190 OCEAN AVE W - BUILDING INSPECTION (2) Ei"L1 �4t4k:.Y:l
The Commonwealth of Massachusetts ,
ttS� L � SIEM
a Board of Building Regulations and Standazds
Massachusetts State Building Code,780 CMRyy�� Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate,'Ylbe�hYi���p,210a
n One-or Two-Family Dwelling
U This Section For Official Use Only'
[I1" Building Penuit Number: Date Applied:
Build ng Ot7 cial(Print Name) Signature Date
/� CTION 1:SITE INFORMATION '
ry 1 1. r-0p U d r_erss: �� Assessors Map&Parcel Numbers
L l a Is this an accepted street?yes 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 Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2 Owner'of Record: C, MA,
game(Print) City,State,ZIP
a$ � ?S/$vV 9769
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR]e(check:all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief
y Description of Pro osed Work:
�'Tt��' 'O �i�' (LO N 'f4+fl
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 Appkication Fee .
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ -7 Sit) ❑Paid in Full ❑Outstanding Balance Due:
ok ^oY,+"-Cp c' -I I I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
� /
.LC«r/q tr! 'rp..kri.[-4 License Number Ekpiration Date
NameofCSLHoldei% rim i.'.JL 5 'j
' List CSL Type(see below)
F c.9M �-
No.and Sh=t T-3'Pe 'Description.,
C/7/)'/ ✓} //rr1 pa 1Sy U Unrestricted(Buildingsu to 35,000 cu.ft.
R I Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M I Masonry
RC I Roofing Covering
WS I Window and Siding
SF Solid Fuel Bunting Appliances
�� 'n/oZ�Oy/ �RrklJtacw47�, bY�ig,�. I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) !�
� HIC Registration Number XP 'on Date
HIC =Comprany Name o Il CIr HIC Registrant Name
'S Eiy t��mVSfKJc�rmlQcGLlt fiYe
No.and S or Email address
0 �rl r4 ^4 o, ,Is 6/SSid3e�Yl
City/Town, State ZIP Telephone
SECTION 6:WORKERS,COMPENSATION INSURANCE AFFIDAVIT(NLGJ: 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 7ae OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S GI'FNT QR CONTRACTOR APPLMS PQR$[J34PING PERMIT'
1,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.
` � r
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.
Print Owner's or Authorized Agent's Name(Electronic Si e) Date
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.a 142A.Other important information on the HIC Program can be found at
vww.mass. og v..'oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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 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"
The Commonwealth of Massachusetts
Department oflndustrialAccidents
l Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
NVorkers'Compensation Insurance Affidavit:Builders/ContractorsMectricians/Plumbers.
TO BE FD,ED WPPH THE PERM rnNG AUTHORITY.
Applicant Information Please Print LeObh•
Name(Baines/organization/fndividual):_�C+s✓42Gt TZ�Fi:�o t(
Address: SR l'a44 oLl
City/State/Zip:_ �,,e4 M,{ &a h7) Phone#: --1)-3G rF/
EGOWmctor
an employer?Cheep the approprfate box:
m a employer with Type of project(required):
employees(full aod/orp it time).•
m a sole proprietor or �• ❑New CoushuebOn
partnership and have m employees working forme in
y capacity.(Pro workers,camp,vsnnance required] S. Remodeling
m a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. Demohnue
m a 6omanwner and will be hirirng contractors m conduct a0 work m my property. 1 will 10 Q Building addition
ure that all contractors either have workers'compensation msiaarnce or are sole 11.Q Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
a general co0hacter and I have hhed the subcomactors listed on tlse attachedghectse sub-contractors have employar and have worker•comp.insarancei 13.❑Roof repaiTS
are a corporation and its officers have exercised theirrlght of exemption per MGL c. 14.Q Other§I(4),and we Gave no employees.[No workers'comp.in""' reyuvW-1
'Any applicant that checks box#1 must also Sa out the section below showing their workers'compensation policy h*,,mm.
?Homeowners who submit this affidavit indicating they are doing as work and than hire outside contractor must submit a new affidavit indicating such.
tCmtracton that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the wb<mtmctors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'coarpensadon insurance for my employees. Below is thepolicy and job site
informadon.
Insurance Company Name:
Policy#or Self-ins.Li
tt M r/wC' •60/!Ea(n O/.,l D I Expiration Date: 6 i
Job Site Address: �i=��4cu /
— Lyn tuQr�e�.enty/ city/state/ziP ✓ hnt C�/
Attach a copy of the workers'conalfensation policy declaration page(showing the policy nfi�6er and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I car nwrvy ccnrry na meparnt dpenaMes ofperlury that the in akon provided abo is true d correct
Si ature: p ate:
Phone M
Oracial use only. Do not wrke 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#•
Information and Instructions
Massachusetts 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 or 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 licensing 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)name(s),address(es)and phone number(s)along with their certificate(s)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. Self-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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in thepemmit/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 etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
07 YOF SAL.EM, IVI4SSACF"E775
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MAYCK 7)jMs4STJ)M=
DnEcrcmt cFruRucmxFmY/BumnmocnwgcPm
Construction Debris Disposa/Afdavit
(required for all demolition and,.renovation work)
in accordance with the sbxth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of AWL 040, S 54; Building Permit# is isSUed with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit facility as defined by MGL c 111, S 150A.
/The debris will be transported by.
