21D MARION RD - BUILDING INSPECTION The Commonwealth of Massachusetts
�l CCCY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CLIR Sar
Revisedd Mar 2011
b Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
ThisSaction.ForOfficial uxonlyl `
Building Permit Number: Date A lied
tY' .
• Building Official(Print Nay O ignatur - Date
SECTION 1:SITE E F05MION
1.1 PropertyJIT) 'MR'rl nya L 2 Assessors Map& Parcel Numbers
s
1.la Is this an accepted street'?yes_--. �no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use r Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2 PROP.ERTY'OWNERsffiPL
2.1 Ownerto Rcord: �
p e.YYI�/lh �m ( 11
Name(Print) _r City,State,
VCT7 "n
No.and Street Tellepho6e Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
r
SECTION 4: ESTI&LATED CONSTRUCTI N COSTs-
Item
Estimated Costs:
Official Use Only.
Labor and Materials)
1. Building 5 I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard,cityrrowm Application Fee
❑'Cotal Pioject Cost(Item 6)x multiplier x
f 3. Plumbing S 2. Other Fees: 3
1. Mechanical (IIVAC) 'S List: i
i. Mechanical (Piro
Sul1rression) _ S '['otal All Fees: 5_ -
- --- Check No. Check Amount: __—Cash AmOnnt:__
n 1'111al Project Oust S J { 7j—ram
`� ] Paid in Fall 0 Outstanding B:dana Uu
SECTION 5: CONS'rRUCI'ION SERVICES
5.1 Construction Supervisor Li ease (CSL.)
License Number •.e ra o t Dore
Name ot•CSL II[older, ( � List CSL Type(see below)
'i2 )� 4I� tYrA I 4 ia— Type OFLICIBurning
Description
No. and Street
��� R 2 Fain s u el ing cu. lt.
i1. R 5e2 Faintly Dwelling
Ci -/rown, State, ZIP �f
RC verin
1VS Sidin
SF urning Appliances
I I Insulation
Pole honeholl Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) WM5
r— HIC Registration Number 4En.
I IfC t" N\�.n or f IC Re ism nl at e
No. d [reel ! Email address
\ 4
City/Town, State, ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 1 25C(6))
Workers Compensation Insurance affidavit must be c pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No...........
SECTION 7a: OWNER AUTHORIZATION TO DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR HUMMING PERMIT
1, as Owner of the subject property, hereby authorize IrC —
to act on my behalf, in all matters relative to work authorized by this adding permit application.
Print Owner's Name(Electronic Signature) t
SECTION 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby est under the pains and penalties of perjury that all of the information
cunt.' ed in this application is true a d a cu ate t the best of my knowledge and understanding.
Print her s or Aut torisd.\gent's Nante(E1411 -1—
«o gaatum) ;t
NOTES:
ffprrogramor
Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
r gistered in the Houle Improvement Contractor(HIC) Program), will not have access to the arbitration
guaranty fund tattler M.G.L. c. 1.12A. other important information on the EI[C Program can be found at
wwwam:tss,l,ovroca Information on the Construction Supervisor License can be found at wtvw.in;us.so�'dL
F-
2. W'hen substantial work is planned,provide the information below:
tloorarea(s,l. !t.) (including garage, tinishedhascmendattics, decksorporch)
livingm-ca(6y. d.) _ [fabitable room couter or tiraplaccs -----_— Numberofbedrooms
't of bachrivtm; Number of haltAmilts
------------ --
rvpc or heating syatcut ----,_-- Nunberofdacks! pnrihes
I)pe„fcoohw' syacnt
G,MI Prol.et 1yu.uo ;ub;f itutJd La rule't ('u,['
The Commonwealth ofMassaehusetts
Department oflndustrial Accidents
Office of Inveydgations
600 Washington Street
Boston,MA 02111
kv . www.mass govIl is
Workers' Compensation Insurance Affidavit: Builders/Contractors/EI pleastri e Print m ibly
er
Applicant Information
Nye(g usines9lOrganizetion/Individual):
Address: a
City/State/Zip: Phone.#:
Are you an employer?Check the approprirIam
Type of pioject(required):
4neral contractor and I 6. ❑New construction
i.❑ I am a employer with have hired the subcontractors
emPloyees(full and/or part-time)' listed on the-attached sheet 7. ❑Remodeling
2. I am a sole proprietor or Pa t=t Tme sob-contractors have g, (]Demolition
ship and have no employees employees and have workers' 9. ❑Budding addition
working forme in aay capacity comp.insaranae.t
[No workers'comp.insurance 10. Bkctdcal repairs m additions
5. ❑ We atz a corporation and its
required-1 officers have exercised therr 11.❑Plumbing repairs cr additions "
3.❑ 1 am a homeowner doing all work right Cf exemption per MGL 12.[]Roof repairs I
coyselE insurance orequired.]t comp e. 152, ( and we have no 13.0 Othcr
employees.ees.(No workers'
comp.insurance required.]
