41 NORTHEND AVE - BUILDING INSPECTION The C'onnnunweahh of Massachusens --
9� Board of Building Regulations and Standards Cl I'1' OF
Massachusetts State Building Code. 7JO CNIR SALLM
H.•ri.rrd.11m 'n��
Jh Building Permit Application To Construct. Repair. Renovate Or Demg
lih
One-or Tow-Funu(t Du ellint,
This Section For OI •ial Use Only
Building Permit Number: /Ulto Applied:DuilJing Olticiol(Print N;une) SigttalurcOuleSECTION I:SITE INFORMAT
L I Property Address: 1.2 Assessor blap& Parcel Number
Y( /tJn J7 E V Q
I.la Is this an accepted street?yes no M1lap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District [Imposed Use Lot Area(sq It) Fronlage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.5 St)) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal s stem
Check if cs❑ > ❑
SECTION2: PROPERTY OWNERSHIP'
oaod.qrmet
f Record:
(Print) City'.Stale.ZIP
6 q�-r" elephune Email AJdmss
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairsls) ❑ Alteration(s) ❑ 1 Addition ❑
Denwlitian ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specify:
Brief Description of Proposed Work': t I •I ]
` SECTION a: ESTIMATED CONSTRUCTION COSTS
ItclttME,,,,,rn,,"a,Estimated Costs:
(Labor and .Materials) Official Use Only
I. S I. Building Permit Fee: f Indicate haw fee is determined:
2. ElS ❑Standard City�Town Application Fee
❑Total Project C'ostt(Item 6)s multiplier r? PluS '. OtherFees: S
J. \lc \'A0 S List:ire u nS Total .\li Fees: Sr CheckNis. ('heck,\nunutt: Cash \motmcTu Cosl: S ��SdFaV ❑ P;dd in Full 0 Outstanding ll:thmce Due:
SECTION 5: CONSTRUCTION SERVII'FS
5.1 ('onstruction Supcn isur License(C'Sl.l
License Number 1:\Piralion Date
Nettle of l'Sl. //older `",✓✓- O
List CSI.1)pe Iscc
— -� �2dG'' --- ---------- 'r>pe Uacripliun
No. and Mrect
IDuilJiUS tina 15,11111)a. It.)
-- �_l_!��/ li I2cstricteJ Lr�Pamil D\\cllin
C'igiro\sn,Slme.L1P AI 1 Masonry
NC I Rooting Covering
...—. %S I R•indow;md Siding
SF tiuftJ Fuel Ilurning Appliances
_ I Insululiun '
l'elc hone F3nail address D I Demolition
5./2R��eg iste{edLume ImproverIlent Contractor(HIC) LDIAfte YM r L I/--G I IIC I cgislrtli n 1 unlller But
un I
I IIC'C'onlpun) Nan •or I IC Itagistrant Name
NU.untl�5uc• � � P��A�� / � Email address
Ci /To/own,State,ZIP ��— v Tdcohune
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.......Z-i9 No........... 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nmne(Electrunic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
ALL Rf� Hg'AgA
By entering to �a here y nder th ns d p allies of perjury that all of the information
contained in t S aP I l �cwrate the b o sy knowledge and understanding.
LYN�I, MA 01904
Print Owner's t t t a ectrul�jw" 1 D e
NO'f ES
1. \n 0wncr who obtains a build' gqtfinit to o his.her o work,or an owner who hires an unregistered contractor
(not registered in the Hume Ira ovemrnI C tractor IC) Program),will no have access to the arbitration
u program or guaranty fund nJcr\I.G.I c. 14:.k.96er important information on the HIC Program can be found at
\%o,% nml„ \ ,v,l Information on the Construction Supervisor License can be found at o \ \ nml
2. \Then substantial\cork is planned, provide the information below:
Total flour area(sq. ft.) - I including garage, finished basenlentattics, decks or porch
Gross li\ing area uy. 11.1 ._-_- . , -- Habitable room count
Number of lirci laces_.... _ Number of bedruums
i \'unlher of bathrooms - _ Number of half hallo -_
I)pa of heating s)dent Nionher of decks, porches - ..
