101 MARLBOROUGH RD - BUILDING INSPECTION (3) Vb I I�z
r—r— lot ziI ZS
The Commonwealth of Massachusetts
,Iti 4a!!T Board of Building Regulations and Standards CITY OF
• Massachusetts State Building Code, 780 CMR SALEM
Revised Mar?Ol
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
NBuilding Permit Number: Date Applied:
11 3 1
Building Official(Print.Name) Signature U M Date
SECTION L• SITE INFORMATION
I 1.1 Property Addre 1.2 Assessors Map&Parcel Numbers
r0I 1�A6by
1.1a Is this an accepted street?yes Map Number Parcel Number
1.3 Zoning Information: L4 Property Dimensions:
Zoning District Proposed Use 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.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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rhr)r9ord��� �le
Name(Print) (( ^ City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Otw ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building
1. Building Permit Fee:$ e7L Indicate how fee is detetanined;
$ � ,;.
❑Standard City/Town Application Fee o
2. Electrical $
❑Total Project Costa(Item 6)x multiplier x
7C
3. Plumbing $ 2. Other Fees: $ w
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amon
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due: �#�
SECTION 5: CONSTRUCTION SERVICES
5.1_L►censed C_{o/1Jtrygtructioo 5uo(ervisor fCSL) � �/�
flS) PO UL9.� License Nuro��, Exo__ti__ Date
Liam-of L-_ older
N- List CSL Type(see_below) ,aCi
es T e - - - Description
U Unrestricted(uD to 35,000 Cu.Ft.)
afore R Restricred i&2 Faatil Dwellin
M Mason at
Telephone RC Residential Roofing Coverin
WS Residential Window and Siding
Sr Residential SOtid tact Bumin A fiance Installation
D Residential Demolition
5 2-�Re�stere . ome im_or dent nhactorlFQC_l _
rrrc cc _ or Re a R_eetstmetton - ff5
Z Expiration 13atel_
Siena - - Telephone
Email Address
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT.(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be 5911eted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issux of the building permit.
Signed Affidavit Attached? Yes ..........16 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETEID WHEN
OW S NER' AGENTOR.CONTRACTOR.AEPLIES FOR BUILDING PEBNIIT
L__ - !L as Owner of the subject property hereby
authorize
to act on my behalf,in all matters
relative to work authorized by this building P PP permit application.
jk r
Signature o-0_waer. Dale FJ
oSEC�T/ION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
1,--- ' ----- JC l ��;_L ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
berha il F
P Sie o rz
(Si ed A�g�ent,
e
the pains and penalties of perjury) - --
. - NOTES: - -
1. An Owner who obtains a building permit to do his/her own work or an owner who hires an tuuegistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will rror have access to the arbitration
program or guarenty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found n 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable mom count
Number of 5replaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of beating system Number of decks/porches
Type of cooling system Enclosed
Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF si .Em,, iNLxSSACI-ILSETrS
BULDi\G DEP M ENT
120 W ASHLSIGTON STREET, 3° FLOOR
TEL. (978) 745-9595
FA.Y(978) 740-9846
K1tiBEIBI.BY DRISCOLL
,MAYOR : THO&tAS ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BU ILDLNG CO`L%fISSIONFR
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)
(address of facility)
Ar-
signature of permit applicant
date
JcheitilTJoc
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MA 02111
' 'n 'n�3%l0n iu��i. 3,IlCCl1.Iii�1lr__ Build�i'S/LOQr'a-1:9i�r'EleCi?"1C13a3/PiQTnbero
��/orkar� C7 P Please Prin- Uaib'
�,D o iican t Inaorma:ion
;i a, 3asines;r garizaion t dr dual):
\dd>sss;
�t � t it }
:it~f/State/Zip: hone #: ICJ
Type of project(required):
re you an employer? Check the appropriate b x: 6 New.construction
4, u I am a general contractor and I
I am a employer with have hired the sub-contractors 7 �Remodeling
employees (full and/or part-time)
listed on the attached sheet.t
I am a sole proprietor or partner- These sub-contractors have 8. ❑Demolition
ship and have no employees workers' comp.insurance. 9. Building addition
working for me in any capacity.
