36 LAFAYETTE PL - BUILDING INSPECTION (2) 2: O F 2
_. 401 — l 2� ZZ. -7
The Commonwealth of Massachusetts
i, Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 7S0 CMR SALENI
��,.✓ Rerl.red blur ZOII
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date.Appli
Building Official(Print Name). Signature- - - Date
SECTION 1:SITE INFORpMAT10N
1.1 Property Add es : 1.2 Assessors Map&Parcel Numbers
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Tuning District Proposed Use Lot Area(sq Il) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard - Side Yards
_ - tear 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 Dispostd System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner[oinc rd:
me Print C
��fi�_ � City,State,ZIP
Nu.and Street I Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check. that apply)
New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) . Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Ot er ❑ Sp �'
Brief'Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building $ I. Building Permit Fee:$ :ndicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application Fee-
❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S 7. Other Fees: .$
d. Mechanical (11VAC) .S List:
5. Mechanical (Fire
Suppression) S rotal All Fces:$
Check No. _C'heck Amount: Cash Amount_
ri. 'fatal Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Constru n Supervisor i pse(CSL)
2 ,r) License Number VXpirau WIt
Nnmc of CSL Ilo •r List CSL'fype(see below)�7 _
Type.. Description
No.and Street �
U Unrest rictedarr s u l0 35,000 Co. ItJ
(� R Restricted Ic@2 F;unil Dwellin
Cityi fown,Stale,ZIP 61 .1 ason
RC Rooting Covering
WS Window and Sidin-,
SF Solid Fuel Burning Appliances
i
I Insulation
Telc ion" I net Email aJJress D Demolition
5.2 Registered Home Imgruvemen Contr i (IIIC _
YI IIIC Registration Ed,
I -u me� r I trt Name
No.and Sti•e / ! Email address
5 l33
City/Town,State,ZIP 'fete hone .
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.,152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc of the building permit.
Signed Affidavit Attached? Yes No...........❑
.SECTION7a:OWNER AUTHORIZATION TO HE COMPLETED WHEN:
OWNER'S AGENT OR CONTRA CTORAPPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorizep ( t�✓t�(l
t9 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'O AUTHORIZED AGENT DECLARATION
By rTra7 y name below, I hereby attest u er the pa' s and enalties of perjury that all of the information
Coll wined in ills ap true and accur to to the a of k vledge and understanding.
Print l we 's or rlut torized Agent's N;unc(Electronic. iga lure ate
NOTES:
I. An 0vvner who obtains a building permit to)To his/her own work,or an owner who(tires an unregistered contractor
(not registered in the Flome Improvement Contractor(FIIC)Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass,gov!oca Information on the Construction Supervisor License can be found at wwsv.mass.eov�/dM
-� 2 When substantial work is planned,provide the information below:
'total floor area(sq. ft.) (including garage, finished basement/attics,docks or porch)
Gross living area(sq. ft.) Flabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type oChealing system Number of decks/porches
l'ypcofcoolingsystem Enclosed Open
1. "Ibtal Project Sgmve Footage"stay be substituted tor"rotal Project Cost"
HOME IMPROVEMENT CONTRACT Sold,Famished and Installed by: III
PLEASE READ THIS CONTRACT THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
908 Boston Turnpike Unit I,Shrcwsbury,MA 1545
Toll Free 8779033768;Fax 8009863610
I0/26/2013
Branch Name: Boston North Date: ME Lic#C 02439 RI Cont.Lic# 16427
CT Lic#HIC.0565522 MA Home Improvement
Branch No: 33 Contractor Reg.# 126893 Federal ID#
75-2698460
Installation Address: 36 Lafayette PI Salem MA 01970
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
Mrs. Euloida Mariano 978 744-7136
Mr.Rommel Mariano 978 744-7136
Home Address: 36 Lafayette PI Salem MA 01970
(If different from Installation Address) City State Zip
E-mail Address (to receive project communications and Home Depot updates):odaseven6(W,yahoo.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 V�
buy,and THD At-Home Services,Inc.("The Home Depot")agrees to famish,deliver and arrange for the installation("Installati tit
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 attached hereto and any Change Orders
(collectively,"Contract"):
Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount
7184848 Windows 7184848 $4,852.30
Minimum 25% Deposit of Contract Amount
due upon execution of this contract Total Contract Amount $4,852.30
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.
