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5 HOME ST - BUILDING INSPECTION (_r_-7 3(q i �13 -I '�.- 1(0O S p C�t2oT0T-� The Commonwealth of Massa'11ASI �CTIONAL CITY OF Board of Building Regulations and Standards SALEM O % Massachusetts State Building Code, 7$Q1Ctal _2 P 1 2 Revised d/ur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only ., Building Permit Number. Date ppliedr _l Building Otlicial(Print Name). Signature Date SECTION 1:SITE INFORtNIAT10N` 1.1 Property AddrrT —75Y 1.2 Assessors Map di Parcel Numbers L i 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 III Frontage(11) 1.5 Building Setbacks(R) Front Yard Side Yams Rear Yard Required Provided Required 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? Municipal❑ On site disposal system ❑ Check if yesE3 SECTION2: PROPERTY OWNERSHIP! 2.1 Ow n f cordpfnVtf �� ►�� me Pnnt City,State,ZIP No.and Street T— Telep—� Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check a"at apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs( Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work=: SECTION-1: 71ATEDN RUCTION COSTS Item Estimated CosOfficial Use Only Labor and Mate I. Building S g Permit Fee: Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cose(Item 6)x multiplier x 3. Plumbing S �,�ther Fees: li /�� 4.Mechanical (HVAC) S List: �l 6� ) 5.Mechanical (Fire S Total All Fees:S Su ression) Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due: ta (� SECTION 5: CONS'rRUCrION SERVICES 1 5.1 Constructi isor Licen CSL) '1i U1 License umber Espi tiu ate Nanc of CSL Holder--d List CSL'fype(see below) No.;aid Street Type _ - Description U Unrestricted(Buildings tip to 35,000 cu. It. R Restricted 1&2 Fz unily Dwelling Cityrfown,State,ZIP N Nfilsonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances t ��I ��`�� I Insulation Tcl hwre Ematl address D I Demolition 5.2 Registered Home In vem nt Con actor(HI ) HIC Re station N m er Exp uti n Date flq, 44;�A t !Name No.a Email address Ci /Town,State ZIP Telephone SECTION 6:WORKERT COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.$ 25C(6)).. Workers Compensation Insurance affidavit must be compiged and submitted with this application. Failure to provide this affidavit will result in the denial of the Wuan a building permit. Signed Affidavit Attached? Yes ........ ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATIOMTO HE COMPLETED WHEN. " OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT' 1,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Nmne(Electronic Signature) Date ON 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By enter' my name b w,I hereb ttest under the pains and penalties of perjury that all of the information cont.' ed in this a 'catioi ru .nd curate to the best of my knowledge and understanding. caner' rfk oho cd i gcl 's Ranie(Electronic Signature) Date NOTES: 1. An Owner wino ob ins a building permit to do his/her own work,or art owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(111C) Program),will not have access to the arbitration program or guaranty, fund under M.O.L.c. I42A. Other important information on the HIC Program can be found at Www.mnsS.v� v'oca Information on the Construction Supervisor License can be,found at wwtv.mass.aovldlrs . 2. When substantial work is planned,provide the information below: 'rotal floor area(sq. R.) (including garage, finished basementlattics,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 'fypeorcoolingsystem Enclosed Open_ i. 'Total Project Square Footage"may be substituted for"roCd Project Cost" HOME IMPROVEMENT CONTRACT Sold,Famished and Installed by: PLEASE READ THIS CONTRACT THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike Unit LShrewsbury,MA 01545 Toll Free 8779033768;Fax 8009863610 Branch Name: Boston North Date:9/15/2014 ME Lic#C 02439 RI Cont.Lic# 16427 CT Lic# Branch No: 33 HIC.0565522 MA Home Improvement Contractor Reg.#126893 Federal ID#75-2698460 Installation Address: 5 Home St SALEM MA 01970 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: Mrs.Gladys Brou hton " ' (978)7454996 Mr.Thomas Broughton 978 7454996 Home Address: 5 Home St SALEM MA 01970 (If different from Installation Address) City State zip E-mail Address (to receive project communications and Home Depot updates):skyman2992nahpeprint.com Marketing emails will not be sent from The Home Depot. Project Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,and THE)At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installati �n on")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(where applicable)attached hereto and any Change Orders(collectively,"Contract"): Job#:(internal Reference) Products: Spec Sheet(s): Project Amount 7779009 Roofing 7779009 $11,582.20 Minimum 25% Deposit of Contract Amount Total Contract Amount $11,582.20 JJJ due upon execution of this contract Customer agrees that,immediately 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 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# 7779009 included as part of this Contract,sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). 