6 MADELINE AVE - BUILDING INSPECTION (2) t fie Conunumveallhot'Massachusclts
1: '� Board orl7uilding Regulations and Standards CI I'1'OF
Massachusetts State Building Code. 780 CNIR SAlli\I
Building Permit \pplic;Itiun 'ro Construct. Repair, Renovate Or tulish a
(bna-or Tn•u-Piunill' Dm'ellinIq
This Section For Ot'Bcial Use Onl
tBuilding Permit Number _ Date Applied:
y
1�1 tcil Luriizy
BuilJing 011icial(Print N,une) signature Dote
SECTION I:SITE INFORMATION
1.1 Property nss / r 1.2 Assessors Map di Parcel Numbers
I.to Is this an acre Ced street? 'es no Map Nunsher Parcel Number
I.] Zoning Information. 1.4 Property Dimensions:
Luning District I'nrpnxd Uie Lot Area(sq II) Frontage(11)
1.5 Building Setbacks III)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.61Vater Supply:(M.G.1.e.qU,§Jq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone?
Chock 11.es❑ Municipal❑ On site disposal s)item ❑
SECTION2. PROPERTYOWNERSHIPs
2.1 Owner! R cord:
Nano(Print) City.slate,ZIP
N- 11 Street Tee � Email Addmss
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all!W apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Dem lition ❑ Accessory Bldg.❑ Number of Units_ Cher ❑ Speedy:
Brief Description of Proposed Work^
ECTI N �: ESThMATED CONSTRUCTION C TS
`1
hens Estimated Costs:
ll.abur and \Imerials) OFllclal Use Only
I. Building S I. Building Permit Fee: S Indicate how let is determined:
2. Illectrical S ❑Standard City,Tuen Application Fee
t. I'hnnh;ng S O Total Project Cush(Item 6)x multiplier _-
. Other Fees: S.
4. .Mechanical ill\' \(') S List:
\Icch,mieal tFire --- --- - - --
Cu rnssiun) S Tutal .\IlFees: S
Check No- ('heck :\npnmC C,ish \ unc
n Total project Cast i ❑Paid in Full -- m�i0 Oulstanding lial.usce Due:
SE(JIONS: CONSI'RUCTIONSF.RVI('FS
5•1 ConstructiuR`Mrwotz�T-.----
nisor Li (C'SL) W
[L{_ lanc
I icensc Number
N,une ul l Si. 11 dv,� � ((�� r (�—
-0�••-y SLNY/� hJ ( isICSLI\Pclseclmluwl.__._
- � --- I'�pe Description
No. .Ind$Irve
U UnresnicicdllhlilJinlsu m1S.11UUcu. It)
� R Rcstrioed Ih2 f.unil - Dwcllin
Glk T fawn.State.L P ,St klason
RC R,hoin Onvrin
_ AS %A'indaw:md.Sidin
SF Solid fuel Burning Appliances
CI �/ I hlslduliun
Finail address U Demolition
5.2 Registered II 1ppruq{l��he it Cowf r(Iqg
,/ {
r'lE IIIC Rvit6tnniun Number ISsp uhu Uule
111 'C' I 1pil 1) �Ilie o I C' ialry 1 Nan10
No. m1 •el — + 1 Lmail address
40
CitytTown,State ZIP relc hone
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 Issuance the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7%:OWNER AUTHORIZATION TO BE CON PLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit applic li .
Print Owner's Name(Electronic Signulure) ule
SECTION 7D:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest uAdder the pains and penalties of perjury that all of the information
con ne in thi t'on is true and accu at to t e bes f n knowledge and understanding.
r
Print t s ner'i or:\uthurire ,\gcnl's ante I 'I �tn nlc Signs ore uw
NOTES:
I. .\n Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HICI Program),will no have access to the arbitration
program or guaranty fund under\I.G.L. c. 142A.Other impurtant information on the HIC Program can be 111und at
wo,s 111A." •;01 ',.I Information on the Construction Supervisor License can be found at
\\'hen substantial lwrk is planned, provide the inrurnlaliun below•.
rota) Iluor area(sq. 11) _ (including garage. finished basement attics,decks or porch)
Bross living area liy. It 1 _.... _ Habitable ruunl count _ .. .... .
