29 HORTON ST - BUILDING INSPECTION (2) 2-9. 2- , L47 C$113 > 2-03
IL The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
V
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit N b : Date Alied: G - 30-
-_1
Building 0 ficial(P ntjVat e' i Date
SECTION 1:SITE INFORMATION
1.1 Property A 1.2 Assessors Map&Parcel Numbers
��
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L 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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own r eco
WAALO
�/?VM M()
Name(Print) City,State,-ZIP
No.and Street :�.` Telephone mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repmrs(s) 6 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑- Number of Units Otfiq ❑ Specify:
Brief Description of ProposedWork2: -r-—t - -
�r s
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Five $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su rvisor Licen CSL) / ( �.
e V `,�t LiceYN,14 E�cpi o
Name of CSL Holder
) ,� A List CSL Type(see below) IA
No.and Street iL'O-!`awl*Yf Type Description
'^ q U Unrestricted(Buildings up to 35,000 cu.ft.
City— /lo�wn,State ZIP �— I R Restricted l&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
C•� I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improve at C�o'n'ttraaccttoor,.( IC)
1N&E:D /� - HIC Re stration Number o Wdnat,
HIC Co an o HIC e
No.and S Email address
Ci /Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be rnpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issupee of 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 e��ecnd&,t
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest and the pains and penalties of pequry that all of the information
contain this application is true and accurst to Je !
Toy knowledge andapplication is true and accurat to knowledge and understanding.
Print Owner's or Authorized Agent's Name(E SignalurO Dad
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 Home 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
Information on the Construction Supervisor License can be found at
2. 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 Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
;1
Department oflndustrial Accidents
Office of Investigations
-�.� 600 Washington Street
+ 7 Boston, M4 02111
F ZtI< www.mass.gov/dia
`Yorkers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers
ApVheant Information ! Please Print Legibly
Name (Business/Organization/Individual):
Address: ��� try1T ( yvL
City/State/Zip: hone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New constriction
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
These sub-contractors have v F� nantnlition
workingfor me in an capacity. employees and nave workers'
Y P tY 9. ❑ Building addition
[No workers' comp, insurance comp. insurance.:
required.] . 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L❑ Plumbing repairs or additions
myself.
to se o workers' com . right of exemption per MGL
y [N p 12.❑ R50pk,pairs
insurance required.]t c. 152, §1(4),and we have no ,
employees. [No workers' 1, Other
comp. insurance required.]
"Arty applicant that checks box#I trust also fill out the section below showing their workers'compensation policy information.
+Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 sub-contractors have employees,they must provide their workers'comp.policy number.
am an emiVoyer 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.lk r �14 Expiration Date:
Job Site Address: �Jnt�1 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 IA for insurance coverage verification,
d da hereby cerd un r put and pqnaldes of periury that the information provided ab ve is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
- . ..'.DaTaiMMmorY'•'Y`I_.
CERTIFICATE OF LIABILITY INSURANCE DZV12013
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 Ii15URE0,the pClicy(les) must be andcrsed. 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). CONTAC
PRODUCER NAME:
MARSH USA.,INC. - PHONE I INC.N a
Two ALLIANCE CENTER IAIC No.
�L
3EE0 LENOX ROAD,SUITE 24N ATLANTA,GA GA 30326 INSURERS AFFORDING COVERAGE 26387 NAIL 0
iCG45t-HomeOGAW-1}t4 INSURER 0.:Steadiest Insurance Campany 15575
INSURED INSURER B:Zuddl Amenran lOSWarLE CO
THE HOME DEPOT,INC. New Hampshire Ins Cc 23Mi
HOME DEPOT USA.INC.- - - INsuRERc: 23e17
2455 PACES FERRY ROAD,NW INSURER D!116no'd Nadonal Ins CO
BUILDING C-20 INSURER E
ATLANTA GA 3D339,
INSURER?: ..
COVERAGES CERTIFICATE NUMBER: ATL-=15954504 REVISION NUMBER:7
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTV14THSTANOING 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 ANDCONDITIONS OF SUCH POLICIES.IJMRS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN R TYPEOF INSURANCE I POLICYNUMBER MM/00 MMIDwunrr— 91000,000
GL0 LIMITS
L
A GENERALLIABILRY 48R7714-03 I030112013 03N72014 EACH
s
iwE�TE s 1000.00
X COMClA1MS-MADE MERCIALGENERALLIASIUTY 1
aOLCUR S,D00,0 LIMITS OF POLICY XS MED EXP and s EXCLUDED
00
OF SIR:fiM PER OCC PERBONAL t ADV INJURY S
GENERAL AGGREGATE 9 9=001
— —^-- PRODUCTS-COMPIOPAGG S 9,000.0w
GENL AGGREGATE LIMIT APPLIES PER S
X-- POLICY �O' LCL Ma1N D IN I 1,0W,OW
0 AUTOMOBILE LIABILITY RAP 2930663.10 031012013 031012014 Es adds 1
BODILY INJURY(PC Parson) S
X ANY AUTO '
