0039 MASON ST - BPA-19-153 The Commonwealth of Massachusetts
1 Board of Building Regulations and Standards FOR
Massachusetts State Building Co CMR,7`"ed' ' MUNICIPALITY
�( USE
1 Building Permit Application To Co/n ,Repa , Reno a Or Demolish a RevisedJanuary
One-or Twy Dw in 1,2008
This Se tion For i se Only
Building Permit Number: a pplied:
Signature: /O `f
Building Commissi ner/Inspector of PKildw Date
SECTION 1: SITE INFORMATION
1.] Property Address: 1.2 Assessors Map&Parcel Numbers
3`A f�'lgSc�n Sf. Sa `Q .Inn
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: - 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(ft)
1.5 Building Setbacks(it)
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. Ow` 4er'of d:
t a«� 39 hr\01Sr�r�S�
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify:C y NJ Q-r
Brief Descripdo of Proposed Wort': T
0.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Cp Sop d() 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (ITVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ (p Soo , p� ❑Paid in Full ❑Outstanding Balance Due:
��jj t
SECTION 5: CONSTRUCTION`SERVICES
5,.,11^Licensed Construction Supervisor(CSL) 1 b 3''l 3 Z- 13
License Number Expi ion a[e
-Name of CS Jl er Hold Type( ) r 7
Address o t�L� ` List CSL T e see below
Type Description
U Unrestricted(up to 35,000 Cu.Ft.
Signs R Restricted 1&2 FamilyDwelling
3 15_� C M MasonryOnly
O�O -] J RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 -Registered H�t}tne Improtvcme\nt Contractor(HIC) 1 2-O O
H1C Compa Nam or HIC Rrepzs�ic�a N� Registration Number
Address f _� }
_ xpi tion Date
Si tore 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 of 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I> ACL C' `\ Q _ V 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
behalf.
M(a c) Sc3Jlaa , NQ
Print Name
% O
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of a du
NOTES:
1. 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 M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 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 basementlattics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
If www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name(Business/Orgmiration/fndividual): u
Address: _L
City/State/Zip: O l Phone#: 1 D 315
Are you an employer?Check the appropriate box: Type of project(required):
l.)Q I am a employer with 9_— 4. ❑ I am a general contractor and I 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.1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp.insurance 5._❑ We are a corporation and its
required,] officers have exercised they 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions
myself.[No workers'comp, c.152,§1(4),and we have no 12.❑Roof r ans
insurance required.]t employees.[No workers' 13.W otherLnt o V 9r
comp.insurance required.]
*
Any applicant that checks box NI most also fill out the section below showing their workgs compertetiw policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire onside cceds tors must submit a new affidavit indicating such,
tConvactors that check(his box must attached an additional sheet showing the name of the subcoem mors and their workers'comp.policy information.
lam an employer that is providing workers'compensadon insurance for my employees. Below is the policpandjob site
information.
Insurance Company Name: AI /mil
Policy#or Self-ins,Lic.#: Expiration Date: �'] [ 2
Job Site Address:a�� N\4a ) _ City/State/Zip: SS ,
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 a 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby eerily an der the pains and penahes ofperjury that the information provided above is nuuee and correct
L Signature: srir�,n � Date: �I� qj l cT
Phone#:q,2 cc)�14: — I Sr,) I
Ofciat am only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
AC-0-R& CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDNYYY)
10 04 2012
PRODUCER (978) 745-6464 THIS CERTIFICATE IB ISSUED AS A MATTER OF INFORMATION
Rome Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE CQVERgGE AFFORDED DY THE POII IES BELOW.
P.O. Box 958
Salem MA 01070- INSURERS AFFORDING COVERAGE NAICri
INSURED INSURERA:xautAlus Ins Co.
Maric'B Roofing INSURER6:AIM
245 Andover Street INSURER C'
IN$UNER
Aeabo D MA 01960—
COVERAGES NSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVIi FbR THB POIJCV PERIOD INDICATED,NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIPIGATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLI(:IE$ DESCRIBED .HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDMONS OF SUCI4 POLICIES,
AGGREGATE LIMITS SHOWN MAY HAVE BE"REDUCED BY PAID CLAIMS.
