1 LEVAL RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations ;utd Standards CI'1'1' OF
Massachusetts State Building Code, 780 CNIR SALLM
Building Permit Application To Construct. Repair, Renovate Or Demolish a
Orre-or Tuu-Fumilt' Dwellm.e
This Section For Of a se Onl
=—fJu,ld,ngOIfl,,jI
er: ) to Applied:
N:ane) Siytature Date
SECTION I:SITE INFORDIATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street0 yes no Map Nunther Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sgll) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required PruvidedRequired Provided Required Provided
1.6 Water Supply:(( G.1-c. 40.§5a) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owne f Recoi r
6A
;uticx, 7Q
Nne{{lPrmt)
1USta"
ty. � IP
No.;old Str � Te ff
e–ibune
P Email Address j
SECTION J: DESCRIPTION OF PROPOSED WORK'(check a hat apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: !�>
SECTION a: ESTIDIATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building g I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
1.
Plumbing S 2. Other Fees: S
{. \lechanical (11VAC) S List:
S. .\leclianiral (Fire
_ —._- ----- ----.—_. - ...
Su rrcssion I S Total \II Fees: S --__ -------- ----..._..
e. Total Project Cost: S Check No. __Check :\mount: _ ----- C',uh Amoull: _
�� —
13 Paid in Full ❑Uutst;coding Bal;mce Due:
SECTION S: CONSTRU(-T1pN SERVICES
5,1 constr- ction Supenisor License(CSI-)
Licetsc Nunther I�%pirul on )at
N;uttc al l'SI. I folder ___iii JIIJ —
List CSI.1)pc(we
_► -lien =— ISPC Description
No. and Sired
U l4tresuideJ IBuilJin s ti to iS,lllll)cu. ll.l
m it R 1(cstrictcd 1&2 Fumil Dttcllin'
C'itei lotto ti ttc. P M Nlasonry
RC Roolling Covering
WS R'indow and Siding
SF Solid Fuel Burning Appliances
I Insulation
'I'cle fume hmaJ address D Demolition
5.2 Registered Ilam Imp vent• Contra for(HIC)
I IIC' Registratmn Numttcr lispi alit utc
111 ' 'o , n• egt tr nt Name
N t treet Emuil address
Ci /Town, State,ZIP "rete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 4 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 the building permit.
Signed Affidavit Attached? Yes .......... No...........0
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 matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) to
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below.
I hereby attest r the pains and penalties of perjury that all of the information
contained in this a lication is true and ace rate t the est of ,y knowledge and understanding.
Print unmet s or: uthorrcd Agent's Nmne(1:1116krMilf Slgnaunc Dm
NOTES:
I. 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 nu have access to the arbitration
program or guaranty fund under \I.G.L. c. 142A.Other important information on the HIC Program can be found at
tutrt n .i.. a i Information on the Construction Supervisor License can be found at tt?t r?.nia.+ „ t .IIL
2. When substantial wurk is planned, pro%ide the information below:
Total Iluor arca(syn fl.l _ _____(including garage, finished basement attics,decks or porch)
Gross li%ing area(sq. Il.) _ Habitable room count
\umber of fireplaces.,_ Number of bedruonts
Num
llis
I\pchdeoatlingrsyu'Ient — — 1`tumber of decks,rporches Open
t, "total 11roicct Square Foulage'nits be substituted Iir"Raul Project Cast"
CITY QF S.�ti[, �tiL�SS.ICHC'SETts
OLLLDL (; OEP.tRT mar
I.0 A.IiHCVGTON STXjAr, J FtCCrt
rEL 1978) 14S.9591
KIJ®ERLBY ORLXOLL F.tX(979) 74984
bUYoIt rRQ,%W ST.Ptd
DIIIBGTaIi CI PCBLlC vRovl�rY/eCQ.DfNC coSnn33roNHR
Construction Debris Disposal At'tldavit
(required for all demolition and renovation work)
In accordance with the sixth edition orthe Stats Building Code, Iso CUR section 111.S
Debris, and the provisions of,MGL o 40,914;
Building Permit b is issued with the condition that the debris resulting from
111, 3 I10A.