[140 workers' comp. insurance 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions
officers have exercised their
reouired.l 11.❑ plumbing recess or addurons
❑ I am a homeowner doing all wor right of exemption per bfGL
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑�,Roof repairs
employees- [ io workers' 13.Ld'Otlrerj�--
insurance required.] t comp.insurance required.]
ry applicant that cfiecks box Rl muscalso fill Out section below showing their workers'compensation policy information.
,tractorsthatcheck his box mostvitan dichedaan addi Tonal they are sheegshowing the name o IllwoTk and then ti the sub-contra conCaties and their workersde contractors must subrrdL 'compapolicy information.
n as enrployar i a1 is providing worker s'compensadurl insurance for my employees. nefow fs tisepoucy and;ov site
brntation.
urance Company i tame:
Expiration Date:
licy# or Self-ins.Lic.#: 1!'( L Q�l''�---- y
City/State/Zip:
t Site Address:
compensation policy dec�'drration page (showing the policy number and expiration date).
tach a copy of the workers' Of
:lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition Wcriminal DER an o a
e 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
up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
,estigations of the DIA for insurance coverage verification. _
o hereby ce i nd r th pains and penalties of perjury that the information provided above is true and corrzct.
Date: /j
nature: `
one #:
Officiaf use only. Do not writ77=7P
y city or town officfaL
rmit/License 9
City iir Towri:
(ssuing Authority (circle one
1. Board of Health 2.BuildiClerk 4.Electrical Inspector S.Plumbing Inspector
i. Other
Phone p:
;ontact Person:
Z
BU3
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ficc or Con�um�r
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THE HOME - "C)EPOT-A,
W=I.tCHASO FJ'LLONE-- �. tv3rdwith ti e
1455 PACE-
GA 30339
e"'
DATE IMMIDDIYYYYI
ACO CERTIFICATE OF LIABILITY INSURANCE 023201,
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(SI, 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, suhject 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 andorsement(si. C NTA T
PRODUCER NAME: IFA%
MARSH USA, INC,I PNONE AIC No'
TWO ALLIANCE CENTER EMAIL
3560 LENOX ROAD,SUITE 240f ADDRESS:
ATLANTA,GA 30325 INSURERS AfFOR01NG COVERAGE NAIC p
Steadfast Insurance Company 126387
INSU0.ERA: p y
W0492-HomeD-GA'M-I6-17 Zurich American Insurance CD I23841
INSURED INSURER a
THD AT-HOME SERVICES,INC. New Hampshire Ins�'o 23841
INSURER C: '
OBA THE HOME DEPOT AT-HOME SERVICES Illinois National insuranceinsurance Company 23817
269
2690 CUMBERLAND PARKWAY,SUITE 300 INSURER D
ATILANTA.GA 30339 INSURER E:
INSURER F'
COVERAGES CERTIFICATE NUMBER: ATL-00374fi646-14 . REVISION NUMBER:8
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. LIMITS
q00 UBR POLIOYEFF POUCYEXP
HIER. TYPE OF INSURANCE i POLICY NUMBER MMIDDfr/YY MMIODIYYYY
LTR 1 I i iGL04887714-06 I03,0112016 I0310112017 9,WO,WO
A X I COMMERCIAL GENERAL LWBIUTY EACH OCCURRENCE 'a
DAMAGE TO RENTED 1,000.000
1 PREMI ES aoccunence i
CLAIMS-MADE C OCCUR EXCLUDED
i� I LIMITS OF POLICY XS I MED E%P(Any one penpm
OF SIR:SIM PER OCC i PERSONAL S ADV INJURY 9'000'M0
GENERAL AGGREGATE
9,900,000
' GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG i
9.000.000
X POLICY❑ jEC BT I LOC
OTHER: I I I 1,000,000
8 AUTOMOBILE LIABILITY
!BAP 2938663-13 I03,0t2016 ! 71012017 CCMe�e SINGLE LIMIT
I a00ILY:NJURV;Psr persanl 1i
FANY AUTO h I SOOILY INJURY(per acclden!)1
ALL OWNED SCHEDULED I KELP IM$URED AUTG PHY DMG OPERTY DAMAGE S
AUTOS PR _
NON-OWNED 1 I. _ ._. - -Per accident' -
1 `- HIRED.Al1TOS- - AUTOS I I I S
I I
I UMBRELLA UA8 OCCUR EACH OCCURRENCE i
I�EXCESS LUIa H CLAIMS-MADEI I AGGREGATE s
S
DED RETENTION i
C WORKERS COMPENSATION WC015519215(AOS) 0310112016 '03N112017 X PERT oRH-
ANDEMPLOYERTLIABIUTY YIN WC015519217(AK,KY,PIN.NJ,4TJ 0310U201fi I03N112017 E.L.EACH ACCIDENT i 1,000,000
C ANY PROPRIETORIPARTNERIEXECUTIVE N NIA . 1,000,000
D OFFICERIMEMBER EXCLUDED? WC015519216(FL) 0310112016 0310112017 E.L.DISEASE-EA EMPLOYE s
(Mandatory In NMI 1.000,000
Continued yes,descnee under CoUed on Additional Page E L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS below
1
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be anached If more space is required)
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
FATLANTA,
T-HOME SERVICES,INC. SHOULD ANY OF THE :EP
OESCRI13ED POLICIES BE CANCELLED BEFORE
HE HOME DEPOT AT-HOME SERVICES THE EXPIRATION DHEREOF, NOTICE WILL BE DELIVERED IN
PACES FERRY ROAD ACCORDANCE WITH TLICY PROVISIONS.
