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15 MADELINE AVE - BUILDING INSPECTION (2) --- I'lie Cbnunoll weallh of blas�achusclts ��(1 1: ' y Board of Iuilding Regulations and Standards CI'I')' OF rr\f/ sl ;J \lassarhusetts State Building Code, 7SO C NIR -\LG.\1 RvI i.4•II.I IJI•al i t Building I'ennit Application 'f u C'onstrucL Repair, Rrnuvate Or Demolish a Or)e-or rivo-f ,,,)ill DtrelhokV This Section For 011icial tAt only building Permit Number. —_ Date, plied: ap �7 IIwlJiny UDicial IPrin1 N�une) Signature Da e SECTION I: SITE INFORMATION I.I Property Ad t(r I A 1.2 Aaessurs Nap S Parcel Number I 1 Ake _ 1.la If this an acne led street' •a no \fnp Norther i'arcel Nunther 1.3 Zoning Information: 1.4 Property Dimensions: Lorin DDislrfcl Proposed U a Lot Amu(sq II) Fronlage(11) 1.5 Building Setbacks(it) Front Yard Side Yams Rcor Yard Required Provided Required Provided Required Provided 1.6 Water Supply:IM.G.I.c.JU.§54) 1.7 Flood Zone Information. 1.8 Sewage Disposal System: public❑ Private❑ Zone: _ Outside Flood Zone? Check ff esO Municipal O On site disposal system O SECTION3: PROPERTY OWNERSHIPI 2.1 Ownerll (cords (N;ww P itt� Lily,.State,'.IP No.:utJ Store q Feleptione Freud Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check at at apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairsls) Alleration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.O Number of Units er ❑ .Sp•cily: Brief Description of Proposed Work': SECTION 4: ESTIM.A D CONSTRUCTION COSTS llcm Estimated Costs: Il.abur and \Lueriais) CIMCIa1 Use Only 1. Building S I. Building Permit Fre: S Indicate how lee is delertllined: '. FIvorical S ❑Standard Cilffussn Application Fee ❑Total Project C'ostl I Item 6).n multiplier I J. I'hnnhing S _'. Olher Fees: S J. \ledtaim'll ill\ W) S List:-- ..___ _-- 12� • 9 1lechdnical ills _ __ ___ -- I \uiq+ressiUnl S Total .\ll Fees: S -- -- -- . n Total 1'roject Cnmt S ('hed. No. _...-_Che"Amwuu: l'.uh \momw ❑Paid in Full ❑... ... ding Ilahutce Due: st.'ClION5: ('I)NSI-Rii(-'riONSFKYl('F.'i 5.1 ceiie Number I \pirijlioll Date Naim:o1TSI I foldcr I ust0l. PC lkscritidon No. and street ­ M asoll L it%Tmn.stac.75 — Itmilin Cowrin KC W S W i 11ju%v nd S id i n SF Sulij I:ugl Ilurning Appliances I institution l'elc hone �D 1:�niail address,.d..d.,,. Denudiliun onernefor(1111C) .11.2 Registered Ilume n1proven --- �gjslruiu Name I IIC 11qisiration Miniticir 1:%piratiwi Diii: i:rnail address lent C Q. and Street Ci !town, state ZIP fete hung SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 153.1 l ISto pro CM) Workers Compensation Insurance aMdavit must be completed and submitted with this application. Failure vide this atyidisvit will result in the denial of the issuance of the building permit. ou"u"is permit. Yes ..........(3 No...........C3 Signed Affidavit Attached? CONIPLETEDWHE�N ",Jru i ATION i TO BE COIN'R SECTION 7s.OWNER AUTHORIZATION TH.[ORIZATF01 ..rniq AGENT OR CONTRACTOR—TOR APPLIES FOR BUILDING PERMIT I, 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, �Mta FIH700-wer's Naine(Electronic Sidn"tun") SECTION 7b:�O%VNER 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. Patti Prim t)%%ne.i or:%%ithorvvu Agent's Hume Ilaean Nons: ;�Is her—u%,n %vork.or in owner who­hircs an unregistered contractor1. .fin Owner who obtains a building permit to do taut registered in the Hume Improvement Contractor(HIC) Program).will nu have access 10 the arbitration pprogram or guaranty Lund under M.G.L. e. 142.A, Other important inrurmation on the HIC progr,1111 can be round at Supervisor License can be round atk,wk t".11; I 111rormatiun on he construction information 2. \%Tien substaillial%vork is PI;jj1ncd, provide the I includinbg gaelow:vige. finished basement attics.decks or porch) rotal Ilour area t,4. 