AA�LrL&NED SC
DULEO $ELFINSUREDAUTOPHYOMG BODaYINJURY(Peraod°"°> t
0 DAMAGE S - !
NON-OWNED
HIREDAUTOS AUTOS S
UMBRELLA UAS OCCUR EACH OCCURRENCE 8
EXCESS UAS CLAIMS-MADE AGGREGATE S
S
DED RETENTIONS 11201 0 01 014 STATU- 0 H.
C WORKERS COMPENSATION 3357514(ADS)
AND EMPLOYERS'UABIUTY YIN WC0 W5315(AK.AZ) 0310112013 031012D14 EL EACH ACCIDENT S I'�'
C W ANY PROPRIETORIPARTNERIEXECUINE N NIA 1,0M,000
D OFFICERMEMBER EXCLUDED?
WC03357531R(Pu 031012013 O3N12014 EL DISEASE•EA EMPLOYE S
(Mandatary In NH) L000,000
Ilyyea,deaaibe uraw I! DISEASE-POLIO LIMIT S
OESCRIPTION OF OPERATIONS 0.b I OAODD
C WORKERS COMPENSATION WC033575317(KY,NC,NH,VI) 03101a 3 1=112414 (EL)LIMIT
C WC033575318(NJ) 03101r2013 03f012014
DESCRIPTION OF OPERATIONS/LOCATIONS[VEHICLES (Attach ACORD 101,Addltlonal Remarks Schedule,ll mom space is required)
EVIDENCE OF COVERAGE
CERTIFICATE HOLDER
CANCELLATION \
THE HOME DEPOT INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455 PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS.
'BUILDING C20
ATLANTA,GA 30339 AUTHOR260 REPRESENTATIVE
of Marsh USA Inc _
Manashl Mukherjes _K&%AXOkZ ` �`-
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of'ACORD
it
e Piooamavwe�<rfso /��wac4uayk�:
O(Gce ut CgnsamerA(Cairs Fr usmess Rc*31;.on L;cans �r ragia}raLolt slid for Indrviu'u}w only
6 ° ;before tha expiration date. Tt s'onn3retuln to
OM IE IPf bVEMENT COr1TPACTOR Office o£Consumer
Affair-nud Ytu>inessReg"ln ion
Rec�lsttatlont�93 1 .�YBe Y01'aik'Plnza%-Suite 5170
Explra ` Supplane t and Boy*on,l4iA'Oz1Y6
The Home Oepo •" q`F{ �;
RICHARO FALL
ZE90-CUMBERLA „ •� 3 -r".�'r..._. ..- 1 ' ;I
R`�LAN` , GA3033,9'N+ c• •UoVe(sccretary - ' -r.,; `OEvalid e
CITY OF &UEM, 1NL_1SSACHUSETTS
BL'WWG DEPARTNONT
\ 120 WAiSHNGTON STREET, r FLOOR
TEL (978)745-9595
FAX(978) 740-9846
Kl�{BERIF_Y DRISCOLL
(MAYOR THoalas ST.PIERRE
DIRECTOR OF P4BLic PROPERTY/MU DING CONLMISSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
�f1 azn��
(name of hauler)
The debris will be disposed of in
,
((name of Facility)
(address of facility)
s gnature of permit applicant
Jot
dcbnsai .l,is
l
Int Massachusetts - Department of Pu-blic.Safety
Board of Building Regulations and Standards
License CSSL-099699: �!
ROBERT POCZOBUT : _
172 WHALENS LANEA ,, I j
Salem MA 01970 -: <a''
��^- mac`;`• - expiration -.
cornntisswner 02/08/2014 -
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2013-09;03 09:03 2614READING 7819428601 » Home Depot AHS P 1/7
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PLEASE READ TINS
Btxmh Namc:Boufgn North&Somtlt Date: Sold,Fnmishei and Installed by:
W2013 THD At-Horne Service,,Inc.
