20 NORTHEND AVE - BUILDING INSPECTION (2) 'I r
The Commonwealth of Massachusetts
_ u Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7h edition OF SALF.,M
Revised January
7/�J) Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, ?008
One-or Two-Family Dwelling
This Section For Official Use Only
BuildingPermit Nwnber: Date Applied: �i
�+ Signature:
Building.., mn M �oner Inspector of Buildings Date
�CVI SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
20 4.0 r</72:✓o Ayc
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District i Proposed Use y Lot Area(sq ft) Frontage(a)
1.5 Building Setbacks(it)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if ves❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print Address for Service:
T.fif
Sigmture Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Dotal Project Cost'(Item 6)x multiplier x
3.Plumbing $ 1 Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ S�2 7 ❑Paid in Full ❑ Outstanding Balance Due:
0--\oLd A h v cwr�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �5 y//o
ya3�9 /
License Number Expiration Date
Name of CSL-HolderJ� List CSL Type(see below) U
t O S�.CRi�Ai✓
Address 1'v Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
7�� 7fq y711 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
-o/2 5.4 a fe i'e/A ter/
Address
.� � Expiration Date
Signature — - 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 APPLIES FOR BUILDING PERMIT
I, A'r1 041//�a , as Owner of the subject property hereby
authorize L A i ,e ec 'r �✓%����-o^e to act on my behalf,in all matters
relative to w rk authorized by this building pennit application.
Signature of Ownev Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
T, Lgwa.� -wee //,//.e%.-„L ,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:
l. An Owner who obtains a building pennit 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11 O.R6 and 110.R5,respectively.
2. Wlien substantial work is plarmed,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 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"
DATE(MMIDDIYYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE 10/02/2009
tODUCER (978) 462-0833 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
yfield Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
7 Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
.0. Box 400
field MA 01922- INSURERS AFFORDING COVERAGE NAIC#
SURED INSURER A:LIBERTY MUTUAL FIRE INS.
awrence Hildebrand, LLC INSURER B:
0 Sheridan St. INSURER C:
INSURER D:
'oburn MA 01801— INSURER E'
OVERAGES
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.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS --- - -- — ---- -- - --- - --' --
R ADD'L POLICY EFFECTIVE POLICY
S EXPIRATION
TR DULSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD/YY LIMITS
DATE MMIDDM')
GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES Ea occunence $
CLAIMS MADE 7 OCCUR MED EXP(Any one person) S
PERSONAL B AOV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $
PAN
Y JE� LOC I I
ILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
UTO
WNED AUTOS BODILY INJURY $
(Per person)
DULED AUTOS
D AUTOS BODILY INJURY S
(Per accident)
OMED AUTOS
PROPERTY DAMAGE $
(Par accident)
LIABILITYAUTO ONLY-EA ACCIDENT $
AUTO OTHER THAN EA ACC S
AUTO ONLY. AGG $
MBRELLA LIABILITY EACH OCCURRENCE S
UR CLAIMS MADE AGGREGATE $
UCTIBLENTION $
A WORKERS COMPENSATION AND 0139538 10/02/2009 10/02/2010 X TCRY U, S ER
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000
ANY PROPRIETOWPARTNER/EXECUTIVE 500,000
OFFICER/MEMBER EXCLUDED? Y Owner is exempt E.1-DISEASE-EA EMPLOYEE It
Il Yes,describe under E.L.DISEASE-POLICY LIMIT S 500,000
SPECIAL PROVISIONS below
OTHER /
]ESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLE$/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
Job at: 87 Beverly St., Brookline
CERTIFICATE HOLDER - CANCELLATION
( ) _ (617) 739-7542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
Brookline Building Dept. FAILURE TO DO So SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
ATTN: Frank Hitchcock INSURER,ITS AGE RREPRESE TA 'ES.
333 Washington St. AUTHORIZED REP E NTATIVE
Brookline MA 02445-
0ACORD CORPORATION 1988
1CORD 25(2001I08) Page]of 2
NS025 mIoum
The Commonwealth of Massachusetts
= — Department oflndustrialAccidents
4' "s Office oflnvestigations
=� 600 Washington Street
` Boston, MA 02111
T www.mass. ov/dia om- g
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Z,4"e,•rc-
Address: 3o Sfe�.a/o
City/State/Zip: Phone hl: 7 Y1 7 -f P V ut
Are you an employer? Check the appropriate box: Type of project (required):
1.0"I am a employer with 3 4. ❑ I am a general contractor and I 6. New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a solc proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for mein any capacity. employees and have workers' p ❑Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or.additions
3-❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs '
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ..
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. '
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: An/ IV
:.Policy#-or Selt itas.,Lic.#: 0i''39. 3$' - .':'.'' - ' Ezpiratioii Date:
Ioli,St[eAddess ''�70��,te � C Ctry/State/Zips/e�'� �
Attach a copy of th2rvobkers' compeiasattoirpolicy i, ' 1Aa Sfion page-(s1 61.i. the policy'nuniber grid expiration date):
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains and penalties ofperjury that the information provided above is true and correct.