LiLn �
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Sign ture of applicant
Date
05/25/2016 09:17Kowalsky Insurance (FAX)781 231 2021 P.001/001
.1�1 � DATE(MMmOIYvvY)
ACORO CERTIFICATE OF LIABILITY INSURANCE Si25i16
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(es) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement onthiscertffirate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PROCUCER ACT
Richard A. Kowalsky Insurance PHONE FpX
544 Lincoln Avenue (781) 231-2020 No_ (181) 231-2021
A ESS: RKOKowal6
P.O. Box 999 kyIasurance.Rom
INSURE S AFFORDIWS COVERAGE NAICt
Saugus, MA 01906 INSURERA:Essex Insurance Cozapany
INSURED INSURERB:Associated Industries OF MA 14U
E 6 R construction Inc. INSURER c:
5a carroll Street INsuRERD:
Chelsea, MA 02150
I NLAIRER E
NSIRER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE U5fED 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPEOFINSURANCE INSR VND POLICY NUMSER MILnIYYYY MMIIDUNYYY LIMITS
A GENERAL LIABILITY 3EE3236 4/11/16 4/11/17 EACH OCCLRRENCE $ 1 000 000
CONM FRCW GFNF RAI I MI C ITV
DAMAGE TO RENTED $ 50 Q00
CIA MS NAEE x occuR NED E)P VAwone Permr) $ 10,000
PERSONLAL&ADVINJJRY $ 1,000.000
GFNFRN Af C,RFGATF $ 2 QQQ QQQ
GEN'L ACG R UMITAPPLIEEPER: PRODUCTS-COWIDPAGG $ 1 QQQ QQQ
POLICYELATE PFO LOC
AUTOMOBILE LIABNP/ CObH W ED SINGLE L MIT
MU) $
ANYAUTO BODILY INd RY(Per Neon) $
AUOOVJNED SCHEDULED
AUTOS CS BODILY INJ_RY(Per exident) $
HIRMMITDS NAON-OMEO PROPEWYDMMGE $
Pr nmdenl
$
UMBRELLA LIAR OCCUR EACH OCCLFRENCE $
EXCESS LIAR OAIMS-MATF AC,CPF.IATF $
DEC RErEW ION$ $
B WORKERS COMPENSATION VWC 6016262012012 6/4/16 6/4/17 Y.WATU- oTH-
AND EMPLOYERS'LIABILITY YIN
A PROPRIFTORPARTNFRPXE('I.TIW F.I.FP_HA.OFM 100,000
OFFICER.MEM�R D(a UDED9 NIA
(Mantabn in NH) E.L.DISEAE-EA OI LCYEE 100,000
Mos.desalbe under
SCRIPTIO N OF OPERATIONSbcbN E.L.DISEASE-POLICYLMa 500,000
CESCRIPTONOFOPER MONS/LOCATIONSIVEHCLES (Attostl ACORD 101,A44Ibonel Remarks Schedue,Ifmorasoace is regtl¢e)
Construction _
Job Locatior:
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE BE SCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
ACCORDANCEWITH THE POLICY PROVISIONS.
• AUTIDPo2E0 REPRESENTATIVE
Richard A. Kowalsky
001988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Phone: Fax: (617) 466-0311 E-Mail:
Massachusetts Department of Public Safety
�. Board of Building Regulations and Standards
License: CS-077231
Construction Supervisor
I EDWARD J TRAINOR
' 58 CARROLL STREET » 1.�
t CHELSEA MA 02160
�..�n CA-- Expiration:
Commissioner 02/13/2018
,A Vhe (pomvrreanuiea�o��/r!a�ac�%u4eL[6
Office of Consumer Affairs&Business Regulation
OM
IMPROVEMENT CONTRACTOR
egistration. :j"35896 Type:
xpiration: 5k$7f201$; Individual
EDWARD JAMES TRAIN R '
j�
EDWARD TRAINOR��4._,�3��.�'
58 CARROLL ST =
CHELSEA,MA 02150 P-- —�, rear..
Undersecretary
Commonwealth of Massachusetts
City of Salem i s
.120 Washington St,3rd Floor Salem,MA 01970(978)745.9595 x5641
Return card to Building Division for Certificate of Occupancy
it
Fermi ,g-'°s PERMIT TO BUILD
FEE $0$0.00 „
DATE ISSUED: 7 1 2 1
This certifies that SECOND PICKWICK TRUST THE DSM RLTY/DIV OF
has permission to erect, alter, or demolish.,a building—_227_HIGHLAND AVENUE Map/Lot: 80141.0
as follows: Signs SIGN PERMIT AS APPROVED FOR:
TARGET/CVS PHARMACY
Contractor Name: LEONARD POYANT
DBA: POYANT SIGNS
Contractor License No: CS-024491
7/1/2016
-Building Officials' Date
This-permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within s z rtgnths after issuance.The Building Official
may gram one or more extensions not to exceed six months each upon written request.
All work authorized by this permit shall conform to the approved application and the approvid consttuctiondocuments.for which this permit has been granted.
All construction,alterations and changes of use of any'building and structures shalt be in compliance with the local zoning bylaws and codes.
This. ermit shall be displayed in a location clearly visible from access street or road and shall be maintained o eA for PY p pubic inspection for the entire duration of the
work unfit the completion of the same.
}
' `The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials,are provided on this permit.
q i _
H IC#: "P+rsors Contracting with unregistered contractors do not have access to the guaranty fund'(as set forth In MGL 042A).
Restrictions:
,
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
1