12 JANUS LN - BUILDING INSPECTION y� The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
d ' One- or Two-Family Dwelling /
•v This Section For Official , Onl r
f
Y
X
7`
Bull' ing PeniuY-Number . Date A hed'4
t
Building Official(Print Name) `Signature s, Date
SECTION 1 SITE INFORMATIO
1.1 Property Address 1.2 Assessors Map& reel Numbers
L la 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
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:
Public ❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
.SECTIQN2 P7777�ROPkRTY`OWNERSIIIPt`r"
2.1 Owneri
Name(Print) City, State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOIiTCZ (check all apply) _
New Construction El Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : �—
=.
SECTION 4:,ESTIMATED.CONSTRUGTION COSTS;
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ IJ Build ng I I TetrnifFee: $- .rindtcate how fee is determ nedi'.
❑ Standard City/Town Application Fee `
2. Electrical $ s
gTotal Project Cost (Item 6)�x multiplier.' x
3. Plumbing $ 2 Oth rFees $  �
4. Mechanical (HVAC) $ List
S. Mechanical (Fire $ Total All Fees $
Suppression)
Check:No. Check Amount Cash:Amount.
6. Total Project Cost: $ ❑Paid in Full ❑ O tstand ng Balance D'ue:
SECTION5i CONSTRUCTIONSERVICES
rName
nstruction Supervisor L�se L) License Number Expirati tat
CSL Holder
List CSL Type(see below) )
Street t ;TYpe Desenpt oti,
f�� � U Unrestricted(Buildings u to 35,000 cu. ft.)
�1� ff7p R Restricted 1&2 Family Dwelling
Qty/Town, State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Im oveme t Contractor(HIC) I� /
I-!IC Registration Number Expinati D to
HIC e Name
f1
No. and S r Email address
city/Town, State, ZIP J Tele hone a
SECTION 6: WORKERS' COMPENSATION TNSURANCEAFFIDAVIT(M.G.L. c. 152:§ 25C(6))-
Workers Compensation Insurance affidavit must be mpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issua e of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER A'UTHORIZATION,TO,BE COMPLETED WHEN,.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BOLDIN' 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.
Print Owner's Name(Electronic Signature) D to
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
Ain
my name below, I hereby t under the pains and penalties of perjury that all of the information
Fthis-aonlications i true d a urao best f my knowledge and understanding.
zed Agent's ame Electroni Signature) Date
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
ww'w.rnass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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"may be substituted for"Total Project Cost"
11-07-'12 10:07 FROM-THD PRODUCTION 5087569009 T-445 P002/004 F-650
_..I....- - ----
JJ�_ I J/b/:1 'l'ne HorM t>C.ptn na-nv.nc w.+.w
345A Greenwood Street,unit 2,Worcester, MA 01607
Toll Free(800)657-5182;Fax(508)756-g923
Branch Number:31 Federal ID n 75.2n9")6 ME Lic#C i)Z439;RI Cool.Lice 16427
CT Lic#Hi ()565522;MA Rome)mpnwement Cnntr�a}ct>pr�}Reeggg,#12689-1
Installation Address: " L � � 01
City State Zip
Purchaser(s)e Work Phone: Horne Phone! Cell Phone:
L J
Home Address: ••
(if different from installation Address) City State Zip
E-rnail Address(to receive project c,nor unications and Homc Depot updates): ,--
❑I DO NOT wish to receive tiny marketing emails from The Hume Depot
Protect lnlarntatfent Undersigned("Customer').the owners of the property located at the above installation address,agree%to buy,
and THD Al-HoMe Services. Inc. ("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")of
all material$ described on the below and on the referenced Spec Shect(s), all of which are incorporated into this Contract by this
reference. along with any applicable State Supplement and Payment Summits}' attached hereto and any Change Orders (Collectively,
"Contr iuv);
tub#: rrmmur ern,..!+) Products; Sheets #: Prn ell Amount
/� Rooting Siding WinJn+ws .- Insulation 7
b' 1 61 ❑<iuttcrs/Ever$ FAtry Dmis ❑ (� ],]•• _ _ a s ao
Roofing ElSidine E1Windows htsulatiun $
❑(Sut[er�/Covers ❑E.ntry DrnnA ❑�,,,
Rrxfflng Siding Windows�tnsulation $ ,
LjGutters/Covers ❑Entry Dann❑_„_ t
Reodng Siding Windows In+ulatlon — -�
❑Gutters/(`nvCi'a []Entry Dana []
Minimum2q%t)epaaltatConiturs Anartmidueupon.cxecudannttldseontmeL Total Contract Amount $
Maine Pnttttawers may not deprodt more than one-third ofthe CencrrxtAmount
Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate
(une fur each Product m defined by an individual Spec Sheet) and pay any balance due. As applicable. each Customer under this
Contract agrees to he jointly and severally obligated and liable hereunder.
