127 NORTH ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts 7LENI
Board of Building Regulations and Standards INSPECT Massachusetts State Building Code, 780 CMR ln1s a
r Building Permit Application To Construct, Repair, Renovate Or Demofi a
One-or Two-Frnnily Dwelling
This Section For Official Use Only
1
Building Permit Number: Date Applieds -ILq t I LLEL-
Building Oilicial(Print Name). 3ignattue- '. . . Date
SECTION 1:SITE INFORMATION`
1.1 Property Address: 1.2 Assessors Nlop&Parcel Numbers
1 AXJC� S i
1.I a Is this an accepted street?yes tm M1fap Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy tl) Frontage(It)
1.5 Building Setback$(it)
Front Yard Side Yams Rear Yard
Required Provided Required - Provided Required Provided
1.6 Water Supply:(Iv1.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public Private❑ Check if yesD
tZ i V P, SECT[ON2: PROPERTY OWNERSHIP)
2.1 Ownert of Record: ,"� D 7�
. nod Of¢ Pe7p2 tf4fzWrvr��v Gi':RG 2�?
RR me(Print) City,State,ZIP
12-�) N U tAl?
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building0l, Owner-Occupied Oa- Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: ltG WIV
Brief Description of Proposed Work-: 5u71t 7errtdW1 /CtTt`7PA/
SECTION a:ESTENIATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
l/ ❑Standard City/Town Application Fee-
t. Electrical ❑Total Project Cost?(Item 6)x multiplier x
3. Plumbing S 41 2�Qther Fees: .$
4.Mechanical (IIVAC) S - List:
5.Nlechanical (Fire S Total All Fees:S
suppression)
Check No._Check elmautt; Cash Amount:
G.Total Project cost: S as « ❑Paid in Full ❑Oulstandiog Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 CunstructimtSupeivisorLiceuse(CSL) otf6)ra33
License Number Espirat on Date
Name of CSL Holder jZ
! List CSL'rype(see below)
t0?� —rrL i 11 xy47",q/N R> Type. . Description
No. and Street - --
4f4y r wf U Unrestricted Duildin s u l0 35,000 cu. tl.
R Restricted I&2 F:unit Dwelling
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7 I Insulation
Tcle hone Email address D - -1 Demolition
5.2 Registered Home Improvement Contractor(HIC) l07 a7
_:J—� '. cm eir eo HIC Registration Number _ .rpi lion Date
f IIC Contpemy Name or IIIC Registrant Nalbk>
Email address
City/Town,State ZIP Tele hone
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 Ishuance of the building permit.
Signed Affidavit Attached? Yes ........A No...........Cl
SECTION 7u:.OWNER AUTHORIZATION:TO BE.COMPLETED WHEN'
OWNER'S AGENTOR CONTRACTORA,PP_P/LIES FOR BUILDING PERAUT'
I,as Owner of the subject property,hereby authorize 0 L
t9 act on my behalf,
in all matters relative to work authorized by this building permit application.
e7`P 411112,/467V / k;_
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.
L
Print Owner's or Authorized Agent's Name(Electronic Signature) Dute
NOTES:
I. 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 nor have access to the arbitration
program or guaranty fund under IvI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. �oL +''Ol'a Information on the Construction Supervisor License can be found at www.mas.�so:'Jos
t 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.-f:) 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
1. ',fotal Project Square Footage'may be substituted fur`"rota Project Cost"
r
2 eCommonwegUh.ofMassachmeus
Department oflndustriadAccidents
0J)W eflnvestfgadons
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Leant Information / Please Print I:go ly
Name(ausineworganizationthdhidaw .J P CC)Y 7 Coo
Address: l w6d/0Ti41IV
City/State/Zip: i�Rn'7� Phone
Are you an employer?Checkthe-appmpriate- Type of project(required):
1: I am a employer with . . 4. Q I am a general contractor and 1 6.. ❑New construction ..
employees(full and/or part-time)' have hired the sub,conuactms 7. 0 Remodeling
listed on the attached sheet.I
2.❑ I am a sole proprietor
no etor or partner- Demolition
ship and have no employees These sub-contractors have 8• ❑
working for me in any capacity workers' comp. insurance. 9, ❑ Building addition
(Noworkers' comp-inSOXIMM 5. ❑ We are a corporation and.its lo.❑Electrical repairs or additions
required.] officers have exercised their
aIl wodc ight of exemption per MGL I1_0 Plumbimg.repairs or additions
3_El I am a homeowner doing
myself [No workers'comp c 152,§1(4),and we have no 12.❑ Roof repairs
insurance requir-al t employees.[No workers' 13.0 Other
camp.insurance zequitod-1
'Any eppticent that cheers lux#1 mastalw ffiaog8ese�timrxbw�hov+in%.theffwockeis'.wmy�osetion PORCY iufommflm
t Honmo e a who sari MM'S affidavit ivd 8e7mdoi'ell wod:aadEaeo bite outs&..nt ac o must submit anew a i�'ida It
tContractmstlmt elect this tioxa ef�ed a�tadditiond sdset>fa>�E then a of a¢mbcoataaetma and ffiea woei:are ow plcY
er that is r ' n uraneefor my emplgyem Below is the policy andjob srte
I am'an-employ p ovidirrg ; y
infnnrtadoa L`�� yyzy7Urr1L, rN� GD.
Insurance CompanyNamc 4 j!
V•/�i- 315 -3173'7-'�—OJO i3xpnationnatc: tea'
Policy#or Self-ios.Lic.#: t ';
Job Site Address:
)� /V o 2i7t = city/s atelzip.. q�� rr4 06,' I
Attach a copy of the workers' compensation policy dedar ation page(showing the policy number and eaph adva date).
