175 LORING AVE - BUILDING INSPECTION i
The Commonwealth of Massachusetts
LBUnildingPermit
Board of Building Regulations mid Standards CITY OF
SALEbI
Massachusetts State Building Code 780 CMR
0 Revised Mar 2011
g Permit Application To Construct, Repair, Renovate Or Demolish aOne-or Tivo-Family Divelling
Chs Section F6rOffcial Use Onlber.; - ent Name) _ ': Signature Date.--
SECTION 1: SITE INFOMMATION
1.1 Property A d 1.2 Assessors Map& Parcel Numbers
1.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
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❑
SECTIOiY 2:;'PROP.ERTY'OWNERSHIP'.'
2.1 Owners Record-
-,,
Name(Print) City,State Zip
���� ��,,� �C
No.and Street Tele Email Address
SECTION 3: DESCRIPTIONOF.PROPOSEDWORK''(checkall at apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTINLATED CONSTRUCTION COST$
[tern Estimated Costs: Official Use Only,..
Labor and Nfaterials
I. Building S I. Building PermitFee $ indic5te how fee is determined:
❑ Standard City/Toivn•Application Fee
Flectrical 2. $ �. -
- ❑"Coral Project Cost (Item 6)x multiplier. x
3. Plumbing S 2. Other Fees: S
t. Mechanical (IIVAO) S List:
5. Mechanical (Fire $
Total All Fees: S
Sn : ression)
Check No. Check Amount: Cash Amount-.
6 total Project Cost S � / 0 Paid in Full Cl Outstanding 13;dn11ce Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 C
onstruclAoit Supervi License (CSL)�Zz —
License w ber - -- E.cpirat' a at
Name of CSL I lo! r C]l
r List CSL Type(see below)._
No nndA f Type - Description
U Unrestricted(Buildings u to 35,000 cu. 11.
_ R Restricted 1&2 Family Dwelling
City/Town, State, "LIP VI blusonr
RC Roofing Covering
WS Window and Siding
Solid Fuel Burning Appliances
I Insulation
relz hone Email address D Demolition
5.2 Registered Ho,,= lrs�rovet entP�2(kl[C)
HIC R gistrition Number EWitioDatCel
[IIC Coma or i ' R� �
No.and et �`� Email address
City/Town, State, Z P Tele hone of
SECTION 6: WORKERS' COMPENSATION INSURA FFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be co eted 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 ........... ❑
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 � GZJ�
to act on my behalf, in all matters relative to work authorized by this building application.
U
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby ane u r the pains and penalties of perjury that all of the information
contained in application is true and a curate the st of my knowledge and understanding.
Pflnt OIVnCr'$ r Authurite� ;e it Nano(E cctr nit 6 a urc) tie
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 tbod under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.m;ue.,,ov oca Information on the Construction Supervisor License can be found at www.mass.co�(IL
2. When substantial work is planned, provide the information below:
Total floor area(sq. R.) _(including garage, tinished bascinent/attic.s,decks or porch)
tlrov living area(sq. tl.) Habitable room count--
Number of fireplaces- Number of bedrooms
Number ofbathrooms Number ofhalvbaths ---- —
I vpe of hruing system . -_ _-_ __--_ Number of deck 'porches
-------------
)pe of cooling ;yucin__ Fncloied _Open _
I. `I nfal [It ,jcct titilllll'C Iltily bl' �Ilbti[Ih lted t�,l hd.11 PI"niiCt CUit
office
SIT201, S WU 10,
-102114-7017
Workers, CoJ-flPCU,,iifl,.,
W11 Ins"lun
Pictise Print LtEj!hly
Name (Bi,sitiess/organizatiori/in(livicitial):
Address:
City/St to/Zip:
Y W
Phone#:_
(sell
Are i an employer? Check the appropriate box: Type of project(required):
I 4. ❑ 1 am a general contractor and I
I I am a employer with 20 have hired the sub-contractors 6. El New construction
employees(full §nd/or"part-time).* listed on the attached sheet. 7. E] Remodeling
2.El I am a sole proprietor or partner- These sub-contractors have 8. n Demolition
ship and have no employees
working for me in any capacity. employees and have workers' 9. E] Building addition
[No workers' comp. insurance comp. insurance.[ 10.E] Electrical repairs or additions
5. ❑ We are a corporation and its
required.] officers have exercised their I LEJ Plumbing repairs or additions
3.F-1 I am a homeowner doing all work right of exemption per MGL 12.El 04f-repairs 4
myself. [No workers' comp. c. 152, §1(4),and we have no
insurance required-]t employees. [No workers' 13.�?Other YJPJ4U'T-_7
comp. insurance required.]
*Any applicant that checks box 91 must also fill out the section below showing their workers'compensation Policy information.
t lionleowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
tContractors 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.