GA 30339
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Manashi Mukherjee
C 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101)-_ __ The ACORD name and logo are registered_marks of ACORD _.
_ = CSSL-099699
ROBERT'POCZOBUT _
172 WHALERS LANE
SALEM MA 01970
02/08/2019
Joa Contacts
Friday,October 21,2016
° Comments Lead: 9616034 _!Oj Advanced Search 2:10 PM
InfolUpdates Homeowner Information Job Information
Commissions
Homeowner M/M Ronald Danna Sale Amount $2,486.00 Balance Due: $1,864:00 .3
-
Homeowner2 Product 6500/6100 Series Windows(8%)
Costs Job Site Address 101 Marlborough Rd. - Status Sale/Material Ordered
SALEM,MA 01970 Branch Boston North
Documents - - -
Measure# 79014656
Schad Measure County ESSEX v Sales
Billing Address 101 madborough Commission Rate
Homeowner - - SALEM, MA 01970 Consultant Name Term Date Solit Comp Plan
Job Issues _ _ - a JAMES M CORLISS 100.00%Straight Commission'
Primary Phone (407)256-0557
Labor Update - - 8 - - - 7 -� - -
Work Phone (985)860-3214 Ext. -Back: No Cross Ref# 1-8946239472 Siebel Ord... 349633 1
Order Detail Cell Phone I . _ Key Dates - 1
Work Phone 2 Sale Date 10/15/2016 FUP Date _ _j
Order Ent ry Cell Phone 2 Credit Date 10/15/2016_ FPD-Customer
Payments Email ka_osfactor@gmail.com RTP Date - 10/17/2016 Post Install Date_
Cross Street Start Date 11/1/2016 FPD-Home Depot
Permits _ ..... _ _ ... . .
PO - Marketing Inspection
Referral Store 2686-SALEM,MA 4 Job Indicators
Result Combo Base Store 2686-SALEM,MA Partial Job.
Lead Source 0080 Store Associate-OLS Lead Paint:Assumed-LSWP Requir
Services -
Show May �A�
TouctrPoints
User (Date (Time Status Corr. Appt.Date IAppt.Time Consultant 1
Update Job Ashley S Asigbey 10/18/2016 10:55 AM Material Ordered No 10/15/2016 1:00 PM JAMES M CORLISS
Work Orders MARTIN PARKER 10/17/2016 9:03 PMIOrder Received-PSG No I 10/15/2016 1:00 PM JAMES M CORLISS
MARTIN PARKER 10/17/2016 9:03 PMIMeasure Complete No 10/15/2016 1:00 PM JAMES M CORLISS
Mary Harris 10/17/2016 2:38 PMIReleased to Production 'Ili No 10/15/2016 1.00 PM JAMES M CORLISS
Mary Harris 10/17/2016 2:31 PM Order Entry No 10/15/2016 1:00 PM JAMES M CORLISS
JAMES M CORLIS I 10/15/2016 2:50 PMICredit Pending No 10/15/2016 1:00 PM JAMES M CORLIBS
JAMES M CORLIS 10/15/2016 2:50 PM Sale Pending No 10/15/2016 1:00 PM JAMES M CORLISS
Dayend Dayend 10/14/2016 9:08 PM Sent to the Field No 10/15/2016 1:00 PM JAMES M CORLISS
Sheneetah Chisol 10/14/2016 11:05 AM Confirmed-Left Message No 1 10/15/2016 1:00 PM JAMES M CORLISS
Internet Lead 10/3/2016 7:54 PMIPre-Book No 10/15/2016 1:00 PM JAMES M CORLISS
Internet Lead 10/3/2016 7:54 PM Lead Entered No
Close Print
Home Depot Contractor License Numbers:
MA Home Improvement Contractor Reg. # 126893
Salesperson Name and Registration Number:
JAMES M CORLISS :
Home Improvement Agreement
THD AT- HOME SERVICES, INC ("Home Depot") or Service Provider named below will furnish, install
and/or service the equipment listed below at the price, terms and conditions as outlined on this form.