i
I\pe of Coolillg i\sicill FnQlosed Llllell
\. "I'mal Project Squaw Footage"nwy he substituted litr-folal Project Cost-
CITy OF Si1a _ _,N12 Naas kCHLSE-ITS
r BUILDING DEPARTNI.&NT
120 \'I/.1SHL�IGTOV STREET, 3 FLooR
> TEL (978) 745-9595
F.m.-c(978) 740-9846
Ki. BERLEY DRISCOLL
IVLAYOR T mwST.PtaRRa
DIRECTOR OF PULIC PROPERTY/OCRDING CONLUISSIONER
Workers' Compensation Insurance Af)Tdavit: Dy��d�ontractorvlElectriciane0lumbers
Applicant Infrarmation LMARK HO Please Print Legibly
V;ImC I13mitxss,Organirafionrindividual):
479 BROADWAY
Address: GOAFad KACKinnPY
City/State/Zip: (781) 592AL%99.
Are you in employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time),* have hired the sub-con(ractors
2.❑ lain a sole proprietor or partner- lived on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9. Building addition
[No worker'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their IO. Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself. [No workers'sump, C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers' I3.❑Other
sump. insurance required.)
-Any upplicaat dw chwks but of most also rill ow the sacti,w Wow Showing their workers'compensation polity information.
'I11"e0wd:n who mhotil this affidavit indicating her are doing all work and Then him"'Side cenlractars mnft a:hruil a new al3ldavit indicting such
('emrxlurs that chwis this box must anubod an addiliutml shod showing the nwno of the rubwontnctora and Ihdr waken'wrap.policy inlermod",
fan an emrployer that is providing workers'compensation
bl aarancefor my eanp/oyees Blow/s th
inurn u polly andfob site
Insurance Company Name: D1 Policy 4 or Sclf-ins. Lie. q: Expiration Date:
Job Site Address: Ci(yistate/Zip:
Altach a copy of the workers'compensatloo policy declaration page(showing the policy number and expiration date).
Failure to secure cuverage as required under Section 25A of%lGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year im rlsonment,as well as civil penalties in the form of STOP WORK ORDER and a line
Of UP to$230.00 d day:��� �,t�Kl ME6;I copy of this statement may be,forwarded to the Office of
Investigations ofthe DIA fen-rrgragegtenwrtrpgeyr.ry- alion.
l do her y cer ij_ ode opal VAttMalal 0ri WAY
that Nu injurmut/ern provided ubu i.Y/ltle as d carrecL
t t t OCtf yard:
1) 592-5900
i
iOflicia!use mdy. AS rror wrire in this area,to be completed by city or town gjiciul
City or'I'avva:
Permit/t.lcense
Issuing Authurily (circle one):
L Board of Ileu11h Z. 13uildlnq Bepartulenl I.Cityrrmi,n Clerk J. Electrical Inspector 5. Plu7fimpector
6.O111L'r
i
Contact Pennn: Phonelt: --
--
1
Information and Instructions
\lassachuscits 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 hire,
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 ur building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local gcensing 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)nume(s),address(es)and phone numbers)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)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. Scif-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the 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 commercial venture
(i.e. a dog license or permit to bum leaves cte.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
'rhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
07-05-2011 01:32PM FROYrCLEMENT ARCHER INS. AGENCY 9TS-922-92T6 , T-677 P.001/002 F-665
A VflD' CERTIFICATE OF LIABILITY INSURANCE (MN'Daff"
06/05/2011
PRODUCER (978) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ARCHER INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
271 CABOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BEVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INsuREIan ESSMX TNS. CO.
