12 MOUNT VERNON ST - BUILDING INSPECTION *- s I
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
i Revised Mar 20!1
IBuilding Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Sj Date
SECTION 1:SITE INFORMATfW
1.1 Property Address: i 2 m e'nc+i 1.2AssessorsMap&7
41 tubers
Lla Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Properly me ons:
Zoning District Proposed Use Lot Area(sit ft) Frontage(R)
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 Record:
00I27' F Sv lA/9 L s A C EM A4,9 OGI'7C>
Name(Print) City, tale,ZIP
2-0 /% /� y/ ✓ "P&- '10-Wrc)
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(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:
Brief Description of Proposed Work 2: S C /A/1/L ✓ ie
Xi s it A/G Gt/JC» IJ//n/C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ & 6(/ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City[rown Application Fee
2.Electrical $ U ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ D 2. Other Fees: $
4.Mechanical (HVAC) $ O List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
� — Check No. Check Amount: Cash Amount:
6,Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Oil 7 y S
4 vm�Ix ew S `)Ay I) License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)tl
/2 S 0x)F S72
No.and Street /� Type Description
��� M� y�q,77 U Unrestricted(Buildings to 35,000 cu.ft.
R Restricted t&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/ SF Solid Fuel Burning Appliances
(j �7 VH /G VC I i Insulation
Telephone Email address D Demolition
5.2 Registered.Home Improvement Contractor(HIC)
Eno COA)Sit2cACTynv rA�c /G86�2 5V.2 v , D
tt HIC Registration Number Expi ionn Date
HIC Co pany Name or HIC Registrant Name
2� W Q S(//7C /✓G
tre Email address
Xcpfc-c1) AM o/YHv 60 -W-I&V
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 of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
�J APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Cq-1 ao S L/Ay 14
to act on my behalf,in all matters relative to work authori d by this building permit application.
N ylz'( FSP/A.11 L y 40112.
Print Owner's Name(Electronic Signature) I l5ate
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contained in this application is true and accurate to the best of my knowledge and understandin6—//
F✓�A/6Ccc» LiAvt) 2
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 can be found at
www.mass.cov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"
CCI•yOFSiUE.�,h 1tWsS IcHI:SEVFS
I BCILOING DEPAWrMENT
120 %V.\SHLYGTON STREET, 3"FLOOR
TEL 978 745-9595
(973) 7 k0•9846
>laF Rf FFY DRISCOLL TtiO.%L\SST.PlE.RA8
',LALYO t
DIRECTOR GF PUBLIC PROPERTY/BCBJ3ING COJ11MISSIUNER
Workers' Compensation Insurance AfTldavit: Builders/ContructorWElectrlcianvPlumhers
%oolic;ant Inrormatinte / Mats Pnrint Lefzihly
.Mimi:lltu�itle.r.Grgantratintu lndividuoll: 'Ck1.t kS��`�'Vr ' r- C—
ddress: 2�1 ill �L//DTP/1� � 2� m"o
City/State/Zip: DT )f Ld � PhoneM: �rD1 1=7�36I
Anr-�efyou in employer!Check the appropriate box: Type of project(required):
I.C I am a employer with_�_ 4. 0 1 am a general contractor and 1 6. Q Now construction
capinyens(tall and/or part-time).• have hired the sub-uontrsctars
2.0 I am a sole proprietor or parinur• lived on the mtached nhcut t y (.(temodeling
ship and have no employees These suMcontractore have 4. ❑ Demolition
working tar me in any capacity. workers'comp. insurance. 9. 0 Building addition
[No workers:comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
).❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or udditiens
myself.(No workers'comp, c. 152,11(4),and we have no 12.0 Roof repairs
insurance required.) t employees.(No workers'
cutup insurance required.) IJ.QOIher
•,%ny apph,ml dot ehwka but of mual atrl all out the rvctiva baWw ahawiny(hair waken'eampanaui✓n pansy mdnmatlan.
'I Lvneuwm"who whmit this rnldavit indieylny they.me doing all work and than hire"Iside tontnetan man nihmit a new 3171davit indiainy.lack
<limrv:wn than ah«k this box meal aaashed an adJieuruJ.her ahuwiny rho owns of the nbaumncWn anJ thalr woAert'eump.pulley Inrarmanon.
I urn an employer that If pruyldHrX rvorkers'cumpeuradun l+tsuruneejor my employees. Below is the poKvy and Job We
injornrudo.e.
In..,urweeCompanyName:''l� rnla".I Va:�
Policy 4 or Sclf-ins. Lie. it: W C its� \� ,,g' �L.-)GI n ) � Expiration Dale:` ,L�4 I
Job Sila Address: li'2- tM(/(.U'l4 V�Jt'1��)�"�", City/Slute7Zip: s.2dl _Jl _ M, M o(9-
AUacb a copy of the workers'compensation pulley declaration page(showing the policy number and expiration data).
Viiluru to weure euverago as required under.Suction 23A of,%1GL c. 172 can lead to the imposition of criminal penalties of i
tire up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER.and 4 lino
of up to S!!0.00 A day against ilia violator. Ile advised that a copy of thin•,tatmnent may ba furwurdcd to ilia Oft9ca of
I•lvrltigatinnr of Ale nIA for insurance coverage vcritieutien.
