133 1-2 NORTH ST - BUILDING INSPECTION (2) LO Z�
RECEIVED r n
The Commonwealth of Massachl
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,7E"W*1 -S P 1- 05 SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
t One-or Two-Family Dwelling
This Section For Off
eial Use Only,
Building Permit Number;`. `Date Applied:
1
Building OfScial(Print Name) ` Signature "
SECTION;1:SITE INFORMATION,
1.1 Pro e Address 1.2 Assessors Map&Parcel Numbers .
) Z�/� atrrN, Si: �
1.1 a Is this an accepted street?yes no Map Number cel Number
1.3 Zoning Information: 1.4 Property Dimen,tons: /t/�
Zoning District Proposed Use Lot Area(sq ft) Frontage
1.5 Building Setbacks(ft)
Front Yard Side Yards ar Yar
Required Provided Required Provided I Req I Pr v"
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dispos?R tem:
❑ On site sal
Zone: _ Outside Flood Zone? Municipalsystem ❑
Public❑ Private❑ Check if yes❑ y
SECTION 2: PROPERTYOWNERSHIP' l
2.1 Owner'of Record: /
Clnc Z FF;\Itf C4 be w .tic. QIR?U
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) �rrAlteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of ProposedWorV: e- eA-e_ a L•e.� l c
1„wb e) 1ZtL- 1 At
C�l.6CxY�.t<�"QI t 1MR Ivy
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use'Only'
Labor and Materials
1.Building $ UJ 1. Building Permit Fee:$ Indicate how fee is determined;
❑Standard City/Town Application Fee
2.Electrical $
❑Total Project Costa:(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ - -
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total AD Fees:$.
Su ression ..
Check No: Check Amount: Cash Amount:
6.Total Project Cost: $ ZZ p�j ❑paid in Full ❑`Outstanding Balance Due:
l3y z•"'
1 ,SECTION 5:. CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�qA �nol.2n , I <1Ii, License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) y
I 4 1
No.and Street CRRestric"
Description
O r9�3 ricted uildin s u to 35,000 cu.ft.City/fown,State,Z w and Sidinuel Burning Appliances
es,7-%1 -290 Seen b;�_ ek e.�-.hcLCt on
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) /
11 /62103 t f3/av/7
Kecv 34nder,cc. HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
I2 TreaAms )Cr- - Sl4n _b,'�j- a2�C'L COr'
No.and Street Email address
1-.,-etC .,.�, OICi23 $'5�7-8512S'SG
Ci /Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance f the building permit.
Signed Affidavit Attached? Yes .......... CK No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR J.WiLDING PERMIT
I,as Owner of the subject property,hereby authorize -C�.,„ a n Alp r$Pn
to act on my behalf,in,all matters relative to work authorized by this building permit application.
C k,�2_ C-7•
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Sean An12CScn Is-ho&
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
wtivw.massgov%oc l Information on the Construction Supervisor License can be found at www.mass.govh /dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,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"may be substituted for"Total Project Cost'
The Commonwealth ofMassachuseds
Deparriment ofladustrialAeddents
I ComgressSftw4 Smile100
Boston,ALI0211 4-1 01 7
www.mtcet:.govMa
Workers Compensation Insurance Affidavit Builders/Contradora/FJwWcians/Plumbers.
TO BE FHZD WITH THE P=M7=G AU7NORITy.
AnollcantLormation Plesse Print I.eEibb
Name(Bnsma§s/Agamrafion$Odtvidud; d'a
Address: 12 <� S 1cv�2
t'.:'ity)State/Zip:i—) , Q aS /V. , 01523, Phone#:
Are you w employer?Clock the appropriate bo:: - -
Type of prefect;(repaired):
l.�a employer ' e-Florae$(fall endkrpol"Ine)•i 7. Q New comb"
2.Qlam e.,eok}aopiieroraparmership.aodhave no emoo"m worllIDs, forme in 8: : iVdCjitlg
mympadry.[No workah eomp.laaamee mquvedl
3 Q I am a homeowner d*9 an work myselL 1No worked omp.WIMM a required)r 9: DeIDolititl�'
1. . . . l0 p Bw7ding 6ddNon.
4 Olem a homeownar and will be hiring emuactms to condM ON Warr oamy property. I will
creme that an contommm eidrer have wodrms'compemedom iosm ume,am sole I I.Q Electrical repairs or additions
P°> 016"hh°°' °yOQH' 12:[]Phmlbmg'iepeus ai edtlitions
5.❑lamageneraleomne mdlhm Mmdmom6.edmra l&ftdodtbema3edsheist 1i. Roof .
7bme.subbccntmmma ave have employ—and h worlrm M:Camp nmumof: �.
6.0wema coryotire ®md its officers have eaenised Porun tofexempfie per.MG nLo. 14.QthbcK _.
151,41(4),andedlarir:ro emploYw•`[No wmkm'cu�:imtwoceregaheaj � - ,. .. .
•Homeowner who subimrt Poisa�dantiudiatkg theysacti0n aebwslf5wtag�mwdkas'camipmeotion lwd
Aay oppLraot chat ebeelw lies dl meat oleo 5a ore the '
1 "dahg an work��edtive oubrde eo>mactoca avud 69mOenewat6davitnrlioftMch
Scom memra tot check thii bu most etlerbed on W"oml shed dhawmg tm rmme ufthe sib comiamom nod rime Wh1dMm nor ttime amnia hm
employees.Bffie sob-e,amlW.beye,emPl-%era,that,'muupuovtlethca wmlma'.:Camp-policyjmoa- .
lain an m kygr that+sproniding 4wrkers'Compemu&n inarmunaefor my e;46 e, Below is fhepoticy aedjoAsi e_
lnforniaAMIL
Insurance Company Name Yew e 1 e r S —
Policy#or Self-ins.Lic.#: P Jy����P,^I r7 Expiration Date /Z di 4
Job Site Address: `/-1 AJ V r City/StatrJZip: Sia e m ,�o GI�7
Attach a copy of the worke's'compensation policy declaration page(showingtpe policy number and expiration date).