Payment Summary: The Payment Summary# 7184848 ,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). -
GENERAL TERMS AND CONDITIONS
Responsibilities:
The Home Depot: will provide the Products identified above,make arrangements to have the Authorized Service Provider perform
the Installation services in a professional and workmanlike manner,and arrange proper insurances. Unless otherwise expressly
provided for herein,Authorized Service Provider will obtain required permits and provide permit numbers.
Customer:will identify any property lines,easements,covenants,underground or overhead utility lines,pre-existing physical or
ltrdan2-SA Page 1 of U
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS CONTRACT
NOTICE TO CUSTOMER
You are entitled to a completely filled-in copy of this Contract,signed by both you and The Home Depot,at the time you
sign. Do not sign a Completion Certificate before the Installation is complete.
Acceptance and Authorization: Customer agrees and understands that this Contract 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 Contract cannot 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 of and has received
a copy of this Contract. Customer acknowledges receipt of the Notice of Cancellation,and that The Home Depot has orally
informed Customer of Customer's right to cancel. Customer's signature below constitutes Customer's acceptance and
execution of each of the applicable Contract Documents.DO NOT SIGN THIS CONTRACT IF THERE ARE ANY
BLANK SPACES.
• You are entitled to a paper copy of this Agreement if you choose. If you consent to an emailed copy,your consent applies
only to this Agreement.By contacting sales office_(877)903-3768 ,you may update your email address,withdraw your
consent,or obtain a paper copy of the Agreement at no charge. By signing below,you confirm the following:
• You consent to receive only an emailed copy of this Agreement
• You have access to a computer that can receive and open entails and PDF(Adobe Reader Version 10.1.4 or
later)formatted documents.
• Your email address is correctly listed on the Home Im rovement Contraclt
Submitted by:
Sales Consultant Jason Beisiegel
License Name.
Telephone No. (877)903-3768 Mr. Ro ariano(Oct 26, 2013, 11:51 AM)
Sales Consultant
License No. (as applicable)
Accepted by:JB68(Oct 26, 2013, 11:52 AM
CANCELLATION: CUSTOMER MAY CANCEL THIS CONTRACT WITHOUT PENALTY OR OBLIGATION BY
DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER
SIGNING THIS CONTRACT TO THE ADDRESS LISTED ABOVE. THE STATE SUPPLEMENT ATTACHED
HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S
STATE.
1IM12-SA Pao. 12& 13
f 3 Rilassaehusc[is -Department of Public i,. aieb/
' Board of Building Regulations and,Standards
License CSSL-099699.. -�
ROBERTPOC
172WHALL+NS LAW&':-
Salem MA 91970 _
9.'
-t1
Vic-; n
Cornsn)ssm^t=r 02108/20/4
CITY OF S'Uu Etii, !UNSSACHUSETTS
i BUILDL\G DEPART.\L&NT
130 WASI-INGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.ALX(978) 740-9846
K!\iHERLEY DRISCOLL
itiLWO;t THO-LAS ST.PIER118
DIRECTOR OF PUBLIC PItOPERTY/BU1LDDJG CONNISSIONER
Construction Debris A Disposal "p Affidavit
(required for all demolition and renovation work)
x.
' In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l L5
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
(name of faci it )
�^ �
address of facility'
sign mro ofpermit applicant '�
_ 13
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q v an employer' Check the appropriate lips. t ppe of pr odect(regmredl, i
4 1 1 1 art a cren ral ntracm, and 1 1
am a employer witlI_ c. ;J No c . 'i('1n
have tl e wlr-co tr.,ceors
emplclees full and/o' par!-time).` r, '� F rxtdel.n�
listed on 'h tta�hed sleet.