Hallmark Homes, LLC INsuRr=R B;LTBERSY MUTUAL
479 Broadway INsuaEna
INSLntER D:
[LynnMA 01904- INSLMR E;
COVERAGES
'(HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSL RED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMEI IT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU RI
ECT TO ALL THE TERMS, EXCLUSIONS AND CONDONS OF SUCH POLICIES
AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS,
1L ADD'L POUOYTFFEOTME PODCY ppplpAnOli
LTR NS TYPE OF INSURANCE POLICY MM®ER DATE(MMMOHY) GATE(aTM(D LIMNS
A GENERALL WUTY 3DDS694 06/07/2011 06/07/2022 EACHOCCURRENCE i 300,000
X COMMERCIAL GENERAL UAEIUTY NPRE ITT Ea t S 50,000
CLAIMS MADE OCCUR / / / / MED EXP ane $ 2,000
PERSONALaAWiNmRY s 300,000
GENERA.AGGREGATE i 600,000
GENII.AGGREGATE LIMIT APPLIES PER: - PRODUCTS-CDMPOP AGG i 600,000
POLICY JET LOD / / / / nannm
AUTOMOBILE LIABILITY / / / /
COMBINED stNGLEuwr i
ANY AUTO c2aaR dmO
ALL WANED AUTOS I / / / BODILYINJURY S
SCHEDULED AUTOS Tle Pam)
HIREOAUTOS / / / / BODILY INJURY
NONOVWED AUTOS (Per mcift.p $
PROPERTY DAMAGE
It (PeT- 7gmcm i
GARAGE LIABILITY _ AUTO ONLY-FAACOOENT i
MIYAVTO / / / / OTHC•RTHAN EAACC i
AUTO Was_ AEG 5
EXCESSA ucoF�e LIABILITY / / / / EACH OCCURRENCE S
OCCUR �CWMS MADE AGGREGATE S
S
DEOUCTBLE
RETENDON S E
Ea WORMIS COMPPNSATSDN AND wci 31S 332704 019 02/09/2011 02/09/2012 X TDRYUMrrs RR-
EMPLOYERS UABILOY _
ANY PROPMETORMART�CITIVE EL CACW ACCIDENT i
OFMCERIMEMBER EXCLUDED? / / / / EL DISEASE-FA EMPLOYE s
HYm,ALPRO MSIOI
SPECVALPROVIBIONS OoiOw EL DISEASE•POLICY LIMIT i
OTHER
OESCRPRON OF OPERATIONSILOCATIONSNENICLESBMLLSIONSADDED BY 9/DORSEM 'MMMAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCPoBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING INSURER VAL VOR TO MAIL
NSM 10 DAYS r;N NOTCE Ta THE CERDHCATE HO ED TO ntE LEFT,BUT
CITY OF LYNN FAILURE To DO 90 SHALL IMFOSI:NO OELIGAYI KIND UPON THE
CITY HALL lKSUREFL T79 AGENTS OR n
1 C3NTRAL SQUARE, AUTHORRED REPRFSEMATNE
LYNN MA 01901-
ACORD 25(2001/08) RPORATION 1988
�ta INS026 p104],06 ELECTRONIC LASER F RMS,NC.-MIXII 2?-a5a5 Page I d 2
t
QUALITY - EXPERIENCE t t
SERVICE I t Insulations
HO.ilE,:IIPROI E, ,E:YT Hallmark - siding
L,C'E'TE -101444 -- Homes L.L.C. - Roofing
(u.ASlRGC7lO.A`SC:PERI%/SOR - Replacement
LIC'EV'CE=n6406,,4 Windows Specialists
8L7LEER.SLICES`CE=470 - ® 479 BROADWAY, LYNN01904
(781) 592-5900
CONRAD McKINNEY, President Established 1964
Member Better Business Bureau® vv'11'vv'•hallnutrkhomes.net
Sen ing Eastern 1Nlassaehusetts MEMBER OFTHE LYNN S PEA BODYAREA CHAMBER OFCOYIMERCE
O�rm-I"; name t
� q Jam ,/X( �� N� p „ne � 1� ��y_� 6 q
h,h address Z �l-l.'� 1—N "T� �_. ��SiL C'
,.ti stale���� Zips ,
Specifications
t �
t
-- l
Cash price 0(goods and sere ice;: ..........................._................................................._....
