57 OCEAN AVE - BUILDING INSPECTION (2) $33.0 10 ,
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\ —— — --- I hC C'omntonwealth of Massachusetts
Board of Building Regulations and Standards CI'fl'OF
tr Massachusetts State Building Code, 780 C'NIR S,\LEAI
Building Permit Application ro Construct. Repair. Renovate Or Demolish a
One-or Tau-Family Divellin.K
This Section For Ofricial Use Only
Building Permit Number: ate Applied:
min.., (yam
Building 01116al(Print N;une) Signal Duta
SECTION I:SITE INFORMATION
L I Property AJdres : 1.2 Assessors Map& Parcel Number
-7 0�, A f
I.la Is this an accepted street?yes Vf no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed(Jse Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(fl)
Front Yard Side Yards Rear Yurd
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dbpasal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? MUalelpal❑ Gn SIIC diSpuYLI Sy111'ill ❑
Chock if es❑
SECTION2: PROPERTYOWNERSHIPI
2.1 Owner.of Record:
s� G M #.A*
I ame(Print) City.
State.ZIP + /
Nu.and Slreet< �g 20
relephone Email Addmss
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ FE.xisting Buildin Owner-Occupied ❑ Repairs(s) ❑ Alteration— ❑ Addition ❑
Demolition ❑ 1 Accessory Bidg,❑ Number of Units ° Other Specify:
Brief Description of Proposed Work=:
S
SECTION a: ESTIMATED CONSTRUCTION COSTS
lean Estimated Costs:
Labor mid Materials) Offlcial Use Only
I. Ouilding S I. Building Permit Fee: S Indicate how fee is determined:
_ Electrical S ❑Standard City/Town Application Fee
❑Total Project Coil'I Item 6)x multiplier _.. .x
1. Plumbing S 2. Other Fees: S
4. \lechanical II11'.\('1 S List:
Su,rression) S 'rotal \II Fees:
7J6[(, ZO Cheek No. ('heck Amount: Cash \moron:
e. Total Project Cost: S ❑ Paid in Full 13 Outstanding Bal:mce Due:
SEC"FION 5: CONSTRUCTION SERVICE'S
5.1 Construction Supervisor License CSLI
'7
License Number I c irnliou );I
Na1nc ul'01. I lulder
I ist('St. i')pe(see hclalU
Na. .utd Street I)pe Description
-- i .�,ts �n t/J, -� IC 1 a " U Restri led (llui liil li l01$,UIItl eu. IL)
n ,�W' I- 1 n 4 I 1 µ Itcstricted LC2 Tamil � Dticllin
Cigil'oan.Swte.LlP M Mason
RC Roolin Corerin
._—. VA Window and Siding
�l ti Solid Fuel Ilurning Appliances
I Insulation
lelc hone F maN address D Demolition
5.,2Regiis W Registered IIIunit
IImrro pvvemenI Con tractor
f(\HIC)) /11617 1
A '
1�'t ACC I QAtr 6 v y IIIC Registration Numlvr Fspiratiun Date
III ' um ' ny Nm •or IC'I Is r Nano '
cox (3 (/0utrarr .
Nu.;u5v#r �v�rn A /�4 /1 0171() y,-,�-Z�l3Y� Lm 'laddress
City/Town.State,ZIP 4 fete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 I uance of the building permit.
Signed Affidavit Attached? Yes ......... No.........- O
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 NA93 L-a* 4-1 A-r-�,
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owncr's Nane(EleNane(Elcel uc Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering Illy name below.I hereby attest under the pains and penalties of perjury that all of the information
contained in this pplication is true and accurate to the best of my knowledge and understanding.
fo �&
Prim Ihlncr's or:\uthorired Agcnl's Nunnc(Electronic Signature) pate
NOTES:
L 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 Hume Improvement Contractor 1 HIC) Program),will t have access to the arbitration
program or guaranty fund under.M.G.L.c. 112A.Other important information on the HIC Program can be round at
„\+,+ 111.1.+ „ ,v.1 Information on the Construction Supervisor License can be found at,t>t,t.nl.t.+ St'• Inn,
2. \\'hen substantial wurk is planned, provide the information below:
Total flour area Isq. R.) - I including garage, linishcd basement attics,decks or porch)
Gross lit ing area I sq. 11.1 _ __. Habitable room count
Number of lircplaccs Number of bedrooms
.Nunlher o1'hathmunu Nw»ber of half hallo
I)lie of heating s)s(cm Number of decks, porches
I\lie of e,Rdlllg it steill 1,11closed Op211
1. "fal.11 Prljact Square Footage"111a) he substituted fur"fowl Projco Cost-
1
Office of Consumer Affairs d Business Regulation