^ t am a sole p,opl to o partner- l ,
ship and nave no employ e
Th se sul oner'.,ttxs pare -l. ❑ Demo u.oTi
m. llov- s ;d' ave a of i.ers'
woikmg for me s an - capK`ry u. Pa 4 n ad n
No workers' co.np. Slsura,cP comp In t ll _
1C'.iJ),I ui. p r r , s rr a�diuous
I S.. [ Wt a a corporation and Is ,
rnouired ]
S rl 1 am c homeo vnei doing A week-:
eirn, rc have c. er svtheir Plume na _pauso Iddih:,ns ,
m�'selt l?vo workers Coupa of c m :,or, p MGL l 12 _j Rao,y a rs
c 1� t.lr4 a,d we na nr n
ins- anc ._q.ilred] t -
1,io°t is INc'yvol6_r-, 1 .
omu.irsar rlc,,required.] I Ij i
'A-••appLcml mm c,eds ho,.Xl ,nuSLAn,Loll of if,.ce laln i,elm+ chn „ rl e,-
i Hamenwnu5 wln mc'nc h a ,h i •^ ¢u r t, ar .Im ill,cr r ;r r 5 r'.nu o'm tiro n,Si :�i+nu r ,: -,ua+�i d< im ud,; V
n ,
Cq,.na"tors„tai he A this ho e rst ch d an a atior sn t sh..w ir. h nor no in t con ramr r,d sate wh.ch_ o .hn;e emi ,have
i
;.rrloF ees. if tn_sa cmira rots.ra,•e ernla . !r mac pro,ite their .<<Lec Coln, p�li }n umh :
, .
T rim an enipinper that is providm.,,irorkers'conrpensaticrn irasuran.c_^for tin'entpinvees Below it the pnfier and jun sire
i.nfnrrnadon.
1 y
InsuranceComparivName: , iw r /111r�
r^ ScH ins Lic �'7�
ionSr'x.At'ures _ .�'_ .. . .y 1
Attach a copy of the workers`compensation policy declaration page (shotving the policy number and es:p[;anon date.i.
Failure to sec'ore covera"t as required under Section '_SA of MGL c. 1i2 can lead to the imposition of criminal penalties of a
fine up to t 500 OU andror c r v a lingrisn meet a w 11 a,civil r ral i. e m th--iorm of a STOP WORK ORDER and a fine }
of up to.S i(;(}n a a < a_ainst LW, +mlator- E a, i,ad Ilial o; Ili nietem_ul ,ray h>_tr, ardeo t[ Il C'es e.or
]m.s[iar' ens o`thI 1T
do herebi Certify uride t e p¢ rs .d pe then o"pertun that the in/'arnratior provided�a bo ve is true-and.Corr ec[
Phcme � -
(If(cria/ use anh. Do not,rite in this area. to be Conti) eted i,y cin�Or WWII oj(tciaC
ICir%l or Town: Permit i"DCantle it 1
Issuing.Authority lTv t circle one e
1.Board of HealEh ^_.building Department 3. CiiyrTown Clerk 4.Electrical inspec75. mhirg Inspector
6, Other
II
Contact Person I Phone M: l
i
' J
12
✓fie 1J07JinxMtU/EctC a ./l uan4 &etia
\ Office of Consumer Affairs&Business Regulation ' :License or registration valid for individul Ilse only
�`�ww'P/
OME IMPROVEMENT CONTRACTORbefori the'expiration date..If found return to:
Office of Consumes Affairs and Business Regulation
Registration ti2fi893 Type: . 10FarkPlaza--Suite5170� - Expuafion f312014 - Supplement 4aid Boston,MA 02115
The Home Depot At Hae SQrvi4es _
w
RICHARDh'ALL6NE ,1
2690 CUMBERLANf) ---
ANR�A,GA 30339 ..E-'j"%� Undersecretary_ °I of valid v ithout signature
Z.