The home Depot reserves the right to issue aChange Order or terminate this Contract or any individual Product(s)included herein,at
its dixerelion,if The Home Depot or its uuthori7.ed Service provider determines that it cannot perform ila obligations due to a structural .�
problem with the hone,environmental hazurds such as mold. asbestos or Iced paint, other safety concerns, pricing errors or because
work required to complete the job was not included in the Conntract-
Poyinient Summary: The Payment Summary # -214 /Qy included as part of this Contract. set,% forth the total
Contract amount and paymerm required for the depokils and final payments by Product(as applicable).
NOTICE TO CUSTOMER
You arc entitled to a completely filled-In copy of the Contract at the time you sign. Do riot sign a Completion Ckrtirtcate(now
there is one Completion Certificate for cacti listed Product as defined by individual Spec Sheets)before work on that product
is Complete,
lu the event or termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expemi"
and services provided by The Home Depot or Authorized Service Provider throm1ib the date of termination, plus artyy other
amounts set fortb in this Agreement or allowed under applicable law. THE.HOMF. DEPOT MAY WITHHOLD AMCIUNT'S
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADf:, WITHO(!T
LIMITING THE HOME DIipOT-S OTHER REMEDIES FOR RECOVERY OF SUCH AMU(!N'15.
AA aaq�'S-and AuthorGxttlon: CustomC•asmav and understands that this Agreement is the entirC agreement lx:tween Customer
and The Ham a f)epot with regard to the Products and Installation services and supersedes all prier discussions and agreements,either
oral or written, relating to said Products and Installation. This Agreement cannot be assigned or amended except by a writing signed
by Customer and The Home pot. Customer acknowledges and agrees that Customer hag re .understands.voluntarily aueepis the
termv of and has r> ceive py of this Agreement.
Submitted by: /,/lx7
Cuss Sig to Date Sales onsultant's Signature nl
)S.._ Telephone NV-.._...._.—., -----..._......
Customer's Signature Date Sales Ctmsultant License No.
(;ANCELLATION: CUSTOMER MAY CANCEL THIS "'s arplicablo
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRVATEN NOTICE. TO THE HOME
DEPOT BY MIDNIGHT ON THE`, THIRD BUSINESS
RAV •L Liu Crl`Nl1U!` W"Be AFuvP ,rvwJ TIIF
t,z '•� d 1.(' 'ir05t7.➢7v(7 iH -.tlfu:/1 rlf iXf"%i4S[L 1�76Si>Z,i -
t= �.—. � I�PD.7J'tiit£llt nt..ftz(f7rllr r,tt,flu lliiPE&F
r�rl.
� .)00 tr f)r itYtstE z+£;'[
Workers' Compensation Insurance Affidavit: Iittthicrs/i ottcraetors/�iechici�as/I'hlmbets
;lRplicant information Please Print Legibly
Name (Business/Organization/Individual):
Address:_ ----
City/State/Zip: At"Cc�,
, :�3O�3q Phone#: � _/� � �
Are an employer? Check the appropriate box: Type of project(required):
I. I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-t me).
have hired the sub-contractors 6. ❑ New construction
2.❑ I zm a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
workin for me in an capacity. employees and have workers'
g Y P tY• 9. ❑Building addition
fNo workers' comp. insurance comp. msurance.t.
required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself o workers' co right of exemption per MGL .
y [N tap. 12.❑ f epairs
insurance required] t c. 152, §1(4),and we have no
employees.[No workers' 13. Others _
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 most submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the subconttactots and ante whether or not those cad ties 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 lnsurance for my employees, Below is the policy and job site
information.
Insurance Company Name: 6��!�l(Q
Policy#or Self-ins. Lic. #:_ �/ Expiranoa Date: .._
6 Job Site Address: 10 . I . ll�✓I City/State/Zip: L�
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 S 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 insurance coverage verification.
I do hereby c ti u r tl pains d penalties ofperjury that the information provided above ' true and correct.
Si atur Date: _
Phone#:
Of use only. Do'not wrtle 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#: ;,ire
CITY OF SALEM, iAxsSACHUSETTS
BUILDING DEPARV tENT
N 130 WASHIINGTON STREET, 3PD FLOOR
TEL. (978) 745-9595
FA.X(978) 740-9846
KIitBERI.EY DRISCOLL
MAYOR THoa�LiS ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 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:
(name of hauler)
The debris will be disposed of in
-- me of fa qin- �
—�A(address
*s, pplicant
date
Icbrisl(dH:
I
,p+ Massachusetts -Department of Publ!c Satety
r' " Board of Building Regulations and Standards .
License: CSSL-099699 Q�• .� y
ROBERT POCDOBUTX r
172 WHALENS LANL
Salem MA 4970
Carnm+ssioner 0 210 812 01 4
- � Off of Consumer Affair and B uusinee Regulation
10 Park Plaza Suite 5170
.- Boston, Massachusetts 02116
Home Improver"bdJContractor Registration
Reqistration: 126893
Type: Supplement Card
SO
Expiration: 8/3/2014
The Home Depot At-Home Services ,
2690 CUMBERLAND PARKWAY SfUtT30b
ATLANTA, GA 30339
y!-
,. Update Address and return card.Mark reason for change.
