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12 LYNDE ST - BUILDING INSPECTION t I� The C'onunonwe:dth of Massachusetts y; } Board of Building Regulations and Standards Cl FY OF Massachusetts State Building Code. 7SO C'MR tiALL\I Re risdJ.I fur'll!l Building Permit Application To Construct, Repair. Renovate Or Dentoli One-or Ti o-Funtilt Dn elling This Section For Official U Onl Building Permit Number: Date App(ied: Mw Building Official(Print N;unc) Signature pale SECTION I:SITE INFORMATION 1.1 Property Address: 1.3 Assessors NIAp& Parcel Numbers 1.la Is this an accepted street?yes no \fap Number Parcel Number t.J Zoning Information: 1.4 Property Dimensions: Zoning District Proposed(Jsc Lot Area IN R) Frontage(11) 1.5 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.Jg.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ lone: _ Outside Flood Zone?Check if ycsC3 Municipal O On site disposal system ❑ SECTION2: PROPERTYOWNERSHIPI 2.1 Ownerl of Re d: Name(Print) 14 ) L ny.Slate,ZIP — and Street - Telephone &nail Address SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition Cl Accessory Bldg.O I Number of Units_ Other ❑ Speci t Brief Description of Proposed Work': SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estinmted Costs: II.; and.\laterialsl Official Use Only 1. Building $ 1 r' I. Building Permit Fee: f Indicate how ree is determined: '_. Electrical S ❑Standard Citffown Application Fee O Total Project Cost'(Item 6)x multiplier _ —_x j 3. Plumbing S - 2. Other Fees: S 4. .Vxhauica1 ill1.\(') S List:— _ 5. \Icchanical Wire S —_--- tiu„re�siunl Total AH Fees: S ('heck No ll f heck Amount —Cash \momu: n. Total Project Cost: S �3 7 ❑Paid in Full 0 Outstanding (lal:mce Due: s r SE("PIONS: C'ONS1'RIIC'rIONSERVICES 5.1 Construction Supervisor License(CSL) I.iccnsu Numhcr Pcpi aUou I Ile N:II I1c Uf t''I. Ilold•r - C�- UWSAIndow c below)-_-�1-------- ----------- Description No .u1J Streetstricl'd(IhlilJin�s l to 7S,n110 ul. IL)__ icwd Ir2 fanlil Ihsdlint llvl r %11 St'le./e Pl1in Cmerin ow and Sidin SF SuliJ fuel Ilurning Appliances Insulation 'I elcrillonc hanuil address U Demolition 1.2 Registered Ito apruve eat Contractor(HIC), r be 4) tY (JO�_ �� ��� I IIC Rcgist�iun NuntM'r I(s ira un Uule puuy. uuc or I IIC Itcgi. uy le EU� `Z No.Aid S'�.et r Ij 1� �` � Emuil address 1 I )nft �> Ci / own,State,ZI Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 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 Issuance 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 see lA✓� rl to act on my behalf,in all matters relative to work authorized by this building permit application. j � Print Uwnei s Name(Electronic Signature). Date SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under th airs and penalties of perjury that all of the information contained in this application is true and accurate I the estof ,y k owledge and understanding. Print Ors nei i or:\umnoriieJ.\gent's Name 11(iectronic S gnalurel Oki;: NOTES: I. :\n Owner svhu obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor 1 nut registered in the Hurtle Improvement Contractor(HIC) Program).will M) 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 :,..I Information on the Construction Supervisor License can be found at Il)t,),I llao�SIo\ -It,, '. W'hen substantial work is planned,provide the information below: Total dour area(sq. ft.l . I including garage, finished basement attics,decks or porch) Gross liv ing area I sq. 11.1 . _ -- Habitable room count \unlbero I'll rcpl%cs_.__ Numberol'bedrooms - N'umher of bathrooms Number ul'half halhs I's pe of heating is stems ., . - -- .`'Imlhcr of decks, parches . . . . I" pe"I'Coollllg it Stein Fncloscd " "-Open 1, "Total Projact Square Footage'maN he suhstituted for"total Prljed Cost- CITY OF S,V-EM, AksS.1CHUSETTS BL'LLDLVG OEP.1A71LLNT 120 WASH LNGTON STREET, 3'O ROOK TIM (978) 745-9595 K1%c9EAUY DRLSCOLL FAX(978) 740.9846 MAYOR T}iOaW ST.PX"S DIRECTOR OP PLSLIC PItOPEjtTY/8L•Q,DC4G COJbLLSSIONER Construction Debris Disposal Aftldavit (required for all demolition and renovation work) and the provisions of MGL c 40, S 54; Ins,accordance with the sixth edition of the State Building Code Debri , 180 CMR section 111.3 Building Permit a is issued with the condition that the debris resulting from I SOA. Ihis work