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36 LAFAYETTE PL - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 71" edition Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised One- or Two-Family Dwelling Aril 15, 2009 This Section For Official Use Only Building Permit N er: Date Applied: Signature: �2C Jl Building Commission&rrinspector of Buildings Date SECTION 1: SITE INFORMATION 1.1 Propert Alldr ss: 1.2 Assessors Map& Parcel Numbers 1.1 a Is this-an accepted strda?yes no ~ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tt) Frontage(ft) 1.5 Building Setbacks(it) 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❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Ow r of Recor�]-1 �^� 1-4 im Yr1P_.1 G'l�n '�Jl.�t-c ` qe li, �LC�- ✓C'1`'WI ' t� ,�-� / Name(Print) Address for Service Signature Telephone - SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Othe ❑ Specify:_ Brief Description of Proposed Workz: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials L Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier fff x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 0 Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 7 ` yi-}ldj ` License Number Expt au n Date Name of CSL-H lder List CSL Type(see below) Addre J Type Description U Unrestricted(up to 35,000 Cu.Ft.) R Restricted 1&2 Family Dwelling Signat e M Masonry Only Qu 4Z �33 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home prov ment C tractor IC) HIC Comp e r HIC Registran Registration Number Addres � Expirati D to Sign Telephone 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 IssuanceQf4i rebuilding permit. Signed Affidavit Attached? Yes .......... No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR gPLrES 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. Signature of Owner Date - SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION I, I G —f-- , 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 behalf. Pri in Sig _O er or Auth ized Agent Date (Signed under thl pains and penalties of a du ) 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 and Construction Supervisor Licensing(CSL) can be found in 780 CMR Regulations l I0.R6 and 110.R5, respectively. 2. When substantial work is planned,provide the information below: Total floors 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" � 1 ACORD,u CERTIFICATE OF LIABILITY INSURANCE DATE 02/20/090/03, Y). PRODUCER 3-404-995 lJ.,, FTHIS CEP.TIFiCATE IS ISSUED AS A P4ATTER OF INFORMATIUM -rsa USA, 1az, CNLY AM) COMFE;RS NO R!iGHiS UPON THE CER1iFICA.;FE ,,. HOLDER. THIS CERTIFICATE DOES NOT AMEND, E.".TEPID GR . =.ee rBcre=s:'ina_s"ca. ALTER 7iic COV_?AGE 7E0 E ! TAE PCLI;••:_S.S 1 - 1Anta C 3 311 N URE2 r v,)n`1 Ital O�2 f.3.i::J -ICI e INSURER A __ -_- __ _. _ _.__r ( d li nREHB -` I Lch A-:. can :.nsa CC 16535 INSlsln_C:N_1'S On T, IJN10N e J_LRF: 1--lS (' OF YI1'^_S _ 11445 e(Suit 300 -�'— Atlanta , CA 30339 INSURER O:Naa+ Hampshi to Ins Co 23891 L_ INSURER E:Ill ino is Na C1 Ins Co 2J817 COVERAGES - THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT, TERM OF2.CONOITION.OE ANY.CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS.CERTIFICATE MAV 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. IN So 00 POLICY EFFECTIVE POLICYEXPIPATION LIMITS TR N RO POLICYNUMBER DATE MMIOD AT MMIDOf/Y A GENERAL LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE $4,000,000 X COMMERCIALGENERLLIABILITY LIMITS OF POLICY ARE EXC SS PREMISES Ea occurence $ 1,000,000 A I CLAIMS MADE MOCCUR "OF SIR: $1,000,000 PER CC" - MEO EXP(Any one perms) $EXCLUDED PERSONAL S ADV INJURY S 4,000,000 GENERALAGGREGATE S 4,000,000 GEN'L AGGREGATE LIMITAPPUES PER: PRODUCTS-COMP/OP AGO $4,000,000 X7 POLICY PRO- - LOG B AUTOMOBILE LIABILITY BAP 2938863-06 03/O1/09 03/01/10 COMBINED SINGLELIMIT (Ea a<ciden0 S1,000,000 X ANY AUTO ALLOWNEDAUTOS BODILY INJURY S (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Pe,neideni) NON-OWNED AUTOS X SELF INSURED AUTO - PROPERTY DAMAGE S PHYSICAL DAMAGE (Pe,a<ddenq GARAGE LIAR ILitt AUTO ONLY-EAACCIOENT $ ANYAUTO OTHERTHAN EAACC $ AUTO ONLY: AGG S A E%CESSIVAIOR•LLA LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACHOCCURRENCE S5,000,000 X OCCUR ECIPIMS MADE - AGGREGATE f5,000,000 A OEOUCTIBLE - S RETENTION S $ C 3566916 (CA) 03/01/09 03/01/10 % WC STATU- OTH WORKERS COMPENSATION AND i RY LIMITS R D EMPLOYERS'LIABILITY 3566915(ADS) - 03/01/09 03/01/10 E.L.EACH ACCIDENT 51,000,000 ANY PROPROTORJPARTNEREXECUTIV F. OFFICERIME"ER EXCLUDED? 