Failure m secure coverage as,required under Section 25Aof MGL a 152 can lead to.the imposition of eairninal pearaltirs ofa
fine up In$1,500M and/orone=year Wit,as wel as ca fi pcnalties m the form of a STOP WORK OitDVEL and a fino
of up to$250.00 a day againstdi�vkl-tW : Be a(Wised thata copy of'tiiis statement may be forwarded to the
Investigations of thaDIA for.insuranceODVCrAgCv&ificatioL. _
i do hereby ter asd ofperjury thaft>tt i�rforarati°n provided ab is
S. Date:
S
Phone#: r7oi-5-07 7
Official use on!R De Qetarffc raSAa eta,€o be�arFldedbY dry or town bffieiat
PermitRlcense'# <
City or Town: r
Isstdng Audwfty(drde o
1.Board of Health Z >3 g 3 {Sfy/town Qerk 4.Electrical
lnspecWr 5:P1¢ ;
6.Other r ,g
contact Person Phone'#: " y
'`����® CERTI ICATE OF LIABILITY INSURANCE 12/3/o14
THIS CERTIFICATE IS ISSUED AS A irA OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFFMAT' Y NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF PIS DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORED
REPRESENTATIVE OR PRODUCEI FL AND THE CERTIFICATE HOLDER
IMPORTANT_ if the cerfiRr�a holder 4>m. INSURED.the poncylles)toast be mdomed. I SUBROGATION IS WAIVED,subject to
It*tarm and condlioos Of the pOeq,mmin may:egWm an eNaotsement A statement on this seTlBoafe does not comer rights m the
cartBfcate-holder in Bea Of such
PRODUCER NAME: FM
YAg,TAN INSURANCE AGENCY C PHO (781)438-5577 Nn (781)279-2134
271 Main Street go=R�Fyarjan@yarjaninsurance.com
Stoneham, MA 02180 ,O
aM7m6Gel aEFaRmah covERlLCVI rAwa
INSURED J P CONSTRUCTION INSURERA:SAIMTY INSURANCE COWANY
JOHN `PAULYI ffMRERS:NAUTILUS INS CO
63 R wsURER,c LIBERTY MUTUAL INS CO
NAHANT, MA 01908 �D'
617-257-1500 INSURER E
NlSURE(i F:
OVERAGES CERTTFI ATE NUMBER: REVISION NUMBER:
THIS is TO CERTI THAT THE POLICIES OF NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIR TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERT N,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.IECT TO ALL THE TERMS.
EXCLUSIONSAND CONDITIONS OF SUCH .LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE Rm POLICY NUMBER ARMO LIMITS
Rt GENERAL LIABILITY EACH OCCURRENCE s 1,000,000
COMMERCIAL GENERAL LMIUTY PflEL115ES a f _
CLAIMS-MADE ®OCCUR MEDECP(AMWa Panaa) f
Y 556-IL075396 6/17/1410/17/15 PERSONAL a Aw muRY s
GENERAL AGGREGATE i 210 0,000
PRODUCTS-COMPIOPAGG S
GEN'L AGGREGATE LIdtT APPLIES PER= f
POLICY PRO- LOC
COMBINED SINGLE LIMIT S
AUTOMOBILE UABADY (Ea a-da )
X SODILY INAW(Pa Pe ) S 500,000
X ALL OWNED AUTOS Bods.YruAw(IwaccKw) S 500,000
SCHEDULED AUTOS Y 5919291 /1/14 411/15 �PROPERTY DNAAmE f 100,000.
aabM)
. ..X.-HIRED AUTOS f
X NON-OWNED AUTOS S
EACH OCCURRENCE f
- UMBRELLA LIAB OCCUR AGGREGATE f
EXCESS L" C7 -
S
DEDUCTIBLE f
RETENTION f ATU- OTH-
wool "S CGINPF3iSATiW7 mf�
[3W YENS �<rs<+aL� WC1-31S-379374-010 -0/22/14 0/22/15 EL EACH DENT oA El DISEASE-FA EM S
U ��t_���- E.L.DISEASE
o€sOR
DE CRIPnONGFOPER 7XVGtLocA, SirEum2R +> hOT. � � •NmolaipxehtagLa6d)
C rtificate Holder 13 Insured
C FICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BERORE
THE EXP N DATE THEREOF. NOTICE WILL., BE z 8
ACCO CE THE POLICY PR es a>� f
I — --- AUTHOR
� _ aaat(aTtTnElS'bi�
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t, Massachusetts Department of Public Safety - C'%/e�eaorc��eaweueall/o��/laaJa�mlelG
' Board of Building Regulations and Standards 3 9 —Office orCousumer.Affairs&Busiuess Regulation
.
Construction Supen'isor 1 &Z Familr _—.l OME IMPROVEMENT CONTRACTOR
egratrahon. 107527 Type:
License: CSFA-049M
xpirahon - -8/4X2016 Partnership
r JOHNBPAULA � rY J:P.CONSTRIJCTION:CO -
63 TRIMOUNTAIN
L 1
` Nahant MA 0198$
' John Paula - v -
a 63 Trimountam Road
;t Expiration - Nahant,MA 01908 Uaderseeretary
Commissioner 04124/2016
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CITY OF SALEA MASSACHL SE M
BEnDmDEPARTMEmr
120 WAgM4GTCNSTREET,3RDRDOR
TkL(978)745-9595.
PAX(978)740.9846
KIMBERLEYDRIS(DLL
MAYOR THC UM STAERRE
DMECTMorrliMCPA MRW/BtIIMMCX?MM[ssroNER
Construction Debris Disposa/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 c40, S 54; Building Permit d is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit 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:
roc euD
(name of facility)
(address of facility)
i ture pf applicant
26 N
Date(