requited '- Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑. Zone: _ Outside Flood Zone? Municipo]O On site disposal system (3 -
Check if es1
SECTIONM PROPERTY OWNERSHle
2.1 Owner'of Record: '
.., C Id, de4'4- 3ern .er SR,1-Q� M,4 0 i70
�5me(Print) City,state,ZIP - .F -
m a ' (IY ST . 97(p, 7 9s pa3b
No.and Street - 'Telephone Email Address _
SECTION 3:DESCRIPTION OF PROPOSED WORK](check all that apply)'
New Construction❑ Existing Building 13M7- -�)
pairs(s) Alterations) ❑ Addition ❑
Demolition D Accessory Bldg.❑ _ NoOther O Specify:
" Brief Description of Pr s \Vork':' _
°,�i�s rR e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only.
Item Labor and Materials -
I Building S B ] 1. Building Permit Few$ indicate how fee is determined:
❑Standard City/Towrt Application Fee
2. Electrical S ❑Total Project Costs(item 6)s multiplier r
3. Plumbing S y° 2?Qlher Fees: $ _
4.Mcclianical (fiVAC) S List: -
5.\Iechanic:d (Fire Cotaf�\Il Fees:
S"
Su ression) - - -
Check No. Check Amount: Cash Amount.
t6."rotal Project Cost: S, l� 8-7 0 Paid in'Full - 13 Outstanding Balance Due
�"Vt�
v
4 4.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 9
rK olial", ?Dci License Number Expiration Date
Name of CSL FlotWder
List CSL'rype(see below)
No.;Uid Street The, 'Description %
U Unrestricted cu. R.
Y\-\ 6 v, R Restricted I&
Z71tyrFo%vn,State,ZIP IV Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances,
I Insulation
Telephone, Email ad-'-- D
e 5.2 Registered Home ImprovIementI-, Contractor(HIC) 3 - /6
ri 6-1-7 v _ --o t V or HIC Registration Number Expiration Date
I I IC CdJpojy NW�Zvlteg t Name,
rVI iQ)k',P-,-
No.mid Street S b"Sbop;4 -C —�9- Email address
ff 10 7,n
City/Town,State,ZIP 4Z Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT IM.G.11 a;c.ISL 1 WOW
. .. .................
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Isivance of the building peffniL,
Signed Affidavit Attached? Yes ..........E3 - No...........0
SECTION lac OWNER AUTHORIZATION TO 09 COMPLETED NVHEN
01VNER'S AGENT OR CONTRACTOR APPLI SFO1tBUICDINdPERMiT'
1,as Owner of the subject property,hereby authori
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
s See ^C
Print Owner's Name(Electronic Signature) Date
7
SECTION 7b:OWNERi ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain in this app cation is true and accurate to the best of my knowledge and understanding.
Or C�
Print Owner's or Authorize Agc#'s Rome(Electronic Signature) Date
NOTES:
LL 1. An Owner who obtains a building permit to-to his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program)i will lt_o_t have access to the arbitration
program or guaranty find under M.G.L.c. 142A.Other important information on the HIC Program can be found it
Information on the Construction Supervisor License can be round at
f- When substantial work is planned,provide the information below:
Total floor area(sq. ft-) (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 Numberoffialf/batlis
Type of heating system
Number of decks/porches
Type orcooling system Enclosed- 'Open
3. rotal Project Square Footage"may be substituted furrutal Project Cost"
CITY OF SALEA MASSACHUSEM
f BUIID]NGDEPAR7MENT
120 WA9MgGT0NSTREBT,3IDFLOOR
7kL(978)745-9595.
FAX(978)740-9846
KINIBERLEYDRISaD1l
MAYOR 7)"AAS STAEM
DmEcrmCFPUBUCPRCMM/BUMDMOCUMMOMR
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 MGL c40, 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 deposit facility as defined by MGL c ill, S 156A.