shall be disposed of in a properly licensed waste disposal raeility as defined by NIGL c 111, S The debris will be transported by: (name ut hauler) -p The debris will be disposed of in (na w40taciliply) ; , 1 �OkCei (iddre» orrJcil,ly) aynJmr o(permir rpphunr �41J e i o p/1<..55fls 2Zdadll S' De�Jrrrlrr,e7sl,ofI?,9f1u5+Htj1 Accidents' re of,Inve,�li,�ttrtJ)res a J 'DO Washinglon,Slr>?el r, Boslon, A114 02111 47 W1vav,araaaS&g0V1dirt Workers' Coanpeaasation InsurarEa AffieiaAt: Builders/Contractors i'�lzctritifans/Piumbers Applicant Information Please Print Legibly Name (Business/Organizationilndividual): Address: r,nit�ri�n9 lam City/State/Zip: Phone #: q42�0 &5-7 �51 rw Ar an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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 employees and have workers' working for me in any capacity. 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 I'llAing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. oof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other 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. tContractors that check this box must attached an additional sheet showing the time 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: — Policy # or Self-ins.Lic. #: Expiration Date: i Job Site Address: 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 u d r t e p ns andpenaltigs ofperjury that the information provided above is true and correct. Signature- Date: l 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 -- -- 3. =(2 1 CERTIFICA7E OF LiAS11-fry INSURANCE THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CCRThICATL HOLDER. -XIS D, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENUTE A CONTRACT BET'11IEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIT REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. INIPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies) must De endorsed. If SUBROGATION IS WAIVED, subject iD the terms and conditions of the Policy,certain pclicies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). pprvracr _ PRODUCER 1-404-993-3000 NAME: ----' "'- ' A< Marsh USA, Inc. PHONE --- _—_ AIL F-MAIL homedepot.certrequest@marsh.com ADDRESS:Two Alliance Center, 3S60 Lenox Road, Suite 2400 INSURERS)AFFOROING COVERAGE .NAIL% Atlanta, GA 30326 Steadfast Ins Co 26387 Fax (212) 949-0902 INSURER A: '-- Zurich American Ins Co 16535 INSURED � INSURER B: ----'-"-'' The Home Depot, Inc. New Hampshire Ins Co 23841 INSURER C. P — —._...__.. Home Depot U.S.A., Inc. Illinois Nat' Ins Co 23817 2455 Paces Ferry,Road NW INSURER O: NATIONAL UNION FIRE INS CO OF PITTS 19445 Building C-20 INSURER E: _. _._....._..__.._ Atlanta, GA 30339 INSURER F I Illinois Union Ins Co 27960 REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: 19834682 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B W ELO 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. -__._______ Iry BR AOLI SUER POLICY EFF POLICY E%P LIMAS LTR TYPE OF INSURANCE POLICY NUMBER MMIDONY MMIDOIYYYY A GENERAL LIABILITY - GL04887714-01 03/01/1 03/Ol/12 EACH OCCURRENCE E9,000,000_-- DAMAG TORE N ED 1,000,000 X PREMISES(Ea accurrenre f COMMERCIAL GENERAL LIABILITY EXCLUDED MED E%P(Ant one person) - f CLAIMS-MADE OCCUR OCCUR "----- VERSONALBADVINJURY E9,000,000 % LIMITS OF POLICY XS —R ATE E9.00 0 000 X OF SIR: $1M PER OCC GENERAL AGGEG ,000 -- PRODUCTS-COMP/OP AGG $9,0001000__ GEN'L AGGREGATE LIMIT APPLIES PER: f X POLICY PRO- LOG 1 01 12 COMBINED SINGLE LIMIT H AUTOMOBILE LIABILITY BODILY 2938863-OB a id m 1,000,000 BODILY INJURY(Per person) E ANY AUTO BODILY INJURY(Per accident) S ALL OWNED SCHEDULED ---.......... '- AUTOS AUTOS PROPERTY DAMAGE E NON-OWNED Pena (dent HIRED AUTOS AUTOS E X SIR AUTO F Y EACH AGGREGATE _- f UMBRELLA LIAR OCCUR AGGREGATE E - __...._....... ___._ EXCESS LIpB LIAIMs-MADE -- f DIED RETENTIONS - WC STATU- OTH- C WORKERS COMPENSATION WC061967352 (ADS) 03/01/1 03/01/12 X AND EMPLOYERTLIABILRY YIN WC0619fi7354 (FL) 03/O1/1 03/01/12 E.L EACH ACCIDENT f 11000,000 _ D ANY PROPRIETOWPARTNENE%ELUTIVE NIA OFFICERIMEMBER E%CLUOE07 a WCOfi 1967353 (CA) 03/Ol/1 03/01/12 E.L.DISEASE-EA EMPLOYE f 1,000,000 F. (Mandatory In NH) Ifyes,desaibp under E.L.DISEASE.POLICY LIMIT $1,000,00 DESCRIPTION OF OPERATIONS below C Workers Compensation WC0 619 6 7 3 55(XY,MO,NY,WI, V)P3/01/1 03/01/12 P TX Employers KS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/1M E Workers Compensation WC1192778 (DSI) 03/01/1 03/01/12 SIR 1M DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 10%Addlllonal Remarks Schedule,it morospace is repulred) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN THE HOME DEPOT, INC. ACCORDANCE WITH THE POLICY PROVISIONS. HOME DEPOT U.S.A., INC. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE �— BUILDING C-20 _�- ATLANTA, GA 30339 USA ©1988-20i3O ACORD,CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD jfiero_hd 1 d.� ✓fee, '�Jam+mxa7ui�e�a�.�aaaac/tudeCld Office of Consumer Affairs&Business Regulahon- . - 1 l - O'M ROVEMENT CONTRACTOR �- Reglstrallo_n '126893 Type - Expiraian--.pp3/201 � Supplement - - The Home Depok�Rt H,�orne�setvices � 2690 CUMBERLAf+I�1 RARKWRY.S �� �- - A'(�, GA 30339 "" e "-Undersecretary r- .'=' :\lass:rchusctts- Department of public sal'm Board fit'Baildint Rcgulatiort> and St:ntdards Construction Supervisor License License: CS 101433 -__.........._._� Restricted to: 00 SERGIO SANTOS 11 HAWKINS STREET NO 1 SOMERVILLE, MA 02143 y Expiration: 8/302012 ( nnmi..incr Tr:: 101433 i• I ti HOMEENPROV'E'MENT'CONTRACT • ' PLEASE READ THIS Sold,Furnished and lnstalled:by Bruno Name:'.Boston 'Date: // �dr THD At-Home Services,IrW ( - d/bla The Home Depot At-Heme Services 345A Greenwood Street,Unit 2,Wwccatcr,MA.61607 . .- Toll Free(80 657-5192;Fax(508)756-8823 Branch Number.31 Federal ID#75-169W,ME 11c#C OZ439;RI Coat tic#16427 CT Irc 0 HIC 055665522;;;MA Home imp,o =ut Coodxctor Reg.#IM93 Installation Address: Z ^err.P{ $e Est [[s►t �Xet elf70 . - City - State Zip. . Ptvtbnaer{e): . . - Work Phone: How Phone: Cell Phone [ ] [IV 74i-730C R791 74.4 C Home Address, (if different from butallation Address) City State Zip Email Address(to receive project communications and Home Depot updates):' - ❑I DO NOT wish to receive any marketing retails from The'Home Depot Project Information- Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy, and-THD At-Home Services,Inc("Me Home Depot'')agrees to firmis deliver and arrange for the installation("Installation")of . all materials described on the below and on the referenced Spec Sheet(s),all of which me rpo into this Contract by.this reference,along with any applicable State Supplement and Payment Summary maachrd hcrm and en CChange Orders(collectively, "Contract"): Job#: ft�Rdewdd I Producte � so' s)k: Project Amount 3�7 ❑ 'Cm�❑EnnyDDoorss ❑lnsolanon $ 01tooling cover, ❑Windows jresalatiaa $ • ( ^� .❑cauen(t`vrrs �ntryDoots ❑ � � � ❑Roofing OSiding [I Windows 0 Insulation - ❑Timm(Covers EMutry(hors r7 $ Roofing Siding Windows Insulation $ . ❑Gross%Coves ❑Forty Poore fl . Main=25%Deposit of Contract Aransas due upon emutim of this can&&& Total Contract Amount $ err Maine Purchasmsmay not ftootmare thaaamm4nt«the CprmaaAmomf. �3.r�0` �: 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 Pmdutt(s)included heroin,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.emors or because work required to complete the job was not included in the.Cormact. Payment Summam Thc'Paymcnt Summary is 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 listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the evert of termination of this Contract,Customer agrees to pay The Home Depot the costs of materW labor,expenses and services provided by The Home Depot or Authorized Service Provider through the date of taoainatioa;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 DEPOTS OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. _ Acceotance and Authorieation: CmLon car agrees and understands that this Agreement is the entire agreomont 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 oclmowledges and agrees that Customer has read,understands,voluntarily accepts the terms of and has received a copy of this Agreemeut Accepted {! Sabydtte " 's Sigoamte Date Sales Consultant's Signal= Date X Telephone No. • 7 30 • /D Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS (as applicable) . 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 SUPPLEIMENT ":ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTfCE.ADmr70NAI.TERMS AND COMMONS ARE STATED ON in.REVERSE SIDE AND ARE PART OF T@g CONTRACT 04-11-11 C-RC wtw-Bauch Fie Yelbw-Customer