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6 LORING HILLS AVE - BUILDING INSPECTION (13) The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 - ,Q Building Permit Application To Construct,Repair, Renovate Or Demolish a o - One-or Two-Family Dwelling o- l This Section For Official Use Only s Building Permit Number:, Date Ap e . ' r i Building Official(Print Name) Signature - 6-ate SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers Q 1.1 a Is this an accepte street? cs 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❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner[o rd: `(moo Fr7�`r Ih O (Print) 11�" D� zlm Name ( City,State,ZIP 42 4 c�17,� No.and treet ephore Email Address SECTION 3:DESCRIPTION OF PROPOSED W z(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) CKIAlterations) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Cher ❑ Spe ify: Brief Description of Proposed WorkZ: �- U SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs:Labor and Materials) Official Use Only 1.Building $ L. Building Permit Fee: $ Indicate how feeds determined-. 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multitiplier x. 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire Su ression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Superns' o ense(CSL) � Lic nse Number Expi t Date Name of CSL Hot r, List CSL Type(see below)0 No.and Street ', / Type Description I}/1 U Unrestricted(Buildings u to 35,000 cu.ft.)51 6III((( III/// R Restricted 1&2 Family Dwelling City/Town,State, P M Masonry RC Roofing Covering WS Window and Sidin l— SF Solid Fuel Burning Appliances e ----- �� 1 Insulation Telephone Email address D Demolition 5.2 Registered Ilpme Improvement Contractor(HIC) HIC Ikegisfratron Number Ex rat n Date 1 a o \ strat Name No. S� t _ Email address Ci /Town, State,ZIP1 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 Issuan of the building permit. Signed Affidavit Attached? Yes .......... 16 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 +6� 1 �9 6 1 to act on my behalf,in all matters11l!relative to work authorized by this building erm application. Print Owner's Name(Electro�gnature), Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding J Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 can be found at www.mass.vov/oca Information on the Construction Supervisor License can be found at www.mass. ovt? /dps 2. When substantial work is planned,provide the information below: Total floor 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 halfibaths 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" CITY OF SiUXIM, NL-kSSACHUSEITS BuILDIING DEPARTMENT 130 WASHIINGTON STREET, 3° FLOOR `� of TEL. (978) 745-9595 FAX(978) 740-9846 Kj�jBFRT RY DRISCOLL MAYORTHObiAs ST.PtERRB DIRECTOR OF PUBLIC PROPERTY/BuILDLNG COJmnssIONER 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 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 MGL c 111, S 150A. The debris will be transported by: C7 (name of hauler The debris Fwill be disposed of in : V (name of facd ty) (address of facility) A /Z1 signature of permit applicant date a�e��wir,a�x ,. HOME IMPROVEMENT CONTRACT PLEASE READ THIS Branch Name:New Sold,Famished and Installed by: B England Date:Y/J i THD At-Home Services,Inc. Branch Number:3t d/ti/a The Home Depot At-Horne Services 908 Boston Turnpike,Unit 1,Shrewsbury.MA 01545 Toll Free 877-903-3768 Federal ID It 75-2698460;ME Uc#C 02439;R1Cont.Lic#16427 > /Cf Uc#HIC.0565522;MA Home Improvement Contractor.Reg.#126893 Installation Address: �SO��25/7/I�J ,�r///e ke/7 -:7gkw((M/1 ei 7x) City State Zip Purahoser(s)- Work Phone: Home Phone: Cell Phone: Home Address: (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑I DO NOT wish to receive my marketing entails from The Home Depot Proi9q Information: Undersigned("Customer'),the owners of the property located at the above insmllation address,agrees to buy, and THD At-Home Services,Inc.("The Home D3 POC)agrees to famish,deliver and arrange for the installation("Installation')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 end any Change Orders(collectively,Contract"): 11.G1 rv�'V// Job#: ruts: S Shee s R: Pro'ectAmount Roofing Siding Windows 0 Inwlmion CIGuaers/Covers CIE Dan, ❑ ,9AJ49d4. Roofing Siding inflows Insulation p�d� / [�� ^� r� DGuaers/Covers []Entry Doors Q/�'ral Roofmg Singid Windows Imalauon` — cY []Guners/Cavils []Entry Doors❑TD Roofing Siding Windows Insulmioa - []Guners/Covers []Entry Doors ❑ $ Mirdmum 25%Depnat d Coahap Anroum due upon execution of this C maw- F ' MaimPurrhl maym depWi reth=om4bW,(tho C.&WA..g Total Contract Amount $ 't� 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 bejoindy and severally obligated and liable hereunder. The Home '.:v. y. -,. F .:.