132 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
.Massachusetts State Building Code, 780 CMR, 7'"edition Buildi
ng Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One- or Tiro-Funtill Dn elling
This Section For O Only
Building Permit Number: /J, � at p lied:
Signature: "'�'�''J -
Building Commissioner/Inspeciii6of Btfildink
to
SECTION I:sTTINFORMATION
1.1 Property Address: 13 Z fVorfk _r t , 1.2 Assessors Map& Parcel Numbers
1.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: _
Zoning Distnct Proposed Use Lot Area(sq B) Frontage In)
1.5 Building Setbacks 01)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record•
�4o, Zerber 2 /✓arm rf
Name(Print) Address for Service:
J-et Cm Fr l f �— oo y T?0 -
Signature Telephone y7
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': l I - -- s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offlclal Use Only
Labor and Materials
I. Building s J 3 .3Qo , 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard Ciry/Town Application Fee
*Electncall f ❑Total Project Cost'(Item 6)x multiplier x
f 2. Other Fees: f
cal (HVAC) SList:
al (Fire STotal All Fees: S
Check No. Check Amount: Cash Amount:
oject Cost: f /3 Sao, 00
� 13Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supper%isor(CSL) / 00g1i 2/27 7.n/z
b • �tr't�er,G4 D. Ise IJd L.ceneNumber Eapuauon Dote
Nyjme of CSL Helder Lut CSL Type(sec below) 1n/f
�6<„t Jt• fthtrvl/= Mt. dl jyj T Description
Address U Unrestricted(up to 35.000 Cu. FL)
F � R Restricted 1B2 Family Dwellm
Si gnat re
s ��9�2 6f���q�� RC Rcs dermal Flooring Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 112 ?-jr
le
y
HIC Company Naa�prte or HIC Registrant Name Registration Number
�1 pa+e
Address i /� /� ��,r_3�9� Expiration Date
Signature/45/f.4 f Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... 0 No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Ltowork
as Owner of the subject property hereby
to act on my behalf,in all matters
rized by this building permit application.
Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 W 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 he found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfbaths
Type of heating system Number of decks/ porches
Type ofcoofingsystem Enclosed Open
3. "Total Project Square Footage"may he substituted for 'Total Project Cost"
CITY OF S.u.Eai, 1rL-kSSACHL;SETTS
M DING DEP.IRTMEINT
._ . ., .... 120 WASHINGTON STREET;..3' FZ.00IL
TEL (978) 74S-9595
FAX(978) 740.9&M
IV MBE"Y DRISCOLL
MAYOR -I1f06(AS ST.PlF11ti
DIRECTOROFPLeLICPROPERTY/SV DLVGCO\L%USSIONER
Workers' Compensation Insurance AMdavit: guilders/Contractors/Electricians/Plumbers
aynllcant Information Please Print Legibly
Nalne IBusirwv.Organ,rarion,lndv,drul): Fre / l`/Pr1 o X1, J ° F ✓ . 70o- e • pnvt �-f
Address: 6".2 D
City/State/Zip: fa,--rr d1?- t`- 111YY Phone #: /7 - f�f_ 7/
.\re y9tu am empleyeri,Chuck the appropriate box: Type of project(required):
1. 1 am a employer with �L 4. 0 1 am a general contractor and I
6. ❑New construction
employta(full and/or pa u1urnt).0 have hired the su&contraemrs
2.❑ I am a sank proprietor nr partner-
listed on the attached sheet.: y ❑Remodeling
.,hip and have mrcmployeca These sub-contractors have V. ❑ Demolition
workingfor me in an capacity. - worker'comp.insunnoe.
y 9. ❑building addition
We are a corporation
required.]
workers' comp. insurance 5. ❑ rPe and it
officers have exercisedt 10.0 Electrical repairs or additions
rcquired.l
hear
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152.41(4),and we have no 12.0 Roof repairs
insurance required.)t employed.[No workers'
comp. insurance required.) I3.0 Other
-Any applicant than aiwcka than Of mYet alatr fin tma tb sonian bylaw showing Italia waken'compensation policy infumranas.
'i I.o maws who submit this affid avk indicating they an doing all wok and than him amide eantmnesots mum auhoil a now,aftldsvil indiering suck
=f.m,m,,,,n than chwk this box main atimhed as mldithnd ahsr.hawing an none of the ark-eeorscio i ud their workers'conb.policy iafomauaa.
/am an employer that/r providing workers'rornpenaaden/naarance for try emp/ayers. edtrw a the pef/ry and Job sIAY
informarion.
Insurance Company Name:
Policy Nor Self-ins. Lic.N: Expiration Date:
Job Site Address: y/StatdZip: 4
,%[tack a copy of the workers'compeesatio■policy declaradow pop(showing the policy outobar and expiration date).
Failure to secant coverage a&required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or one-year imprisonment,as well as civil penallid in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. Ile advi..sed that a copy of this statement maybe forwarded to the Ofrice of
Inac,ugmions of the DIA for insurance coverage verification.
1,10 hereby aerrily under rho pains and penis/des of perjury thar the infbraredow provided above is Irmo and carrre .