INER ADO'L TYPE OF INSURANCE POLICY NUMBER PODGY,EEF DATEMMIDO/YYM) D
i'ITIICy EEI'IRATNIN
ATE MNYO UMfiS
A GENERgL LIABIDTY EACH C R ENCE p 500,000
X COMMERCIAL GENERAL UARILRY DAM 7p RE D
PR 09 S ED Peeutwop a 300,000
X CLAIMS MADE ❑occuR LM230521 05/28/2012 05/29/2013 MEDEXF M au �0 5,000
PERSONAI ADVINJURY a 500,000
GENERALAGG GATE p 1,000,000
Y
GAUTOMOBILEGENTAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPA 0 1,000,000
POLIC LI
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT
(PA 400dmo p
ALL OWNED AUTO$
SCHEOULEDAUTOS / BODILY INJURY
(PN PP ) p
HIREDAUTD9
NON•OWNSDAUTOS / BODILY INJURY
(Pot Aa dMI) p
PROPERTYOAMAGE
GARAGE LWBIIRY
(Per 2 !AI) p
ANYAUTO AUTO ONLY-EA ACCIDENT 4
OTHER THAN EA AC s
EXCE89AARBRELIA LfABID7Y AVTOONLY./ / �/ AGG 7
OCCUR CLAIMS MADE . RRENC p
AGGREGATE 0
DEDUCTIBLE
RETENTION 9 / p
B WORXERB COMPENSATION AND 4165541s 09/13/2012 09/13/2013 yyTTppTT II{R
EMPLOYERS'LIAEILITY X TOY NTS
ANYPAOPRIETOWPARTNER4?XBCUTME
OFFICEIMEMBER EXCLUDED? UAL EACH ACCIDENT p 100,00If ym 0
nppdbe ISI / / / / E.L DI$EASE•
SPECIA EA EMPLOYEE p 100,000
SPEGA m N8 EelP.v
OTHER E. DISEASE-.POLICYLIMI7 E 500,000
UESCRIPTIONOPOPERArpN$B.00gTIpNSNE1DOLES�(OLUSIpp$AODEO BY ENDORSEMENTr$PECWL PROVISION$ ~��
CERTIFICATE HOLDER
(97B) 762-4667 CANCELL N
- 9NOULD ANY OF TINE ABo\'E DESCRIBED POLICIES BE CANOELLED DEFORE THE
EXPIRATION DATE THEREOF, THE IB RE INSURER MALL ENOFgYOR TO MAIL
ARTNDR PARENT 3R DAYS WRRTEN NOTICE TO THE CERTIFICATE HOLDER NAMED To THE LEFT,BUT
39 MASON STREET FAILURE TO DO SO SHALL RMPOSE NO ORUOA770M OR UABILRY OF ANY HINO UPON THE
INSURE AGENT$OR REPRESENTATIVES.
SALEM REPRESENTA
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®AGGRO CORPORATION 1988
Pogo 1 of 7
TQ t�iamvm°ozr°e `��"��`4r` b License or registration valid for individul use only .
`� Office of Consumer Affairs&Business Regulatloa g
PVT HOME IMPROVEMENT CONTRACTOR � before the expiration date. If found return to:
Registration 120823 Type:
Office of Consumer Affairs andBusiness Regulation
Expiration:- 302014 DBA 10 Park Plaza-Suite 5170 _
Boston,MA 02116
R60FINGI$EALCOATING;
MARIO'SABATINE�. -
245 ANDOVER ST
PEA6ODY,MA01960 �
Undersecretary _ Not valid without signature
Massachusetts- Departntcnt of Public Safetc
Board of Buildin-_Regulxtit3tis and Standard ^,
Construction Supervisof 5Qecialty License
License: CS SL 103432 _ f
Restricted to: RF �! s
MARIO SABATINE
245 ANDOVER ST '
PEABODY, MA 01960 a
Expiration: 10/8/2013.
f
('„nnui>vimcr �rrfk<103432 _ € _