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6 LORING HILLS AVE - BUILDING INSPECTION (8) The Commonwealth ot'Massachuscits / a Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 C'MR, 7"edition OF SALEM RrvisedJ<Inuatrr �°'�• 1. -'008 Building Permit Application 'fo Construct, Repair, Renovate Or Demolish a One-or Tiro-Family Dwelling This Section For Official Use_Only Building Permit Numbe . pplied: Signature: Building ummissi er/Inspector of Buildings Dute SECTION 1:SITE INFORMATION 1.1 Prope ty A ress: - ,lf�� % 1.2 Assessors Map& Parcel Numbers l.Od 11/I 1#t tie C- I.1a Is this an accepted slr t?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions- Zoning District Proposed Use Lot Area(sq fl) Frontage(11) 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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal stem ❑ Public❑ Private❑ Check if yes❑ F F y SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownern of ecord: 1,2 twa Name(Prin Address for Servic Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check al at apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) MI Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work-: l I SECTION 4: ESTITOATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials I. Building S �- I. Building Permit Fee:$�_Indicate how tie is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (i1VAC) $ List: 5. Mechanical (Fire $ Total Ail Fees: $ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed �Co ,nstruction Supervisor(CSL) I 15ed) c.{/(� License Numfxr I.spi ali� i utc Name o(CSl. ld*r117, ! Lisl C'5L I)Ipe(see below) ._RE—U)5LlC- h :WJre, t Description U l InrestrictcJ(up to 35,000 Cu. Ft.) It Restricted 1&2 Famil Dwelling Signul e M Mason Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home 1 rovVyient Co tractor HIC) �,,?r� fill — str:mt Registration Number ZiWub dress Expiration at Si re '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 IssuapZ of the building permit. Signed Affidavit Attached? Yes .......... Nu...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT TR 1, — Ta� ,Ai) � 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. lTZ L� Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, YCI{ Q7•� ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. 6 Print Na S r ( vFe or Au anted Agent Date Si med u der the pains and penalties ofperjury) 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 trot have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned,provide the information below: Total floors 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 halt/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted lbr"Total Project Cost" FROM :2676-4Citchen DeSign FAX NO. :9784663706 Nov. 08 2010 09:16AM P1 HOME DWROVEMENT CONTRACT PLEASE READ TE98 Sold,Lrumishad and Installed by: Branch Name: Boston Datet((-J-!g_I O _ 119)At-Hunto Setvices,Inc. d!b/a The IIome Depot At-Home Setvioee 345A Oreenwoa!Street,Unit 2,Worcestar,MA 01607 Branch Number:31 Toll Free(g00)657-51 K2; A'ax(508)756-11823 Vederal ID a 75-269R460;ME Lac#C t12439;RI Cont.Lic#16427 Cr Lie M 0565522;MA ITome Improvement Contractor Reg.#1261493 Installation Adds'ess: 4 Lo 1Cr w(y l�,(..t_s-- A.*- C- 5 _S A•/e, . 44A- O(q 0 7a City State Lip Purchaser(s)t Work Phone:_ Hmm PtK w .. Cell Planer pgp,drrp- �e K [ ] [:"gj `7Yi _ [`l7B] 317 6a33 [ l 1 l Hate Address: (if different from Installation Address) City State 'Lip ,1�.y}7T - E-mall Address(to receive project communications and Home Depot updates)" ����,,������)A- 71 I ❑).DO NOT wish to receive any rarketitig emails from The Hnmc Depot k V Protect Information Undomigmd("Customer'),the owners of the Property located at the above installation address,agrees to buy, and THD At-Plnme Service%tan.