Iattianeiirployerilialisprovidirigit,orkers'conipelisatiollitistirancefortnyeniployees. Below IT the policy and job site
information. lie.
Insurance Company Name:
Policy# or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy ded ation 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$j,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$2.50.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the or insurance coverage verification. I I . - I C1.
_= 2�� =. ton provided abo e is tie and c
certl i an 17
1(10 1 ereby I a and naltiespfperjitryfliatilicinformat*
1 Signature: Date: ._._
Phone 4: 4nLC4�0 � lal.
"Official use only. Do not write in this area, to be completed by city or town q
Ole
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
84/20/2013 01:23 17818940331 TODD RIDEMAN PAGE 01 _
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
40115
//h n1+� Sold, D At-ed and Installed by:
Branch Name: Boston Date: '�/ /'(� / T Fu At-Home Services,Inc.
�---/� d!bla The Home Depot At-Hmue Services
908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free(80U)657-5182:Fax(508)845-6017
Branch'_Number:31 Federal ID 4 75-2695460;M8 Lic#C 02419;111 Cont.Lie#IfA27
r/7� 1 Cr Lic H/tC.0565522;MA Home Improvement Contraaur Reg.#126g93
Installation Address: f / 4 AA_l�D
City State Zip
Purchaserls): Work Phone: Home Phone: Cell Phone:
Home Address:_
(If dillerent from Installation Address) City State Zip
E-mail Address(In receive project communications and Home Depot updates)' _ ,-
❑I DO NOT wish to receive any marketing emails from Thu Home Depot
l�ro' formation: Undersigned("Customer'),the owners of the property located at the above installation address,agrees to buy,
and T AI-Home Services, Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation('Installation")ul'
ull materials described on the below and on the referenced Spec Sheens). 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#: aomvmteeevw., Products: Soor Sheets #: _ Prolect Amount
Ronfing usiding R Windows ❑insulation
6 7 ❑Gutters/Coven, ❑Entry Doors ElS7/ y� $
Rmtfing ❑$icing Windows Insulation $ L 1 /] �.t --�
❑GuIWOCovers ❑fntry Dwrs ❑
❑Roofing ❑Siding ❑Windows ❑Insulation
❑Guncrs/Covers ❑Entry Dams❑ $
Rtxrfing ElSiding El Windows ❑Insulation
❑Gutters/Cover, ❑Entry Dour, ❑
M'admum 25%Deposit of Cmrtrea Amount doe upon execution rdthis toutrad.
Total Contract Ams unt $
Matce Purdtmers rao'tad deposit more tlttdt one4hir0 the(.atustlAnlount.
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 fight to issue a Change Order or terminate this Contract or any individunl Products)included herein,at
its discretion,if The Home Depot or it,authorized service provider determines that it cannot perform it,obligations due to a structural
problem with the home,environmental harards 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
Payment Sanctuary; The payment Summary # /� included as part of this Contract, sets forth the total
Contract amount and payments required for the deposits and final p moms 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 estb 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(he 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.
Acre re and A thorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and The once Depot with regard to the Products and Installation services and supersedes all prior discussions and agreements.either
oral or written.relating to said Prducte and Installation This Agreement cannot he assigned or amended except by a writing signed
by Customer and T •Home Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the
terms of and has bed a c y of this Agreement
Acce ��a� Submitted bY'
wJ o/ x o?6
Customer's Si u Date Sales¢ us iltaWs Signature Date
X Telephone No.
Customer's Signature Date
Wes Consultant License No.
CANCELLATION: CUSTOMER MAY CANCEL THIS Ia"npO11M11e)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN 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
SPECWICAId.Y PRESCRIBED BY LAW IN
CUSTOMER'S STATE..
NOTICE:AbDIT10N,A1,TERMS AND(X)NDITIONS ARE STATED ON THE REVERSE SIDE AND ARE PART OP THIS CONTRACT
1011-12 white-8 MCI Falls veaow-Customer
Ili
CITY OF SlUZZtiI, ;tiL1S5.1CHL'SETTS
' OULLDNG DEP. MILEINT
"120 7UNLYGTON STREET, 3' FLOOR
TFL (978) 745-9595
I<1Jt3ERLEY D(LISCOLL F.L't(973) 740-9345
NL-kyOII TH0\N3 ST.PIERM
DIRECTOR OF Pueuc PROPERTY/BCILDLNG CONLNUSSIONER
Construction Debris Disposal Aff7davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 ChIR section 111.5
Debris, and the provisions of NM c 40, S 54;
Building Permit hi is issued with the condition that the debris resulting from
this work shall be l 11, S 1 SOA. disposed of in a properly licensed waste disposal facility as defined by NIGL c
The debris will be transported by:
(nanta autor)
The debris will be disposed of in
(name of r.Aty
-----(adJress ut latility)
'1' aN(C UI u'ntit applicant
tt C
ens :pa tnw i Q� Pub!!