Signature: `� �l-r/ Date:
Phone# 7t/ 7f9 /77i.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
'T�esr�ai�=a e� v.w.v.v am va • maswx +.m . ia� a .�..
H _ O nee A�tltl��,`/ 781.789.9711
CS090389
Cay Owners Zip Code Owners Hem.Phaae Owns,Work Phone
� larryhildebrand@verizon.net
P,ojeet Atltlrass P,ojee[CiN Pmjed2ip Cod. P,oject prone
/y /b
Quality Roofing by Lary Hildebrand,heminafter referred to as"Contractor",hereby proposes to famish to Owner all materials and labor necessary to roof mdlor improve the
above premises in a good,workmanlike and substantial manner according to the following terms,specifications and provisions: X1 4-,
a.Description of the work and the materials to be used: L el I
Use tarps to protect house&property from shingle removal&installation. t J) __-✓IA /
_ Remove all old shingles from the house dispose of in dumpster we will provide. 1
Examine roof deck We will make any minor repairs free of charge up to I sheet of plywood
t 1)At the edge of your roof,&all valleys we will install GAF Weather Watch Ice&Water Shield
p 2)At the edges of your root;eaves and rakes we will install 8"premium drip edge.
3 At a es Wyour-too f we wr Frests GAF Pro Start to protect your hone from hi gh win
3)) stoma I- a to oo ec otecha rea a mere rare
II 30 Year Architectural s m_n ce nor m —
�nsfalrGA'F cobra ige Vent
sIYiAF-Rrd-ge es
------ltcompletia -&--mstatlatiorrc P O
'otal-costmcindesalliabor,matenals;permit&disposaiasdmmbedabove.-
b.Descri of a��pt ne s atlwip NOT be worked on: J.'C2'T Y- � Cl -
/1J /klr7J� ,�Ct rs 9 r/i y 3 Z --- -
a
J, This I ter pecifrcations maybe continued on subsequent pages(see page number below).
C.Payment: ontrec o m uses t r�/rm/,rrrLLL/���ab wolr�k, subec t/q a ditims and/or deductions pursuant to a h�arYized-.c�hiar orders),f r e�
y Total Sum of$ i/- /,�U //� - �'S Down Payment(if any)S 2 4 v ) /G1/
PAYMENT DUE WHEN AMOUNT PAYMENTS TO BE MADE IN INSTALLMENTS AS LOWS:
1. Balance upon Completion SO rY'/iQv By check upon receipt of invoice for draws as
described under "Payment Due When" to the left
2. column.
3.
4.
d./Commencement and Completion of Work: Substantial commencement of the job shall mean either the physical delivery of materials onto the premises or the
performanceof any labor and shall be subject to any permissible delays as per prevision(3)on the reverse side of this proposal/contmct.
Approximate Start Date: Approximate Completion Date: _
e.Acceptance:This proposal is approved and accepted.I(we)understand then;are no oral agreements or understandings between the parties of this agreement The written
terms,provisions,plans(if any)and specifications in this proposal/contract is the entire agreement between the parties.Changes in this agreement shall be done by written change
order only and with the express approval of both parties.Changes may incur additional charges.
Additional Provisions Of This ProposatiContract Are On The Reverse Side And May Be Continued On Subsequent Pages(see page number below).Road
Notice To Owner on page two(2)before signing.Read"Arbitration of Disputes"provision on page two(2),provision 10 and the NOTICE following this
provision.If you agree to arbitration,sign on the line below the NOTICE where indicated.Also,sign in the same place on EACH COPY of this contract
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES You may cancel this agreement if it has been signed by a party
thereto at a place other than an address of the seller,which may be
his main office or branch thereof, provided you notify the seller in
l�9 lla writing at his main office or branch by ordinary mail posted, by
telegram sent or by delivery, not later than midnight of the third
�ga
ppmma me dale business day following the signing of the agreement See attached
� notice of cancellation for an explanation of this right.
l NOTE:This proposal may be withdrawn after_days from
approved lconaade I daV If not approved and signed by both parties.
Form RPC-C Copyright01996-2008 ACT Contractors Fonts(800)8205656 www.cafform.com Page one of_9 Total Pages
r 1
' �l� V/M1N110911OG�1� O�.i��•kNLC�GYI��-'
�'� office of Comamer Affain B Business Regnladoo
HOMEIMPROVEMENT CONTRACTOR
Registration-. 148422 Try 288758
Expiration: 9t27J2011
Type: Individual
LAWRENCE HILDEBRAND-
IAWRENCE HILDEBRAND tS
30 SHERIDAN ST. i'ndenecretary
WOBURN,MA 01801
MassaCNusettx- Department of Public Safeq
Board of Building; Regulations and Standards
Construction Supervisor License
License: CS 90389
Restricted.to n 00
LAWRENCE HILDEBRAND �{
30 SHERIDAN ST
WOBURN MA$ 0180T -
'd )R LICENSE
Expiration: 5t24/20/0
('onunYssiondF- Tr#: 25739
s