The debris will be transported by:
Cc- rt . n
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
`MCI .4
Signature of applicant
f r-- f
Date
_ z Sze ComminveaM ej massaekrse&
Depffltw .d of�aat?toW d Acdde.?Fs
Office of
30s_mAr A14 02311
..— a9rt�Y)a2FLi^SaO7��Zf£ -
VVerEmrs' Com-pensatiamn 1.asa ranee MURdaasr embers
Ingo€m2tisp Pie-se Pjag F&M L�
N<'Lille(Busine_cclOrganizatioa'3ndividuap:9ONf�// -�
Address: q®S 6e5-6jr1 Oc;CrPIK�
City/State,/Zip: S�!9M ,# o elaw i hone i': SO b"- to,6a -
f.re you an employer?•Cuecft the appropriate box: Type o€project(required):
I.❑ 1 am a employer with k. I am a general contractor and I G. ❑New construction
employees(full ancYor part-time)= have hired the sub-contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet g 7. ❑Remodeling
ship and have no employees These sub-contractors have S. Q Demolition
worlcina for mein any capacity_ workers'comp_insurance. 9. ❑Building addition '
[I`lo woricers'comp_insurance 5. We mr:a corporation and its
required.] officers have exercised their I0.0 Electrical repairs or additions
3. I am a homeoamer doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself[No worlcers comp. c 152,§1(}),and rue have no 12 Q Roofrepa,irs� (
insurance required_]i employees[No workers' t3 ther W 1 n JD�32
comp_insurance required-]
.'Any applicant tbai checkx box 21 must also fill our the rad meton belotvsltomine theiraanrla+s'co ^s+f%on potiey information
,I fornummers AID svhmit this ahtdavit indicating-they are dohm W1 work and than hircomside contractors mnstsubmitanemaRidatntindienmesuch
Contractors that ebc&-this box mustanadled aaoMianal sheet sbotvhie the nano:critic enMneiramors andtheirnwhers`comp.policy information.
rpri rn ea.-plorer trier is prnridtrzg tvarS�s'canpensariaa ins�Paace jor mar enrplovees. ;3elory is rbe policy and job size
fe jor raaolr - -
insurance Company Name: L /G�/ j
Policy#:or Self-ins-Lie..'. t G ® J !y / d J L 1 ✓ E�Viradon Date: a Dj
Sob Site Address a It S r Ciy/State/Zip: �� �e. ^1 �) ✓�
Attach a copy of the veorltess'cote® psation policy 2eciararion page(showing the policy uw ber and expiration date).
Failure to seem coverage as required under Section 25A of MGL c. IM can lead to the imposition o€criminal penalties of a
fine up to S 1500.00 andior one-year imprisonment as well as civil penalties in due font oft STOP WORIC ORDER and a fine
or up to S250.00 a day aggggaiosttlie violator- Be advised that a copy of this statement maybe forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
F da he ebp ce, rdeP vah2s aedpena>iu aj)perjcm=ih the a+z,fdr sz�zorzp:avided rbove u ire e_rxd ceracc�
Simrature: 0`, Date: I I S
Phone !- 5-bq — 91;,a—
Vfs.ciei use asFP. �a._at tp:Ye ire rhrs area Po ire u+sz�tezed Sp�P Or iOPIR��
Gity or Town: ?ermittucense#
issuing Authoi?ty(circle one):
I.Board mX-Realth 2.3uilding Depa tment 3,aV—a ow--Glens n EWMa ra]Inspector S.Phimbing snspector
ri.Other
Contact Person: Phone#~
INJE AT➢11 CA U E OF UABI 16 U ➢ SURAm'CE D (NB�D,YYYY,
THIS CERTIFlCATE IS ISSUED AS A IIBFltT'fER OF MFOMM110M ONLY AND CONFERS NO RIGHTS UPOIR THE CE RTERMTE HOLDER.THIS
CERTIFICATE DOES NOT AFFlRNATIV9-Y OR NEGATIVELY AN WO. SCIEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT B[ZWEEBVV THE RSUING INSUR6R(S), gUTlIOR®
. REPRESENTATIVE OR PRODUCER,AND THE CERTIFlCATE HOLDER.
IMPORTANT: If the uwusl m nOm8r is an ADDITIONAL INSURED.the poGeyOeS)must he hmdoaspa, RF SUBROQATTON]S WAIVED subject to
me terms antl Conditions of the POf1Ly,ceybi0 PONCIes may require an endorsement A statement on this certificate apes not confer rights to am
certificate holder in lieu of such endomement(s).
PRODUCER CONTACT
TWOALUANCEGMB FROM
3550 LENOX ROAD.SUI)E2400 " a m
ATLANTAL GA 30326 AODnas
100492-HomeD.MW-15.76 ArPpRORtGwvgyGE pq�e
INSURED D13pitBtA $fElWiastl ' 2638T
THE)AT-HOMESENICES INC. Dpyypeta=aNmAm®tran( Cp 1
OSA THE HOME DEPOTAT-HOME SERVICES INSURER C.NESEHORPSNIM[IRS -A IANO PARWAY.SUfiE�O 2381
TLANTA.cA 30339 INSURER D. FWDERSEQUEaoy
y{gp
RRSURERE_ -
COVERAGES
CERnFICATENUNBER_ ATL47052420509 REVISIOMNUN6172_T
THIs Is TO cERnPr TF1AT THE POugEB OF INSURANCE LISTED BELOW HAVE 8ffi4 ISSUED TO THE INSURtn NA80®ABOVE FOR Ti$POLICY PERIOD
INDICATED, NOAIMTHS T,gND1NG ANY REOUIR�Nf,TEM OR CONDITION OF ANY CONTRACT'OR OCHER DOCLMMM r vlRna w EQPIO :.sobm.aol5
CERTIFICATE FRAY se 15suED ort"a"PERTREN.-Ote ntyvRANCE AFFCMM 6Y THE POLICIES DESCRIBED HEREIN IS SUEJECT TO ALL
EXCLUSIONS AND CONDITIONS OFSUCH POLICIES.LWTS SHOUIBI MAYHAVE BEEN R®UCEUBY PAID C AW1S. THE TERMS.
