5 OCEAN AVE - BUILDING INSPECTION (3) 6 I\
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR S
Revised dMar Mar 201/
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
V� Building Permit Number: ate Applied:
y SM6i,,e d 5 l
Building Official(Print Name) Signa re Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
_5 ocer� AvenvZ
1.1 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 It) Frontage(It)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record:
Si\i M
Name(Print) City,State,ZIP t
rj Ocno-n (Jsve Q'Ia-741- 758q Jill�Jev+CbwricclfwK�et�•c
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) N(I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2:SYnI l� — 2 --�-
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:
❑Standard City/Town Application Fee
2.Electrical $ t
❑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: $ (p �-jp ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRU
CTION SERVICES
5.1 Constntction Supervisor 1.•icense(CSi.) eoa9az i '1 2, 2012
CMG License Nunttwr I%piration Date
Name of CSL linlder
List CSL Type(sic below)_AL-
No.and Street
Street
1 Description
U Unrestricted(Buildings n to 35,000 cu.11.
N—e UtV�1.0(���'7 �t� ���9�J0 R Restricted 1&2 famit-Dwelling
Citylrown,State,Zt " M Mason
ry
RC Itoofin.,Covering
WS Window:�,_•.,_and Siding
SF Solid Purl Burning Appliances
Insulation
Telephone L'rnail address Q D Demolition
5.2 Registered home Improvement Contractor(HIC) '7$
��,, ID17_7 luN.
.��S&yV5!1 tKO'�._�f4'I'Gj�, t y HIC Registration Number 6.ipiration Date
Iil :CAnpuny Namc orr f llC Registrant Namc
_ Street
No.and Street f?mall a ress
Ci t s e,Z1P 1-- _
t, Tcicpltoac
SECTION F:WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G,I,.e. 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 lssuanc,of the building pcmlit.
Signed Affidavit Attached? Yes.......... No ...........Cl
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 Mil 0PW(NAC %
to act on lily behalt;i r all matters relative to work authorized by this building permit application. ---
;o,
5Pri ts N;unc(I'le.clmnic Signature) bats
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering illy name below, 1 hereby attest under(he pains and penalties of perjury that all of the information
con 'n this pplication is Mild aCCllrite to the best of my knowledge and understanding.
OwnersorAuthorizcd. a t`sNmnc(GleetronicSi Due
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistet•ed comractor
(not registered in the Home Improvement Contractor(HIC)Program),will uor have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information oil the HIC Program can be found at
www.rtrass. oviuca Information on the Construction Supervisor License can be found at ww w•.mass.eov;dns
2, f When substantial work is planned,provide the information below:
Total Floor area(sq. ft.), (including garage, finished basententlattics,decks or porch)
Gross living area(sq. NJ Habitable room count
Number of f replaccs 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 Cose,
f CITY OF SM.EM. iNLxsSACHUSETTS
• BUILDI`i IG DEPARTMENT
• Jr 130 WASHIINGTON STREET, 3' FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KI1iBERL EY DRISCOLL
MAYOR THo%w ST.PwjtRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
t1C2dCO C— VqS- Ljct Chit
(name of hauler) o
The debris will be disposed of in
Gr Me ll o i S6M
(name of 11ki ity)
�►unY��„ rn.�
ddressoffacilit )
signature of permit applicant
elate
a�b �w�r.dx
i CITY OF S.0 am. NIASSACHUSEM
;. BunmLNG DEPARTJfENT
120 WASHLNGTON STREET, Ya FLOOR
off` TEL (978) 745-9595
FAX(978) 740-98"
KI\tBERLEY DRISCOLL
MAYOR THOMAs ST.PtERRRB
DIRECTOR OF PUBLIC PROPERTY/BI:ILDLNG CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( /l_. Please Print Leeibly
Name(Busirn&Organizatiorvindividml): RPr�LO [.31R C t f V Cm-G✓l�
c
Address: o �Tkoa C, � l�-% y2 .
City/State/Zip: N Pi Phone #:_
Are,you an employer?Cheek the appropriate box: Type of project(required):
1.0 f am a employer with] Z 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the subcontractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 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 workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
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,§1(4),and we have no 12.M-Il6of repairs
insurance required.]t employees. [No workers' 13.❑Other
COMP. insurance required.]
Any applicant that flecks box 91 most also fill uut the section below showing their workera'compensation policy infummtion.
*I I.xnewvnera who submit this affidavit indicating they are doing all work and then hire outside contractors mmi submit a new afrdavit indicting such.
=Cumm etms that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
l am an employer that is providing workers'compensation insurance for my employees. Below is the polity and fah site
injormadon. �+
Insurance Company dame: C7YC�-t >AT� k"S-
Policy k or Self-ins.Lic.q: WC 00-74 2.4 4--2..1 Expiration Date:����//1D 3'Qsr2p I-L
Job Site Address: C3CLn 1��S O O1 cY
A-4Y Cityistate/Zip: 1Ltivv-- Pe
Attach a copy of the workers'compensation policy declaration page(showing the policy number and 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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.
l do hereby certtjy the ppgLqs a d penahles ajperfury that the informadon provided above is true and correct.
rn;t ire• Date: 2 Li— Za l I
Phoned:
Official use only. Do not write in this urea,to be completed by city or town official
City or Town: Permidl.icense#
Issuing Authority(circle one):
1. Berard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person' _ _ __ Phone#:
a =` u
w J C
C �' l0 t49N//C¢ O�✓!�L([ddltC�[W
N e;—�tC 69YN!