this work shat) be disposed of in a properly licensod waits disposal facility as defined by NICE c
The debris will be transported by:
(n.una of'haular)
The debris wi II be disposed of in
(nam o mlily)
( ddrtaoYr�.•,t,iy�
itn Nre u(r rm,t rppti,ant
tl 600
02-1
M_
lt.,,A, E"C_�
Workers' (2crEpellsatlor, )rEsrr�atice n3jiliail�
lease FrhA IL ep- blv
Address:___
City/state/zip:
Ty
Army ' employer? Check the appropriate bo X2 co ctor and re of project(reqnired):
YX2 j I am a general contractor I Prl am a employer with 4. 6. 0 New com'—'actioa
-atehid the sub employees(fall audlor part-timL).- have ree su
. I
2-[l I a-in a sole proprietor or partner- listed on the attached sheet. 7. E] RemodelL1149,
ship and have no employees These sub-contractors have 8. L]Demolition
working for me in any capacity. employees and have workers' 9. Ej Building addition
[No workers' comp. insurance comp.insurance.1 10.0 Electrical repairs or additions
required.] 5. We are-a-corporation and its
3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.0Ro
c. 152,§1(4),and we have no Ore -S
pah
insurance required.]t 13. Other
employees. [No workers'
comp.insurance required.] ) In 4
-Any applicant that checks box#1 must also fill out the section below showing their workeni'con7pensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indiwting such.
;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whetherarnot those enti6eshave
employees. If the sub-contractors have employees,they must inovide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below,&thepolicy andjob site.
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: Lp—,k _City/State/Zip:_ �- _
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to see d under Section 25A of MGL c. 152 can lead to the im
are coverage as require . position 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 fire
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.
Ido hereby certify.ur ert pails and ofperjuty that the information provided above is Ir fid correct.
S1_na e Date-
Phone0,
Official use only. Do not write in this area,16 be completed by city or town officiaL
City or Town: PerniftMicense#
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#:
Jul 0612 10:00p BOB DANGELO 9785157765 p.1
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Sold,Famished and Installed by:
Branch Name: Boston Date: y ��201 THD At-Home Services,Inc.
d/b/a The Home Depot At-Home Services
908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free(800)657-5182;Fax(508)845-6017
Branch Number:31 Federal ID#75-2698460;ME Lie#C 02439;RI Cont LicH 16427
1 D + CT Lie#HIC.0565522;MA Home Improvement Contractor Reg.k 126893
Installation Address: I FCVo1 ICs( -V Pvh M 4 01476
City State Zip
Purchaser(s): Work Phone: Home Phone: Cell Phone:
POK, W44 464y
Home Address:
(If different from Installation Address) City State Zip
E-mail Address(to receive project communications and Home Depot updates):
RI DO NOT wish to receive any marketing entails from The Home Depot
Pro*act Information: Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy,
and THD At-Home Services,Inc. C'Me Home DepoCJ agrees to furnish,deliver and arrange for the installation("Installadon")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#: aaQ"a a�a.) Products: Spec S s #: Project Amount
Roofing Siding IRWindows Insulation
a3G j 1 pIp - ❑ []Entry 6-
Gutters/Covers Entry Doors l y �/
67 / $ Sy o[q
Roofing KSiding Windows Insulation fp
❑Gutters/Covers ❑Entry Doors r-1 $
Roofing Siding Windows 0 Insulation j I
$
❑Gutters/Covers ❑Entry•Doors fl
Roofing OSiding FJ Windows 0 Insulation
❑Gutters/Covers []Entry ❑Entry Doo $
Minimum 25%Depatitof Contract Amount due upon execution of this contract Total Contract Amount $ f gya7 `
Mame Purchasersmay not deposit more than one-third of the Contact Amount
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.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Pmduct(s)included herein,at
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home, environmental hazards such as mold,asbestos or lead paint, other safety concerns,pricing errors or because
worts required to complete the job was not included in the Contract. _
Pavment Summary: The Payment Summary # Q?l 10%' , 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-in copy of the Contract at the time you sign. Do not sign a Completion Certificate(note:
there is one Completion Certificate for each fisted Product as defined by individual Spec Sheets)before work on that Product
is complete-
In
ompleteIn 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 Home Depot or Authorized Service Provider through the date 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 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 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 Agreement 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 Agreement JJJ
Ac eep by� Sabmi
X 5� GlJaryrJ 7--6- � X
Customer's Signature Date Sales Consultant's Sig are Date
r f t'ri_iss,rrhusetts - Department,.dr. Public Sati2i•r -
•` oard ci 9w!�ling Regulation; and ! tUm,ard;
ira•iv,e: CSSL-099699 F
ROBERT POCZOBUT - 1`-
172 WHALENS LANE
Salem MA 01970
i
l;,n nrnrf.c;o�"'r 02/08/2014
Acc; ' CERTIFICATE IFICATE O LIABU Y iNSURANCE
AIF R,;YI/LIr
� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE %IO+DER. TILS �
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED 9
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. It SUBROGAT30N 3S IMAIVED, subject tD
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the 1
certificate holder in lieu of such andorsement(s).