11 ) Habitable room count Njijjjhcr of bcdroonis \timi,er of I-irvi,lacci \11111ho kit hathrounis Nmtihcrofdccks, parches I pv 01'en be ilb,totitcd tkir 'klt.d Projeo Cost- IL I oi.d Vroi�0 square F, Aug 26 12 06:29a BOB DANGELO 9785157765 T— HOME IMPROVEMENT CONTRACT ` L► G �'—�I 1 1Gt( PLEASE READ THIS Sold,Furnished and Installed by: Branch Name: Boston Date: U �S/ aol a THD At-Home Services,Inc. d(b/a The Home Depot At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(800)657-5182;Fax(508)845-6017 Branch Number:31 Federal ID#75-2698460;ME Lie#C 02439;RI Cont.Lie#16427 CT Lie#HIC.0565522;�MAHome Improvement Contractor Reg.#126893////Installation Address: �.S �/��.2 �-�AAC_ - .�Dc[XPm9 4 o/y70 City State Zip Pumbaser(s): Work Phone: Home Phone: Cell Phone: srt r. 14.1 77t:2 [y7?171/s 89/3 [ l t l [ ] [ l 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 any marketing emails from The Home Depot Protect Information: Undersigned('Customer"),the owners of the property located at the above installation address,agrees to buy, and THD At-Home Services, Inc.(`The Home Depot") agrees to furnish,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 and any Change Orders(collectively, "Contract"): Job#: ammmi tur.t - Product:: Sec She s M Pro ect Amount Roofing OSiding ®Windows El Insulation 6Y47S3z []Gutters/covers oEntry Doors C7 S/3 d 80 $ y006 Roofing Siding 0 Windows Insulation $ - []Gutters/Covers []Entry Doors r-1 Roofing Siding 0 Windows 0Insulation []Gutters/Covers C]Entry Doors[J $ Roofing Siding 0 Windows LJ Insulation []Gutters/Covers QEntry Doors n $ Minimum 25%Deposit ofCommct Amount due upon execution ofthis contract Total Contract Amount $ .;r 0oc)—' Maine Purchasers may not deposit more than one-third of the Contract Amount / 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 Product(s)included herein,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 errors or because work required to complete the job was not included in the Contract. Payment Summary: The Payment Summary # C:YS"9y6 , 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 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 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. Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement 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 acknowledges and agrees that Customer has read,understands, voluntarily accepts the terms of and has received a copy of this Agreement. Acc by: Submitted by: Cmer's Signature Date Sales Consultant's SignatulfDate The Commonwealth of Massachusetts Department of Industrial Accidents lu Office of Investigations I. 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Narne (Btuiness/organization/Individual): 1,(�%l1 U� Address: ;z2llil o l 'yh ? ,YY� (l.& City/S /Zip: .' � . Phone#: `f?06 & 7 15)� .;Are YIP&an.employer.?Check the appropriate box: Type of project(required): 1. I am a employer with . 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 workingfor me in any capacity. employees and have workers.' . Y a tY - 9. '❑Building addition [No workers' comp. insurance ` comp. insurance.$ ] re uired. 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions q , 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roo pairs insurance required.]t c. 152, §1(4),and we have no l employees. [No workers' 13. ther CA/[ comp. insurance required.] *Any applicant that checks box#1 trust 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. ;Contractors that check this box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information, Insurance Company Name: L �l I � I rF� lb Policy#or Self-ins.Lic.#: � Expiration Date:_ Job Site Address: .Q, tj th:� 1��F 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 der t e pains d nahles ofperjury that the Information provided above ' true d correct Signature: 11> fl Date: Lit j Phan #: 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 .-- 6. Other - Contact Person: Phone#: Fo T CITY OF S,1I.EtiI, �I.�SS.ICHLSETTS Bl ILDLNG DEPARTMENT 130 WAsHINGTON STREET, 3' FLOOR -0 TEL (978) 745-9595 FAx(978) 740-9846 Kl.