Customer Information:
Ronald Danna 9616034
First Name last Name Branch Name Lead#
101 Marlborough Rd. I SALEM MA 01970
Customer Address city State Zip
(407) 256-0557 (985) 860-3214 11
Home Phone F Work Phone# Cell Phone#
kaosfactor@amaii.com
Custom I er E-mail OF Address
NOTCE RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR
OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT:
908 Boston Turnpike Unit 1 Shrewsbury MA 01545
Address City State Zip
or Email CustomerCancellationNorthEast@homedepot.com
BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE
SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT
CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE.
YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME
DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME
DEPOT OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME
CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU.
OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT
HOME DEPOT'S EXPENSE.
THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT
TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLED-E-THAT YOU HAVE BEEN GIVEN ORAL
AND WRITTEN OTiCE O UR RIGHT TO CA CEL.
Acknowled,� b
X � 10/15/2016
Customer's signature Date
• 1
Distribution: White- Home Depot Yellow-Customer Copy
WINDOW SPECIFICATION SHEET - Spec.Sheet#: 9616034 Sheet: 1 of 1
�1
Customer: Ronald Dennis Job#: 9616034 Consultant: JAMES M CORLISS Date: 10/15/2016
New Wintlow
Hinge Locations
Existing Window Measurements Grids Product Options Labor Options From outside,
Left to Right
Bays,Bowls
Location Color Rough Opening if of bars #of bars Csmnts,t Pnl,
use L,RmS
Glass Misc Items
Hardware Code
Screens For doors use
g Mull "S"=stationary or
` m m E v ° $ N "%'=Operating
w Style Wraps _ ycy L w c.0 ° v� 2 ` 0 2 to
`
r Room Floor Code (V/N) Style Code Series Coda W xe 5 h '� u s
STO,Gla-Pack'.Standard e,F,wlaP ,
1 FAM 151 PW Y PW 6100 WH WH 28W 23W 51 Lite
STD.GlaaaPack:Slandar0 F,It'i
2 FAM is C2 V PW 610 WH WH 4900 5200 101 S,GBG WH?W C ALL 4 4 ALL 4 4 Lan
HT
STO,Glas.P. StendaN F,WRAP,
3 FAM 1. C2 Y PW 6100 WH WH 49W 52.W 101 S,GBG WHT,W C ALL 4 4 ALL 4 4 LSR
HT
SPECIAL CONSIDERATIONS:
Armin Color WHITE MISC1:FF,MISC2:ML,Line Level Notes2:Care not to damage picture glass on window being r
motor Casing Type emoved,MISC3:ML.Line Level Nori Care not to damage picture glass on window being remov
Bay or Bow window: as
eatboard material(vinyl only-Birch or Oak)
ay Project Angle(30 or 45)
Bay Flanker Type(DH,SH,or Csmnt)
Top of window to soffit(inches)
f bed to soffit,color of soffit material WHITE I have reviewed and agree with all the job specifications above and the
onslmct Roof(Yes or No)' Special Terms and Conditions on the following page
Garden Window:
eatboard Material(vinyl only-White Plumb,Birch or Oak)
Wall Thickness(inches) Customer Signature
ditim at Shelf(Yes or No)
There is no guarantee that new shingles will match existing color.