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Workers' Comp-.t.tis_tsi,,I. "IlS
Meant ihfrii ma wTl _- _ ,_ _f lea i'' r'_ I IU!�
'v d.i,.; (gt, r ct-• _�.n ,t�..!!-d`.iL . ,...:__ 19 ,>"�--= •` py---. _-. _ -
fo,
-- '2`o`.3-
cir) c�ta.tol�. • 'd91,�i/�1`r "X,+✓Y�'Phoar
e c t
Ar ��oy n employer' Check the appropriate bo.� T ape of project(i eyuuedl �
4111rTatenratcruavrzndl !
1. am
__ I at
` I tr cm employer wr,i I r L.Ne c.-1
e hod sub actors I
emoloytes(full and/or p r;-time). ^ -
'.Lj ] am a sole prep: l or parent INK on !h anschad sheet, I t LJ R ^aUdclino
TWO sub.conuumorshave rl -
slop ard 'haveno employee
t�Dcmolu r l i
m tl� s a a have aver I,et�' — i
1 wo,lang to, me m and canac;t;; 1 t I o, v 1✓d otr a n, t I (
INo woken' camp msamce, camp inx „We.
l t t l r p t s or ddi'aons
Ian _are. a orl.oratior and its I a(I,Q j;—
ctficers have eaercn e the;f Lj>-tomb 1rr,,ela ars o: addiiioas
3 _I 1 am a homeowner dolrg all work: I s
rig h nS x ;tnt,, nn p MG' I 1"
mtseh [No wn e come.
insura>,^e requ.r C.Jt c 1^_. t`1l . lad ice he n;•� I i
t riple"..-_,. iNo wo Imo_ o 'IOlth I
come. insurance required.1 I � I k
A- appiic.al lhai :h Ccis h0: XI rtu4 il6a no ow menP w"an.,Am"I' 01C,1'marl 'non �.-
r Henenwnus why suanr F am'ti .�nLic m_,r yar do'n ,ll,,11 'r won We nu s.e.nnrracM nisi sLhn, r nf`ida•ii ,am ir
'C.an,ramnrs rhat eheo:this Uac mLst a:ach..d ar eaQiun^„shen sr,u-n- he na an`.tn-m" cemrne nc Ild s:a:e'helm o no luoseemn-,"t 4
emrlovss. lC tat su'remnracrors have emnlm:zs,tee umtt nmviGe fhee v.,:rl:nscorrp.policy n+vnner.
I tort an amploper that is provihi.,workers'camperrsutiora insurance for nr;foUPir!nees. Belrno i:: nca pnlic7 and job Fire
I
in;jnrmaaott' @ 1 - ;
insurance Company Name: —
. - p iration ➢ . d-
Polin5' 6 o :"'-ins, l ic. p ate
--
loir Site„ddl
Attach a cope of the workers'compamation policy declarauun page (showing the po{tcl number and expiration uau.i.
Failure to secure coverage as required under Section=S.A of MGL c. 152 car.lead to the imposition of criminal penalties of a
At up to S1300.00 and/or or.e-vsaf imprisonment. as vwell as civil penahies in the farm of a STOP FtORI.ORDER and a fine r
of up to,5250 00 a day a_a; .m A y:o ww. E an,,, t',, . ..,,n 0,,s.,I, m u,,V ha fnru erdeo u 1 the Of% of
_ 1r,.zs6^t6nnsn`ta_.KAbi ns_ranc , nr'icn'I __ .._—
I do hereby e tJi ,.n it e pen andpena.iiies of perj w� drat ikc infol-,ati.trr pro,aLd aoor c tr true and n rect.
C;,.n,a` --- -- - Dar• _. — _ �
AMC A �I
Offtrigl use nnl.;, Do not rate in ONE area w be completed trn c[rr orlolra ojjtctal
I
City or Town: Permitl Acense 4
1issuing Authority (circle.nne7:
1.Board of Heaftii .Building Department 3.CityiTown Clerk 4.EVecirical Inspector 5.Piumnirg Inspector it
I ". Other
Contact P.-teen
Phone k:
i
t� Llassaehusetts Department of Public.
ic.
Board of Building Regulations and.Sttan,dardS _
License. CSSL-099699.
172 WHALL+NS LAN$f
Salem MA O1970 '
,?FCai1Vft
Cnnnnissluner _ _ 02108/20/4
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