d
Branch Number:31 and 33 wa The Rome Depot At-Hume Services
908 Bosom Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Frec 877-903-3768
fcdcral Ill#75-2699460;ME I.ic#C 02439;IH Cent I.lc#16427
Cf[ic#HI OS/.t522,MA Horn Improvement Cunonrtry Reg,#12fiu97
Installatm Addrem: ((4u�tLV J129 01990
City Slate Tip
Yurchaxerysl: Wok Pb pm: Home Phone: Cell Plan:
� .s127�1(-ao
Home Address:
(If different from Inmallmim Address) City State zip
E-mail Address(to receive project canununicadons and Hume Depot uruiares):_=mUj •(KU ft5 n•
1 DO NOT wish to receive any marketing¢entails form The Hone Depot Pro
e_c_tp orm,,' Undersigned("Customer"),the owners of the progeny loomed at the above installation address,agrees to hay,
and TTIIs—dAt HumRe�Ser"cM]ail(•"I'hr Home Depot")ag=%to fumi fl,deliver and arrange for the inbmllatimc('7ushdhdIM")of
all materials described on the below and on the rel'crenced Spec Sheet(s), all of which we incorporated into this Contract by this
reference,along with pay applicable State Supplernent and Payment Summary attached herein and any Change Orders(cclicrorively,
"Contract"):
Jnb#: aa..w wm.a,ri
' 2411un x: Rpec y'Irtrt s #; Pmjer't Amount
Roofing Skiing Wtndmas Insulaunn
Z2t1�2 ❑Gannets/Covers 1;ntryDorm; 1 _ �9�733 13 fd •?D�
Rooufing Siding Windows lnxutat,mn
(]Gutters/Carvers 0unary Doors [] $
Rimers Siting WiDowns Insuladen
❑Gmtem/Covers ❑hurry Lhxw(]_.
❑Rwhnx Siding ETWindrow ❑jasulauon
EIGuawn/Cow;ra ❑tlnlry Dours p
Minimum 259 Deposit ofCmimad Amount due,uponexacuirm of this amha:t .I.nlnl Contract Amount $2I� -'7O /
Main ma Pordsmara y milldcpodt name than oneihtrd Mlbe Cammetpmpum. V
Customer agrees that,immchately upon ermplerim Of the work for each Product.CnatONICT will execute a Urmpletion Certificate
(one for each Product as defined by as individual Spec Shect)and pay any balance due. As applicable,each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depo reserves the right to iseue a Change Order or terminate this Contract or any individual Product(%)included herein,at
its discretion,if The Home Depot or its authorized service provider deu.Tmines that It camut perform its obligations due to a strudoral
problem with the honae,enviroluncntal hazards such as mold•asb,%LcN or lead paint,other%afety,concerns,pricing errors or Ixwause
work required to complete the job was no included in the Contract-
Payment Swung", The Payment Summary# R11571 included as part of this Contract, xLv ninth the Total
Contract arnuunt and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOM EH
You;arc entitled to a C071lately riled-in copy of the Contract at the time you sign. Du not sign a Co 1pletirn Certificate(note:
there is one COMPleton ertifuate for each listed Product as defined by Individual Spec Sheets)before work rot that Product
is complete.
In the event of termination of this Contract,Customer agrees to pay The How De t the cats of materials,labor,expenses
and services provided by The Home Depot or Authorized Service Provider the dale of termination, film any otter
amounts set north in this Agreement er allowed under apppplicable law. THE ROM a DEPOT MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE IIEPOSIT PAYMENT OR OTHER PAYMRNT'3 MADE WITHOUT
LIMITING T'HE HOME DEPO'i"S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
pcee fame•n u zalkn; Customer agrees and understands that this Agreement is the entire agreement between Customer
tee"
tome Ihptd wtt regard to the Products and Installation services a d supersedas all prior discussions and agreemcnix,either
oral or written,relating to said PAxlass and Installation.This Agreement cannot he assigned or wounded except by a writing signed
C.'u by Customer and The Home Depot. skuner aclmowlcdgu%and agrees that ashmner has read,understands,voluntarily accepts the
terms of and has received a copy of this Agremcnl.
A pt by:
s >Rude t}S4: Sub Red
a /
Cut lConutntsSt tSu a urc Uaue
X_ • ._ Telephone No. 1 2 / ^�1Y7y
Customer's Signature Data Sales Consultant Liculaw No.
CANCELLATION: CUSTOMER MAY CANCEL THIS taro+wtiwbtal
AGREEMENT W111101fT PENALTY OR OBLIGATION
BY DELIVERING WRITl'EN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE.
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS '
SPECIFICALLY PRESCRIBED BY LAW IN
CCIS•rOIHER'S STATE
NCM('P.r ADDITIONAL TEj ant AND CONDITIONS ARE R1'At'EU ON THR REVER\TtmDF.A"ARE PART OF THIS CON VXACr
06.04.13 While Granch Flo Yelow—Customer