?•. 3 3q'c::q'Ul ist J,45 8d1(7 s"'n"'ards
CSSL-099699
ROBERT.POCZOBUT
172 WHALENS LAND,"uSalem MA 0070
t:in. ;a=i=s�s�nF�r 02/08/2014
.e...._..T�c -
THIS CERTIFICATE I5 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE LIABILITY INSURANCE
CERTIFiCAT£ HOLDER. THIa
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORCEP SY THE P+'ORIZE5
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIB, AUTHORi2:£D
_ REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. i
IMPORTANT: If the certcate holder is an ADDITIONAL INSURED,the policy(ies) anu ondorsed
s:he . it SUBROGATION IS WA,VED,subject ro i
irequire an endorsement. A Statement on this certifica. 0 tl'
.does net tonfer eights e
the terms and conditions of the policy,certain policies may y
I certificate holder in lieu of such endorsement(s). - _ _----- - -
NAME: —' FAX
PRODUCER PHONE
MARSH USA,INC. IAJC No
P1JO ALLIANCE CENTER E-MAIL -
3550 LENOX ROAD,SUITE 24CO ADDRESS:ATLANTA, 30326 - INSURERS AFFORDING COVERAGE 387 NAIC4
Stead(asl Insulence Coneany 26535
100452-HemeC-GAW-13-14 wsuRER A° 16536
INSURER B.
Zurich AmEN'an Insurance Cc
INSURED New Hampshire In;CD 23941
THE HOME DEPOT,INC. INSURER C
HOME DEPOT U.S.A.,INC. Illinois National Ins Co 23817
2456 PACES FERRY ROAD,NW
msuREa D:
BUILDING C-20 - - INSURERE:
ATLANTA,GA 30339 INSURER F:
COVERAGES
CERTIFICATE NUMBER: ATL-OM1595454A REVISION NUMBER:7
THIS IS TO CERTIFY THAT TH ;POLICIES OF INSURERIOD
ANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY WHICH THIS
CERTIFICATENMATY BESISSUED OR MAY PERTAIN,N, THE ERM OR CONDITION OF ANY INSURANCE N URANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTPTO ALLO TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMSRi ISM . UMn3
IF TYPE OF INSURANCE POLICY NUMBER 1 MMID MID 9,oWA00
A GENERALLIABILRY - I GLO4887714-03 i0310112013 0310112014 EACH OCCURRENCE 5
f A A N s 1,WD,000
PR MI S runenca
X COMMERCIALGENERAL LIABILITY
EXCLUDED
CLAIMS-MADE OCCUR LIMITS OF POLICY XS I MEO E%P(AnY one Person) �S BOOOOCO
OF SIR:SIM PER OCC PERSONAL 8 ADV INJURY S _
GENERALAGGREGATE S 9,000,000
PRODUCTS•COMPIOPAGG S 9,000,OOO
GEN'L AGGREG�ATIE LIMIT APPLIES PER: S
X POLICY 1 f PRO LOC COMSIN O SINGLE LIMIT 1,000,oW
B AUTOMOBILE LIABILITY
BAP 2938663.10 1031012013 0310V2014 Ea ac III I S
X BODILY INJURY(Per person) ;
ANY AUTO BODILY INJURY(Per acdden1) S
ALL OWNED AUtOESULED SELF I NSURED AUTO PHY OMG PROPERTY DAM AGE
NON-0W VED Par accident S
HIREDAUTOS AUTOS _ I S
EACH OCCURRENCE S
UMBRELLA LIAR ,OCCUR -
AGGREGATE S
EXCESS LWB CLAItdS•MADE � S
DED RETENTIONS WC033575314(A ) 03I011201 031 1! 014 X wC STATU- OTH-
G WORKERS COMPENSATION 1,000,000
ANDEMPLOYERFUABIUTY YIN WC033575315(AX,AZ) 03/012013 0310112014 E.L.FACHACCIOENT S
G
ANY PROPRIETORIPARTNERIEXECUTNE N NIA 1,000,000
OFFICER/MEMBER EXCLUDED? WC033576316(FL) 031012013 I031012014 E.L.DISEASE-EA EM1IPLOYE S
D (Mandatary to NH) 1,000,0W
It yes,desafta under E.L.DISEASE-POLICY UNIT S
t DESCRIPTION OF OPERATIONS below 1,000.000
G WORKERS COMPENSATION WC033575317(KY,NC,NH,VT) 031012013 103012014 (EL)LIMIT
C WC033575318(NJ) 03101/2013 031012014
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101.Additional Remarks Schedule,If mom space Is mqulmdl
EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
THE HOME DEPOT INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
HOME DEPOT USA,INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2455PACES FERRYROAD,NW % ACCORDANCE WITH THE POLICY PROVISIONS.