- c -''r.: ,.:r ,, 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 authorized service provider detemunes that it or an perform its obligations due to a herein at problem with me home,environmental hazards such as mold,asbestos or lead paint:other safety contras,pricing errors or because work required to Complete the job was not included in the Conttr/ract.fl �q Payment Summary: The Payment Summary# ��b©` ( , included as Contract amount and payments required for the de Part of this Contract, sets fact the total posits and final Payments by Product(as liceble aPp 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: I there is one 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 Home Depot or Authorized Service Provider through the date of termination,plus env 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. Acreotance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer oral 1 he Hume Depot with regard d the Products and Installation services and supersedes all prior discussions and agreement,,either oral or a relating lu said Products and r acknowledges This Agreement cannot be assigned or amended except by a writing signed by Customer;ofandand The Nome Depot.Customer acknowledges and agrees that Customer has read,understands,voluntarily accepts the temu of and has received a copy of this Agreement. ��D_qA 6 Submitted by: Customers Signature`ffi"""Y•ryDate Ory"�- -+t —_ —w Sales Conui nI's Signature D-- x Customer's Sigmiume Dare Teleplwne No. 6�J'��Y G10 CANCl"1 ATION: CUSTOMER MAY CANCEL RIS Sales Consultant License No. . 2 AGREEMENT'WITHOUT PENALTY OR OBLIGATION m.;yy,6v„rile BY IIEIAVERING WRITTEN NOTICE-T'O TTIF:HOME DEPOT BY MIDNIGHT ON THE. THIRD ItUSiNNN,4 DAY AFTER SIGNING THIS AGREEMENT. THE ' SPATE SUPPLENIF:NT ATTACHED HERETO f CONTAINS A FARM TO USE IF ONE IS SPF:CIF'ICALLY PRESCRIBED BY LAW IN CUST'OMER'S STAT I1 NDrµ:a:ADD]r1UNAL l'nµMS AND CONDITIONS ARK STAIRD ON THE RNVKNSr•:SIDE AND ARE PART'OF THIS eY rATNADI' 00 ID-08.18 WNi6-82ncN Fee Yellvw_CUHgaa 1 �QL AT-HOME SERVICES }}�� Customer: r` e t4 NR R Q)� Job # q)5 L1YJ To whom it may concern, Re: address: � DR ]At � }.��� I S nrsF' Y42, S9 40.0,mv Concerning the above location, We give the Home Depot approval to install : Number of windows Style (Double Hung/Casement, name type) b I P +VI L P} -1 4-1 O r) cp Color Manufacturer A IV ( I e R 5 U n N $ D v L` Exterior finish as agreed to be PVC (wrap to—'m)�/ o color We agree to the grid or lack of grid configuration Nb Are grids between the panes of glass? Ny As stated these proposed windows do meet with the Condo Management approval. Signed�/�-r,�A �7�°e o� "Q�Print ��r j KIrn,, k C mar, 4 M anap Jrlassaebusetts Department of Public Sale?y Board of 3uildina Reaulations and Standards License: CSSL-099699 Construction Supervisor Specially - ROBERT POCZOBUT 172 WHALERS LANE i SALEM MA 01970 on �rn mrssi-.ner 0 210 812 01 8 The Commonwealth of Massachusetts Department of Industria(Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 u www.niass.gov/dia kkwrkers' Compensation Insurance Affidavit: Builders/Coutractors/Electricians/Plumbers. TO BE FILED tl'ITH THE PERIIIITTMG ALITHORMt. Arinlicant Information Please Print Lecribly Narne (Business/Organization/Individual): Address: City/State/Zip: Phone 4: i Are you a mployW Check the appropriate box: Type of project(required): I. 1 am a employer with_2�employees(full and/or part-time).• 7. []New construction 2.❑I am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling any capacity.(No workers'comp.insurance required.] - 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'camp.insurance required.]t 10 ❑Building addition a-❑I am a homeowner and will be hiring contractors to conduct all w ork on my property. I will ensure that all contractors eitherhave workers'compensation insurance or are sole I 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ These sub-contractors have employees and have workers 13.n Rgef repairs comp. � r4-1„�( 6.❑we are a corporation and its officers have exercised their right of exemption per MGL C. 14. the[ i 152,§1(4);and we have no employees.[No corkers'comp.insurance required.] " 'Any applicant that checks box#l must also fill out the section below shoving their wtirkers compensation policy information. t Homeowners who submit this affidavit indicating they are doing al work and then him outside contractors must submit a new affidavit Indicatinesuch. tCopaactors that check this box must anached an additional sheet showing the name of the sub-co6tractors and state whether or not those entitieShave employees. If the sub-contractors have employees;tbey must provide their workers'comp.policyt number. I am an employer that is providing workers'compensation insurance for rap employees. Below is the policy andjob site information. p �— insurance Company Name: Policy#or Self-ins.Lic.9: Y f 1�� -, �3 t Expiration Date: Job Site Address: '4City/State/Zip: Attach a copy of the workers'compensatio policy dec aration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. [do hereby certify u de t pa' s an penalties of perluty that the information provided a ove is rue and correct. Si nature: Date: Phone#: F ficial use only. Do not write in this area, to be completed by city or town officialy or Town: Permit/License.# Office of Consumer Affairs dd Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home ImprovementContractor Registration }:- _ Registration: 126893 Type: Supplement Card Expiration: 8/3/2016 THD AT HOME SERVICES, INC. RICHARD FALLONE - }- 2690 CUMBERLAND PARKWAY SL ITE_300 j ATLANTA, GA 30339 /Update Address and return card.Mark reason for change. -"" 7 Address Renewal J Employment I Lost Card CAI <5 ITT-Den l . _�� �L A•./Rr,./, �//f_�L tiJorfl Ui4/�: —Q3Ctice of Consumer Affairs&Business Regulation License or registration valid for individul use only before the expiration date. If found return to: c E IMPROVEMENT CONTRACTOR - � Office of Consumer Affairs and Business Regulation ,Registration 1�68.93- Type: 10 Park Plaza-Suite 5170 Expiration 81312016` -- Supplement Card Boston,NIA 02116 THD AT HOME SERVICES INC - THE HOME DEPOT AT HOME SERVICES ,T j 31CHARD FALLONE 2690 CUMBERLAND PARKWAY$ - 4'h M,GA 30339 Undersecretary Not lid wi out signature Y