3566917 (FL) 03'a l/09 02/01/10 E.L.DISEASE-EA EMPLOYEE 51,000,000 Ilyes,desc,l6e under E.L.DISEASE POLICY LIMIT 'S1,000,000 SPECIAL PROVISIONS below OTHER D Workers Camp ensation 3566918 (KY, MO. NY, WI, ) 03/01/09 OJ/O1/30 F T% Employers Exeeas TNSC45694422 (TX) 03/01/09 03/01/10- ccurcenc a/SIR 25M/2M C Workers Compensation 4801323(QSI) 03/01/09 03/01/10 GESCRIP710H OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENTI SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION - TWO AT-HOME SERVICES, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO$HALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2690 CUMHERLAND PARKWAY SUITE 300 REPRESENTAbvES. ATLANTA, GA 3033.9 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)Ckomtaus hd ©ACORD CORPORATION 1958 ' iiv+oaAn— f� i ENERGY PERFORNtkNCE RATINGS . . . [`SriUbeGCtl CE nF7vC�aacr^,(TO�G�r� U-Facter a Solar Heat Gain Coefficient .F�,y) .CoaAdc*cGu+mrda de Ertgi¢`'alar . !0 . 32 1 . 8 0 : 29. ADOMONAL PERFORMANCE RATINGS CVA1.lLaC+ON 3Utr�].rFMaAaA oe PETat>t►�MO Vlsi ble Tran tmittance- - hancNslan de L+II`+L�N 0 . 52 - rNrp n dm+mtrd kr s Aaad at d aMwnmU ama++a rd x nadfY 7miR dm.IFPL dos M ramrmr4d.�ry Oa11G .d am rot„,rrvrc a,.xrllaMy d i7 v�.a an��a.aadt Rsn�ecnnrt alnr.a atta aonct vr?onwa :- _ . tearma&'n w`rtr9cd7 . . Etl.hptarm rbJa aA�.t+os aman an b ti �d+rAI+L aaa dtm'mhai r rv�daao boI si__. {roA�to m uad�a oa rfaG az+ .da 7r u�onpnG?�6 W Wx un cEnory r poAon 1 ` d a afcad>Paa�n aFsAm Q>at.A or r .. gecdra IiAG m�rnY't ,v dat Not" io?rn�4p 7m� . COam del SMsti ara i ua axe do ass t+�m Un Lc g..aLLf Laz roc LNSRCY 9taR - ctglon(,I : uo ccn¢cn, Noccrt '. ' 'HC r6r SiAA .. Gam. un Ldad a>L111ca pa•a 1>(.) . - ct?1Qn(�>( tNOROL_7L1A: Noc Ci, - , Nocct Canccal, '4,c IND Ra.Ln G0fCLusa 3/3Y(N-RU . t�r� IND: Raf tcxo Od/V LQ<Lo I J.1 aut/H-R+1 ' LJ'C : 1 4 5 / - 4 5 =FAQ ecobado: 91.E cn IGO c-y- E�9 =C3�/O1 aatiJ - Hs Hofcun 2331110. L+p b6al(or paobd eieM SUr mbatc_To Irma mon Vw.v.mrWta9or.. Cuarda>im rhlusla Pon 7an6kon.mLahus EHEt6T ST1.0 taro mnau rrm aoim h isA.'htlr r«xmr tucpcc `, - , ',.s,..:. ✓flee Lanvmanuw.a.LF/e o�,./`�aaea�ueelfa : �\ Board of Building Regulations and Standards l lug. i HOME IMPROVEMENT CONTRACTOR t r t Registration:. 126893 + Exparat+ort -'8/3I2010 Type-:=Supplement Card The Home Depot At Home 5emce - RICHARD FALLONE - S 2690 CUMBERLAND PARKWAY S q}LA�N�A,GA 30339 Administrator 06-OCT-2009 11:55AM FROI,FHNE DEPOT 2674 PHONE CENTER +617616728517 T-666 P.001/004 F-805 • c[UPH E INIPRO V EMENT CONTRACT PLEASE READ THIS Sold,Famished and Installed by: Branch Name: Boston Dale: tV/, /��� THD At-Home Services,Inc. d/h/a The Home Depot At-Home Services 345A Greenwood Street,Unit 2,Worcester,MA 01607 Branch Number:31 Toll Free(900)657-5182; Fax(508)756-8823 Pectoral ID#75-2698460;ME Lie#C 02439;RI Cont.Lie#16427 CT Lie#565522;MA Home Improvement Contractor Rug.#126993 Installation Address: LA`P:41 11r. 1 I c City State Zip Purchaser(s): Work Phone: Home Ph9nC: Cdl hove: p11N1� � �A[�IANU [`77X] " Home Address; .j(oT.1-r� (if different from Installation Addres, City State Zip E-mail Address(to receive project communications and Home Depot updates); (^O W1fN1 L1 I seveki r,(d�c ID77. we" ❑1 DO NOT wish W receive any marketing emails from Thu Home Depot Preleet Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At home Services,Ina("The Home Depot")agrees to famish,deliver and arrange for the installation("Installation")of all materials described on the below and on the referenced Spec Sheet(&), all of which are tramporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders(collectively, "Contract"): Job#: u_. .,n,.m..e...l Products: S tic Sheets #- Pru'acl Amount [, p Roofing Siding indows ❑Insulation (6, l 057� ❑Guucis/Covers ❑Retry Dooms ❑ ❑tloo ling Siding ❑Windows ❑insulation ❑Gutu:ts/Covers ❑Envy Doors ❑ __ $ ❑Roofing ElSiding ❑Windows ❑Insulation ❑Gutters/Covers ❑Unary Doors❑ $ ❑Roofing ❑Siding Windows Insulation ❑Gumers/Covers ❑Entry Doors ❑ $ MinimumM Deposit of Contract Amount due upon execution of this contract Total Contract Amount $ 39 - oL Monte re Mae Purebasen may not deposit me than one-third of the Contract At....L / I Chtstomer agrees that,immediately upon completion of the work for each Product, Customer will cxecutn a Completion Ccrtificutc (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 bejointly 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 audtonzed service provider determines Thar it cannot perform its obligations due to a structural problem with the home,environmental hazards such as mold,asbestos or lead paint,other safety cmtocrns,pricing errors or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary # 6 L/S A__, 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). NOTICE TO CUSTOMER You are entitled to a completely filled-fin copy of the Contract at the rime you sign. Du not sign a Completion Certificate(note: there is rare Completion Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Customer agrees to pay The Home Depot the costs of materials,labor,expenses and services provided by The Foie Depot or Authorized Service Provider through the date of termination, plus any other turnouts set 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. Acceptance and Authorization: Customer agrees and understands that this Agreement is The earin agreement between Customer and Tlme 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 alfspgned or amended except by a writing signed by Cusstonrer and The Home Depot. Customer acknowledges and agrees that Casmme has mad,understands,voluntarily accepts the terms of and has received a copy of this Agreement. Ace y: / Submitted by: X-' us[om 's Signature Date Soles Consulhmt's Signature Dale __ Telephone No. Customer's Signature Date, Sales Consultant License No. CANCF,LLATION: CUSTOMER MAY CANCEL THIS (as apprcohtc) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOIVIE 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 CUSTOMER'S STATE. NOTICE-ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTItAC'r 7.16-09 C-SC White—Branch Fie Yellow—Cuammer Pink—Sales Consultant pri n'd or uil Su,l -Dtpartmtnt of public Safaj Buard of Rrulatmns and StxndarJa Construction Strpervisor License ,., Lieens.: CS 74722 Restricted W: tD KOS7AN71NOS S VAFTIS 18 HANSON ROADi.:e::. SAUGUS,MA 01906 Espiradon: 7 19412412 T(fi ' - f�mmi;d�wer Restdtted lo: 00 00.Uartstri gomts IG-1 2 F+a^4 Fa0erc to Possess s torrent edition of the . sse*osem yW'Bonding Cep b tease for revocation of tws tictost. Bthr to: grWW.Mus.GotlOPS _ i 9k, Tha fiommonwoalt.k of Ylassachusztts neprrn entcf7ndustrial Accidents I I - - I '.. rV 1 -z.U l prl ;lp I SOrr!t — i Nazrie (Business/Organization/Individual): Address: Ile -- City/State/Zip: Phone �1-Tlr ��r `�` ����� Are yo an employer? Check the appropriate box: rTyperoject(required):. 1,Iaam a employer with r)( 4. ❑ T am a general contractor and Iw cons ruction employees (full and/or part-tune).* have h red the sub-contractorsmodeling listed on tbr. attached sheet.2.❑ I am a'sole proprietor or partner- These sub-contractors have molition ship and have no employees employees and have workers'working for me in any capacity. ilding addition comp. insurance? [No workers' comp. insurance lo.❑Electrical repairs or additions required.] 5. ❑ we area corporation and its officers have exercised their 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all work right officers have lion per MGL myself. (No workers' comp. g p p 12,E] Roof repairs c. 152, §1(4), and we,have no insurance required.] t employees. [No workers' comp. insurance required.] •Any applicant that checks box#1 must also lilt out the section below showing thcir workers' compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavitindica tin such. TContrac tors tharcheck this box must attached an additional sheet showing the name of the sub-contractors and wale whether or not those entities have employees. if the subcontractors 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: Policy #-or Self-ins.Lic. #: Expiration Date: � � � - � tt - Job Site Address r O �' � City/State/Zip: 2,L aS.—Oiq,7U Attach a copy of the workers' compensation p cy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Stctio_1125A.of MGL c. 152 can lead to the imposition of criminal penalties of a - 11 1 16 F F��' . firm up to &1,500.00 and/or one-year imprisonment;-ate--of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investl ations of the DIA for insurance coverage verification. I do hereby certi an r e p s an penalties ofperjury that lire information provided above;is true and correct. Date —*1 — Si a ore: j Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Perm t/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector 6. Other Phone #: Contact Person: