45 LARCHMONT RD - BUILDING INSPECTION I I'he C'onunonwealth of Massachusetts
Board of Building Regulations and Standards CI'I'1' OF
Massachusetts State Building Code, 780 CMR SALLM
L Revi.ced.1/oo•V)//
Building Pennit Application To Construct, Repair, Renovate Or Denwlish a
One- or Tw u-Farnilc Dwelling
This Section For Official Use Only
Building Pennit Number: Date Applied:
Building 011icial(Print Mane) Signature ate
SECTION 1:SITE INFORNIATION
I.1 Property A r C
49 1.2 Assessors Map& Parcel Number
Oh
I.la Is this an accepted street?yes no_ Map Number Parcel Numlxr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District PmpoxJ lJse Lot Area(sq 11) Frontage(II)
1.3 Building Setbacks(D)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal s slcm ❑
Check if es0 P W" )
2.1 Own1%Rec SECTION 1: PROPERTY OWNERSHIP'
2.1 Owne of Rec rd:
Name(Print) City.State,LIP
No.and Street �-� /i - relephone Email AJdnss
SECTION 3: DESCRIPTION OF PROPOSED WORK'( heck 10 t apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Denwlitioo ❑ 1 Accessory Bldg.❑ I Numbe.of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
N Ih
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Officinl Use Only
(Labor and Materials) y
I. Building 5 _ I. Building Permit Fee: EZ_ Indicate how fee is determined:
I ? Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(item 6)x multiplier ___ x
i, l'lunthing S 1. Other Fees: 5
4. .Mccltanird IIt\'AC) S List:_
3. .\fcchanical (Fire 5 .---- __-. -- --- _--
.Su t ressionl Total :\II Fees: 5
ChcyJr. u9 .'heck :\mount _ V�Cash Amount:n. Total Project Cuss i aid in Full I]Outstanding BaLmce Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cunstructio Supenisor License(CSI.)
._ __ _ct_- �,�1t_.___._.__— Licata• 'uniher L%pu'at m )ate
None ol'C'S1—11oIJcr
` •��/J� � List CST.1)(k Isce h¢lowl
No. )PC Description
and Street 11
U l InrcslricrcJ(Buildings up to 35,090 cu. Il.l
R Restricted 1,4L,2 Fuotil Dwellin
ilfott , ttc. .I M Mason
RC Rm it Covering
WS Windowmd Sid ind
SF Solid Fuel Burning Appliances
1 Insulation
l'cle bona Email aJJmss D Demolition
5.2 Registered Home frallr vement Contractor(HIC)
1 Vle oy 4 L-h/lnlr IIIC I11v igrt un Nuntbcr lisp all n Uotc
I lic C• t� A m Ne or I IIC'Regis m ac r
No. :ntd •el I -07 r f E rDQ23 Emuil address
City/Town, State, ZIP 'felc hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 25C(6))
Workers Compensation Insurance affidavit must be con pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan f the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: 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 ma rs relative to work authorized by this building permit application.
7-e r—r7m— rAj -- 1
Print Owner's Nmne(Electronic Signature) I Dat'
SECTION 7b:OWNER( OR AUTHORIZED AGENT DECLARATION
By entering my nam elow, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this a pli lion is t e a accurate to the best of my knowledge and understanding.
l 4n'
Print Oancr'sor:\ Iht iced Abe tS Nume(Electronic Signature)
NOTES:
I. :\n Owner who obtains a building permit to do his:her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will!Ud have access to the arbitration
program or guaranty fund under I.G.L. c. 112A.Other important information on the HIC Program can be found at
Information on the Construction Supervisor License can be found at �ON .IB,,
2 When substantial work is planted, pro%ide the information below:
Total floor area(sq. ft.) _ _--_1 including garage. finished basemcnt'anics,decks or porch)
Gross living area I sq. 11.) Habitable room count ._
Number of fireplaces--- --- Number of bedrooms
Number of bathrooms Number of half hathS
F%pe tit heating S)Stern Number of decks, porches -
Iypeofeoolhtgsystem _ Fncloscd
1. "1'tnal Project Stelae Footage-mas he substituted lire"focal Project Cost'
08/05/2011 13:40 15087568823 THD AT HOME SERVICES PAGE 01/07
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
' 3a [ l Sold,Furnished and Installed by:
Branch Name: Boston Date: l�0 THD At-Home Services,Inc-
Branch The Home Depot At-Home Services
345A GromWood Sucel,Unit 2,Wmtesfew,MA 01607
Branch Number:31 Toll Free(8W)657-5182; Fax(508)756-8823
Federal ID 0 75-2&98460;ME Lic it C 02439,Rl Cont.LAC#16427
` ` Lic p 0565522;MA Rome Improveamu Contractor Reg.0 12093
Installation Address: / ,, �1 e rJW 1 74-IF-a C¢/54wv
City State Zip
s): work fq r HoomPhrme: Cell phone:
[lft7 ?4'V—;-w (9y�1 ezJ�� 30
How Address: - —
(If different from Installation Address) City State Zip
E•mnd Address(to receive Project communications and Home Depot updates)- .—
❑I DO NOT wish to receive any marketing emails from The Home Depot
pro ornmtion: Undersigned("CDstmrer'),IlW owners of the property located at the above installation address,agrees to buy,
TFID At-kJome Services,Inc-("7Le Horrre Pieper")agrees to furnish,deliver and arrange few
f which = rtthoe installation(-Instanatiow)of
all
ratod into this Contract
reference,materials
with SAY appiimbic State Supplement and paybed an the below and on the referenced ymment Summary oattached hereto and any Change Orders(collectives
"Contract").
Job*'. nr~� ticCtr• Spec Sh s)9: ProieetAmrmni
oofmg Siding indoors insulation $
5748f169 ❑oatco/ce.era ❑EntryIkons ❑. . 0SSY8 ( 86 I
Roofing ❑Siding ❑windows -1 Imailstioo $
❑cmaas/Co.ers ❑Entry Doors p _ .
Roofing ]Sitting ❑Windows LJ Imulation $
❑ours/Gtverx ❑Entry Doors Q .
❑Roofing idwe, ❑Wirndaws Lj insulation
0outlrn/Goren% ❑An%Doom ❑_ .
Mndm om25%DePOSit arCwtiac.Aaaaatd=.PtarareCUBOrOfthis CRIATOM Total Contra..Amount
Maine Purchases mar not depus;t more than oneltmmd arthe t-.adradt Amaaat.
(%ummcr agrous drat,immediately upon completion of the work for each Product-Customer will execute-a Complction-Cxrtificatc
(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-
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Product(s)included herein,at v.
its discretion,if The Home Depot Or its authorized service provider determines that it cannot perform its obligations due W a structural
problem with the home,eavironmental hazards such as mold,asbestos or lead paint,other safety concerns,pricing errors or because
work required to complete the job was not included in the Contract
Payment Sum nory: The Payment Summary# 15S 19-L-6 . included as part of this Contract, sets forth the total -
Contract arnotmt and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
Yon are codded to arnnqk G71ed4n copy of the Contract at the time you Sign. Do riot srgu a CompledOD Certificate(note:
there is one Completion Certificate for each fisted Product as defined by individual Spree Sheets)before work on that Product
is complete
In the event of termination of this Comraet,Customer ogre"to pay The Home Depot the arts of materials,labor,expenses
and services provided by The Home Depot or Authorized Scrvice Provider through the date of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITIHLOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE, DEPWIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S OTHER REMF.DWS FOR RECOVERY OF SUCH AMOUNTS.
Aae tame and A thoriaadom es Customer agrees and understands that this Agecmcnt is the entire agreement between Customer
an The ome Depot witb regard to the Products and installation services and odes all prior discussions and agreements,either -
oral or written,relating to said Products and installation.This Agreement t assigned or emended except by a writing signed
by Customer sand The Hame Depot Customer acknowledges and agrees tlad has txstands,voluntarily accepts the
terms of has received a copy of this Agreement
q g Submitted
X ? // X 7
Qrstomcx s Signemre Dale Sales Consultant's Signature Date �1
x _ Telephone No.J�.S- zJ 3- � 7 Y
Customers Signature Date Sales C<msultam License No.
CANCELLATION: CUSTOMER MAY CANCEL. THIS tasappltcabrei
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRLTTEN 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 IF ONE IS
SPECIFICALLY PRFSCRIBED BY LAW IN
CUSTOMER'S STATE.
NOTICE:ADDrtaONAL TFRarc AND CONDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OF TAM CONTRACT
1.7.18 rsc Whits-Branch Re Yeluow-Customer
CITY OF S.0 ENf. NLASS.XCHL'SETTS
BI;ILL)MG DEPARTLLNT
120 W.uHLYGTON STREET, Y°FLOOR
TEL (978) 74S-959S
FAX(978) 740.9846
KIJ®ERL.EY DUSCOLL
MAYOR Tm usST.Pmxaa
DIRECTOR OP PCBUC PROPERTY/aUILDLNG CMWISSIOV Ea
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 l 11.5
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 NIGL 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)
si4iruref permit applicant
Jat
h hnud•Lw
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.Licenser, C'S SL.99699 :
Restricted10: WS. '
ROBERT POCZOBUI n
i? BEACH ROAD APT. 45
. LYNN,.MA 01902.
'ExpuauAri. 6!2(!t2
l i.pu a v:niri•'
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �'j_ {� Please Print Legibly
Name (Business/Organization/Individual): ` ne j � / k Z D T
�
Address: oZf• f .tyYlsV� Pl+ 1�1.��
City/Sta /Zip: 'hone #: 6?52-6-1 a—
Are y an employer? Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P Y• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.;
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. o workers' com right of exemption per MGL
y [N p. 12.❑ R epairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13. Other ►JI rl j4
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 must submit a new 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 11Al�t Ce
Policy# or Self-ins. Lic. #: �O �] 1 1:9 Expiration Date: _3 Mf
Job Site Address: � py✓I pN � City/State/Zip: !�"
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 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 certify under t e ains nd nalties of perjury that the information provided above is true and correct.
Signature: Date:
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#:
DATE(MMMOIYYYT) �I
CERTIFICATE OF LIABILITY INS Aw-k- 02/2!/2011..
u
. �
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CcRTI ED BY HOLDER.THIS
BE OWC TTHIS CERTIFICATE FOF INSURANCE DOES NOTVELY OR LY AMEND, EXTEND CONS7TUTE A CONTRACT BETWEEN OR ALTER THE COVERAGE
ISSUING NSURER(E)TAUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
If SUBROGATION
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must he endorsed. TION IS WAIVED,does not confer rights to sj to the
t to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate
certificate holder in lieu of such endorsemenl(s}. . . -
CONTACT --" -"-'
1-404-995-3000 NAME;_.-----'-Fax�------��---
PRODUCER PHONE --
Mazsh USA, Inc. .L4 NR.�aOt-.---_.____..____-_.--_..-.
EMAIL
ADORE S' --- NAIC a-,
Two Alliance
cer Center.C 3560 Lenox Suits 2400 INSURERS AFFOROINGCOVERAGE _ .-
Two Alliance Center, 3E60 Lenox Road, __�-_ --t.l---------'-'— a63a7
Atlanta,-GA 30326 Steadfast Ins Co •-_ --- ------ -
__ INSURERA: ---- 16535f
Fax (212) 948-0902 INSURER 0: Zurich American Ina CIS
INSURED `
23841
The Hama Depot, Inc. INSURER C: New Hampshire Ins Ca-_-
23817
Honk Depot Q.S.A., Inc. INSURER D: Illinois Natl Ins Ca --
2455 Paces Ferry Road NW - NATIONAL UNION FIRE INS CO OF PZTTS 19145 _
Building C-20 mauRER E: -""'�- ---21960
Atlanta, GA 30339 - INSURER F: Illinois Union Ins Co _
REVISION NUMBER:
COVERAGES CERTIFICATE NUMBER: 19834683
BEEN
IRA
THIS
IST TO ED.CERTIF THAT
POLICIES
NY REGUIREMENN TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT ALL
T HICNITMS
EXCLUS ONE CERTIFICATE MAY
AND BE ISSUED
OR MA PERT N.THE INSt OF SUCH POLICIES.I MITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
HEREIN IS SUBJECT TO ALL THE TERMS,
-------- ----• POLICY POLICY EXP LIMITS
ADU SUER POLICY NUMRER MMIODNYYY MMIDDIYYY 9 D00,000
LTR
.NSR(" TYPE OF INSURANCE 03/01/1 O3/Ol/12 EACH OCCURRENCE f ------
GL04BB7714-01 s�.