1),
IC 7_ s�A9
O�riu/use may. Do not write in this area,to be,umpleted by city or town i fi-iaL i
City or ruwn: Permiul.lcenseM _.
hsuinr.\ulhonly (circle onc): — - ---
I. Iluard of llrallh Z. Huilding Department ).Cityf row n Clerk a. Electrical Inspector 5. numbing Inrpeetor
6. Other
Person: ..Phone-s:
KERGO
�. &
Fully Insured SON Licensed
Free Estimates HOME IMPROVEMENT Ma. Reg#152754
Specialists in:
Vinyl Siding q7P P90 00yq
Replacement Windows
"Lifetime Guarantee on all work and materials"
(617) 365-3391
Owner's name Pot W Z t r 6 Q rp
Job address_ '�' N'arN '/Vf ,f t. City ✓-4/Cw State h4 . Zip
V ;,.y/ Specifications
fiain9 lnli tall tMitren �/ro�-Mare fo ewt; rl ,.A
w;14 �_ Bt✓t er do crd ro4h CY'Jfoos tiet$2 ¢�� 4�•--s/v✓/.
c,. thr r-Jt4// V.-v/ Ja{f,4 a..l rtke
a,J Fc.._:, ,.t_i~iL . r J *�// ft✓< ti .. efa/ 9 -d
t,#/ r.f¢."t a. Fear . Talc l. y5t dUa: ,
re. ave all debr;f a-d (ee/ace a(o w.-fPo47r .
Cash price of goods and services:............................................................................................................... ................................ $..... w.:3.���'.'.
Down payment or payment at commencement:................. ............................... ........... ................................. y f 00
Payment when 50%complete:....................................................................................................................................................... $....... .
. ..........
c0 , d
Balance upon completion:.......................... ............................................................................................... ................................... $........Y....: .........
Est. Start Y/, /0 9 Est.Comp.
/ Contractor will do all of said work in a professional timely manner.
The only work to be done on this property is that which is stated in this contract,any additional work will be at an extra charge. You may cancel this
agreement within 3 business days of signing this contract. Contractor will provide all warranty papers and guarantees. Contractor will remove all
construction debris.
I/we, the owner(s)of the premises mentioned above, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor
and workmanship, to install, construct and place the improvements according to the specifications, terms and conditions, on premises above
described.
.24 .2UUqq
Dale...... ......f..............................f...........................
. . .
Signed. ! . ......... /. ............................
FREDERICK D. KERGO
Fes-✓ /��
....... .......... ........ _.............................. ._............... Signed.......................................................................................
rner Avner -
' CITY OF SALEM
PUBLIC PROPRERTY
�.,.,. DEPARTMENT
Construction Debris Disposal Aftida% it
(required litr all demolition and renu\aeon work)
In accurdance \\itlt the sixth edition ul'the State Building Code, 780 CAIR section I 1 1.5
Debris, and the provisions uf'1v1GL c 41),S 54;
Budding Permit k is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111. S 1511A.
The debris will be Ir//Jnsportcd by:
/ 4Q"'n o ' ke ih av' I
Inume of hauler)
I he debris will be disposed of in
(name ur Iau tty) .
t.nldn.. „r gnlnvl
.i�nalwe nt piuntl .y+pha and
late
����D Workers' Compensation and Employer's Liability Policy
NorGUARD Insurance Company - A Stock Company
L, r„ ,� .... Policy Number FRWCOOSS62
INSURANCE Renewal of FRWC906404
GROUP
7
/^ R OU P NCCI No.[25844]
1` Policy Information Page
[S] Named Insured and Mailing Address Agency
Frederick D Krego AUTOMATIC DATA PROCESSING
62 Dane St �. _ INSURANCE AGENCY, INC.
Somerville, MA 02144 1 ADP Boulevard
Roseland, NJ 07068
Agency Code: NJADPIII
Federdl Employer's ID 20-0590213 Insured is Individual
I
[2f -Policy Period
From June 10, 2009 to June 10, 2010, 12 01 AM, standard time at the insured's mailing address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
I
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $100,000
Bodily Injury by Disease - each employee $100,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any.state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
- -- -- — -- _-..
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change
by audit. (Continued on another page) -
Total Estimated Policy Premium ; 1,117 -
Total Surcharges/Assessments $ 59
Total Estimated Cost $ 1,176 � wV_, -
INTERNAL USE xx Page - 1 - Information Page
MGA : FRWC008862 .- WC 000001A
Date : 06/15/2009
MANOTE
16 South River Street-P.O. Box A-H• Wilkes-Barre, PA 18703-0020•www.guard.com
Rb51�oT'B�It��1Ei�a�i7II(s'>+ 7�BXM89'�
HOME IMPROVEMENT CONTRACT OR
Registration: 9/152754
Expiration: 9/27120/2010 Tr# 274099
Type: DBA
KERGO HOME IMPROVEMENT
FREDERICK KERGO�-
62 DANE ST
SOMERVILLE, MA 02143• Administrator .
Massachusetts- Department of Public Safch
Board of Building Regulations and Standards
Construction Supervisor Specialty License
License: CS SL 100922
Restricted to: WS
FREDERICK KERGO
62 DANE STREET
SOMERVILLE, MA02143
Expiration: 2t27Y2012
Tm: 100922