PRODUCER1-866-9666-4664 CONAMNTACTE:-
Marsh DSA IaC. PHONE AIC N61,
AI l6 E:
EDDRE
homedepot.certregaeat(tlmarsh.COm ADDRESS
Two Alliance Center, 3560 Lenox Road, Suite 2400 iNSURERjSI,AFFORDING COVERAGE MAIC#
Atlanta, GA 30326
Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26387
INSURED INSURERS: Zurich American Ins Cc 16535
The Home Depot, Inc. INSURER(: New Hampshire Ins Cc 23841
Home Depot D.S.A., Ino. - -
2455 Paces Perry Road NN INSURER D: Illinois Natl Ina Co 23017
Building C-20INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445
Atlanta, GA 30339
INSURER F: Illinois Union IIIB CO 27960
COVERAGES 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.
VPoucyF�JPMCT
YPE OF INSURANCE OLS POLICY NUMBER MDO UCY EFF MMIDDV�P LIMITS
BILm GL04887714-02 03/01/1 03/01/13 EACHOCCURRENCE $ 9,000,000
PREMISES Ea $1,000,000
CIAL GENERAL LIABILffYIM&MAOE �OCCUR MED EXP(Any ane p M.r) $EXCLUDED
S OF POLICY XS PERSONAL B ADV INJURY $ 9,000,000
R: $1M PER OCC GENERAL AGGREGATE $ 9,000,000
GATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 9,000,000
PRO_ LOC $
B AUTOMOBILE uAamnY BAP 2938863-09 Ol 03/01/13 EOaacdtlentSINGLE LIMIT 1,000,000
X ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS OS
NON-OWNED - PROPERTY DAMAGE $
HIREDAUTOS AUTOS (Per neddent) ,
X SELF IKSUBBp PRY DMG $
UNBREI r e'JAM
OCCUR EACH OCCURRENCE $
EXCESS LJAB CWMSJNADE AGGREGATE $
DED RETENTION$ 1 $
WORKERS COMPENSATION WC019736915 (AOS) 03/01/1 03/01/13 X WC STATU- FIR
C AND EMPLOYERS LIABILITY
YIN NC019736917 (PL) 03/01/3 03/01/13 E.L.EACH ACCIDENT $ 11000,000
D ANY
OFFICE PRIETORIPARTNERIEXECUTIVE❑ NIA
OFFICER/MEMBER EXCLUDEDT N NC019736916 (G) 03/01/1 03/01/13 E.L.DISElSE-EA EMPLOYEE $ 3,000,000
8 (Ma"durinry, NX)
11 describe antler EL DISEASE-POLICY LIMIT $ 1,000,000
DErkersOCOF OPERATIONS bebw
8 Workers Compensation _ NC1192494 (QSI) 03/01/1 03/01/13 SIR (AOS) SIR (GA) 1M/750,000
C Workers Compensation WC019736918 (NI) 03/01/1 03/01/13
F ITX Employers XS Indemoity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/lM
DESCRIPUON OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 101,Atltlitiunal Rerrurka ScOeEula N mere apace IS re9uiretl)
RE: EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THS HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS.
2455 PACES FERRY ROAD NN AUTHORIZED REPRESENTATIVE
BUILDING GA 3
ATLANTA, GA 30339 l/�(p+ LJl-o--2-•
DSA
O 198$,2010 ACORD CORPORATION.�,'AII rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks`ef ACORD}g°
Sthoratoa_hd
25776028
Office of Consumer Affair s&Business Regal ikon t
OME IMPROVEMENT CONTRACTOR-.
Registration :*126893 fYp<'
'Expiration. ./3(2012 . Supplement
-'The Home Depot ht Norrie sr
,it
t ti � Vii.
RICHARD FALLONE
2690 CUMBERLAND PARKWAY S ���= ��— ,, -
.. A'l,P,'NYA,GA 30339"'{. -
Undersecretary
MERG
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T1Nr�S
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