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0003 MARINERS WAY - BPA-13-701 Q I'he C'onunumcrakh ut�1:usachuseBs N i l Ilsr;trd of Building Regulations and Standards CI'1'1' OF �I A✓/ ') ';, Mitssachusctts State Building Cude. 7J0 ChIR SALEM Building Permit Applie;tlion To Construct. Repair, Kenuv;rte Or Dcnuslish u Ono-or Tun-FamilP Uu ellir This Section For OffliciAige On Building Permit Number: _— Date \ plied: Iluddmy Ulliwil(Print N,ane) I ems" 3�a-s l SI'gilal ` Dale SECTION is SITE IN ' 1 ON 1.1 Property rests 1.2 Asses o p di Parcel Numbers I.la Is this an acre led street? es no btap Nunsher loured Number 1.3 Zoning Information: 1.4 Property Dimensions: Luniny District I'rapow (Uw Lot Arco(sq Iq . Fro lluye ill) 1.5 Building Setbacks(It) Frum Yurd Side Yuma Rear Yard Required Provided Required Provided Required Irovided 1.6 Water Supply:11M.G.1.c.qa.§54) 1.7 Flood Zone Informations 1.!Sewa`a Disposal System: Public❑ Private❑ Zone: _ OuLside o'-`una? Check il' es❑ Munieiptd❑ On site Jispusul ss xtcm O SECTION2. PROPERTYOWNERSNIPI 2.1 Ownerto eco d: Mane(Frio!) / . � �1 ` r City.State,ZIP Nu.and Slrcet //,- IL^- e1rP� bmml Address SECTION J: DESCRIPTION 11 OF PROPOSED WORKS(check that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairsts) Alterations) ❑ Addition ❑ Demolition ❑ .Accessory Bldg.❑ Number of Units Other ❑ Specily: Brief Description of Proposed Work": — SECTION 4: ESTIMATED CONSTRICTION COSTS Item Estimated Costs: iLabor and Materials) Official Use Only I. Building S I. Building permit Fee: f '�hsdicate haw fee is determined: '. Flectrical S ❑Standard CitylTusvn Application Fee I 1'lunihing S ❑Total Project Cost'(Item 6)x multiplier _.-- x _. Other Fees: S_ 4. \iceh.utic.d ill\ \(') S List: Su „rc;sioni S fotul.\II Fccs: I, Total Project Cnvtt Sf h ('hcd, \u. ( heck:lmsnurt: _l'a,h \nnnmc O P.lid in Full 0 Outstanding 11.11,utce Due: SECTION 5: f'ONS'1'RI f"fION tiF.RYIC'F:S S,I C'unstructiollSuP•n'•Sur .1cense( _ --- -- -- —' '/)' u`J inher I',pinlau I) le N,une +l'l{'S)I ILd1 lut('SI. I\pehecbelu,sl...... . No. r A - —r - 11 l inrestrictcd I BuilJiu n li 10 14,IIIItl eu. IL1 µ µe,trioed NO f.nnil Ds\cllin µC• Rlx+lin Coscrin µ'S µ'indew',uld Sidin Sp Sulid fuel Ilurniny Appliances . )�i��� I Insulation `ifl---r- 1����� hnuul,IJdrvss U Denwlitiun l'elc bona 5.2 Registered 1 Imp' v me t� net HIC) IFRegulr;itio umhuf I.gti liol ale IIIC' ' i Lu nr A sl q lama [:mail address No. and Ci /Town.State ZIP fete one SECTION 6:WORKERS'COMPENSATION 1 RANCE AFFIDAVIT(M.G.L,C. 152.1 25C(6)) Workers Compensation Insurance affidavit must be pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Isau of the building permit. Signed Affidavit Attached? Yes .......... No...........O 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 1 to act on my behalf,in all matters relative to work authorized by this building permit application. t print U\vner's Nwne(fileetmnic Signature) SECTION 7b: OWNER'O iLu rill RIZEDAGENT DECLARATION By ante Ivy naive below,[ hereby attest on r t pains and p allies of perjury that all of the information contain in his ap 'cat is true an cur o the be kn ledge and understanding. utu - I'rinl Ue nei f ur:\uthurireJ, genl's Nwnu 11'. 