E '? °' License or registration valid for individul use o
t„ � w _ Office of Consumer Affairs&Business Regulation
HOME CONTRACTOR before the expiration date. If found return to:
C h n: Office of Consumer Affairs and Business 12eg ul
N W rn Registratio . 164675
Ca e c ? o Expiration. -16/27/2011 TAl 290056 10 Park Plaza-Suite 5170
q_
' tY v o 0 Type: Private Corporation Boston,MA 02116
`v o Z > 2
m a u p -`'A REDCO CONSTRUCTION INC
W F p PATRICK REDDY ,
ti U a Q } a
" 8 PHEASANT RUN DRIVE
X NEWBURYPORT, MA0195 0u �U�nsde_r.s.e�c6re.t.aP�ry co
_ -
L S
Not valid without signature
LU
= 3
X lla00Z ' 6\
REDCO-1 OP ID: KQ
,4�oRv CERTIFICATE OF LIABILITY INSURANCE DAT 105123/ ")
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 polley(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and Conditions of the policy,certain policies may require an endorsement A statement on this Certificate does not Confer rights to the
Certificate holder in lieu of such endorsemen s.
PRODUCER 978-"5-5301 NM%TE T
Arthur S Page Insurance Agency 978-462-0890 PMOM Eat Ne
57 State St
Newburypott,MA 01960 ADDRESS:
88:
None
INSURE S AFFORDING COVERAGE RAIL/
INSURER A:Scottsdale Inc CO
INSURED Redco Construction,Inc. INSURER e:
Erica Reddy INSURER C:
8 Pheasant Run Drive
Newburyport,MA 01950 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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
LYR TYPE OF MURANCE POLICY NUMBER P LIC EFf MPOLICY LDNTS
GENERAL LWSNITY EACH OCCURRENCE E 1,000,0
A X COMMERCIAL GENERAL UASILDY' CPS1186773 06/08110 0=8111 pREMISEs Ee ocanenrA E 60,00
CLAIMS-MADE aOCCUR MED UP(Arry one pwIan) E 5,00
PERSONAL S ADV INJURY E 1,Do0,
GENERAL AGGREGATE E 2,000,00
GEWL AGGREGATE LIAR APPLIES PER PRODUCTS-COMP/OP AGG E 1,000,00
POLICY PRO- LOC E
AUTOMOBILE LABILITY COMBINED SINGLE LIMIT
Ea awdnrd
ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED BODILY INJURY(Per a dent) S
AUTOS TOS
NONOWNED PROPERTY E
HIRED AUTOS AUTOS
E
UMBRELLA LIAR C CU R EACH OCCURRENCE E
EXCESS LAB C OLAIMSIMADE AGGREGATE E
DED I I RETENTIONS E
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERA:XECUTIVE YIN EL EACH ACCIDENT S
OFFICERMEMBER EXCLUDED' E-1 NIA
(MaMeNny In NNI EL DISEASE-EA IAAPLOVE E
I ea,deE(nDe under
DESCRIPTION Of OPERATIONS below EL DISEASE-POLICY LIMB E
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aeaah ACORD 101,AddINanal R rb Sa uN,I men aPw,Is n KIInd)
CARPENTRY
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Jill Pabich ACCORDANCE WITH THE POLICY PROVISIONS.
6 Ocean Ave.
Salem,MA 01970 AUTHORED REPRES ATNE
None fu
(15 1988-2010 ACORD CO ORATK)N. All rights reserved.
ACORD 26(2010/06) The ACORD name and logo are registered marks of ACORD
MASSACHUSETTS ASSIGNED RISK POOL
REQUEST FOR CERTIFICATE OF INSURANCE
Use this form to request a Certificate of Insurance from an Assigned Risk Pool Carrier.
Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the
Certificate of Insurance should be issued. If this form is fully and accurately completed, the Certificate of Insurance will be
issued and distributed by facsimile to each fax number provided below,within two(2)business days of the carrier's receipt.
This Form may be mailed or faxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information refer to the
Certificates of Insurance section located in the Producer Communitysectlon of the Bureau's website,(www.wcribma.ora).
1. Name, address, telephone number and facsimile number of the INSURED:
Name: Redco Construction Inc.
Mailing Address: 8 Pheasant Run Drive Newburvoort MA 01950
Physical Address: Same
Phone: 978-270-8740 Fax: 978-255-2489
2. Name, address, telephone number and facsimile number of the CERTIFICATE HOLDER:
Name: Jill Pabich
Mailing Address: 5 Ocean Ave. Salem MA 01970
Physical Address: Same
Phone: 978-741-7589 Fax: None
3. Name, address, contact person, telephone number and facsimile number of the PRODUCER:
Name: Arthur S. Page Insurance
Mailing Address: P.O. Box 391 Newburvoort MA 01950
Contact Person: Kate E. Quill
Phone: 978-465-5301 Fax: 978-462-0890
4. Policy Number, Policy Effective Date and Policy Expiration Date
If a Certificate of Insurance is needed for more than one policy term, provide the Policy Number,
Effective Date and Expiration Date for each policy term.
If the policy has not yet been issued, you must attach a copy of the Notice of Assignment.
Policy Number: WC007424421
Effective Date: 03/05/2011 Expiration Date: 0 3/0 512 0 1 2
5. List any special requests for optional coverages/endorsements(see Page 2 for listing of coverages available
in the pool and the conditions of availability)or additional information(including changes in exposure not yet
reported to the caller) that will assist the carrier in the issuance of the Certificate of Insurance.
NOTE., An additional insured(s) shall not be listed on any CertHicate of insurance unless such additional
insured(s)is a named insured on the policy.