-,tBERi RY DRISCOLL MAYOR DIRECTOR ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUnDLNG COSIMISSIONER 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: (name of hauler) The debris will be disposed of in (name of facility) (addres signature of permit applicant date JrbrisaiC,hx , _ Office of Consumer Affair and Business Regulation - 10 Park Plaza - Suite 5.170. . r Boston, gssachwsetts. 02116 Home Imp oveve6t\lc,,O 'ntractor-Registrati.on Registration: -.12B893 .. TYPe: Supplement Card i z r w F�PlraOon:' 8/3/2(71d The Home Depof At-Home Selvi ° _ RICHARD- FALLQNE d 269D CUMBERLAND PARKWAY _ h ATLANTA, GA 30339 C Ar�-• sy"v`vw • Update Address and return card.Mark renson,for change: _ Address Rcnewel Qmploymcnt 1`'I Last Card . ors-cni � sarA•oaroa-cmi2ie .- - .. .. .. �/�ia 'V1anw�waauea .�✓f�o?eadaa&;'.. . _ sue\ Ofliee of Consumer.Affnirs&;Business Regulation Licanse or registration valid for Individul use only . OME IMPROVEMENT CONTRACTOR _ before the expiration dnie. If found rcturn�,.to .. y Office of Consumer Affairs and Business Regulntton C3, _ Reoistratlon ,146893 - -�. TYP° 10 Park Plnzn-Suite 5170 - Expirstton:;,:'0/`3Pt}1'4 Supplement Card. Boston,MA02116 ' _ .The Home DePdl PJ ftna' er-V Era naY^IQ - RIGI-TARO pAIL(SNh'ttit•J• 2690 CUMBERLAh6 Pb)'if'l(>dWS YS A°fLrANi ,'GA 30339'r f.;. '` Undersecretary 4, jvithi�ls nature CERTIFICATE OF LIABILIT)f INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ' CERTIFICATE DOES NOT AFFIRMATIVELY 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 INSURER(S), AUTHORIZE+I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the I certificate holder in lieu of such endorsement(s). 1-866-966-4664 CONTACT PRODUCER NAME: Marsh USA Inc. PHONE FAX No 9M1 A/C No): E-MAIL homedepot.certrauest@7marsh.com ADDRESS:q Two Alliance Center, 3560 Lenox Road, Suite 2400 - INSURERS AFFORDING COVERAGE NAIC It Atlanta, GA 30326 --- Pax (212) 948-0902 INSURERA: Steadfast Ins CO 26387 INSURED INSURERS: Zurich American Ins CO 16535 The Home Depot, Inc. INSURERC: New Hampshire Ina Co 23841 Home Depot U.S.A., Inc. 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co 23817 Building C-20 INSURERE: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURERE: Illinois Union Ina CO i27960 COVERAGES CERTIFICATE NUMBER: 2577.6028 REVISION NUMBER: THIS IS TO CERTIFY THAT THE ROLICIES 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 I 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. ADDL SUER POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE POLICY NUMBER MM!DDM'YY MM/DDIYYYY LIMBS A GENERAL LIABILITY GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 X - PREMSESAMAGE ToE.ccurRENTEanca S1,000,000 COMMERCIAL GENERAL LIABILITY ---- CLAWS-MADE O OCCUR MED EXP(Anyone person) II EXCLUDED X LIMITS OF POLICY XS PERSONAL S AOV INJURY $ 9,000,000 X OF SIR: $IN PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 9,000,000 X POLICY PRO AOC $ B AUTOMOBILE LIABILITY BAP 2938863-09 0 Ea accideCOMntSINGLE LIMIT 1,000,000 _ NX ANY AUTO BODILY INJURY(Per person)ALL OWNED SCHEDULED BODILY INJURY(Per accitlenl) $ AUTOS AUTOSWNED PROPERTY DAMAGENONHIRED AUTO$ AUTOS PeraccitlenlSELP INSUR D PHY DMG UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ - $ WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 X WCSTATU- DTH- C AND EMPLOYERS'LIABILITY D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA WC0197 3 6 917 (FL) 03/01/1 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMSER EXCLUDED? N❑ IS in NH) WC0197 3 6 916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yyes.Oesmibe under - $ 1,00•'..000 It m0 PTON under OPERATIONS below E.L.DISEASE LIMIT E Workers Compensation WC1192494 (QSI) 03/01/1 03/Oi/13 SIR (ADS)/SIR (GA) 1M/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/LM DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF COVERAGE J CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES PERRY ROAD NW AUIHORIZEO REPRESENTATIVE BUILDING GA 3 USA /1 /. ATLANTA, GA 0339 l/ .,_r- LJ! ©198 32010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD?= Jthornton_hd ='10. it ty f v h r k t f M f'. ♦ t i71 .(. _ i� { i A .�i € ' 21 SPRING ROAD 5A DIRACUT MA } I 1 t i 9 '. .: {