('"flee Home Depot')agrees to fumisb,deliver and atraage for the installation("Ltstallation")o'f all materials described on the below and on the nrferuncod Spec Sbcd(s), all of which are incorporated into this Cataract by this reference,along with any applicable Slate Supplement and Payment Summary,attached hereto and any Ctumge Orders(collactively, "Contract"): Job#h tammwo :l Products.. Np6c, s 8• N'Aloct'A t Ql(afing Siding ❑Windows detion ^� 31 3 L 3 Q(luuem,Cevcs Ornay Doom ❑ I I S 6 3 q $ Raxdting ❑siding W+rskdws []Insulation $ pcuttem 1 Covets []Entry own 0 _ - .. .. ..--- fang Siding Wmdowx ❑Insulation ❑Guam/C'nvem QEnny,Desoto El Ituufmg ❑siding Windows insulation ❑Go#=I Cnvem []Entry Doors ❑ Mhbmm25%rlepmRortinlradAmoom due neat emmann ofthnamrad. 'fatal Contract Astronaut $ Mafia AndassaxmaynradMothmnedmnanNMrd ttheCoubWAmmwL --`---Ctfdtbmirr agues that, immediately upon ctmtpptetiun of the work for each Product, Clnstomer'will-mccutc a-Cornplotion Certificate (bnc for each Product as defined by an individual Spec Sheet)and pay any balance aloe. As applicable.each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issa a Charge;Order or terminate this Contract or any individual PrW uct(s)included hcmin,at its discretion,if The He=Dapul a ita authorised service provider dcunmines that it cannot perfoom its obligation%dam to a slrxct old problem with the horn,environmental hazards such as mold,,gsbeArs;or lead paint,other eafuty concerns,pricing tenors or because work required to complete the job was not included in the C: trsrpl Paymenty n Summary; The Payment Summary # 3 /� B 3^ , included as part of this Contract, sets Furth the total Contact amount and payments required for the deposits and Canal payments by Product(as applicable). NOTICE.TO CUSTOMER You ore entitled to a enm letelq filled4n co y of the Contract at the time you sign. Do ram.sign a Completion Certificate(note: there is one Completion Certificate for earn listed Product as damned by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Cmdrtzaer agrees to pay The Home Depot the costs of materials,tabor,expenses and services provided by The Home Depot or Authorized Scxvks Provider through the date or termination,plus asp other amnants set forth In clubAgreement or allowed under applicable law. THE HOME DEPOT MAY Wrl'HHOI, AMOUNTS OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOtrr lMff NG THE HOME.DBPOT'S OJIM REMEDIES FOR RECOVERY OF SUCH AMOUNTS. A me d Lays mw ag era and u nicruamic that this Agreement is the entire agreement between Customer Md'i'be .ate spat with regard to the Products and installation services and supersedes a0 prior discussions and agreements,either oral or written, w said P t and installation.This Agrccma:ntPont bo assigned or amended except by a writing signed by Customer and The umc Do. Customer acknowledges and agrees that ustom�t [cud,understands,voluntarily aucepin the terms of and has ruaeived a copy o tldvgrexment. " A by: Stir Had y: _ to �rkf52�le t�"S`ia Cu we Sales Consulmnt's Signatures Date x Telephone No. 5b 9 Customer's Signature Date Sales Catxularn License No- CANCELLATION CUSTOMER MAY CANCEL THIS (as applicable) AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MR)NICITT ON TAP: THIRD RUSINPSS DAY AFTER SIGNING THIS AGREEMENT. THE. STATE SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE He ONE IS 511W]'FICALYX PRESCRIBED RV LAW IN CUSTOMER'S STATF NOTICE:ADDITIONAL TERMS AND CANDITIONS ARE STATED ON Tim REVER4E SIDE AND ARE PART OF THIR MNPRAC'r 7.7.10 CSC Write-Branch He Yellow-Customer � , J �'' tc� a ' ✓� Standards�� , Boa � ' lt ons anI>o One Ashburton Place - Room. 1301 r.r. ' Bgston; Massachusetts 02108 Home Improvement Contractor Registration Reg islrati on:. 15.3418 Type: Private Corporation Expiration:• 11130/2010 TO 280870 BUILDER SERVICES GROUP INC. -- -- ----- -1-HEODORE PLONA -- — -- 2339 BEVILLE RD ------ � ' DAYTONABEACHr FL 32119 Update Address and return card.Mark reason for change. I� Address Renewal ( I Employment Lost Card DPS.CAI •b WIaU u�:J-0D I IFUFIhU.'Ataa212a0a ,. .,,. _, „ - - _ ' l;uar J of Building Rcgulstiods and Standards License or registration valid for individul use only -� before the expiration date. If found return to: pFFIt^, tt» ,y.Jf.tr, IIOa'LE IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards Registration: 153418 One Ashburton Place Rm 1301 �t! Expiration: 11p0/201D Tr#_ 280810 - Boston,Ma.02108 "NE> type: Private Corporation . BUILDER SERVICES GROUP INC. THEODORE? PLONA - 2It:DUSTRIALRD. '-- otvalid.withoptsignature •-' MILFORD, tAA 01757 Administrator .)1 t��iahnaU -� U.gt:utincai nl I uhlu _ 1 rel� 7 Bu lyd ul' Btnlilut�}tr+ulatium 3iu1 �t uul;tnt - li,usachusctt. - Ut lartmtnt of kuhlir S tard 5 -,Or Construction Supervisor Specialty License L'n.p tl of [3uildinl: Rc�ulatiuns-and stail�l u'ds Construction Supervisor Specialty Lice.rlt'se license: CS SL t001B9 - License: CS 5L 100189 i Restricted to: RF,WS,SF .. , Restriciedlo: RF,WS,SF,IC THEODORE. PLONA . l'I IEODORE PLONA 18 THAYER AVE 10 THAYER AVE }Y' w' AUBURN. MA 01501 n ALIDURN; MA01501 l - Eq,iraunn: 9/1 312 01 1 9113/2nt2 tiL _d Tr=t 100.1 Expiration: .,u.... .m r r • ,,.nd..f.mc,. Trd: 100189 .. i I I ,< CITY OF SAL EMI, UNSSACHUSETTS • BUILDIING DEPARTNt&NT 130 WASHNGTON STREET, 3' FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KIMBERLEY DIUSCOLL T ,�L+►YOR �toMAs ST.PIERRt3 DIRECTOR OF PUBLIC PROPERTY/BL'IIDL\G 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 i 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 MGL c 111, S 150A. The debris will be transported by: n 4 r r 1 (name of hauler) The debris will be disposed of in (name of facility) (address of facility) 'gn ture of plermit applicant to 46n�1rd.k OJPM afInvestigations 600 Washington Street Boston,MA 02111 r Wnw.massgovId is - Workers' Compensation Insurance Affidavit: Buy'tders/Contrar#orsMtcb ician<s/Pln�ibers Applicant Information - Please Print I.et*ablY Name( �+ 9 l -, Address: City/State/Zip: r Phone#: Are y�o an empioyen"t Check the•appropTixte box: Type of project(required); I L.Id l am a employer wit I-LO L 4. 0;am a general contractor and I 6. 0 New oamstcactwn MURS employ=(faIIwWorpacEtime)s ]�avel�ed�esab oo�wl, ;.7_O:R�d�: _ .. _. 2. 1 aa-sole}moprpazmer- -•-- :• . 8_ Demol'�tion: ship and have no employees These sub-oo3p iQSQt i . working'for me in any ealrAdW. - workers'aomP- 9. 0 Building addaioa [No workers'camp•insurance 5-' 0 we are a corporation and its 10_0 Electrical repairs or additions officers have exercised then require_] MGL 11.0 Phw2bingrepairs or additions 3: I am a Lomeowner doing all work t?Sht of exemptionper myself[No workers' comp. . a 152,§1(4),andweLave� 12��repairs insurance raNired-7 t employees.[No wod=, 13. Others comp.insuranceiequirc&I •Any sppticmtmu�Laa St ffiahv�om 4u sxtiaaldow�uwiug S,eirwaclra;'oompP°�yi�O°= - . tso..cnwbo—h a=6ffi&vAMdMftggwyWc dubs nnwo&wd9MVVeasffideeom MCSM Yma.as vaffrhdgi BsveL. t�straeCxs flier elxdc�ustmc msa s[drLodm.e&flwet steowivg tbrMU a cram w&v=hs mz md'AWWWOlowe Comp:poTKy isfotme4am. I am an emPfg'er LWSPrvvl&mg WORM'cvmpemwaox unwrmttefor any ar+pfoyees B Vw is'*tpotiey ardjob site inforaratlon. �- v, rA� Insurance(bmpauyNarre: Policy#or Self-ins Lie Expiration Dates job site Address: . Attach a copy of the workere counperrsaui.' lacy