\umber of lircplaccs .... -... \umber ul bedrooms - -. .. . . . .
\muherofbathrooms — Numberofhallhmh3
Il pe o(Ilvating 3)+Icnl \lmlhcr al'decks, purdles
� I1pe VI ctluhng it ilelll Flld+lsed 01'e11
t, "Thal Project Square fu,+ld4c"1113) IN substituted r0r"1111a1 Project Coif'
2012-05-01 03:52 2686PRODESK 9787401417 >> Home Depot AHS P 1/7
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
Breach Name; Boston Q Sold,Furnished and Installed by:
Date: f� /a THD At-home Services.Inc.
dWa The Home Depot Al-Hume Services
345A(kcenwood Street,Unit 2.Worcester,MA 01607 -
branch Number:31 Toll Free(8f81)657-5182:Fax(508)756-8823
Federal ID or 75-2698460;MR 1"4 C 02439;at Cnm.Li,*16427
/ CP Lic it I IIC.0,565522;MA�"Ons!rcnprovcmmt(]Hgroctur Reg.it126893
Installation Address: 6.- /� / e IJ Ate' /f v2 </f t es+z b!/YrA- 9 7 0
City Shoe zip
lrurchaser(a):
Walk Phoun Home Place: "it Phone:
Sif , 197 _ 85 7 3 ssp t 1
L J t 1 _Ji
Horne Address
(If diHcmnt from Installation Addnea;) .. City Slate Zip
E-mail Address(to repetve project communications and Home Depot updalas): .NO C rr.vRt'-
❑1 DO NOT wish u>receive any mairla ling anwils from The Homc Depot '
Pect o time Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
TNO At-Ilome Service,,Inc,("the Home Depot")agrees to furnish,deliver and arrange for the installation("Installation")or
all materials described on the below and on the referenced Spa:Shea($), all of which ane incorporated into this Contract by this
reference,along with any applicable State Supplement and Payment Summary attached httcto and any Change Orders(collectively,
'Contract");
Jata: r kw iaet,m,
L_f w txt Sec Sh s)Y: Pro'eet Amount
Roofing Siding awl-do-, ❑frtsulatym
623'1 11 j QGauas/covtts QPmy xas ❑_ 5 7 -7 S 3 $ C $$D E0t3
QRaarmg iding irnlaws Insulation
6z 3yy ❑GuessiCovav _ I d
❑entry Dears �.. ��l
❑Rmfing Siding W"indaws ❑Irtmlation }F— --
❑Crurm/Covers Qr.ary rheas Q_ $
i ❑Roofing ❑Siding❑Windows ❑2awlatiou
QCNttcrs/Covers ElEnvy Dons 11 $
Mtdmmr 2s'h Ire eae a't:udrat�n�rmarte uponam,liuratwkmmn,a.
Malm Par limas Total Contract Amoaar $ av
may�tdrp�rmraelnm,anctbintdl��Am,amL 3 S$D
Customer agrees that,immediately upon complution of the work for each Product,t,Customer will executc a Completion Certificate
(rme fro each Predacious defined by an individual Spa;Sheet)and pay any'balance duc. As applicable,each C ustouter under this
C'gnt,wi age s m hejoindy and severally nhligatcd and liable hereundv.
The I lor,ac DcPut reserves the right m issm:a Change Older or terminate this Contract or any individual Praducl(s)included herein,at
Its discretion,if The Hone Depot or its auth r7ad service linavider delemtines that it cannot perform its obligations due to a structural
problem with the home,environmental Innards such as mid,asbestos or lain p ton,other safely concerns,pricing errors or because
Wink mqu and to corrrplete the job war not included in the
''C'}Ioln1uact t,�
Payment Summary: The Paymem Summary a—Z-1.18 1 inciudod ar part of this Conuacr, sets forth the total
Contract amnnnt and payments required for clan dalmsits and final payments by Product(as,applicahle).
