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101 MARLBOROUGH RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY Board of Building Regulations and Standards SALEM � ah ' Massachusetts State Building Code, 780 CbfR Revised Mar 2011 (11 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Divelling This Section For`Official Use Only. ' Building Permit Number:' Date A ied Building Official(Print Name) i nature. Date - SECTION 1: SITE'INF TI 1.1 Property Add 0 1.2,,Ass Map& Parcel Numbers 1.I a Is this an accepted street? yes_ no Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq fit) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.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, PROPERTY'OWNERSHIPi' 2.1 Owner'of jte ord- Name(Print) City, State,ZIP DI d � Q No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF.PROPOSED:WORK`(check all(hat apply) New C Owne(Construction ❑ Existing Building ❑ r-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition (IDemolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only,_, Labor and Materials y` , 1. Building $ _ I. Building Permit.Fee. $ Indicate h'ow fee is"determined: ❑ Standard._City/['own Application Fee. 2. Electrical $ ❑total Project Cost,(Itern.6)x multiplier- - x 3. Plumbing S 2. Other Fees: $ / i. Mechanical (11VAC) S List: �6� 5. Mechanical (Fire S So i ression) Total All Fees: $ Check No. Check AmOnnt: Cash Amount: 6, Total Project Cost: $ �d1 El Hid in Full __0 Outstanding Balance Due sEcTION 5: CONSTRUcTION SERVICES 5.1 Cous coon Supe 'sor License (CSL.) nn�.'r _ License Number Espi air n Date Name of CSL holder 1 List CSL Type(see below) a63zl .t ,5 lanlee .Type- _ Description No. an- treet t,/ n min U Unrestricted(Buildings u el ing cu. [t.) yyv � V L n R Restricted t3c2 P.unil Dwelling City/town, State, ZIP _ NI Nlasonr RC Roofing Covering WS Window and"Siding - - - SF Solid Fuel (turning Appliances Insulation Pcle hone Email address D Demolition 5.2 Registered Home Improvement Contractor(IIIC) HIC Registration Number E.e rat' n Date I-IIC ' n N n or F t Name No. an t Email address City/Town,State, ZIP Telephone 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 ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED 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 application. / k-1 Print Owner's Name(Electronic Signature) Date SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below, [ he att under the pains and penalties of perjury that all of the information contai din this application is tru and acc r to to a best of my knowledge and understanding. Print Owner's or Authorized Agent's Nam (Electronic Signature) NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under N .G.L. c. 142A. Other important information on the IIIC Program can be found at www.mass.,,ov/oca Information on the Construction Supervisor License can be found at www.rnass,,Ov CIL 2. When substantial work is planned, provide the information below: Total floor area(sq. It.) _(including garage, finished basement/attics, decks or porch) Gross living area(sq. ft.) _ Habitable room count Number of tireplaccs__ Number of bedrooms _ Number ofbathroonts Number of halBbaths Type of heating system Number oFdecks/ porches I'ype of cooling sy;tcni _ Enclosed_------_—Open 1. `'Fotal Project Square Footage" may be subsnnncd for"total Project Cost' 12/02/2012 09:25 17818940331 TODD RIDEMAN PAGE 01 HOME IMPROVEMENT CONTRACT PLEASE READ THIS Sold,Famished and Installed by: Branch Name: Boston Date;/7i/Z/ 1 I,- THD At-Home Services,Inc. —/—/ d/b/a The Home Depat At-Home Services 908 Boston Turnpike,Unit 1,Shrewsbury,MA 01545 Toll Free(800)657-5182;Fax($08)845-6017 Branch Number:31 Federal ID#75-2698460;ME Lic#C 02439;RI Cmt-Lic#16427 CT Lic#HI 0565522;MA Home Improvement Contractor Reg.