'tn . i I t 1 NOTES: I. An owner who obtains a building permit It,do his.her awn work,or an owner\vho hires an unregistered cunlractor (,lot registered in the Hume Improvement(enlfacturtHIC) Program),will no have access to the arbitration program or guano* fund under.M.G.L.c. 1 4_'A.other important information on the HIC Program can be Ibund at ,\Uq iI1.M, �;O, ', I Information on the Construction Supervisor License can be found at 1,)\1\ 111.1`; o:'\ 'It" \i hen substantial work is planned,provide the infor including below: e, finished basement attics,decks or orclu garage. p rot al IAwr arcs I sy. µ.l . --- Habit:ablc roust count Grussli\ing Area lsy. tl.l _--... _... Nunibcrofbedroonts —. �unllen+flircpiaces _ _ —_ \umbcr tit llaltKill" \unlherolhadiraol+ls . . - Numberol'decks, porchcs I\Ilk:kit'Iivaling s)stall Open I!nehl,cd .. I I'\I,V 01 eJp11114 i\itelu i. "11'1.1111mice1 \,11111rc 1'1xll.lee Ill;[\ be iub,littncd for"total Project Coll" 03/14/2013 09:02 17818940331 TODD RIDEMAN PAGE 01 HOME IMPROVEMENT CONTRACT ))) PLEASE READ THIS Sold.Furnished and Installed by: Branch Name: Boston Date: 3 J ! THD At-Home Services,Inc. Jam— d/b/a The Home Depot At-Home,Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(900)637-5192;FaX(308)845-6017 Brach Number:31 Federal ID#75-269UW;ME Lie#C 02419,RI Cont.Lick 16427 1 CT Liic � 0/c'11 C1.D565522;MA Home Impmvcmcnt Contractor Reeg/�#126893 Installation Address: /'/Al2//�'� "-ir J10 9 / V T—City State Zip Purchaser(,)- Work Phone: Home Phone: Cell Phone: 6Ltsj I h?_1i&g0~_vo_q Home Address _ (If different from Installation Address) City State Zip E-mail Address(to receive project communications and Home Depot updates): ❑1 DO NOT wish to receive any marketing emails from The Home Depot Protect Information: Undersigned("Customer").the owner,of the property located at the above installation address,agrees to buy, said THD At-Home Services, Inc_(`The Home Depot")agrees to furnish.deliver and arrange for the installation("Installation')ul all materials described on the below and can 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 bercto and any Change Orders(collectively. "Contract")! .lob#: Products: Spec Sheets #: Project Amount ❑rooting Siding Windows ❑Insulaion +� ❑Gu rs ❑ ❑tte /Covers Entry Doors - J� $ 3Oil.o b Rtmfing Siding windows ❑Insulation ry ❑Gutters/Covers ❑Entry Door ❑ 6 $ (jj,J/j OD) Roofing Siding ❑Windows ❑Insulation $ ❑Gutless/Covers ❑Entry Doors❑ Cp I� Roufng Siding ❑Windows ❑Insulation ❑Gutters/Covers ❑Entry Doors ❑ $ Mimmtm 25%DepuitofCommdAmsumdue upon execution of this Conned. Total Contract Amount $ 596q� Uo Maire Purchasers maymodepositmorethanonx-tItifdorthe Contrm Am L Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Cerifcate (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(,)included herein,at its discretion,if The Home Depot or its autborl7Ad service provider determines that it cannot perform in 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 # _,/7�7l 6 , 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 Sen'ice 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 PAYMENT'S MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Aece e"M and Authorization: Customer agrees and understands that this Agreement is the entire ugreernent 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 he 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. Accepted Submitted Is X Cus ignature Date Sales onsultant's Signature Ua Telephone No. Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS Ws 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 SUPPLEMENT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY . PRESCRIBED BY LAW IN CUSTOMER'S STATE. NOTICE:ADDITIONAL TERMS ANY)CONDITIONS ARKS,Al V,ON THE.....