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419 LAFAYETTE - BUILDING INSPECTION The Commonwealth of Massachusetts RECEIVED CITY OF } Board of Building Regulations and Star�CTICNAL SER ICE'SALENI Massachusetts State Building Code, 780 Revisedblur 2011 Building Permit Application To Construct, Repair, RenovMC1r&T`6ishA . 55 lV 1 One-or Two-Family Dwelling This Section For Official'Use Only Building Permit Number: Date pplied: Building OtTicial(Print Name). :. . Signature Dat t SECTION 1:SITE INFORiv1AT(ON w 1.1 Property `LcL �Addrl 1.2 Assessors hlap&Parcel Numbers 1 1.la Is this an accepted street?yes_ no Map Number Parcel Number I Q 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(It) a 1.5 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yesO SECTION2: PROPERTYOWNERSHIP!' 2.1 Owne Recor time(Print) City,State,ZIP No.and Street /_ Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check a at apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s Altemtion(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work: I SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ l I. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical g ❑Standard City/Town Application Fee-. ❑Total Project Cost'(item 6)x multiplier x 3. Plumbing S 2)Other Fees: S a.Mechanical (HVAC) S List: 5.Mechanical (Fire 4 suppression) total All Fees:$ Check No._Check Amount: Cash Amount:_ G.'Potal Project Cost S 6 ❑paid in Full ❑Oidstanding Balance Due: S r 3 11 I I S r 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Constn 11,Sury(sor License(CSL) c$j tu Licer�sc amber r /berr Espir tin Uate Name of CSL 11 Id e List CSL*type(see below) Type - Description S et No. ;m U Unrestricted Buildin s u l0 35,000 cu. tl.) _ 4 A R Restricted I&2 Fami! Dwelling Cityrfown,State,ZIP M Masonry RC Roolin Coverin WS Window and Sidinx SF Solid Fuel Burning Appliances / phone insulation Tole ha02 &nail address D Demolition 5.2 Registered Ho I !pro ntractor(HIC) HIC Registration Number E.pit on Date HIC Company N.vne or tllC Registrant ameT I No.an Email address ! a City/Town, State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE At (M.G L.c.152.§25C(6)), t Workers Compensation Insurance affidavit must be completed-and submitted with this application. Failure to provide this affidavit will result in the denial of the IsIntancectfAlreliuilding permit. Signed Affidavit Attached? Yes .......... No...... ...❑ SECTION 7a:OWNE AUTHORIZATION:TO BE COMPLETED WHEN' i OWNER'S AGENT OR CONTRACTOIt APPLIESFOR BUILDING PERMIT' 1 I,as Owner of the subject property,hereby authorize��� tg act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date i SECTION 7b:OWNER!OR AUTHORIZED AGENT DECLARATION By entering y name b ow,1 her y attest under the pains and penalties of perjury that all of the information contain it this appl' ado is tr an ccurate to the best of my knowledge and understanding. Print Ow er's or Au r ize Age is Name(Electronic Signature) Pate 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(H(C)Program),will tLoj have access to the arbitration program or guaranty rund under M.G.L.c. I42A.Other important information on the HIC Program can be found at www mass.tov:'orfov:'oea Inrormation on the Construction Supervisor License can be found at www.mass.