A OENERALUASILRY _ PR 0 N D 1,000,000
PREMIS reAncel.. }_--.-.----_- ---
X COMMERCIAL GENERAL LIABILITY MEDEXP An one Pe^ent S EXCLUDED -
CLAIMS-MADE a OCCUR 91000,000 -
PERSONAL i AOV INJURY f
X LIMITS OF POLICY XS - GENERALAGGREGATE S9.000,000
X OF SIR: SIX PER OCC PRODUCTS.COMING?AGG f
GENT AGGREGATE UMIT APPLIES PER: S
PRO. 3 0 3 01 1 COMBINED SINGLE UMI 1_-0000,000
X POLICY LOC HAP 2938863-08 E a aI
H AUTOMOBILE LIABILITY BODILY INJURY(Par Person) S
X ANY AUTO SOOILYINJURY(P°raWdanl) f
ALL OWNED SCHEDULED PROPERTY
AUTOS AUTOS fad
NON-OWNEDS
HIREOAUTOS AUTOS -
X SIR AUTO Y Y. _ EACH OCCURRENCE -
UMBRELULIAB OCCUR AGGREGATE f
EXCESS UAB CLAIMS-MADE f
03/01/12 X, WCSTATU- OTH. -_
DEC RETENTION '-'
C WORKERS COMPENSATION WC0619673E2 (ADS) 03/Ol/1 03/01/12 E.I.EACH ACCIDENT f 1,000,000
AND EMPLOYERS'LUBIUTY YIN WC061967354 (FL) 03/01L/1
D ANY PROPRIETORIPARTNEWEXECUTNE❑ NIp r WC061967753 (CAI 03/01/1 03/01/12 EL.DISEASE.FA EMPLOYE S1,000,000___
E OMFF YE"ErMS N„)EXCLUOEDT N 1.000.000
E.I.OISEASE.POLICY LIMn S
NYyaa.deunLaunder
DESCRIPTID N OF OPERATIONS OaIew WC0 619 673 55(KY,MO,NY,WI, ])3 03/1 03/01/11
C Workers Campensation TNSC46244151 (TX) 03/01/1 03/03/12 Occurrence/SIA ]OM/3M
F TX Employers XS Indemnity 03/O3/1 Ol/O1/12 SIA 1M
g workers Compensation
WC1192378 {CHI)
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(AIIecN ACORO fat,AddiUPnal RamaM 9cNNWa,if msn space la^Rsi^41 \
REr EVI➢E14CE OF COVERAGE
CANCELLATION
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBEDTHEREOF.
ICE POLICIES WILL BECANCELLED
IN
THE EXPIRATION DATE THEREOF,
THE HOME DEPOT, INC. ACCORDANCE WITH THE POLICY PROVISIONS.
HOME DEPOT U.S.A., INC-
2455
PACES TERRY ROAD NW
AUTHOR N
AUTHORED REPRESENTATE a -
BUIL /1
eUILDZNG C-20 l//�.�,�^ ��
ATLANTA, GA 30339 'USA
reserved.
®1983.2010 ACORD CORPORATION. All rights
ACORO 25(2010105)
The ACORO name and logo are registered marks of ACORD
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