—SE SIDE AND ARE PART OF THIS CONTRACT 10-11.12 White-Branch File Yellow-Customer CITY OE SALENt, NLlssa,CFiL,SETTS t3ULDW; OEP.1A-nLLNT I =0 'V'U'gCIGTON 3TAEst, VO EtOOlti •� ILL �913) 71J.9S9! Kl l®ERLSY O UXOLL FAX(973) 1 s4734d MAY01 tRECTOtt O'pl BLlG PROplt1TY/eCMMC/C CO.%L3 1t5 Et0 NEtt Construction Debris Disposal Attldavit (required for all demolidon and renovation work) In accordance with the sixth edition otthe State Building Cade. 130 CbiR section 1 Debris, and the provisions of MGL o a0, 9 JJ; Building permit At is issued with the condition that the debris resulting from Ill, 3 1 JOA. this work shall be disposed of in a property licensed waste disposal facility as defined by NICE c The debris will be transported by: Mi � (name of hawarr) The debris will be disposed of in : (name or/acJiiy) nature u perm,t pphcrnt ' 3 f s ic 600 y�_�_ - Y;'D'Y'iCG''3'�• C'tvr$T.S'l;hC>l'�Srd�h".'1rA .i:ut��eh.3dau.W 23rt�ll�dxY 3Za '� (; y y ry leas- l'vnL"le(St:sinessfOrgattization(I¢di%ndm1):_ � � -- phone#: � t J ( k T Clt'y/State/Zip. Are yo a•, n employer`'Check the appropriate box: � � - - . Type of project(required,), 1.t� 1 am a employer with ` ) 4. I am a general contractor and I 6 Ll I New construction employees(full and/or part-time).* have hired the sub-contractors listed on the.attached sheet 7. []Remodeling I am a sole proprietor or partner- ' - � • - These sub-contractors have � g, � Demolition - ship and have no employees to i era ees,and have workers' fi p y 9. .❑Building addition working for me in any capacity. [No worker'comp.insurance comp. insurance., torpor required.] - 5.'❑ We are a corporation and its 10.❑Electrical repair or addrtions , 3.❑ I am a homeowner doing all work officers have exercised their _ 11.❑Plumbing repairs or additions , myself. [No worker' comp. right of exemption per MGL 12❑ Roo pair c. 152, §1(4),and we have no S insurance required.]? 13., her ___ employees.[No workers' comp.insurance required.] *Any applicant that chccly box 41 must also fig out the section below showing their workers'compensation policy information. t 14maeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stare whether or not those entities have employees. If the sub-contractors have employees,they mast provide their workers'comp.policy number. - lam an to er that is provid ng workers'compensation insurance for my employees. Below is the policy and jab site �P Y information. E � - - -Insurance Company Name: �q_ <'I /%h - �1 ,d�' �l //. — #. A r Expiation Date: Policy#or Self-iris.Lic. !1f Job Site Address: City/State/Zip: compensation policy declaration age(showing the policy number and expiration date). Attach a copy of the worker camp p y P Failure to secure coverageas required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a eq fine up to$I,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 DLL-or insurance coverage verification. - d do hereby certify u der Ike am anndjppenalties of perjury that the information provided above is true nd correct Si Date' ` Phone Official use only. Do not write in this area, to be completed by city or town ofcial .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#: ✓DLE l�G.'