#126893 Installation Address: A.2/9�lZaLM ba �+ol;9w/J ill 0=9 City State Zip Purehaser(s): Work Pboue: Home Phone: Cell Phone: 11-N --_ ][ ] [ OLPr] 7�b-4ut�S( k4 Ira 5;17 Home Address: (If different from Installation Address) City State Zip Email Address(to receive project communications and Home Depot updates): _ ❑1 DO NOT wish to receive any marketing mails 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.("The Home Depot")agrees to furnish,deliver and arrange for the installation("lastallation")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#: O0f^gP11p6"^ Products: Spec Sheet(s)M Pro'ert Amount r 1 ❑Roofing ❑Siding IR Window6 U Insulation i ,7b ❑Guters/Covers ❑Entry Doors ❑ 6� �/0 ♦ L Roofing LISiding, ❑Windows ❑insulation ❑Gutters/Covers ❑Entry Docts ❑ $ Roofing Sidiug LJ Windows LJ Insulation t [ ❑Gutters/Covers []Entry Dom E § ❑Roofing ❑Siding ❑Windaws ❑Insulation § ❑Gutters/Covers ❑Entry Doors ❑ Minimum 25%Deposit ofCootrad ArtqumdW open execution ofdds euntrace Total Contract Amount § / I�j 6D Mnim Purcha may net deposit more than one4bu'd of the CaatrxetAmouoL ('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 Order or terminals 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 C/ontract.) Payment Summary: The Payment Summary # 711 �_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 arc 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. Custom"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. Accepted by: Submitted X'�/mil ' /`D�- �444� X Customer's gnature Date SalesConsultant's Signature Date X Telephone No. Customer's Signature Date Sales Consultant License No. CANCELLATION: CUSTOMER MAY CANCEL THIS ins 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'rckMS AND CONDITIONS ARE SEATED ON THE REVERSE.SIDE.AND ARE PART OF THIS CONTRACT' nsnn-+2 Wnaa—Branch File Yellow—Customer I t � Massachusetts -Department of Pu4hc.Ss=,-et;+ ` Board of Building Regulations and Standascis License: CSSL-099699 ROBERT POCZOBUT 172 WHALENS LANE Salem MA 00711 o-' C..<+frati.:n a. Commissioner 02/08/2014 i •rrDrk-PT9 il�,.u,L;i1 ii,_,fi r (ii}/it., 131i_�Ch;a�� ,a- iig..l .i_t ,/.1 di s 6 �1�71�1�t }ar?(nTT>9a}jr7 IlL.i '� �'3't7v �� ok'i"; I I�'_ ..�tICS•/11_�s..f ?�Orilu�!Y;'�...".'%' � � ..'�G.i. *' eddr city/ ;i: i r ip:_ r ne#: r' • ate` < Are yo av employer?Check the appropriate box: 9Type of project(required): 4. I am general contractor and I 1. I an:a employer with 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 B. ❑ Demolition working for me in any capacity. employees and have workers' y Building addition [No workers' comp.insurance comp..msurance3 required.] 5. Q We are a corporation and its l0.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions right of exemption per MGL myself.,[No workers'comp. 12.❑ Roo repairs insurance required.]t c. 152,§1(4), and we have no 13. ther employees.[No workers' O comp.insurance required.] •Any applicant that checks box pl 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 him outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name 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 insurancefor my employees. Below Is the policy and job site information r---� Insurance Company Name:_-_____ (,�__o_-,_ Policy#or Self-ins.Lic.#: �A� t LI7- Expiration Date: / J Job Site Address: () City/State/Zip: WI Attach a copy of the workers'compensation policy decla . n page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL 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 un r th pa! s a penalties ojperJury that the information provided abo a is tr and correct Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town oJrciaL City or Town: Permit/License# Issuing Authorjty(circle one): r 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other - Contact Person: Phone#: ., Uzi n .- 14 CITY OF SaU..F—.%I, N-LksSACHUSETTS • BUILDNG DEPARTMENT 3 N 130 %V.NsNINGTON STREET, 3° FLOOR bona"'` TEL (978) 745-9595 F.4-x(978) 740_9846 KI,ffiERLEY DRISCOLL MAYOR TH0.