�Lov.'d.Lts 2. When substantial work is planned,provide the information below: 'rota) fluor 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 rype of heating system Number of decks/porches Type of cooling system Enclosed Open_ 3. "Total Project Square Footage'may be snbsfituted for"Total Project Cost" Branch Nume; It noon& — r Son,h Data J � Sold.Furnished and Ingalled by: Branch Number; 31 and 33 THD At-Horne Services• Inc. d/Na The Home Depot At-Home Service, 908 Boston Turnpike.Unit 1,Shrewsbury.MA 01545 Toll Free 877-903-3768 Federal IU tl 75-269846o:ME tic tl C 02439:RI cont.lien 16427 Installation Address. `q CT Lie tl HIC.0565522:NIA Hume Improvement Lomtraclor It%tl 126893 [ PurchascHs): 'ty State Lip Work Phone: Home Phone: Cell Phone: [4`'$V 7W./3 l [ A. , ROL, `I-0 [ I [ 1 Home Address: (If different from Installation Address) ❑F mail Address(to receive project communications and Home Depot City State yip I DO NOT wish to receive any marketing emails from The Home��IICs). Project 1`al on: Undersigned("Customer"),the owners of the progeny localed at the above installation attires.,, j try and I HD At-.Home Services, Inc. ("The Home Depot")agrees to (umish, deliver And arrange for the installation 1"lus 1latiori')of all materials described on the below and on the referenced Spec Shoxus). all of which are incorporated into this Contract by this reference, along with any applicable State Supplement mid Payment Summary attached hereto and any Chance Orders(collectively, "Contract"): this Job#. tlbnereY Rer reoee) Products: S Slioxt s tl: Pro t Atmarnt Roofing Siding Windows Insulation O� ❑Gulteis/Covers ❑Envy Doors ❑ ' Roofing Siding. Windows Insulation ❑Gullets/Covers [I Entry Doors ❑ $ Roofing Siding Windows Insulation ❑Gutters/Covers ❑Entry Doors❑ S Rooting Siding Window. Insulaiion ❑Gutters/Coverb_❑L'ntry Dour, ❑ $ :: M1d®no1596 Depotit.dQmlttlFi�oioiimt due upitn"iwefioioodth6 ,T-. .- , . Miune Poiichuxn nhay nil deposit magic tlan iano-tldrd tithe GntraeY Anherm. onl 1I )Il lrannrt Customer agrees that immediately upon completion of the work for each Product. Customer will execute r Completion Certificate (one for each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable. each Cusualwr under this Contract agrees to be jointly and severally obligated and liable hereunder. The.Home Depot reserves the right to issue a Change Order or lemlinatc this Contract or Any individual Product(s)included herein,at its discretion, if The Home Depot or its authorized service provider dearmines that it cannot pcTlorni its obligations due to a strnaural I prohlem coon the home, ern-inmtiicntal hazards such as mold. rst+eslos or lead paint, other safety concerns, pricing oxrrrs ea because work required to complete the job was not included in the Contract. Payment Summary The Payment Summary 1( t0 _ � included as pan of this Contract, sets forth the total Contract amount and payments required for the deposits mid final payments by Product has applicable). NOTICE To CUSTOMER You are entitled to a completely filled-in copy of the Contract at the time yoo si1,m. Do not sign a Completion Certificate I ode: j there is one Completion CerUlicate for each listed Product as defined by individual Spec Sheen)before work on that Product is complete. In the event of termination of this Contract. Customer agrees to pay The Homte Depot the costs or materials,labor,experuses and servicesprovided by The Home Depot or Authorized Service Provider through the dale of termination. plus any other amounts 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 PAYMk:N'1:4 MADI•„ WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Aufhorivtnion: Customer agrees and understands,tha, this Agreement is the entire agreement bLtwmn Custtuner and'i'he Home Depoi wilh.regard to the Products and Installation service,and supersedes all prior discussions and agreentems.either oral or written, relating to said Products and Insiallaticm. This Agreement canna us'ignod or Thdod ceps by a writing signed by Customer and The Home Depot. Customer acknowledges and.ago IJ I Cu n er has rest ors I s, volutuarily accepts the terms of and has received a copy of this Agreement. Accepted by: '7 Submi Customer gn:aure Date ales o , 4I I's S lsaat p Date X Tcic a No.