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13 JACKSON TER - BUILDING INSPECTION i J I� The Commonwealth of Massachusetts u ; Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7m OF SALEM edition Revised Junuury Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 2008 One-or Two-Family Dwelling This Section For Official Use Only Building Permit qumb Date Applied: /�,t Signature: t Building on r Commi / n of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property re 1.2 Assessors Map& Parcel Numbers .eL L l 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 11) Frontage(1l) I.S Building Setbacks(R) Front 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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system O SECTION 2: PROPERTY OWNERSHIP` 2.1 Own t ecor ✓r ZeV Name(Print) Address for Seerrvicce.� Signature Telephone SECTION 3.DESCRIPTION OF PROPOSED WORK(check a that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) O Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': 14-01LLV SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OlTicial Use Only Labor and Materials I. Building $ „ I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: S Check No._Check Amount: Cash Amount:_ 6.Total Project Cost: S 0 Paid in Full 13 Outstanding Balance Due: 7 SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) � `� I�Ftj 1 Cr, License Number F.rpi ion to Name I'C'S lolder List C'SL'rype(see below) .A s T Descri lion U Unrestricted u to 35,000 Cu.Ft. R Restricted 1&2 FamilyDwellin Stg ra a M Mason On1 RC Residential RootingCoverin relephune WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installution D Residential Demolition 5.2 Registered lio t prove rent on I IIC Co s y-bl lqe or HIC R,a istra It Registration mber OL � Expiratioti Dat 7affidavit - Telephone N 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6)) nsation Insurance affidavit must be mpleted and submitted with this application. Failure to provide ll result in the denial of the Issu a of the building permit. t Attached? Yes .......... No...........❑ 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. 3l Signature of Owner Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARA ION I, ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behal Pri Se-alure ) er o Authorized Agent Dale ned can der the pains and penalties of 'u NOTES: I. 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 W have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total Hoors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of firepeaces 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"may be substituted for"Total Project Cost" a n O !Xi O t 3 3 N B p G. 6� t WIAC1i4]e((a- Deparinten(of PUb"C Saretp a Board of Building Regulations and Standards Constml dartSupervisor Specialty License txvnse CS SL 99135 gp3(tjcted to,jE_EV „W S". .LEO A8 BUUJEY=sS' RE T:' . REVERS.MICQ2i5t=' Expiration: UIT2011 4 ('m.uuu ivncr T,a: 99135 O ro m i N (n m CO -a 10-APR-05 03:43P11 FROM-Home Depot 266E ----- -- T-613 P.001/006 F-332 --'-- PLEASE READ-THIS � _ . Sold,Furnished and Installed by: Branch Name: Boston Date,3/3J1 /O - THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 345A Orrenwood Street,Unit 2,Worcester,MA 01607 Bme b Number.31 . _ _ Toll I=(BOO)657-5182: Fax(508)756-8823 Federal ID#75-2698460;ME Lie#C 02439:RI Cant.Liial 16427 CT lie#565522;aeA Home Tntfirovemeal Contractor Reg.#126893 Installation Address: I3 S�KksorvJ ' � S'levt mjof- 011470_ Iry City State Zip Purchaser(s): MOM del( hugs Phone: Home Phone: Cell Phone: 231) 9)Ai [417150t ss ["];t39 '77% Home Address: (If different from Installation Addr4w) City _ re tip E-nmD Address(to receive project communications and Home Depot updates): •� �'�D-l'MA^I I . Covi, []I DO NOT wish to r oceive any marlteting emails from The Home Depot r prgjau�Information: Undersigned("Customer'),the owners of the property located at the above insta114tion address,agrees to buy, an TF-3 TD Ar—Home Services,lnc.