%W ST.PtERRS DIRECTOR OF PCBLIC PROPERTY/BI:ILDNG COMLMISSIONER 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: � I�aCUG (name o(hauler) i The debris will be is osed of in 1 (name of facility (address of facility) sign re of permit applicant d to dcbris�t):d.w I� NEW Office of Consumer Affairand Business XZegulatioil llj 1 o Park P16za - Suite 5.1.70 l Assachlasetts.02116 ISM Boston, stoma Timpxover ontractox•Registration Rellistratlon: 126p93 a — Type: Supplement Card . S Hirplragon: Eli=014 The Home Depot At-Home 5elvi _ P.ICHARD .rALLQNE 2690 cUMBERLAND"PARKWAY F ATLANTA, GA 30339 - c S'wtr Update Address and return card.Mnrkrensonanr ebnngc. . E-Address Renewer Lrmploynrent Lost C11H 9/w_&WWtdlllUaQar/i 0�✓(. 4/arsaw '.. fltlon valid.fo . onsumerArtnirsRHusmess Regvlat,on Licanse or registr GjnceotC for before the expiration dnier 1f found return to ' I" t UME IMPR eWT� NTRACTOR office m ce of Consuer Affairs and Business Regulntion ' �JIMF �'�,. ry r�ogistratlo� $268�3 t Typ°: 10 P°rliPlazn-Suite 5170 r. Ex plratfurf„'0/31,`�E}t'.4 Supplement Card Boston,MA 01116 IamE1 Depot IAI tne''3er5iries r i HARD FALLiSNp;+i7t'1� •bd0 CUMECRLA�J4 P:I ..W 9 ��'�" �— at vnlid svith ut sl nature GA 30339 6 ,5 _ CERTIFICATE OF LIABILITY INSURANCE 11/15/2012 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), AUTHORIZED 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 certificate holder in lieu of such endorsement(s). PRODUCER 1-866-966-4664 CONTACT NAME: _ Marsh USA Inc. PHONE FAX AID No): homede Ot.certre est@marsh. E-MAIL p 4n com ADDRESS: Two Alliance Center, 3560 Lenox Road, Suite 2400 INSURERS AFFORDING COVERAGE NAiC# Atlanta, GA 30326 Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURERB: Zurich American Ins Co 16535 The Home Depot, Inc. New Has - "' INSURER C: Hampshire Ins Cc 23891 Home Depot U.S.A., Inc. 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co 23817 Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 INSURER F: Illinois Union Ins. Co 27960 COVERAGES CERTIFICATE NUMBER: 30289573 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. INSR TYPE OF INSURANCE AODL SUER POLICY NUMBER MM/OUY EFF/ MMNU EXP LIMITS TR A GENERAL LIABILITY - GL04887714-02 03/01/1 03/01/13 EACH OCCURRENCE $ 9,000,000 R DAMAGE01RENT D 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES(Es commence) $ CLAIMSWADE IJOCCUR MED EXP(Any one person) $EXCLUDED X LIMITS OF POLICY XS PERSONAL B ADV INJURY $ 9,000,000 X OF SIR: $IN PER OCC GENERAL AGGREGATE $ 9,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 9,000,000 X I POLICY PRO-JECT 1-1 LOG $ B AUTOMOBILE LIABILITY BAP 2938863-09 3 1 3 Ol EOMse1de,ED SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Par accident) IfAUTOS AUTOS NON.OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident X SELF INSi1R D PRY DMO $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS DAB CLAIMS-MADE AGGREGATE S DEO I I RETENTION$ $ C WORKERS COMPENSATION WC019736915 (ADS) 03/01/1 03/01/13 X WOCRy Ij OEH AND EMPLOYERS LIABILITY D ANY PROPRIETORIPARTNERIEXECUTIVE YIN NIA WC019 7 3 6 917 (PL) 03/01/1 L.03/01/13 E, EACH ACCIDENT $ 1,000,000 { OFFICERIMEMSER EXCLUDED? N WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 E (Mandatory in NH) .yes,de scribe under E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below 8 Workers Compensation WC1192494 (QSI) 03/01/1 03/01/13 SIR (AOS)/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 3014/114 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,AddiUanal Remarks Schedule,If more space Is required) RE: EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. HOME DEPOT V.S.A., INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 ,_)�(ati.rlo 2.i �1 wU�ha.`14t USA Q ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Jthornton_hd 30289573