declaration page(show.ing the policy number sad espiratfou date} is Mplhed under sedim 25AofMGL c-152 can lead to thc.imposiuon of cr oalpenalties of a . Facto segue coveragy,, _ , ....... .. :. .._ s _ _.: a'S`1iDPVPE7R&Odd afore— fiueup to sjt;S . wT" i[ �c`fQim to the Office of ofuptoS250.Ooadayagaishevo1o _ Beavised that a COPY ofthis staommmaybeforwarde Ju ins of the DIA cc eovetageverifrcation. I der hardly under drat Ow laformdaa provided above is true and correct Phone#' Q/J'r d asa only. Do nd write in ddr area,to be avmpldedby aty.ort"n o,O'fdaL City or Town•.. Permit[I3cense# YnUiUg Authority(circle one): r 5_PI�bIngInsPector 1.Board of Health Cd .2.Building Department 3_ ylPown Clerk 4_Electrical inspecto . 6.other Phone# CrVE(MnA/ODrY`/YYl AIR® CERTIFICATE OF LIABILITY INSURANCE _ 02/19,10 PRODUCER 1-404-99J-3n.00 THIS CERTIFICATE IS ISSUED AS A MATT FIR OF INFORMATION Mara4 USA, Inc. i DIILI ANO CONFERS NO RIGHTS UPON Ht C-ERTIFIC _ ' �. h:GLI" o THIS CER 'FIC LrOcS 4ctaede.�OL.c eftrs Cerra-sh..^.om Two .. L=zcx Road, S..c_ 2400 Atiant., GA 30n- ••^^te D.you.. U.S.A., _ V r R ] ____ Amer-ca. Ise Cc 2455 Paces Ferry Road NDI �NSIiRER C.New Hampshire Ins Ce_ Building C-20 INSURER D.NATIONAL "ION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER E: Illinois Union Ins Co-1 17960 COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS TR POLICY NUMBER M N V DATE W lonryyyyl GENERAL LIABILITY CL04887714-00 03/01/10 03/01/11 EACHOCCURRENCE S 4,4nn.000 LGENE�L OR NTED X COMMERCIAL GENERAL LIABILITY - Ea occurrenceL 51,000_000 CLAIMS MADE �OCCUR ((An one PersanL $ EXCLUDED__—_ 3 ADV INJURY 841000,000 GGREGATE S 4,000,000_GEN%AGGREGATE LIMIT APPLIES PER: -COMPIOP AGO S4,000,000 % POLICV PROT LOC B AUTOMOBILE LIABILITY BAP 2938863-07 03/01/10 03/01/11 COMBINED SINGLE LIMIT S1,000,000 (Ea accident) X ANY AUTO - ----- ALLOWNEDAUTOS - + BODILY INJURY $ (Perperson) SCHEDULED AUTOS --- ------- HIRED AUTOS - BODILY INJURY $ (Per acaden) NON-OWNED AUTOS — ---------- X SELF INSURED AUTO PROPERTY DAMAGE $ (Per accident) PHYSICAL DAMAGE GARAGE LIABILITY _ AUTO ONLY EAACCIDENT S ANY AUTO OTHER THAN EA ACC S _—_- _ AUTO ONLY: AGO S A EXCESS I UMBRELLA LIABILITY GL04887714-00 03/01/10 03/01/11 EACH OCCURRENCE E 51000,000 X _7 — OCCUR 1 CLAIM:,MADE AGGREGATE Y 51000,000__ DEDUCTIBLE RETENTION $ S C WORKERS COMPENSATION WCO20342355 (ADS) 03/01/10 03/01/11 X -WC STATI/ OTH- ANDEMPLOYERTLIABILITY YIN D ANY PROPRIETORIPARTNERIEXECUTIVE� WCO20342356 (CA) 03/01/10 03/01/11 E.L.EACH ACCIDENT E 1,000,000 OFFICERIMEMBER EXCLUOEDP E (Mandatory in NH) WCO20342357 (FL) 03/01/30 03/01/11 E.L.DISEASE-EA EMPLOYEE 51,000,000 If yes.describe under - E.L.DISEASE-POLICY LIMIT $ 1,000,000 SPECIAL PROVISIONS below OTHER E TX Employers Excess TNSC46242373 (TX) 03/01/10 03/01/11 Occurrence/SIR 30M/2M D Workers Compensation WC0910566 (QSI) Q3/01/10 03/01/11 C Workers Compensation WCO20342358(XY,MO,NY,W1, ) 03/01/10 03/01/11 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS RE: EVIDENCE OF COVERAGE - - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN THE HOME DEPOT, INC. - - HOME DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURETO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 2455-PACES FERRY ROAD NW' REPRESENTATIVES. BUILDING C-20 AUTHORIZED REPRESENTATIVE ATLANTA, GA 30339 USA ACORD 25(2009101)Jthorvton—hd ©1988-2009 ACORD CORPORATION. All rights reserved. 14481889 The ACORD name and logo are registered marks of ACORD e I Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR I Registration k26693 - TY.k Exp!Iraftoir g7312612_V Supplement! The Home pepof"MH2fXe SeiviCes- - t - RICHARD FALLO�E � 2690.CUMBERLAN©.i!WkKWAV S A'TL5kf , GA 30339 i .,Undersecretary l