�U O 'c7� Cuslontcr'sSignalorc Date Sales Consultant License No. S?esaafihez is -Department of Public Safely Board of Building Regulations and Standard-, - CanstruticnrSvpenisor Speciat.t - License: (MSi 1G -m§D f4c, x, pOBERT POCZOIhI1 - `r 172 WHALYRS A9A 5a1€m 01970= x� _ Expiration ! D21Df �t9y Commisslover r . . Pam o BsC&E o52mw;MM 021P4 2017'---I — — ` dY'keaa'Compemost,om I nat'aTmEm Affeedllsvid1:BUM(gen—WCOR Mmbnlzi1Qe�ne��mallP9mm e a AHa161lilceamt Mega FrAm¢FLeFffly 1ZlaMe ' V Address: Ares nm¢¢mpl®yer Cues&¢Is apprelarlate box: r�tno©f 1pra�eet Q¢oalm9reel): y� 4. I s�a geti€sal coo ctoP and I 6 [3 NeW constrtaction 1 eZ I am a 10 with ,- enaployees(fall and/or part-time).* have hieed the soh-Goubutos 2.❑ I am a sole proprietor or partner- Listed on the aiLsched abc€t. 7. ®Remodeling -ship and have no employees 'these sub-cotitractor,havz g, ®Z emola io d working'for me in a capacity. employees and have saorhers' g ?iY P rl• , 9. ®3tdlding addition [No workers'comp.insurance comp.in,tnance required.] S.®idle are a corporation and its 10.®Electlicai rgparre or additions 3.❑ L am e homeowner doing all work offlcers have eseg oised their - 11,E E 6ing Pepsis or slditioas myself. [No workeis' comp, right of exemotion.perMG,L insurance required.]t c. 152;�1(4),and we have no 12.0 : rs 13.[ r bar• .lnaircatiee required-1 . *Any applicantthatcheckwbm#lmmtolso fill cmtbe Mtimhdowthociogth€irwwimmu'someeaccgcii@alicyinfwfa5tion. tHameoaneriwhosebmitthisafdavitindicating they eredoingallwmitmdthm him wWdacmtmctemmtasubmitaneve�davtivdc ageuc'h. 46ontmatora thatch=kthis6w mastensch.c-dao aft arlJ ehea nhowhrgthenemeofthe so to arso dsatewhetlivor rot those weit;ee haw .employew. .lf the sub-concecmrs have employees,they raust pmvide their wmAM'cmV.polieyn=bw. -llamanemployer BLYOW129hopo&sy eadjob site ,. B fInsurance Company Name: Policy#or Self-ins.Lic.In: ) �—r`''I�h� I�, Expiration Date: � 4_1 Job sit Rddaess:' t Citylstste/zip: Afteelle o copy.of the Wept'c®unpensatims Aee padcg mmrmbcr Brad 041178,401M(date). " rail-are to secure-coverage as required under Section M of hlZ'il,c. 152 can lead to the imposition of erin:LmA pmd&s of a fine up to$1,500.00 aadlor tine-year imprisonment,w atoll as civil p;atalfigs in the foam of a STOP WORK ORDER and a.hne of-up to$$250.00 a day against the violator. Be advised that a copy of this stitement may be forwasded to-the Office of- Investigations of-$e or im iuran6e coverage vs?Section. T d®➢�areby cer2Sfy de 85 ®" eood aaeel9Sas oyperjeay BGaaB Blae anyoma¢Boaagr9-Ailed ebowe is ft a end saraeoL ;�i�tattare• .-��. - D e• .- � Phone#: / �f}zcisP ass®s� Do sroE~✓re9e ire Bkzs mee &a be ptrsa R r]ray 6zdy mr 8mrrsa m�pBdel. ugly ar'Sow®• 1Der ¢e®ye n IIasmimg Atsf(Aeoaidy(Orcla one): Il. ®and®f I($ea1811 B.I�ot1➢du®g SDegaerQ�ea4 2,c�u[y!1 oRa 6aerP� 4;rip �1 IInapector 5.LP9m�lmg If©apesf®r (C®eaIIas& Persia®: Maine#: CERTIFICATE OF LIABILI Y INSURANCE 11118014 ^r, TI115 CERTIFICATE IS ISSUED AS A !NATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON Inc CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER A— BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN COVERAGE AFFORDED SY THE POLICIES - REPRESENTATIVE OR PRODUCEP.,AND THE CERTIFICATE HOLDER. 1NEEN THE ISSUING INSURER(S), AUTHORIZED iNIPORTANT: if the certificate holder is an ADDITIONAL WSURED, the olio ie; must the terms and conditions of ttte policy,certain Policies may require an endorsement. A statemE orondihi 77 c rs-,-Ri afz does not VAI ED,subje he certificate holder in lieu of;Och endorsement(s)- PR000CER � - MARSH USA,INC. CONTACT TWOALUANCECENTER - NAME: 3560 LENOX ROAD,SUITE 2400 PHONE. IAIC No 5n - FIN ATLANTA,GA 30328 -MAIL IaC E-MAIL IOW2-Honj ED.GAW-14-15 - IN SURER(S)AFFORDING COVcigGE INSURED INSURER A:Slasdl St Ins'ranm CarpsT, NAic THDAT-HOME SERVICES.MC_ 2E387 DSATHE HOME DEPOTAT• INsuReR a:ZudchAma ican lnswar c.Cu 16535 690 CUMBERLANDPARKWAY,PARKWAY, S00Ea - tN;UfiER c:NwHanp=hire lns Co ATLANTA,GA 30339 23841 INSURER D.Illinois National Insurance Company 2381J INSURER 5 COVERAGES - CERTIFICATE NUMBER; rNSURERF- THIS IS ED CERTIFY THAT 7tiE POLICIES OF INSUPANCE LISTED BELOW HAVE B ENS SUED�O THE INSURED NAKED ABOVEB OR THE POLICY PERIOD INDICATED: NOTWITHSTANDING ANY PtH I IN,THE INSU A CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IMTH RESPECT TO NAiiCH THIS CERTIFICATE MqY BE ISSUED OR MAY PERT$IN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED H DOCUMENT IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN.-REDUCED BY PAID CLAIMS. NSR LIN TyPEOFINSURANCE DOLS R PO OYEFF IDCLAM A GENERALLIASILITY SR IMOG POLICYNUPASEER i Pd0IDD/YFFF MMPOD CL0 4 68 7714-0 4 1-I41ITs y` COMMERCIALCENERALLIABIUTY 03101201d 031012015 EACH OCCURRENCE S 9.OLG,000 .. CLAIMSMADE a OCCUR LIMITS OFPOCICYXS PR IEUAAAQER IT ED Eaumurr,Ince S 1.00G.000 OFSIR:$1MPEROCC MED EXP(Anyene;n_mm) s EY,CLUDED '- PERSONALBADVINJURY S 910m,o00 _ GEN'IAGCREGATE LIMITAPPLIESPER: - GENERAL AGGREGATE $ 9,000,000 Y` POLICY JEGT LOU ' PRODUCTS-COMP/OPAGG S 9,OW,000 B AUTOMOBILELMUILRY BAP 293B863.fi $ X A _ 03/01/2014 0310112MS COMBINED SINGLELIMIT ALL OVMF _ Eaacdden s 1,0(Y7,000 AAUTOS,s OS, SCHEDULED BODILY INJURY(Perperon) S AUTOS SELFINSUREDAUTO PHY CMG H1REq AUT0.s AUTOS BODILY INJURY(Pera¢ideno s POPEYDAMAGE S M UMBRELLALIAB OCCUR S EXCESS LEAS CLAIld&MAOE EACH OCCURRENCE s DED R["fEN710Ns I AGGREGATE s C wORKEftS pOMPENSgTIDO. WC049101B02 A05 $ C, AND EMPLOYERS'LIABILITY ( 1 03l01201q 03/012015 X WC sTATU- OTH- O ICE ANWY OPRIETOfLPARTNER/EXECUTNE YIN WC0g91D1884[AK) 031042014 03AI1n015 TOR IMII- ER p Rry In EXCLUDED? � N/A EL EACH ACCIDENT S 1.0W,DD0 IMand osedb NH) WC049101883 R ESCRIPTION OF Or ERAT1DN5 helex aunder. ( ) - 03107n014 03101n015 EL DISEASE_EA EMPLOYE 5 1,000,000 C WORKERS COMPENSATION EL DISEASE-POLICYLUAIT S 1,fA0,000 010049101885(KY.NO,KH,VT) 031DI2014 03/012015 C NJ (EL)LIMIT WG0491O18B6 i3OW,0o0 i ) 031012014 031012015 DESCRIPTION OF OPERATION51 LOCATIONS/VEHICLES(Attach ACORD 101,Addlllonal Remarks Schedule,NmaJe space Is requlratl) EVIDENCE OF INSURANCE i ' GERTIFIGATE HOLDER ' I CANCELLATION ' FATLANTA,GA VICES,INC. OTAT-HOME SERVICES SHOULDANy'OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i ROAD - - THE EXPIRATION DATE -THEREOF,' NOTICE WILL BE DELIVERED IN - ACCORDANCE WITH THE POLICY PROVISIONS. I AUTHORIZED REPRESENTATIVE - ofMamli USA Inc. _I 7a_i iy f'! 1: CZ CC A 1,—]S Home fI`prove'*�I�IIi orilI�etoT Rapist ration, .Tyra: supplumantC�:d THD AT HOME 8ERVICE-S, I a. 690 Cll r7�€€ l D FA.RIO AY SUITE 300 -- — RTLANTA,GA 3033J Updau Addy s and refarlE ea d.M3-rk mmm for catangc. .CAI .; ? sav17 J dddr i�sn ra] Em;7Sa;msat j Los!0,i0 . /.n:+•J+�- }� ^1nAr oSCansr, seas FsHvtsa:rL� 3.a a3 . Lkip:;5or7pctra'lon valid#armdividul30"ORIy o ��z Ware the �a�sx� fe 75Yapc3^c s�ptn, � Pf 91F9t°Pt51a��f C J, 1F�=F ..,.� kg �.� tim +sSCpanet+ rr ; ,7ae�aravt7��sine ;�.�rla?ir,� - kt Type: E �m �1u "`=s^. '�syppr€imru ,SJaleL11� 5u ©IemantCaN �� T1,19 A.a Hwr SERVICES,INCH 'YhSFotil"JIfTG��E�f]'FtThIQ�ftE$E�eVICEa ,. - H;ndersr+e9nay- '. .. oC re' w srgma :. QTY OF SALEM, MASSACHUSEM BUILDING DEPARTMENT r 120 WAS19NGTON STREET,3A0 FLOOR nL.(978)745-9595 KBOERLEYDRISODLL FAX(978)740.9846 MAYOR THomm ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUIIAING COMMISSIONER 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 c40, 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 deposit 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 facility) (address of facility) Si nature f applicant a