NOTICE TO CUSTOMER
You ere entitled to a completely µBed-0n CORy of the Contract at the time you sign. Do rot&M a Completion Certificate(note:
there is oar Completion Certificate for each lisped Product as defined by Individual Spec Sheets)before work on that Product
Is complete.
In the event of terminations of this Contract,Customer agrees to pay The biome Depot the costs of materials,labor,expenses
and services provided by The Home Depot(or Authorized Service Provider through the date of termination,plus an other
amounts set forth m this Agreement or allowed under applicable law. THE HOME DEPOT MA Y WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTHER PAVMp:N'n" MADE, WITHOUT
I.INIITiNG THE HOME DEPOT'S OTHER REMEDINS NOR RECOVERY OF SUCH AMOUNTS.
Acceptance and Aadtoriradon: (:uttumcr ogress and Lmdelstavda that this Agreement is dw.rntire agroemem between Customer
and The Ilonre Depot with regard w t✓K:Rtdueax and installation services acid supersaktc all prim discussions and agreements,either
oral or written,relatin@ to said 1'nduG.a and Installation,This AgJeelnent canno assignai(rc amcmletl except by a writing signed
by Cusmllur sad The home Depot Cuaiumcx acknnwlcdgcr and agrees That Cu met d,undaxuuuls,voluntarily accepts the
tem>s of tiros bar rosined a ropy of this Agreement. ////N-ja�1//,/fir,—�
Aaxepted by: Submi h : L/J_
Cus nut's n Sales Conxultam's Sigwtum Uazc
Cuslomer's Signawm Data . .. - —
Sales Consultant Liceruc:No.
CANCELLATION; CUSTOMER MAY CANCEL THIS Ws aaphcabk)
AGREEMFNT WYMOUT 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
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S S rAT'E.
N(rrll.Tt:ADDrnONAL TRRMN AND CONIn'r1ON5 ARM STATED ON THE REVERSE SIDE AND An PART OT TIRS CONTRACT'
or'tslt ,. Witte-Branch File Yollow-Custome,
TOWN OF MARBLEHEAD NO.2"1 ?� f'�
' CUSTOMER RECEIPT
Received from: Name -
Address J
Date
Department
a
Purpose of payment `>
Revenue budget code
Amount
A.
Received by
if! Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
License CSSL-099699 x
ROBERTPOCZOBUT -
172 WHALENS LANBN "�;g
Salem MA 01970 ,s�p 'v
Ik, 4
9.21 IN Expiration
Commissioner 02/08/2014
I
s
I Office of Consumer Affairs&Rusmess Regulation
3 OMEIMPROVEMENT CONTRACTOR
x M <
Registration.�126893 Typi
Expirafio�e� fff2 Supplement
The Home Depd z At'mx�SsrO es
1�RICHARD,'FALLUN ¢
2690 CUMBERLAND PARKWAYS ��•6---� -
-, AYL`AN GA 36339"--:i ,r
�; - Undersecretary
CERTIFICATE Of LJ fi-11 Y INSURANCE
;
THIS CER7IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS i
CERTIFICATE DOES NOT AFFIRMA'iiVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT-BETWEEN THE ISSUING INSUR£R(S), AUTHCRIZED I
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
AIPORTA,NT: )F the certificate holder is an ADDITIONAL INSURED.the p llc/(iss) ,mu t be ardaY a d If SUSROC-A,71C I IS c DI 'U,
the terms and conditions of the policy,certain policies may require an endorsament. A statement n tcis card ,,,a-a dues;r, the ,
certificate holder in lieu of such endorsement(s).
CDCCER 1-866-956-$664 CCOMNEACT
rsh_ IISA Inc. PHONE F'
C o cc: 'A. MCI: 1
medepot.certrequestBmarsh.com E-MAIL 1
E-MAULADDRESS,
Alliance Center, 3560 Lenox Road, Suite 2400 INSURERS AFFORDING COVERAGE NAIC#
tlanta, GA 30326
(212) 948-0902 INSURERA: Steadfast Ins Co 26387
SURED INSURERS: Zurich American Ins Co 16535
e Home Depot, Inc. INSURER(: New Hampshire Ins Co 23841
me Depot U.S.A., Inc.