/du Itereby certify uudef Nu pains Oita pen✓ltle.r ufprrlary drat the Lrjannudwr provide)✓Love it,true laud e✓rrect
_,.... I Dora: _ C 7i I�Z
Uy/iedal uee only. 17✓nuf write in ihis area, tabs completed by city Of/own nf/Jri✓d
City nr I'mvn: . . .. _._ Permiul.leeme
Lluio;•\ulhurily (circlet unu)r
1, hoard ttf Ilcallh !. Iluildln., Mimi urea, I. Pity;l'uwn Clerk J. (ileetrit.11 htlpecmr i, I'htmhinq lulpeetor
G. 00wr
(�u nl.41 0,riw): hhane •l: .
ACCORbirCERT{F{GATE OF LIABILITY INSURANCE 4/2'
THS CERT F,rA-TE IS ISSUE AS A 1A1TIER OF INFORMATION ONLY AND COWERS NO RIGHTS UPON THE CEIMRCATE HOLDER. THIS
CERnFiCATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. S CERTI NOT
THOtDE�7E A CONTRACT BETWEEN THE ISSUNG RISURERP), AUFMO�D
REPRESENTATIVE PRODUCER,AN
gYIPORTANT: the certificate holder is aB ADUFFIONAL RSURED,fie POLCY iss)asset he endorsed. If SUCTION WAIVED,subject to
the tame and condifions of the poGLX INstd e poscies may reWire an endorsement. Astaimpert on this ceA3fints does not confer rights to the
certifcats holder in fieu of such end
PRODUCER Carmen Cocoa
Cocoa Insurance Associates Inc P 7 245- tAx - (781) 246-3926
dba Water street Insurance Age n carmenilgetinsurancehexe.cain
27 Water Street ina. 5329
Wakefield, MA 01880 MSRE AFFORWlG COVERAGE NmCM
mum tSURetA•Commerce Insurance
Sda Construction Inc usuRetB:Bsses Insurance
27 Water St Ste 116 amwRetc'
Wakefield, RNA 01880-3032 RABLU�D`
U6edieE:
IrBUr®tF-
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POI-ICY P9QLD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY 13E 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 CLAM
L
NI TYPEOFINSURANCE Am POLICY ER MMlDDJYyYYl P EFf LIMITS
GENWALLIAJOUTY Eacl+occulaENCE E 1,000,000
X coNeAERcv+LCENErmLLveom DAVAPTO s 50 O
B ctawsanaoE ®OCCUR X 3DF3493 4/7/t.2 4/7/13 NEoERP mope ) $ 1 0 0
PERSONAL&ADVINAIRY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATELGHTAPPIgSPER PRODUCTS-OONPNP AGO E 1,000,009
X1 POLICY PRO- LOG E
AUTOMOSS.E LIABM s
Y asom oslNCLE LMs $ 300,000
aecaaert)
ANYAUTO
A ALLONAEDAUIOS X T3BI.Q47 4/6/12 4/6/13 BO�YNR/RYLPr>cd enq s
X SCHEOULEDAUrOS PROPERTY DAMAGE E
X HIRED AUTOS
X NONowNrEDAuros -
$
UNBRELLAUAB OCCUR EACH OCCURRENCE $
ERCESS WAS CtA1MSMADE AGGREGATE
DEDUCTIBLE -
RETENTION WC 5rATLL OTH-
V1DRL(EAS COMPENSATION X
AND EMPLOYERS LIABILITY YIN 4/6/12 4/6/13
C• p 2amwwwAR7tMO rwTNE � NIA WC131S381490011 EL.EACH�o�Nr 1OO 000
fmyaamawylnNH) E.L_DBFASE-EAENPLOY E 100,000
@ye_-,d abeurRON FOPE T below EL.DISEASE-POLICY LIMITS 500,000
DESCRLESCfePIgN OF OPHtATWNS/LOC1171p13 f VF3ICLE3 LAEeCA ACOAM lei,AtlEmpl Ran&Ae 9�1AaOMa.@more apam b,epNre&I
CERTIFICATE HOLDER CANCELLATION
SHOULDAHY OF I E ABOVE 13ESCMMD POLICKB BE CANCELED BEFORE
l THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED M
ACCORDANCE9rrm I E POLICY PROVISIONS.
AUa�1✓'EA�ITATNB
Carmen COCoa
a 1963-2009 ACORD CORPORATION. All rights re"I'md.
ACORD 25(2009109) The ACORD dame and logo are registered marks of ACORD
4'Ltss:tchusetts- Department of Public Saret
Board of Buildinl�, Re,'ul:Uions and Standards
Construction Supervisor License
License: CS 84795
EVANGELOS"LIAPIS
12 STONE STREET
DANVERS, MA o1923
Expiration: S113t2013
('onunissiona'r' Tr#: 15961 ,
�e �irnvneon�oe��(fi-o�P/t2�asaac�
- - _ (fire of Consumer Affairs&Business Regulation ueeCb
ME IMPROVEMENT CONTRACTOR
- egistration:-
nauo jCg672=�
Exp � 3/24/201' - Type
Supplement
EDA CONSTRUCTION INCH i._
EVANGELOS LIAPIs�t`{�
27 WATER ST SUITE`i 16
WAKEFIELD, MA 01880
Undersecretary
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