bears that cheeks box#1 must also fill out the section below slowing thew wcdM'cotrtpm°aUM Policy inibanaat'w-
*Any a" arc doing an wmtand exn hire outside conosctes most subrral anew affidavit indicating such. �
t Homeowner°who subnrit this affidavit hedintivg 0ty mug and whether or not those anddes how j
tcontnsctors ant check this box want attached an additional short showing asemune of aubeontrectnn I{
employees. If the subcontnetors have cuployew,fimy ruen inmde even wwlata'camP•Policy nornim
employees Below!s the policy and job site.
I am an employer that is providing workers'compensation insurance for my
information ��
Insurance Company Name:
Policy#or Self-ins.Lie.#:_n_�
Expiration Date:
Job Site Address: �t3 City/statelzip:
Attach a copy of the workers' compensation policy decoration page(showing the policy number and expiration date).
Failure.to secure coverage as required under Section 25A ofMGL 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 is the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investi lions of the MA for' e cov a venficatio .
d do hereby cer8fy under a pains d p lli fpef}ury that the mformadoa provided abo is true and correct
Date: --- —
Si ature: i
one#:
Of"k use only. o not write in is area,tb be completed city or town of-----------------
ficial, [
- k
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 4
6.Other 1
Contact Person-
Phone#:
TS CAT"c IMPMCO'n"M
AC�lY CERTIFICATE OF LIABILITY INSURANCE DZ272a13
CERTIFICAIFICATE IS ISSUED AS ;�:iilbkl TE DOES NOT AFFIRMATIVELYGHTS UPON THE CERTIF
EOR NEGATI011f ERS NO II
L OF VELY AMEON ONL
ND,rEXEND OR ALTER THE COVERAGE AFFORDED ABY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITU A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
E
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT:. 1f the certificate holder is an ADDITIONAL INSURED,the policy{Les) must IHI endorsed. US
UBROGATION 9S WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement S, NT T
PRODUCER NAME: I FAX
IC
MARSH USA,INC. PHONE A NP:
E-MAIL
TWO ALLIANCE CENTER PEat _
3560 LENOX ROAD,51117E 2400 ADORE-s:
NAICtl
ATLANTA,GA.30326 INSURER S' COVERAGE
Steadfast insurance Company 26387
IW492-Hamel)-GAW-13-14 INSURER A: 16535
INSURER B:ZUDCh American In$Urirlx CO
INSURED- 23841
THE HOME DEPOT,INC. INSURER C:NewHampshue iris CD
HOME DEPOT U.S.A.,INC.- - Illinois National Ins Co 23817
2455 PACES FERRY ROAD,NW INSURER D:
BUILDING C-20 - INSURERE:
ATLANTA,GA 30339
_ INSURERE: -
COVERAGES CERTIFICATE NUMBER: ATL-W3t5954504 REVISION tdUMBER:7
NOICis 10 ATEO.CNOTTMTH3TT THE ANDING ANYI REQUIREMENT,TERM OR CONDITION OF ANY CONTRALTO OR OTHER DOCUMENT WITH RESPECT TO WPOLICY HICHI 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 IPAII CLAIMS LIMITS
WSSR TYPEOFINSURANCE POLICY NUMBER MMIDD !(MWD I Sow=
A GENERAL LIAeIUTY GLO4887714-03 '031012013 I03101/2014 EACH OCCURRENCE 5
DA S
X PR is S E cwrtence EXCLUDED
COMMERCIALGENERAL LIABILITY LIMITS OF POLICY XS ME0 EXP ona arson) S
CLAIMS.MADE [i]OCCUR OF SIR$1M PER OCC PERSONAL a AOV INJURY I$ 9,000,000
GENERAL AGGREGATE s 9'am'aw..'