NSR
LTR IWFOPINSURAIICE In OLICYEFF PpLICYE]{P
A I GEAIERALIJAa1LIlY fmw= 1Q1(D POUCYNm®ER D Lpp�
X
OL0408n RTN
1405 IQDI6 03NIRDi6 EACHDccumanx s 9W00E
ICONtAERC1ALGENERAL 4A®IIiY
I PR@7156` S
OFSR 1,Wq,OBD
I elAn4saaADE a oceARR FPOUCYXS NEDPxPfAnYurep:ml.)FSIR SIM PER OCC s EXCLUDEDPEtsomntaAwDuuay s 9,000.0E
GB+enlu.Aca7diR6AhE s 9DVJADD
PER_
GENLAGGREGATl="I PpLIES - PRODUCTS_CONFICIPA1� 3 LlNR000
^l pOLICy n JH.T n LOC S
B AUTOrMBILEUABILRy BAP E3836312 WN12D15 03N112016 supltELlar 1.
X ANYAUfO 8pD0.YW411RY S
ALLOWNED (�'T SCHEDULED IPe+Pel�) s
AUTOSF IA�q I SELFm511REOAUfO PfRYOMG SODILYIN.IURY(Per20M®111) 3
HIR[DAlTW I NON-0NTI� PRO pAnAGE jI_'AUTOS - 3
I
H UMEREL1ALW8 COCUR I EACH OCCURRENCE S
HIM EXCESSUAB CUIINSMADE AGGREGATE IS
n DED '1 I RET-MIpNs S
C ANDEMPLOYERS'
PLOYER ENsnnoN TI"
( 16WcsigTu- ORANDEMPIAVERS'LIASILfIY C ANY PROPRIRORIPAIENE OECUNUE YINCODT3f4.9 UKRY.PDLAILVf) 03/01015 IBN1D016eLhatexaca�Nr SD OrWCERMEMOER EXCLUDED, ❑N(W2KtdemylnNH) CDU73f494(H) OBD12016 11310mf6 ELO1sEAsE-EA 3"WS,tlesnipe IvlderpE3CRIP710N OF ONIIRR'OatlAdlfiTID®i Page F1 OLFilSE-P01lcrcnahr s 1.000.000
DESCRIPTIpN OPOPERATIOUSILOCAnousIVERICIES(Adaeh ACORD10LAd=and ReOaUsSOMDi.HIM=a'rBCeIsmWaR ) -
eVIDEiNCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
THD THEHOESERVITAT4j0. SHDULDANYOFTBEABOVEDESCRISMPOUCMBECANCMJMD FORE
D55 PACES FSRYRTAT-HOMESERIACEB `THE EXPIRATION DATE THEREOF NOTICE WELL BE p13N lom IN
ATLANTA.G SOME OAD - - ACCORDARCEWIRTHT'IM POLICY PROVISIONS,
ATLAMA,GA 30339
AUIHDR®RE+RESBtiATNE
ufaianal USAMM
i Nanashi Muhhe&e, -.NLRLcf z 14.zC ,,4�
(D 19884010 ACORD CORPORATION, AN tights TeseIWRaL
ACORD 25(2010105) The ACORD name and logo are registered media of AeORD
7
0.1i CO eiEOfce of Consumer Affairs and Business Regulation
10 Parr Plaza - Suite 5170
Boston, Massachusetts 02116
Home lmproven;ppt.,Contractor Registration
Registration: 126893
Type: Supplement Card
THD AT HOME SERVICES, INC: '„'; :':'!i; : s`;'•'- Expiration, 8/312016
MARK NIADNA ;, ;, ..•:s' > ----...— ----- ------ -- -- --.._.._.._..