Failure to scare coverage as required under MGL c. 154§25A is a aaiminal violatian putushable by a fine up to$l,500.00
and/or one-year impnsonlneat,as wen as civil penalties in the farm of STOP WORK ORDER and a fine of up to$250.00 a
day against the viohito .A copy of this statcineut maybe forn'eided to fire Office oflnveabgstions ofthe DIA'for insuiaace
coverage vasiicatian.
I do hereby certify under I penahies ofperjnry that the information provided above a true and eorrea
Phone M
Oj kW use only. Do not wri{e in this area,to be eoarplered by etry or town o,B7eiaL
City or Town, PermitAUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Chy/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter'152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hue,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer!'
MGL chapter 152,§25C(17 also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited liability Partnerships(I I.P)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured'corrpanies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be acre that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must subunt multiple permit/license applications in any given year,need only submit cue affidavit indicating current
policy information(if necessary)and under"lob Site Address"the applicant should write"all locations in_(city or
town)."A copy ofthe affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or comrmacial venture
(i.e.a dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Page 1 of 1
+ Backto Message certiflom.pdf i /1 + Xy X
ACCWLY CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER.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(les)must be endorsed. N SUBROGATION IS WAIVED,subject to I
the terms and conditions of the policy,certain policies may require On endorsement. A statement on this certificate does not confer rights to the i
certificate holder In lieu of such endomement(s). I
PRODUCER NWW
Ame: Mike Conlon r
DIVIRGILIO INSURANCE AGENCY PxoNE En: (781)592-5220
AD mikeodf ed e.con
270 BROADWAY INBURE AFFOIDINGCOVERAGE NA"
LYNN MA 01904 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674
INSURED INSURERS:
BIG A HOME IMPROVEMENT LLC IMSURERG:
INSURERD:
12 TREETOPS LANE 11111 E:
DANVERS MA 01923 DMURER IF
COVERAGES CERTIFICATE NUMBER: 48120 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.
rp TYPE OF INSURANCE =Lf=l POLICYNamea pM'D M DUYY LLMITS
COMMERCUILOENERALLMBILRY EACHOCCURRENCE S
CUMMBMADE El OCCUR PREMISES EaoD enre $
MEDEXP(A,ryorem.n) $
WA PERSONAL S ADV IMURY $
GENL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S
• POUCY�JEd �LOC PRODUCTS-COWIPAJP AGG $ ,
OMER: $
GLELIMIT
AMOMOBBELIABILTr ettlE 51NQWIN
E
ANY AUTO BODILY DMURY(Per parson) S
ALL OWNED SCHEDULED N/A BODILY INIURY(P.a &nt) S
AUTOS AUTOS
NON..ED Pe eaiQrM $
HIRED AUTOS AUTOS
E
UMBRELLA UAB HOCCUR EACH OCCURRENCE $
EXCESS UJA CLAIMS MADE WA AGGREGATE f
OEp RETENTION $
WORI(ERSCOMVENSATION X1 02TUTI!
AND EMPLOYERS'LIABILITY
ANYPROPRIEPORPARTNERIEXEOUTIVE Y/N E.L.EACH ACCIDENT E 100,000
A OFFICER/MEMBEREXCLUDED? N/A WA WA 7PJU13487OP77415 10/13/2015 10/13/2016
(Memo M1.NH) E.L.DISEASE-EA EMPLOYEES 00,000
n yyeeee Aerobe Omer
OESCRIPnON OF OPERATIONS below EL DISEASE-POLICY LIMIT E 500,000
N/A
OESCRIPTXRI OFOPEPAlIONS/LOCAl10NB/VENICLE9(ACDRD 101,AOdId.I Pemersa SCImNWA,mey be e0ac11e4 N mpreepeo M reqube4)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay ) I
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless she She Prof ofdate Con the above policy precedes the
issue date of this ceNiicata of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification p i
Search tool at www.mass.gov/twdAorkom.wmpensationfinvestigafions/.
I
CERTIFICATE HOLDER CANCELLATION !
Cl yr+Z f•Sj SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
tawUS OI.H.1 S� ACCORDANCE WITH THE POLICY PROVISIONS.
1331�z " I i
SuN2 f M4 AWHORMEDREPRESEMATIVE
• Saugus MA 01906 '—"wry L,.,y
Daniel M.CrowlBY.CPCU,Vice President—Residual Market—WCRIBMA /
C 1988-2014 ACORD CORPORATION. All rights reserved
ACORD 25(2014101) The ACORO name and logo are registered marks of ACORD
v
https://us-mg6.mail.yahoo.com/neo/ie_blank 4/27/2016
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-099866
Construction Supervisor
SEAN.L ANDERSOa
12 TREETOPS Lay �
DANVERS MA oa92 -
i
Expiration:
Commissioner 10126t2017
�\ Office of Consumer Affairs&Business Regulation
OME IMPROVEMENT CONTRACTOR
. egistratlon: 62a 03 Type: f
f Expiration: _ - Individual
SEAN ANDERSONtn;:�=_ - �
SEAN ANDERSON e*
!,V .
81 GERTUDE ST. � ��- ,
LYNN,MA 01902
Undersecretary
t
I