Do\\'I1 pacntant or pavment at conun m enceenc
S.....97
Pacmrntwhen �0%complete: ......................................................................................................
s.(.5.. .4�.c.
Balance upon completion: ........................................
Ea SSiam Est. Comp. SUBJECT TO MASSACHUSETTS SALES TAX
d/ J void A in t:nud I,a,kin...llAe munnrr: Thu onset agree:t notttil the f Film octor w i v anti, signed bi hV oirnel ofam defect m
sor kn;.... ur ni uo r i d The Ionoacit, haf he Gohle oulr it iI/ails Io I epait am speclfted defect, IF,11,ibilie iIcjccrive t epatrs, I,(thin lhil n da-ls o,receljn of
uul l nl m,l udl s"ilod in nn el enl shot/the cow,w to,-he liable be wnd the earl to it of labor and nmleri01,equo ild far anv,repair IF III
Ior'hint I",paid hi the ou nu'Is/, ale reas... -e"Sis actor nel leev and c tpeaves in oddilion w the amoaal due and Impoid thou shall be im'ar'red
ul ll1 ine the I I'tn, and e'unthllonJ ,/)hld canlrael aml%nr ant nevi In connection Ihercu'ith.
i.I ur n e 'lr-1 1/11'Mfi VLWIi'l!j h/u II is horn,ommnmoH d hr o porn'the"to at a place olhet'Ihom w odch'e.ss'ol'the seller which nmr be his main office or-
t r:+ lhLV d:hi u t into unll /ire-rod m die�ellu of hi'main ar hrrtnJr n/lice Lr urilown mail poster,, bi ivied ao)sent or br delivery. not lalet'Ihmi
n:nn Ja the Ihocl ht. nee a q J'Illu1-01, drr si,vung uj Ihio'agredusnr.
\1, .'A'« b,r d,.ne cur rhea prop rn'other dean 1p,c'ilics is thi, carom/�rithom addiiiunul chmger.
Thi. r uu -v cmr rrn om+rla,le uvrcrnian frith us. Gu+rpunr frill fi(nlish nnrru I o'huwed to the mpe of III),k done on above lot operI,upon c0nipletian u%
m!• � nirorl
r -rI r lac hreadr a%Ibis runu'nn hr�ur hark i.,sturmd Cnnlroctm-near I demand nvenm fii c/2c?ol pvr coot cf the conn'ncI price as Ili
Apr mI vl mma�� ..,r Ih nrcoch-
77nr,,,mran a sub%i CI msnik�o'. oericicerrx. nr ndmr,,trims bawnd our(ow"d
Companv furnishes insurance coveiaee
I .I.e the o.s nerls)of the premises mentioned above, hereby contract ,+ th and authorize you as contractor, to furnish all necessary materials.
labor and workmanship. to install.consuuct and place the improvements ac'ordit [o the specifications, terms and conditions,on premises
es c e oe cribcd .,Nch w ar
e .,,arrant and represent that we be_,00d local recor title to as or'ters our own name.
Ih Panic+hmr herruntr .t�m.d Ihev numec un this date
Y)NR: DMc 'I\. ' PRESIDENT iened.:..
/ '.�. ...... 6INter
OR . . . . . .. . ... Signed. f /t��.
R pn.',utui � Ot' er
Office of Consumer Affairs&B siness Regulation
THOME IMPROVEMENT CONTRACTOR
Registration ,101444 Type:
Expiration 6/26/2012 DBA
K HOMES.
Conrad McKinney.,
479 BROADWAY
LYNN, MA 01904
• Undersecretary i
_�- �lassachusctts - Dt•partmcnt u( Puhlit' $:dct�
r�gSf Board of Buildin_ an(l titand:u'ds
Construction Supervisor License
License: CS 64068
CONRAD L MCKINNEY
16 CASTLE CIR
PEABODY, MA 01960
Expiration: 1/21/2013
('mnmissionrr Tr#: 8447