PRODUCTS-COMPIOP AGO S _: 9,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: s
X POLICY PRO LOD 0310112013 031012014 COMBINED SINGL MI 1,000.000
BAP 2938863-10 - - Ea;«teem - s
B AUTOMOBILE LIABILITY I BODILY INJURY(Per person) S __
X ANY AUTO SELF INSURED AUTO PHY DMG BODILY INJURY(Par accident) S
'AU O SCHEDULED - i
AUTOS AUTOS - PROPERTYDAMAGE S
NON-0WNED Per accidentdentl --
HIREDAUTOS AUTOS - S
EACH OCCURRENCE S
UMBRELLA DAB OCCUR
AGGREGATE S
EXCESS DAB CLAIMS-MADE - I ,
S
DED RETENTIONS WC033575314(A S) 0310112013 03101 014 X WC STATU- OTH-
C WORKERS COMPENSATION 1M.000
C AND EMPLOYERS'LIABILITY YIN WC0=5315(AK,AZ) 0310112013 031012014 E.L.EACH ACC DENT S
ANY PROPRIETOWARTNERIEXECUTIVEn 1.000,000
OFFICER.'MEMeER EXCLUDED? _ 1N NIA WC01357531S(FL)., 03/0112013 031012014 E.L.DISEASE-EA EMPLOYE 5
D (Mandatory In NH) - 1,000,C00 -
Ityea,dascnbaunder EL DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS 0.b 1,000,000
C WORKERS COMPENSATION WC03357531T(KY,NC,NH,VT) OY012013 I03101IM14 (EL)UMIT
C WC033575318(NJ) 0310112013 00112014
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD let,Additlonal Remark;Schedule,It more apace 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
2455 PACES FERRY ROAD,t1W ACCORDANCE WITH THE POLICY PROVISIONS.
'BUILDING C-20
ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE
of Marsh USA Inc
Manashi Mukherjee sVlaAnmaw `M^"' 'u'
0 1 988-201 0 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Oflce ai Coosq er Afffii;s�5`Laala ss tl�gdlation-'.. 11emsior registration valid foi-hOv Oloo'trrAy
0147E IfitPRg4 EkiT CO�ATR�1WOR before the axprrataou data of fauud return to:.
, 1STtCCot C4?Yurues Affair 4 an tu3+ne s iiegul� h n
Regtstfzfion >193. � ��Pe 703'atkE'Irza °Sufte3aT0
facpl�ra• s 3uppkme`nt o v Boston,�YdP`QklIb .
Tt>z HoN a De�io"tT f: r ; t _
rn
1
RlCFI.4F.D FA�L ���� �3� f
1890 CUMBERLA �
Uedirsecretary of slid ' ifhoutkgnalure
Massachusetts-Departr„ent of Public Safety
.y Board of Building Regulations and Standards
. .F'F+aiik �e
License CSSL-ON699 'k ,
1
ROBERT POCA)BUT•. r �a
172 WHALENS LANEx'�""
Salem MA 01970 f
Commassvoner Expiration
0210812014
3
y. CITY OFS'U'sm, ibL1 &wFiusETTs
rl i BL[WLYC❑EPARTIF.rT
\ram i120 VIVASHLNGTONSTREET, 3 Root
s T EL (978) 745-9595
RU((973) 7•W-9344
D uECTO R OF PL OLIC PROP ERTy/aL MnL%(G CON WISStON ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
fn accordance with the sixdl edition of the State Building Coda, 730 CM section l l 1.5
Dcbris, and the provisions of rMGL c 40, S 54;
Building Permit hi 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 NML c
l l 1, S I SOA.
The debris will be transported by:
'nb
(namaufhaulur)
The debris will be disposed of in :
(nnma of facility) I
(address ur r��ilit�)---
t
`igi nua olprrmit applicant
American Properties Team, Inc.
TO: 21D Marion Road
FROM: Jennifer Pappas, Property Manager
RE: Window/Slider Replacement
DATE: June 10,2013
�.a�*s�**a>�e*■u:+�r�w».*�s�*.*a►.�a.�.►���s«*r�«:x«ex�rsa*rr�x��e.�ss.s�s�
Please be advised that the Board of Trustees for Pickman Park has approved replacement
windows and a slider for the above referenced unit. This approval is contingent upon them
matching the existing windows and that they fit in the existing opening.. Installation of the
windows must be completed from the interior of the unit and they must be the same in
appearance from the exterior. Should the installation be completed from the exterior of the unit,
you will be responsible for any damage that your contractor might cause(this includes painting).
The Board will not allow windows with grids, crank outs, etc. Should you contractor find any rot
or damage during the window installation,please make sure that it is reported to my office
immediately.
We also require that permits be pulled in advance(regardless of what your contractor may tell
you),and then a copy of the final approved permit once completed must be sent to APT for the
unit file as well. We also recommend that owners obtain a certificate of insurance from the
licensed contractor.
You will need to bring a copy of this letter to the Salem Building Department in order to receive
your permit.