BUILDING 020
ATLANTA.GA 30339 AUTHORIZED REPRESENTATIVE
of Marsh USA Ina
Manashi MUkherjee —A'ta'wDoa„
C 1999.2010 ACCI CORPORATION. All rights reserved.
ACORD 25(2010106) The ACORD name and logo are registered marks of ACORDl ,
+ III
3i
�idlprv�reoraufuaC o�.✓�/,rteececuaesC�c .
(Dtiace of Coasua�aer P_ftair Fc Ea;lae3slicnl lstean 'License or reg stration valid for iudav3clasl u - `�•,`,y
OME IMPROVEMENT COwTRACTOr^ - 6eiore the 0xgaa£Baas dai Cf found return to:,
RegiaYrarian 'fi,2h$93 T,t e �9f ceofCPa+.,p,s�Af€za c 33c1BuMne:sPeFsal:. l�la it
¢ .ltf`Pa3'lC pi£ZA vaatE J•�%(S _
Enpl -ttSr5aSup?,I m ,P�$e�
ant.aro Boston -�0211 �. - .
The Home Derai-"- — Y`'rc`-&,I - 1
�_ -
RICH4RD FAQ'%,]E6 "fii} jrtn ,l' J ���III
2690 CUMBFRLA GA
Unae9•secreaxry ° 'utvalad ithauts;;guatiare
r.
° CITY OE SUE;,t NYLuSACHUSETTS
BUILDING DEP.1RISWUNT
120 WASHNGTON STREET, 3"aF100R
T EL (978) 743-9595
Rvc(973) 740.9846
V fpFRT Ry DR)SCOLL TsommST.PIERRH
MAYOR
DIRECTOR OF Pl:OLICPROPERTY/Ot:ILDNC COSpIISStONER
Workers' Compensation insurance AMdavit; Duilders/Contracture/Eleetrici:tns/Plumbers
%pnllcant Information Please Print Legibly
,Naltle IOusinc'ss,Orytniratiom Individual):
Address:
City/State/Zip: Phone M.
F,4
in employer?Check the appropriate boat LRoof
project(required):
Cl a cmplayer with �• Q I am a gem zal contractor and 1
loyeas(ILII and/or part-time).• have hired the rub-contnctonew construction
a sole proprietor or purtner- listed on the attached sheet temodeling
and have no cmplayeea These sub-contractors have emolition
king fur ma in any capacity. workers'camp.Insurance Building addition
workers'comp. insurance 5. Q We are a corporation and its
qlrcJ.)
officers have dxerctsed their ectrical repairs or additions
J.Q I on a homeowner doing all work right of exemption per MGL mbing repairs or additions
myself.(No Workers'camp. c. 152,§1(4),and we have no of repairsinsurance required.) r employees.LNo workers' her
cumµ insurance required.)
Other—
;Any appllcam dos dtceke tax r 1 mart oleo all Out the weave bolo a,howlng their"kws,mmpeauden Polley intitna,4110a
'1 hawuwnem who mhmil this tlldavil indleuing thry am doing all work ad than hire"laid@ contractors made suhrnil a flaw anldavil indlndng luck
K onuaaron that chvak Ihta box Men anachad ae additlun d AM showing the none of the rubetinuaetcm and shah,workers'mop pulley Inl;,n,adoe.
/urn un eurp/uya that L provldlnrr Ivorkrrs'cornpeuradon htruruner for my ampluyrra Below Ja the polley and Jub sllal
irrforrnutlorL
Insurance Company.Name.
Policy A or Sclf•im. Lie d: Expiration Data:
Job Site Address: City/State/2ip:
Attach a copy of the workers'compensatloo policy declaration page(showing thepoliey number and expiration data).
Failure to secure coverage as required under Scclion 23A of�IGL c. 152 can lead to the imposition of criminal penalties ors
line up to S1,500.00 und/ur one-year imprisonment,as well as civil pcnaldiol in the term ufa STOP WORK ORDER and it line
of up to 5250.00 a day Against Iha violator. Ile advleed that a copy of this statement may be turwurdud to the Oft ice or
Investigwium ul•tha DIA fur insurotea coverage verillcaliun.
1,10 hereby certify under that pulaa and penulder ulprr/ury that the hrjureru/imr provided above is,true mrJ canreL
i'm;tlure' Datd'
Phone 3•
i Uj/ic•fu!use un/y. Oo our write in/hIx urrK to br eump/rled by city ur town t
t -
Citynrl'uwn: ._ _ Permldi.lcenleI
hsulagAulhurity (circle one):I. Iluard of Ileuhh !. Iluildlnq ❑eporhnmtl 1.City/folan Clerk I. baectrtor I Pluntbin4 inrpecror
4. Other ._
Contact l'ertnn:_ _. _ .._ . .. Phana rl: