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15 OAK VIEW AVE - BUILDING INSPECTION
t The Commonwealth of Massachusetts FOR n Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code, 780 CMR USE Building Permit Application To Construct, Repair; Renovate O emolish Revised Mar 2011 One- or Two-Family Dwelling I / This Section For Official Use +7. Building Permit Number: Date ed: Building Official(Print Name) ignature - Daze SECTION 1: SITE INFORMATION 1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street2 yes x no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards - Rear Yard Required Provided Requred 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? Municipal❑ On site disposal system ElPublic❑ Private El Zone: if yes❑ - p SECTION 2: PROPERTY OWNERSHIP' 2.1 O er/ryfRecord- Name(Print) - --T- ----- - - _ City,.State,ZIP - ti !`Si3�l�v� Yw00 p{ gdM"sq-97r - - _ _ No. and Street Telephone �"Email Address - SECTION 3: DESCRIPTION OF PROPOSED WORKz (check all that apply) New Construction ❑ Existing Buildin Owner-Occupie Repairs(s/ Alterations)--❑ Addition ❑ -- Demolition. - ❑ Accessory Bldg.O Number of Units Other ❑ Specify: _ - — Brief Des notion of Proposed WQrk'-:- -- -- - - - SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 13 p 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 All Fees: $ r p ression) Check No. Check Amount: Cash Amount: Tots]Project Cost: $ 3 U 0 Paid in Full ❑ Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES y, 5.1 Construction /Supervisor License(CSL) 03 � /O /VeJl o 1,_ License Number Expiration Date Name of CSL Holder i--/ List CSL Type(see below) No. and Street - . Type Description U Unrestricted(Buildings up to 35,000 cu.R) R Restricted 1&2 Family Dwelling rty/To to e,Z M Masonry --- _ RC - Roofing Covering - -- -- WS Window and Siding Q SF Solid Fuel Burning Appliances Insulation Telephone - Email address D Demolition _ 5..2 VM n Registered Horne Improvement Contractor(EEC) — - / MC Registration Number Expiration Date - HI�P an e or HIC�gistr t l�e L r1 - - - f(G SLf n 1 T No- and Street Email address II &u rno- i Z W -70 kll C /Town, 5tafe, 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 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 PERR�TMT I, as Owner of the subject property, LJ, hereby authorize f/✓ J G.pl'� rA i✓j -� - to a on my behalf, -?all matters relative to work authorized by this building pt ap cation. - �� b l t — 1 1— - - t Owne me( ctronic Signature) - - .=.- —_---_ Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION rByentering my name below, I hereby attest under the pains and penalties of perjury that all of the information ned in this application is true and ac urate best of my knowledge and understanding. Print Owner's or Authorized Agent Name(Electronic Signature) ate 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 ww'A,.nlass.vov!oca Information on the Construction Supervisor License can be found at www.mass.aov,'dus 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 balf/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' i The Commonwealth ofMassachusetis r--- Department of Industrial Accidents � Office of Investigations h � 1 600 Washington Street x Boston, MA 02111 r www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers AplpUcant Informaflon Please Print LegzibW Name (Business/Organization/Individual): O/ �y I Address: �� /�✓ Gl SC✓� � � p City/State/Zip: Alenwbri hone #: 7 �J " 7 IP I 9 Are an employer?Check the appropriate box: Type of project(required): 1 I am a eraP to er with l 4. ❑ I am a general contractor and I _ Y T� . ❑ have hired the sub-contractors 6New construction employees(full and/or part-time):r 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition , workingfor me in an capacity. employees and have workers' Y P h'� 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: 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.❑ Plumbing repairs or additions myself. o workers' com right of exemption per MGL y [N p. 12. Roof repairs insurance required.]t c. 152, §I(4),-and we have no employees. [No workers' 3.0 Other comp. insurance required.] 'Any applicant that checks box#t 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 wbether or not those entities have _ employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. ]are an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. , Insurance Company Name: Zi v Policy#or Self-ins.Lic.#: Expiration Date: J t Job Site Address:/ � V1 f,0z &�t. City/State/Zip: Afk ch a espy of Ike woglkems campemw don poHey decdaratdou page(shooydng Rine poddcy IMUMber and eilskm don 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 aSTOP 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 ins ce coverage verification. l d© ie,zis3 c¢atify urr, a ill w and penalties ofperjmoy toad t0i¢itaformation,�rovdded//aba ¢is akin and cormc?. Si star . / Dat�: 4� -2 Phone#: t - Official use only. Do not write in this area, to be completed by city or town official i City or Town: Permit/License# Issuing Authority(circle one): _ 1. Board of Ilealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: ';4� CERTIFICATE OF LIABILITY INSURANCE 6/8/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, 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(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Maureen McDonnell NAME: J. Williams Insurance PHONE (781)648-9192 FAX 7e1J eaE-0116 ac No• ( 14 Wood Rd NJAIL .Maureen@ jwilliamsinsurance.corn Spite 4 INSURER(S)AFFORDING COVERAGE NAICR Braintree MA 02189 INSURER A:ENDURANCE AMERICAN SPECIALTY »I INSURED INSURER 8:Arbella Protection 41360 O'lyn Contractors Inc. INSURER C;ALTERRA EXCESS & SURPLUS 916 Pleasant Street INSURERD:LIBERTY MUTUAL Unit 4 INSURER E Norwood MA 02062 INSURER F: COVERAGES CERTIFICATE NUMBER;CL126801428 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. INSR TYPE OFINSURAHCE ADDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER IAMIDD(rYYY MMIDD LIMITS GENERAL LIABILITY x X EACH OCCURRENCE 3 1,000,000 X COMMERCIAL GENERAL LIABILITY O AGE ORENTED PREMISES Eao nnancel $ 100,000 A CLAIMS-MADE QOCCUR BC10000197601 /1/2012 /1/2013 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO It 2,000,000 X POLICY PIECTRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea wvdenil $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) 3 ALL OWNED X SCHEDULED 2844900009 /7/2011 /7/2012 AUTOS AUTOS BODILY INJURY(Pet eccIdent) $ 7 X HIREDAUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Pera¢4anl Meftal peye.nt. $ j UMBRELLALIAB X OCCUR EACHOCCURRENCE $ 2,000,000 L. EXCESS LIAR CLAIMS-MADE AGGREGATE S 2,000,000 DED X RETENTIONS 3EC50000112 /1/2012 /1/2013 3 l D WORKERS COMPENSATION X VA:STA7U- OTH- AND EMPLOYERS'LIABILITY YIN MITS ER i ANY PROPRIETORIPARTNERIEXECUTIVE I OFFICE EMBER EXCLUDED? FNI NIA El.EACH ACCIDENT $ 500,000 (Mandatory in NH) C2318413291011 /19/2012 /19/2013 EL DISEASE EAEMPLOYEE $ 500,000 deSci,Da uMer DESCRIPTION OF OPERATIONS ea:ox E.L.DISEASE-POLICY LIMIT S 500 000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ARdeh ACORD 101,Additional Remarks Schedule,It more space is required) i I CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN j CONFIRMATION OF COVERAGE ACCORDANCE WITH THE POLICY PROVISIONS. FOR INFORMATION PURPOSES AUTHORIZED REPRESENTATIVE Jonathan Williams/MEM "g ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(2olnos).Ds The ACORD name and logo are registered marks of ACORD CITY OF Sm—Ems AMACHUSETTS JLMDLNG 0Ev.1ATTLLN-r 110 W.uHLVGTON Srxm, 1'46LOOA � Tt+L �97� 1�S-9S9S KIMBEnEV oUXUL FVc(978) 1449846 .l(AYOR moxU ST.PMUM DImma or m at1C PAGPHATY/st:MDLNG CO\OIISsroNEA Construction Debris DISPasal At'1ldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.1 Debris, and the provisions of MGL a 40, S 54; Building Permit Ail is issued with the condition that the debris resulting from NJ! work shall be disposed of in a properly licensed wute disposal racility as defined by ,&IGL c l 11, S I JOA. The debris will be transported by, �/?Z, al�ngD (n,+ma Of hauler) The debris will be disposed orin : (nam rrau+lily) ' nL- lddrerr of f�,+h+y) + �n�mre of permu ippLunr V/ 0 9