('"ITe Home Depot')agrees to famish,deliver and arrange for the installation('Installation")of all materials described on the below and on the referenced Spec Shect(s),all of which are incorporated into,this Contract by this Rom reference,along with any applicable State Supplement and Payment Summary attached herein and any Change Orders(collectively, "Contract"): Job#: o.wam wr r Pmdadr _ 5 8 a #: I'mer3Amount ng Siding windo Insulation �}9�}8Sa I []Guam rcovers ❑Enay Dome I O, $ $-7 07 ❑Roofing ❑Siding ❑Windows rnsultion $ ❑Outim/Covers❑Fora Doora y � Roofing QSidins LJ Windows. insulation ❑outters I Covers ❑ rs C Entry Doom $ .❑Rcofmg 08iding ❑Windows El Insulation $ ❑Ourters/Covers ❑entry tours � .. 11Bnimum 25%DepodtorGnuunAmount doe upon orenmoa oftha—&a& Toad Contraa'Amomm $ S"l g7 `m Mahe „ namasen they rotdepuaft more then on"hird of the CormfoAmogn4 'Custordei'agrees thltf,immeipa[elyvp'titr•ebmplElibn'ot Me-*O&-for°eeclfFtintlbi.T;Crrsmmer'wil2'execute'trCottiplauon Ceawcat - (one for each Product as definrul by an individual Spec Sheet) and pay any"balance due. As applicable,each Customer under this Connect agrees to be jointly and severally,obligated and liable hereunder. .The Home Dapot reserves the right to issue a Change Order or terminate this Contract or any individual Produm(s)included herein,at its discredon,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 hazar such as mold,asbestos car ns,lead paint,other safety concer pricing errors or because work re ds uired to complete the job was not included in the Coonnrect_ Payment Summary: The4layment Summary# a d 5 a included as part of this Conaact sets forth the toed Contract amounr and payments required for the deposits and final payments by Product(as applicable). .. . . NOTICE TO CUSTOMER . You are entitled to a completely Blled-Tn copy of the Contract at the time you'sign:Do got sign a Completion Certificate(note: there is one Completion Certitleate for each listed Product as'deBned by individual Spec Sheets)before work on that Product is complete. _ In the event of termination of this Coutmct,Customer agrees to pa_v The Home Depot the costs of Materials,labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination,phis any other amounts sot 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. Accontance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer and The Home Depot 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 Agreement cannot be m,T ed or amended except by a writing signed by Customer and The Home Depot.Customer acknowledges and agrees that Colin mer has ad,antlers voluntarily accepts the terms of and has received a copy of this Agreement. A led by: Submitted by: CC— rj/,��/�C.� X 0;441O LRk',Cc turner's Signorine Date Sales Consulrentbs-Siiglnature Dam Telephone No. .7"O �1 Y 3 73 VIL Customer's Signature Date Sales Consultant License Na. CANCELLATION: CUSTOMER MAY CANCEL TIHS (os aPnueabie7 AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN 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 W ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:AvornONAL TERMS AND CA NTIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 6r70-0a C-Se Writs-Branch File Yellow-Customer ;.Plnk-Boles OonsuOam j i i -Board of Buddiag Regulations and Standards e HOME IMPROVEMENT CONTRACTOR t ` Registrahoia 426893 r Expiration W3l2010 1 t • - Typq $upplemenl Card - '-; The Home Depot At-Home Service `. RICHARD,FALLONE - li r 2690 CUMBERLAN0 PARKWAY S 6 ' -- -`- < q`�Af'J�`A. GA 30339 � pdmmistrator r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Itivestig ations 600 Washington Street Boston, MA 02111 tvlvlv.inass.gov/dia Workers' Compensation Insurance Affidavit: TBuildersiContractors/Eiech-icians/Plumbers Applicant Information Please Print_Leo blv Name (Business/Organization/Individual): fInte Address:- City/State/Zip: Ali T 1!�1 ` t Phone #: Are y an employer'. Check theappropriate box: Type of project(required): 1. I am a employer with i ` .� 4. ❑ 1 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 slup and have no employees These sub-contractors have g. ❑ Demolition working for me in an capacity. employees and have workers' y p ty. 9. ❑ Building addition [No workers' comp. insurance comp. insurance? ` i 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 I LEI PI 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 13.