/NYb692[lM�2G/'u ✓ULIX�GR¢G1E�2 Office of Consumer Affairs.wz Eu%-n ss Regclateen - Licence or registration valid for individal u. )My - Qt06? OME IMPROVEMENT CONTRACTOR - before the expiration date. If found return o - - r Office0PaofPlaza Consumer t 5 airs and Business if.gul,.rion Registrat+on .a126893 Ti+Pe. IO Paris P7�za- Suite 5170 ExpiraYioh $l31201:4 _. Supplement lard Boston,MA 02116 Nil The Home De;,ot At Home Sere rEa. �,0 : RICHARD FALLONF f 2690 CUMBERLAND PARVYWAY S gg � _ ,/, CA 30339 =�=" Undersecretary 'ot valid Oithout signature 1 i` r r. --> -� i� r n � -'� �"�l� -' I �� or",MMlncrrr rl ' U gg i r t� ' E EO F U I i] u 11, r� 3 I 0:12i12013 I 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, E)REND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certincatB holder , an AODiTIOMAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS NiAI'VED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement On this Dartifioafe does not.confar rightz to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAMO MARSH USA,INC. - PHONE Fay No), TWO ALLIANCE CENTER WE Na Ern, 3560 LENOX ROAD,SUITE 2400 E-MaL ApOftE55: ATLANTA,GA 30326 INSURER(S)AFFORDING COVERAGE NAIC# 1 G0492-HameO-GAW4 3-14 INSURER A: Steadfast Insurance COmpEny 26387 INSURED INSURER B;Zurich American Insumnae-CO 16$35 THE HOME DEPOT,INC. New Hampshire Ins Co - 23817 23841 HOME DEPOT U.S.A.,INC. INSURER c: - 2455 PACES FERRY ROAD,NW INSURER D: Illinois National Ins Cd BUILDING C-20 INSURER E: ATLANTA,GA 30339 - - INSURER F: - COVERAGES CERTIFICATE.NUMBER: ATL-00315954504 REVISION NUMBER:7 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 TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, R ADOL SUBR _ POLICY EFF POLICY UP _ LIMITS INSR - TYPE OF INSURANCE INS MD POLICY NUMBER MMID0 MMIDD 9,QGO,000.GL04887 A GENERAL LIABILITY 71403 0310112013 03/0112014 EACH OCCURRENCE 8 u DAMAGE TO RENTED 1,OI10,000 X COMMERCIALGENERALLIABILITY - PREMISES IF.ecrnnence $ .r Fvl LIMITS OF POLICY XS - - MED EXP(Any one pers AIMS on) § EXCLUDED CLMADE I OCCUR 9,000,000 ? " OF SIR:SIM PER OCC PERSONAL B ADV INJURY $ GENERAL-AGGREGATE $ 9,000,000 PRODUCTS-COMP/OP AGE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X POLIGY PRO- _ LOC $ -B AUTOMOBILE LIABILITY BAP 2938863-10 03/0112013 03101/2014 F.a rciduurtBINGLE LIMIT $ 1,000,000 - - BODILY INJURY(Per person) $ X ANY AUTO ' ALL OWNED SCHEDULED SELF INSURED AUTO PHY DMG BODILY INJURY(Per accident) E AUTOS ATO-OWNED - PROPERTY DAMAGE § Peraccident HIRED AUTOS AUTOS UMBRELLALIAS OCCUR EACH OCCURRENCE E EXCESS LIAR CLAIMS-MADE AGGREGATE E OED RETENTION$ - C WORKERS COMPENSATION WC033575314(ADS) 0310112013 031Q712014 X WC BTAM O- OTH- J�, G AND EMPLOYERS'LIABILITY WC033575315(AK,AZ) 0310112013 0310112014 EL EACH ACCIDENT - $ 11000,000 ANY PROPRIETOR/PARTNERIEXECUTN E E NIA 1,000,000 D OFFICERJMEMBER E%CLUOEO? WC03357$316(FL) 0310112013 03/0112014 EL DISEASE-EA EMPLOYE 8 (Mandatory in NH) _ 1,QG0,60U ' If yes,descrbe under ' E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C WORKERS COMPENSATION WC033575317(KY,NO,NH,VT) 03/0112013 0310112014 (EL)LIMIT 1,000,000 C WC033 575318(NJ) 0310112013 0310112014 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Romarks Schedule,H more space is required) - EVIDENCE OF COVERAGE CERTIFICATE HOLDER - CANCELLATION THE HOME DEPOT INC. - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HOME DEPOT USA,INC. ' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 245511PACES FERRY ROAD,NW ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING C-20 ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE _ — of Marsh USA Inc. Manashi Mukherjeea'�?�'"' "k""` � ©1988-2010 ACORD.CORPORATION..AIl rights reserved. -" - ---- -- --- The ACORD name-and-logo are registered marks df ACORD ;4 . .ACORD 25(2910/05) - -- --. ----- _— <g-,—_—------.___..--. _ - -