455 Paces Perry Road NW INSURER 1) Illinois Nat' Ins Co 23817
uilding C-20 - INSURER r; NATIONAL UNION FIRE INS CO OF PITTS 19445
tlanta, GA 30339
INSURER F: Illinois union In6 Co 27960
OVERAGES 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.
POUCY EFF POLICY EIP
TR TYPEOFINSURANCE POUCYNUMBER MOO MwDO LIMITS
GENE LLIABIUTY GL0488771442 03/O1/1 03/01/13 EACH OCCURRENCE - S 9,000,000
R COMM UITLGENERAL LIABILITY PREMISESEa=UMnce $1,000,000
TGLAIMSA'IADE a OCCUR MED EXP(Any one pawn) S EXCLUDED
MITS OP POLICY IS PERSONAL SADV INJURY $9.000,000
SIR: $1M PER OCC GENERAL AGGREGATE $9.000,000
GENL AGGREGATE UMIT APPLIES PER PRODUCTS-COMP/OPAGG $ 9,000,000
R POLICY PR6cr LOC 5
D AUTOMOBILE LIABILITY SAP 2938863-09 03 01 03/01/13 CEOMaBBII tlE�DtSINGLE LIMIT 1.000,000
NX .SELF
ANYAU-O BODILY INJURY(Pw person) $ALLOWNED SCHEDULED BODILY INJURY(Per=ddwt) $
AUTOS AUTO-0WNED PROPERTY DAMAGENON $
HIRED AUTOS AUTOS - Per nt
INS D PRY DMG $
UMBRELLALIAB OCCUR h
RRENCE $EXCESS LUVJ CLAIMSMADE $EDED RETENnONEVIORHERSCOMPENSATION WC019736915 (AOS) 03/Ol/1 03/Ol/13TOW
TLL DT4 CAND EMPLOYER5 LDIBILTA YIND ANY PROPRIETOR/PA NERIIXECU IVE N1rC019736917 (PL) 03/Ol/1 03/01/13CCIDENT E 1,000,000OFFIOERIMEMBER IXCLUDEO7 H NIAOFFICERIMEMN10WC019736916 (CA) 03/Ol/1 03/01/13E-EA EMPLOYE $11000,000Uyn,desoibe wrier E-POLICY LIMIT S 1/000/000DESCRIPTION OF OPERATIONS Eebo8 Workers Compensation WC11924 Q03/01/1 03/01/13 )/SIR (GA) 1M/750,000
C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13
F TI Employers R9 Indemnity TRSC46566397 (TI) 03/O1/1 03/01/13 Occurrence/SIR 30M/iM
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AUaca ACORD 101,Additnal Remade Sdmdal%B mere epees b repllred)
BE- EVIDENCE OF COVERAGE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
T88 BOMR DEPOT, INC.. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
HOME DEPOT D.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS.
2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE -
BUILDING C-20
ATLANTA, GA, 30339
USA
®1g88 w o AC CORPORATION. All fights reserved.
1ACORD 25(2010/05) The ACORD name and logo are registered marks'gf ACORD
7thorrIton hd
NFRC
-
.
ENeRGY PERFORMANCE RATINGS
. EVALUACION OEAENOIMIEMOENEAGENCO .
SolarHeatGain Ceeffcient
U-Fac%f Coefidence:4}and a ergia Solar .
FacarU
wsnn paadeGsn'
ADDITIONAL PERcOR141ANCE RATINGS .
. OVALUACION SUPIEMEPfiAAUOE AENCIMIEMO
y..
v _ 4a
'• PcaCIaNFACPmcedurestar desmdnAgwsale to.
recommendarte.NFAC .
