78 MOFFATT RD - BUILDING INSPECTION ;Sy The Commonwe.tlth of Massachusi:tts
• � Btatrd of Budding Regulations and$t:indards _ 1 OR
1�� ', Mrssachusatts State Huldmg Cale 78q CMR T"edition MUNIUSE`I 1(�l
Building Perrntt Apphcatton To Construct,;Rep.ttr (tertov�[e OrvDernohsh`a R�r(ud lann:un
r orTuo Fnirrilv;Dnelhng, � :: ! �rHkY
rs Se�hon FofOfi3ctal Usti Only
Building Permit N be Date Applied;
Signature -" �' -`-
Build gCumm( Doer rufBudJin Dnte
SECTION 12 SITE:INFORMATION
1 I;Prdpe ddress 11 Assessors Map& Parcel Numbers
l.,lp Is this uri.a«epted street)yes l no.= Map Number.?. Pun�l Numh�T
13 Zoainglnfor=tion' 14 PropetYy Dimensions
Zoning Ontnc[ F (RPn t ) rotagepo ) - -
15,Btil1 Setbacks'(tt)
::Pion[Yard % ':' (, Side Yoids ?Rear
- ;Rcquin:d Piovtded .Required Provided 'Regwred rt'mvtdcd _ -
1.6 Water Supply (M aL 8 46 §54)_ 19 Flood Zone Informatkin: .: 1 g Sewage Dtspo*aj.s tam
Zones Outvia Flood Zone?
P _ Pt ❑ Mu O rysteublic17 uaa ❑ onQ.
SECTION:Z 'PROPERTY flWNERSHIPC'
21 wnerioEB r �� f} J
Name(Pnntl Address For Servire
�SiB?!ature. Telephone r -
SECTION,3 DFSCRIPTION-OF PROPOSED WORK?(check aB that apply)
NewConsttuction0 EnsnngBuilding Owner-0ct,upied,. Repaus(s),P Alternti�on(s) ❑ , Addman []
Demohuon AceesstxyBldg ❑ NumberofUa)ts Other gySpeafy
BrieFDescrlpUon of Proposed Wark�.-` "'� - � -
SECTION4 ESTIMATID.CONSTRLICTIONCOSTS
Esumated Costs,
[tern Official Use Only
(LaliornndMatenals). _
1.13uildm $ p-c9 I Buitdtng Perrot[Fee $ Tndic¢tg how fee ts'dntermined
g ;
Stmdurd Ctty/I'twn AppltcattonPee
2 _Electncat $ y(
❑To Pm)ect Coss(Item 6)z multiplier? x
3.Plumbing $ f Other Fam $ _
4.Mtechamcal':`(EiVAC) `$ � Lest
5 Mechanical (Pre $ Total AIIFees $
Su ' stun)
Check No Cheek Amount Cish Amtw_nt
6 Totes!Protect Cot.''$ UP Outstanding Balati�e Due
SECTION S CONSTRUCTION SERVICES
S 1 Licensed Construction Supervisor(c
l�
/�^4 ,,-�, t CI.y) Li�enseNumber Expmuwn Dutc
Na f CSt. Hinder last CSl.Typc tree below) "�
,J �=' -U �� Unrestricinl W to35,000 Cu Ft�l
� � ' . .. :��R Res4uYcJ:.1&2Ftiinit ,Dwrlhn
Res7deot)al Roofin 'Cuvcnn
` ephotx ` 1YS - Restd�titiul WmiWwrindSM I:
SF ,.RisiJcntidlSolid;Fuel'Bumm A I�.uisrinstall.ruun " .
:� '� ' -- , D : RestdenU Demubtion
51 egistered Hame Improveoceat Co(ttractor(HIC) f` C lG{Jf'�
. C ' w3S6Yt u �f2.t J .,
HICCo-- Nam -or HIC Registrant N egtstratwnm Nuber `
� Lo2�� �y„T., Fes;
E,tpfnraon Date
Telephone7.
SEGTTOPI 6 WORKERS' COMPFISATION INSURANCE AFFIDAVIT(M G L
Workers Compensation insurance affidavrtmust be cotapleted and submitted with this appttcuuun Fdrlure to pntrde
', - _' :this afflduvtt wilt result tp the denim ofdre issunrse oflie bwldtng:permu ';;
Signed Affidnnt Attached?` YesOlVo
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
_::OWN ER'S,AGEN1d°OR.CON7 RAI TOR>A PPLIFS FOR BUII DIIVG PERMIT "
(�. - _ •� a`s"C+wner of thesublect property hereby
;authonu: = -4-5%.c.J _ to ac[`on my behalf in a.11 matters ,
_ ; relative[o`work n' �- y this bwtdmg.permrt nppl)chGoa = - -
<' ture`ofthvn ,._ _. Dot> „ ,.SEC'1']ONc7b "OWNER"OR AUTHOR[ZSf)AGENTDECLARATION `
Authon'ud Agent hereby detldre
=that the statements and raformatron an the foregang application aretrue andcurste to the:best of my knowledge and
.behalf
.;Signauue of Owner or Authonzed Agem Date
', (Si ed'unEerthe ' 'ns`"ortd altiesof ) �' . .