--� Address Renewal Employment Lost Card
OPS-CA1 0 50M-04104-0101216
i d
l
l
' RAN
AB�U ERTIFICATE OF LJ PY' IJ N 3 U C'
I"HIS CER rNFICATZE 13 13SUE6 AS_AMATii�R. OF iNFORMATMI'll CIN"", Amz) coNFE7'0 NO plvms UPON TSIE
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE Ct)VIERAGE AFFORDED BY THE PCLICIES
SELOW. THIS CER71FICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE-PiAJEE111 THE ISSUINIC, wsup'EF(S)' 'AUTHCRIm-,
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
iMPCRTAN7: If the certificate holder is an ADDITIONAL INSURED, the policy(es) must be endorzad. If SUBROG"ITION IS
the terms and Conditions of the policy,certain policies may require an endorsement A staterrment on thl's ift-IIS 110-
certificate holder in lieu of such endorsamprit(S).
1-866-969 WTACT
-46-64 cc
arch USA Inc. ,NAMEPHONE I FA"
omedepot.ce I rtrequast@maral-,.com EA bNOuLESS,
wo Alliance Center, 3560 Lenox Road, suite 2400 tlanta, GA 30326 INSURERS)AFFORDING COVERAGE NAIC#
ax (212) 948-0902 iNSURERA: Steadfast ins Co 26387
4SURED INSURER B: Zurich American ins Co 16535
he Home Depot, Inc. INSURER C: New Hampshire Ins Co 23841
rate Depot U.S.A., Inc.
455 Paces Ferry Road NW INSURER D: Illinois-Nail ins Co 23817
uilding C-20 , INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445
tlanta, GA 30339 INSURER F- Illinois Union ins Co 127960
;OVERAGES °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.
SR ADDLSUBR POLICY SIFF POLICY EXP
TR TYPE OF INSURANCE INSR_WM POLICY NUMBER IMMIODM"l IMMIDONYYYI LIMITS
A GENERAL LIABILITY GL04887714-02 03/01/1; 03/01/13 EACH OCCURRENCE $ 9,000,000
RE DAMAGE NTED
X
COMMERCIAL GENERAL LIABILITY PREMISES Me occurrenceI S 1,000,000
ICLAIMS-MADE Fi] OCCUR MED EXP(Anyone person) $ EXCLUDED
LIMITS OF POLICY XS PERSONAL&ADV INJURY $ 9,000,000
X OF SIR: $lM PER OCC GENERAL AGGREGATE $ 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGG 59,000,000
X-1 POLICYF—] FE"CT F-1 LOC S
B AUTOMOBILE LIABILITY SAP 2938863-09 uj/u.L/.L; 03/01/13 COMBINED SINGLE LIMIT
Ise accident
$ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident)
AUTOS AUTOS e PROPERTY
DAMAGE $
NON-
OWN D .E
don AUTOS AUTOS are 't
IHIRED
SELF INSUR D PHY D14C
UMSIIEULAUAEI HOCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE S
DED I I RETENTION$ $
C. WORKERSCOMPENSATION 736915 (ADS) 03/01/1: 03/01/13 X I T`G'Ry1TATjU TR
WC019 LIM T� DE
AND EMPLOYERS'LIABILITY 'N WC019736917 (FL) 03/01/3.: 03/01/13 E.L.EACH ACCIDENT $ 1,000,000
D ANY PROPRIETORIPARTNEWEXECUTIVE NIA
* (OFFICER/MEMBER EXCLUDED? hN
Mandatory In NH) WC019736916 (CA) 03/01/1: 03/01/13 E.L.DISEASE-EA EMPLOYEE $ 1o000,000
lIg describe under
D S6RIPTION OF OPERATIONS Dal.. E.L.DISEASE-POLICY LIMIT $ 1,000,000
* Workers Compensation IWC1192494 (QSI) _03/0 l/3. /01/13 SIR (AOS)/SIR (GA) 1M/750,000
* Workers Compensation WC019735918 (WI) 03/01/1: 03/01/13
* ITX Employers XS Indemanity TNSC46566397 (TX) 03/01/1: 03/01/13 Occurrence/SIR 30M/1X
'ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101.Additional Remarks Schedule,If more space is required)
E: EVIDENCE OF COVERAGE
;ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
014E DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS.
455 PACES PERRY ROAD NW AUTHORIZED REPRESENTATIVE
GILDING C-20
TLANTA, GA 30339
USA
(D 198§-2010 ACORD CORPORATION. All rights reserved.
trnor,is:linininc, Tk^ ArnCin name and lnnnarn ronicfore,ri marks of Arnpn