Should you have any questions or require_additional information,please feel free to call me
directly at(781)569-2675.
cc: Unit File
500 WEST CUMMINGS PARK•SUITE 6060• WOBURN -MA •01801.781-932.9229 •FAX 781-93S4289
JUN-3-2013 23:23 FROM: T0:17815692657 P.1/1
AT-HOME
s�t�v�ce� qqp�p
Jab#
To whom It may concernn.f
Re:address: .2 0 /C eu,,J �t7
1na77j 1rJ 0290- 7
Concerning the above location,we give the Home Depot approval to Install
Numberofwlndows ��Id�NpOtnlj -� r�T>oe�
Style (DaAle Hung/Casement,namewpa). d Ij $ $LIN-CA L` W Aar,-
Color tiff
Manufwwre.&;tq ,rS ."�iRattCe� ( 9a a1 J,�+►If�r/tsr?I✓' 1 )p P�'� ✓hr1a1J�J�
Exted"finish as agreed to be PVC(wrap trim)? a.giyit e,l cola
We agree to the grid or lack of grid configuration b—
Are grids bemoan the panes of glass?,jIJjAI
As stated these proposed windows do meetwith the Condo Management approval.
SI ad pMnt name
11 e ifAKIO
Date;
0G/08/2013 20:25 1781e940331 TODD RIDEMAN PAGE 01
HOME IMPROVEMENT CONTRACT
PLEASE READ THIS
, '� Sold,Furnished and Installed by:
Brareb Name:Boston Norm&South Date:L/z� THD At-Home Services,Inc.
d(b/a The Home Depot At-Home Services
Branch Number:31 and 33 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545
Toll Free 877-903-376R
Federal ID#75-2698460;ME Lic k C 02439i RI Cont.licit 16427
/,yYJj C tic/p HIC.0565522;MA Home ImNpravemem Contractor Reg.RReeg..ft 126893
Installation Address: n /f/�0410-1 R-✓� SA(C►vi AVA Oil r v
City State Zip
Purchmer(s)= Work Phone: Rome Phone: Cell�P7hone:
I
_ 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 mails from The Home Depot
P jest 1 for n: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,
an T At-Home erviccs, 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 Shcet(s), all of which arc 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 p: o....en au n..0 Products: Susc Shoe s a: Project Amount 1
Roofing LjSiding go Windows U Insulation 111
3RDy7 ❑Gump/Covers ❑Entry Doors ❑ 73753� $ N7
Roofing USidiiig U Wi;aows__U insulation $ I�171)
❑Gutters/Covers ❑Entry Doors ❑ "P---t
Roofing LISiding L1 windows El Insulation - $
OGutters/Covers ❑Entry Doors❑
Roofing usidin U Windows U Insulation $
❑Gutters/Covers ❑Entry Doors ❑
Miemtam25"/.DepoWofContntt Attronntdneupnne.a.ti000fthis eomr°es. Total Contract Amount $'�'755` d0
Matoe Purelta maynotdrpoafmotethanone4abdofine CentmeAmoanL J
Customer agrees that, immediately upon completion of the work for each Product, Customer will execute a Completion Certificate
(one for each Product as defined by an Individual Spec Sheet) and pay any balance due. As applicable, each Customer under this
Contract agrees to be jointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Ordcr or tcmtinate this Contract or any individual Product(s)included herein,at
its discretion,if The Home Depot or its authorized service provide determines that it cannot perform its obligations due to a structural
problem with the home,environmental hazards such as mold,asbestos or lead paim,other safety concerns,pricing errors or because
work required to complete the job was not included iii�di}Q$�CQonYt/ra�c/t�./
Payment Summary: The Payment Summary qjte. included as part of this Contract, sets four the total
Contract amount and payments required for the deposits and final payments by Product(as applicable).
NOTICE TO CUSTOMER
Yon 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 e f 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.
Acee fence and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer
and c Home Depth with rcganl to the Products and Installation services and supersedes all prior discussions and agreements,either
oral or written,rciating 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 agree+that CuTmcrreadl,understands, voluntarily accepts the
terms of and has receiver(a copy of this Agreement.Xccept / Submitted b 7
Cos errs S44ture Date Sales Consultant's Signature Date
Telephone No-
Customa's Signature Date
Sales Consultant License NO,
CANCELLATION: CUSTOMER MAY CANCEL THIS (asapplirak,10
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 AND CONDITIONS ARF.STATED ON TRF.REVERSE SIDE.AND ARE PART Or Tints CONTRACT
05.417-13 White—Branch File Yellow—Customer