1 An Owner who t a[ns a butidtng per[nrt to do h... . own work or nn owner who hires nn unregistered wntraUor
(oat[egtstered In tjie Rome Improvement Contructor(HIC)Program) will riot have access to the arbnnwon
ro -' ar unrnnt fund under c. 142A3-Otherim rtantmfortnatibn.on.thaI{IC Pro " nd
Po _ grama -
ConsGvctronSupervrsorllcenstng(CSLj_ca 70C ations110R6d 11n bed m M n0R5 respectively -
'2 Whensubsmntial-fork is planned provide the tnfomwtron below "
Total floors arw{Sq F3) (utcludmg',garage finished basemendattres decl s ur porch)
vGross 6vi ig area(Sq''Ft) Habitable loom cou
be rt
Number oFfireptacu Nmber of u drooms ':
Number at bathrooms Number of iialflbnths '
'Type of heunng system Number of decks/porches
Type of waling system , Enclosed Open
:J "total P`ojeecSquare Footage' may 6I sp t toted fur _T 10 Cast';t
ACORD CERTIFICATE OF LIABILITY'INSURANCE osiiiioa
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PAYCHEX AGENCY INC. HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
1175 JOHM STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
WEST HENRIETTA, NY 14586 COMPANIES AFFORDING COVERAGE
COMPANY
A GUARDINSURANCE
INSURED
COMPANY
BC CONSTRUCTION PRO LLC B
68 B LORING AVENUE
SALEM, MA 01970- COMDPANY
COMPANY
D
COVIt.
AGIts
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.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS -!
LTR DATE(MWODNY) DATE(MM/OONY)
F
ERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $
�LAIMS MADE �DCCUR PERSONAL C ADV INJURY £
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ _
FIRE DAMAGE(Any one lire) $
MED EXP(Any one person) $
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT S
ALL OWNED AUTOS
SCHEDULED AUTOS BODILY INJURY g
(Per person)
HIRED AUTOS
BODILYnt) $
NON-OWNED AUTOS (Perraccidcidenp
PROPERTY DAMAGE $
EJ
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $ -
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE £
OTHER THAN UMBRELLA FORM $
WORKER'S COMPENSATION AND X Vy STATu- OTH-
RY IMIT R
A EMPLOYERS'LIABILITY
El EACH ACCIDENT $ 100,000.00
THE PROPRIETOR/ �INCL
PARTNERSIEXECUTIVE BCWC911392 05/20/08 05/20/09 EL DISEASE-POLICY LIMIT $ 500,000.00
OFFICERS ARE: �EXCL EL DISEASE FA EMPLOYEE $ 100,000.00
- OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
CERTIFICATEHOLOER .. :CA
NGELLAYION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
BC CONSTRUCTION PRO LLC EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL -
�68BLORINGAVENUE 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
SALEM, MA 01970 -- -
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
AUTUOITIZED REPRESENTA IVE
AGGRO 25-S(1/45) OACO�aD CORpOAATION 1988,.
I
f
AC CERTIFICATE OF LIABILITY INSURANCE DATE(MNYDDIYYYY)
D7/28/2008
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Rose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:Nautilus
BC Construction Pro LLC INSURER a Associated Employer
68 Loring Avenue INSURER C:
NS 'URER D
Salem MA 01970- INSURER e
COVERAGES
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDY POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPEOFINSURANCE POLICY NUMBER DATE(MMIDDIYY) DATE(MWDDIYY) LIMITS
A GENERAL LIABILITY NC680529 EACH OCCURRENCE $ 500,000
TO
R COMMERCIAL GENERAL LIABILITY PREM SES EaEI accurrenw S 50,000
CLAIMS MADE OCCUR 08/09/2007 08/09/2008 MED EXP(Any one Person) $ 5,000
PERSONAL&ADV INJURY $ 500,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000
POLICY JECTT LOG
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accNenl) S
ALL OWNED AUTOS BODILYINJURY
SCHEDULED AUTOS (Per Person) S
HIRED AUTOS BODILY INJURY
(Per accident) S
NON-OWNED AUTOS
PROPERTY DAMAGE
(Pe,smident) 6
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG S
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE 5
OCCUR CLAIMS MADE AGGREGATE S
5
DEDUCTIBLE S
RETENTION $ 6
$ WORKERS COMPENSATION AND TORVLIAMITS OER
EMPLOYERS'LIABILITY
ANY PROPRIETOR(PARTNERIEXECUTIVE E.L.EACH ACCIDENT 5
OFFICERNEMBER EXCLUDED? EL DISEASE-EA EMPLOYEES 1
If yes,descriEe under
SPECIAL PROVISIONS I,eb E.L.DISEASE-POLICY LIMIT S
OTHER
DESCRIPTION OF OPERATnNSILOCATIONSIVEHICLEWEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
City of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZE /E/P//g�EB�ENTAATTIVE//