2690 CUMBERLAND PARKWAY SULT ` .0.0 ";':;r - -- -- -------•_..._,_�.._..__.......
ATLANTA, GA 30339
Update Address and return card.Mark reason for change.
sC.A t 0 21Iu•011 Address (_j Renewal u Employment I_I Lost Card
/••;II!' It'!V/I//IIUffNCl/�Il l��b I�NJL/fI/IJCI♦!1
fticc of Consumer Affairs Business Regulation License or registration valid for individul use only
OME imPRogmENT CONTRACTOR before the expiration date. If found return to:
t Office of Consumer Affairs and Business Regulation
�• ` RegistratlQn:.''U6893• Type: 10 Park Plaza-Suite 5170
Expiratitip;'-813%2D1.0., Supplement Card Boston,MA 02116
i
THD AT HOME SERWCH;S;,INC'.'
• THE HOME DEPOTAT.K,9IIi',SERVICES
MARK NIADNA 'c ;';!i•.'!:'
2690CUMBERLAND'PAR44N S
X% M,GA 30339 Undersecretary t vali
d withou si aAture
'
1• i
9�t Massachusetts-Deparhnent of Public Safety
�f Board of Building Regulations and Standards
Construction Supervisor Specialty
License:CSSL
„
ROBIMTIWZX� ---
Salem MA 01470
>I to`' Expiration` : -
Commissioner 8Z/08f2098 [
HOME.IMPROVEMENT CONTRACT
rPLEASE'READ THIS
�a I" [s Sold,Furnished and Installed by:
Branch Name:Boston North&South Date:_ 9 THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
Branch Numbers 31 and 33 908 Boston Turnpike,Unit I.Shrewsbury,MA 01545
Tml lice 977-903-.3768
Federal ID#75-2698460'.ME Oc#C 02439;RI Conl.Ucf 16327
vi
CT.Uc#HIC.05655522,. B
;MA Home Improvement Cronnc nur Reg.0 126S93
Installation Address: SA(-CM I z" Q I(; l d C
—Q— City State 'Lp
Purchaser(s): Work Phone: . Hmoe Phone: Cell Phase:
[ ] [ ] [ ]
Home Address: City State Zip
(If different from Installation Address)
E-mail Address(to receive project communications and Home Depot updates):
❑I DO NOT wish to receive any marketing e,,its from The Home Depot lasted at the above installnuon address.agrees to buy,
project Information: Undersigned("Cuslomer'),the owners of the property,
ver and and HD'4s 1 ionic Serviccut the belo"The nd onmtehe�referenced Specpot I agrees to Shcet(s),all of which are inccorporaled for the aintolOthis C01m actb by this
all reference,along ribwit any applicable State n th Supplement and Payment Summary"ofattachedis hereto and any Change Orders(collectively.
"Contract"):
Join om wa,..,• Products: S Sh''e'/eta #: P Amount
act 19 $ �( g�
' Roofmg Siding endows Insulation
Doors:•❑ ' .. '_ _ _ .'aRW
Roofing sang windows ialasoa $zsr„-.x
OGuam/Covers i]Ennry Doors ❑
Ro.rmg Siding windows insulation $
or,aac.I Covers OEnuy Doms 0
Roofing Siding Windows Insulurion $
OCrvtter,/Cms (]Envy Doors ❑ v
hfinfinum25%Dep®torConanta Amount due upon execution orrhk tarmac Total.Contract Amount $ I r
hfliM Prrrr/naaers rimy tat deposit st re thanonne4hhd orhere Cammd Amautrt .
ficate
Customer agrees that. immediately upon completion of the work for eachbalance d�omerue. As illapplicable,execute
xeeachomple ion Customer unerti this
tone for each Product as defined by an individual Spec Sheet)and pay any
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 Coituatt or any individual Product(s)included herein,at _
its discretion,irThe 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 thejob was net included in the Contract-
pmNoun Summary: The Payment Summary# d�a t[9 . included as part of this Contract, sets forththe total
Contract amount and paymens required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy or 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 complem
In the event of termination of this Contract,Cmto ner agrees to pay The Horne Depot the coals of materials,labor,expenses j
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.
Ace "and Authorization: Customer agrees and understands that(his Agreement is the entire agreement between Customer
and The Hnmc Uepot 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 Agreementcannot 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 ofand has received a copy of this Agreement.
Accepted by: � -�
Customer's Signature Datc. Su onsuhanl'/:ybClg�ol to
uGr Daa�tee-� �'
X Telephone No. \ ` l p�
Customer s Signature Date
Sales Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS sac upPanmu)
AGREEMENT WITHOUT PF.NAUIV OR OBLIGATION
By DELIVERING WRITTEN NoTicE TO THE Homo.
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS .AGREEMENT. 'I'll F,
S'fAT1? SUPPLEMENT ATTACHED HrREI'O
CONTAINS A FORM TO USE IF ONE IS
SPF.CIP'ICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE:ADDITIONAL TERMS AND CONDITIONS ARE STATED ON TOE RR VERgE SIDE AND ARE PART OF THIS
aS1Cts Whae-Branch Fde Yellow-Customer J';e