❑ Other employees. [No workers' comp. insurance required.] 'My applicant that checks box#I 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 anew affidavit indicating such. :Contractors 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. i. I aria an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: t • D I Y Wl I1� c "2 _ Policy#or Self-ins. Lic. #: - Expiration Date: Job Site Address: sBI�G/ �+ City/State/Zip: �ejM ' 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 WORT:ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby7440MORGoi e p Its a penalties of perjury that the information provided above is true and correct Signature: Date: b Phone# Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: ® CERTIFICATE OF LIABILITY INSURANCE DATE19/1 ;VYYY) AC®RO oz/ 9/10 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequesttvmarsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 Fax (212) 948-0902 _ INSURERS AFFORDING COVERAGE __ _ _I, NAIC 9 INSURED INSURER :Steadfast Ins Co :. 26 87 The Home Depot, Inc. NSUREPa.Zurich American Jr. Cc 116535 Home Depot U.S.A., Inc. _ __ ._.� 2455 Paces Ferry Road NW INSURER C.New Hampshire Ins Cc , 23841 Building C-20 ___._...__... Atlanta, GA 30339 INSURER D'.NATIONAL UNION FIRE INS CO OF PITTS 119445 INSURER E:Illino is Union Ins Co 2]960 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY.PERIOD INDICATED.NOT WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INBRD'L POLICYEFFECTIVE IPOLICY EXPIRATION B I POLICYNUMBERLIMIT$LT Y A GENERAL LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE _ $ 4,000,000 X COMMERCIAL GENERAL LIABILITY PREM SESO R[NTED _— Loccunenco)__- $I,OO D,00,0 _ CLAIMS MADE OCCUR _M_ED EXP(Any on_person) $ EXCLUDED_ PERSONALS ADVINJU_BYY $ 4,000,000 GENERAL AGGREGATE_ $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 4_000_000_ X POLICY 17 PRO LOU IS AUTOMOBILE LIABILITY BAP 2938863-07 03/01/10 03/01/11 COMBINED SINGLE LIMIT 511000,000 X ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Pe rperson) $ HIRED AUTOS i BODILY INJURY (Peraccidenp $ NON-OWNED AUTOS % SELF INSURED AUTO PROPERTY DAMAGE PHYSICAL DAMAGE (Peraccidenl) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN,L' EA A00 $ AUTO ONLY: AGE $ A EXCESS I UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11- EACH OCCURRENCE 8 5,000,000 % OCCUR 7 CLAIMS MADE AGGREGATE $ 5'000,000_ —---------- $ DEDUCTIBLE - $ RETENTION $ $ WORKERS COMPENSATION 03/01/11 X WC STATl1 OTH- G AND EMPLOYERS'LIABILITY WCO20342355 (ADS) 03/Ol/10 ___)SORYSIM1rS_ �. ER__._.__.._.._________- __. YIN 0 ANY PROPRIETORIPARTNERIEXECUTIVE� WCO20342356 (CA) 03/01/30 03/O1/11 E.L.EACH ACCIOCNT___81 000,000_ OFFICERIMEMBER EXCLUDED] ffIl.Ykers Mandmoryin NH) WCO20342357 (FL) 03/01/10 03/01/11 EL.DISEASE-EA_EMPLOYE $ 1,000,000 yes,describe under PECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 Employers Excess TNSC46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 3DM/2M Compensation WC0910566 (QSI) 03/01/10 03/01/11 orkers Compensation WCO20342358(%Y,MO,NY,WI, ) 03/01/10, 03/01/11 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THEASOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 [JAYS WRITTEN HOME DEPOT V.S.A., INC. NOTICE TOTHE CERTIFICATE HOLDER NAMEDTOTHE LEFT,BUTFAILURE TO DOSO SHALT. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR 2455 PACES FERRY ROAD NW BUILDING C-20 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2009101)Jthornton_hd ©1988-2009 ACORD CORPORATION. All rights reserved. 14481889 The ACORD name and logo are registered marks of ACORD ,S CITY OF SALEM PUBLIC PROPRERTY �• DEPARTMENT I'.Il: M l t l '•Mlv '11 I.C�•. HII\b. lV)1'Mkl'i •�•111�I.S1.\tiuI11 -4I,•:I1I': I Fl:'17/-7449395 I'.�s:'/711.7J,1V:IJA Construction Debris Disposal AlVdavit (required l'ur all demolition aid renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR scction 111.5 Debris, and the provisions of MGL c 40,S 54; Building Permit q is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c l I t. S 130A. The debris will be transported by: 411arm of I uler 'I'lie debris will be disposed of in I : j addreea,,r nui lily) nal a of Iwrn it+pq icane .I e Ich.i.Jl da