- - i 3canlomtto opD
I ManutacsrrerstlpulatesdotU!eseratlng rend ayralototterpradudPedarm-ce '
ntlngs are Qetem+Nsd let aAsed seta!eael NraC CopanAG""'swwtmanaihmm..NF daesna.recommend my PmduR
al anyD
- ertd does ndtwartantdusulaeIDb tnlarmaWn.wwu�dmcrg _
Este hpncanta ezdpuu que ueaaalarescumplee cantos Procedhkatas apecastes de NFNCO Rnt sY Umanadep I.
pmduet Arswtares usadee per NFACtonde�^ades Par an wdryem ffa de wndidone .
u antlsaWe dPoduda seaadecuade Paaunaao esPcctlkatansulle eon el
especake.NFAemreesmiendarMPoproNeseY W
mle close ayapydadee¢e pmduLto wr+++�C09 � -.
PoAemdd NOrh Pao - .
aI'l v'QUa Lit!*
�aL 1YadvZ f3T1M1
' ' tagiitnfal: NactHetn %art,'
gntral, S.vAlt CprtrTl
wt.RC'.•1•I'S,N.S
(•T atTI,�T,I [T4st?lrT nw[T IT{a1 Alt:c 29
.. �y t:agi5:aina). V.—MOT 51-%Rt iO:Lk"
e
NactB'Gantca 1, Car cantcalr Sue.
i Lz'. Fain UU/Glaea 1/i;'• Ccadiolaclg�yCS
Teatad Size: AU"
* —i,,l;,y Aa vat:o 1'Cf'Jidria 3.1:3 txvf.2
' o occbado: 7.'t4.9 cos x 200.2 cat ...
DP
• _ -_ ,",,�rd'sl; ya5'S/Awt.al tistu•17t�+1/I.x/tyS7e11
.-, , ' 40.J-Oia1
The Commonwealth of Rlassachitsetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name usiness/Orgaru2ation/Individual): . _ � � 6 �_
@
Address: ( i'vytyr'flrrN!I� s`6�
City/State/ -ip:_ GN
Phone 9: �
Are y an employer? Check the appropriate box: Type of project (required):
1. 1 am a employer with 4. ,❑ 1 am a general contractor and 1 6. ❑ New construction
erployees (full and/or part-time). have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sbect. t 7 ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9; ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbing repairs or additions
myself [No workers' comp. c. 152,§1(4),and we have no 12.0 Roo tepahs
insurance required.] t employees. [No workers' 13. ther4131
comp. insurance required.]
Any applicant that checks box fl I must at so rill out the section below showing their workers'compensutian policy information:
t rlonnowners who submit this anidavil'urdiceting they are doing all walk and then hire outside contractors most submit a new affidavit indicating such
tContractors that check this box must attached son additional sheet showing the name orthe sub-contractors and their workers'comp.policy information.
1 am an employer that is providing rvorkers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-his. Lic. #: __� 7�j Jr,�JS Expiration Date:
Job Site Address: (6e City/State/Zip:_
Attach a copy or 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 fora of a STOP WORK ORDER and a fine
of up to$250.00 a day agaurst 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.
1 do hereby eild ,and th ains id penalties of perjury that the iafor•rnation provided above is rut and correct.
Sienaturr
Date:
Phone 4: p� —
Offcial use only. Do not write in this area, to be completed by city:or tolva official.
City or Town: Pernrit/Liceuse#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Citytrown Clerk 4. Electrical inspector 5. Plumbing inspector
6.Other —
Contact Person: Phone#:
CITY OE SM-ENis NWSACHUSETTS
RUNG OEP.jAT%tLN7r
120 U ASPINGTON 5TRBST, )'a R.00R
1'0 I*VL1978) 141.959!
FAX(978) 144984
K11�FJtLBY DRLSCOLL
MAYoit Iko.+w ST.PMUS
OfR9crcx O/pLsLlC PR0PERTY/8t:MDDIG CONOUSSION ER
Construction Debris Disposal At'tIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 130 CMR Section I 11.J
Debris, and the provisions of MOL o 40, S 54;
Building Permit a is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licemed waste disposal facility as defined by,'YIOL c
111, S I JOA.
The debris will be transported by:
(n+ma ut'Aaular)
The debri(swi�11 be disposed of in
(n�m�of facdiry�
l�ddrrrr orfxdlry)
41tJ04ern it Ippkint
4!� pD