07109n"A Page 1 of 7 The Commonwealth of Massachusetts r Department of Industrial Accidents —i ` Office of Investigations 600 Washington Street Boston, MA 02111 �.n�• www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): Address: City/State/Zip: Phone #: b Are an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with_ _ 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 g, ❑ Demolition employees and have workers' working for me in any capacity. 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 1 LE] Plu Ing repairs or additions myself (No workers' comp. right of exemption per MGL 12. oof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks box 01 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 a new affidavit indicating such. Contractors that check this box must attached an*itional sheet showing the name of the sub-contractors 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: ta, Policy#or Self-ins. Lic.4:4118 l� Expiration Date: Job Site Address: l ( City/State/Zip: Attach a copy of the workers' compensation 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' surance coverage verification. I do hereby certify under i e pa s d p allies ofperjury that the information provided a ove is true and correct. Si nature: Dater r 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#: 1 ,a DATE jMWODIYYYY) ACORV CERTIFICATE OF LIABILITY INSURANCE 07/192014 THIS 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 endorsement(s). ON ACT PRODUCER NAME:MAR IFAX TWO SHUN, INC. PHONE A/C No: TWO LENOX ROAD,CE SUITE E-MAIL. 3560 LENOX ROAD,SUITE 2400 ADDRESS: ATLANTA,GA 30326 V1NSURER(S)A;FF0RD1:NGC0VERAGERS AFFORDING COVERAGEMNAIC100492-HomeD-GAW-14-15 INSURER A: nce CompanyINSURED INSURER B: n Insurance GoTHDAT-HOME SERVICES,INC.DEATHE HOME DEPOT AT-HOME SERVICES INsuaaa c: ins Co2455 PACES FERRY ROAD INSURER D, I Insurance Company + - 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. ADOLSUBR POLICY EFF POLICY UP LIMITS INSR LTR TYPE OF INSURANCE POLICY NUMBER MM0DNYYY MMIDDIYYYY 9,000,000 A GENERAL LIABILITY GL04887714.04 03101QO14 0310112015 EACH OCCURRENCE $ X DAMAGET RENT D 1,000,000 COMMERCIAL GENERAL LIABILITY PRE ISE as occur nce $ CLAIMS-MADE a OCCUR LIMITS OF POLICY XS MEO UP(An one person) $ EXCLUDED OF SIR:$iM PER OCC PERSONAIB ADV INJURY $ 9,000,000 GENERALAGGREGATE $ 9,000,000 _ PRODUCTS-COMP/OP AGO $ 9,000,000 GENL AGGREGATE LIMIT APPLIES PER: X PRO- $ POLICY LOG COMBINED SINGLE LIMIT B AUTOMOBILE LIABILITY BAP 2938863-11 03/0112014 0310112015 Ea accident 1,000,000 BODILY INJURY(Per person) $ X ANY AUTO ALL IN SCHEDULED SELF INSURED AUTO PHY DMG BODI LY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON�OWNED Per loan HIRED AUTOS AUTOS _ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LI CLAIMS-MADE AGGREGATE S OER RETENTION WC STATU- "_ , G WORKERS COMPENSATION WC0491018 2(ADS) 310112014 0310112015 AND EMPLOYERS'LIABILITY Y/N WC0491018a4(AK,AZ,VA) 0310112014 0310112015 E.L.EACH ACCIDENTC ANY PROPRIETORIPARTNER/EXECUTIVE[ENIA OFFICERIMEMBER EXCLUDEDT WC049101883(FL) 0310112014 031012015 E.L.OISEPSE-EA EMPD (Mandatory In NH1000,060 I/yes describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C WORKERS COMPENSATION WCD49101885(KY,NC,NH,VT) 031012014 031012015 (EL)LIMIT 1,00QOW C W0049101886(NJ) OT0112014 03N112015 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional'Remarks Schedule,It more space Is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER - CANCELLATION THDAT-HOME SERVICES,INC. LTHE ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE DBA THE HOME DEPOT AT-HOME SERVICES EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 2455 PACES FERRY ROAD CORDANCE WITH THE POLICY PROVISIONS. ATLANTA,GA 30339 RIZED REPRESENTATIVE sh USA Inc. shi Mukherjee J'4auuo�- ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Office of Consmmer Affairs d Business Regu� 10.Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 126893 Type: Supplemetd Card THD AT HOME SERVICES, INC. Expiration: 813=16 • RaGFiARC}-�-AEL(3lGE.,- -- 2690 CUMBERLRND PARKWAY SUITE_ 300 — ATLANTA, GA 30339 Update Address and return eard.Mark reason for etrange. scat 0 201an5111 —. Address _I Renewal L—j-Employment f Lost Card ffice of Conson Affairs&BuituessRegulation License or registration valid for lndividul use osly WEIMPRGVEl1EftTCOWfAAcmlt 6eforetfieexPU%Wndate. Iff000dremrato: Wee of Consumer Affairs and Business Regulation > , 5 Bellist`ratlon: 1�g3 Type: AOarkPlua-Suite 3176 � `. 'Eicpirationall32046 SupplementCard Boston; lfi ,THD AT HOME SERVICES,iiJG . ^`' 1HE HOME DEpOTATHOMESERVICES Rb-Mb FALWNE -. ' 2690 CUMi3ERiAND PARKWAY S - AU 311339 Cnderacreury ". of va wa tli�rsigna CITY OF SALEM, MASSACHUSEM K BUILDING DEPARTMENT 120WASHINGTON STREET,3ADFLooR TEL. (978)745-9595 KIMBERLEY DRISCOI-L FAX(978)740-9846 MAYOR THOMAS STTPIERRE DIRECTOR OF PUBLICPROPERTY/BUILDING cOMMISSIONER 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 111, S 150A. The debris will be transported by: �'O1 Q=L (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) 4Siggne of applicant Dale g� owl aR Oil, 4444 $ ii+➢ x YP C r A ti � lu M3'�4A ro �{ t1� IEtii h`n • .ni.i 59 A i y p i Y�r tea Xt ed MY M R kt F 'S �07131120'15 s I �49y�. .'�"" t�b'• ,��r:% r.4..*&->r ue"..ak�..x _..n==; ' IN$µy'�. Y�5 pl � '(a1." to