,}y- a.SOME IMPROVEMENT CONTRACTOR
2egistration: 111617 Type:
r ;Expiration: 1/1 212 01 5 Private Corpoi'aLc
RICHARD LAMBY
3 OC'.EAN AVE
SALE M, MA 01970 (lodersecrctal I
� S
C' n.n'a CtI"a Su p C rN i a.rS W n ail IN
w,
CSSL-102293
RICHARD LAMBY }<
3 OCEAN AVENUE
SA.LEM MA 01970
05/03/2014
G Ol'i uU'dy CnJ Icon inov" ' •�� -_-'-
an r I r 1�/n(/_ (J(�l✓
/ DATE IMWDDNYYYI
CERTIFICAtE OF LIABILITY INSURANCE 9/4/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ED BY HOLDER DER THIS
®flRTOI�ICAHESDO ESrINOV�A�FOFMINSURANCE DOES NOT CONSTITUTE AEND OR AL ONTTRACTTBETWEENER THE OTHER SSUINGAGE F NSDURER(S)TAUTHORI AUTHORIZED
1 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the polley(les)must be andorsed. If SUBROGATION IS WAIVED, subject to
the terms and if the GDns of the olderPolic i certain policies may require an endorsament. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement e L Northborough 9e1aet: W®st
`1 PRODUCER PHONE'. ---
IEaetern Insurance_ Group LLC (506) 393-7744 1
E-MAIL
I1555 OL19 PJ L!`eel. Np1Cn
INSURERS AFFORDING COVERAGE -
N orthloroug1C MA 01532 INSURER A:We9 tern WOrlfl Insurance CO. ' _
IN9lIRED INSURERS:Harle SV111e We roester Ina CO 6162
INSURER L 6COttedale, Insurance Com an
Mass Weatherasa'c_on Inc - 9357
3 ocean Avenue INsuaeRo:Travelera
INSURER E
MA 01970 INSURER F:
Salasm REVISION NUMBER:
COVERAGES CERTIFICAT4°NUMBER:CL139422206
THIS IS TO CFRTIFv THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
rINDIaATED. NOrN!?HSTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WI-ICM THIS
CERTIFICATE MAY 3E !SSUEO OR MAY PERTAIN, THEI INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TER!d5
I EXCLUSIONS AND CON_.ITIONS OF SUCH POLICIES.,LIMITS SHOWN MAY HAVE BEEN R EDUCED F PAID S
LYE P DIMES
` SURANCE N t POLICY NUMBER M N YY
LrR TYPE OF IN 1 V DOC,0001
Lltt
GENERAL UA81 EACH OCCURRENCE $
' F'REMI E5 E e Re . I 8 100 0011
X COMMERCIAL GENERAL LIABILITY /29/2013 /20/2014 MED FAR(A, One parson S ------ 5 oC)1,',
r{ CLAIMS MADE EOCCUR PP�115119 PERSONAL S ADV INJURY 8 1.000 00" !I
a 2,00C.0
- GENERAL AGGREGATE S _
�r_J -------- PRODUCTS•COMFJOR nG6 4•
2,000_0E
GEN L AGGRE01% JIn:i APPLIES PER g
X POLICY �i.,uF�=.T__. LEE M INL IN 'Lt LI I
IEe ecel
AUTOMOBILE LIARIU."
SOUL INJURY(Per peeonJ 4
AN) AUTO _
ALL OWNED t`-jSCHEDULEO 00000024700E 10/4/2013 10/a/2014 BODILY INJURv(Fr eccieenll S
pUTOE __- I AUTOS PROP
DAMA;E 8 1 00G, on!
X NONOWNE❑ PFr rcidenl
HIRED AUTOS AUYOS T.;
LIASC
EACH OCCURRENCE S �. •000, OCOI
' X UMBRELLA'JAB IOCCUR
AGGREGATE $
EXCESS LIAR CLAIMS-MADE ---
C -- - 30030670 /20/2013' /20/2014 $ _
QED FETENTION1 WC STATU. OTH.
(� WORKERS COMPENSATION 'T
AND EMPLOYERS LIABILITY YIN £.L.EACH ACCIDENT 5 _ 50C'OOJ
ANY FROPRIETov?AFTNERE..ECUTIVE ❑ NIA /3/2013 /3/2014
OFF ICERIMEMBER�CLULI-C B5B44930A13 E.L.DISEASE EA EMPLOYE b —500000
(MBrABIOT IO NH,
Il yes.daicriao I,dv E.I,DISEASE POLICY LIMIT j SU C 00'..
DESCRIPTION OF OPERATIONS Dulow
DESCRIPTION OF DFE,RATIONS I LOCATIONS I VEHICLES (Attach ACORD 10'I,Addlllanal Remark,Schadvl,,0 more,pace la rogvlratl)
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
I( ;SFAIIV8AUTHORI2VD PR /�3
DeboraHona '
;I
X
ACORD 25(2010105;� I 1 •2010 ACORD CORPORA T N, All rights r erved,
INS025(2010M)O". The ACOI4D name and logo are registered marks of ACORD
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
wwwanass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PI»inbers
Applicant Information Please Print Le gib]
Name(Business/Orgaiiization/Individual): PqR Ss w caw K,le, 10
Address: Ceftl eye.= SA'C.FrA M A Q 1 °1 .7 6
City/State/Zip: ,S19geW M& Ol ft Phone#: Q`l g' W I--3Y71
Are you an employer? Check the appropriate box: Type of project(required):
1.ElI am a employer with . 4.X I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
Working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp.insurance•t 9. ❑Building addition
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. [No workers' comp. right of exemption per MOL 12.❑ Roof repairs
§1 and we have no 152, 4 , .y+
insurance required.]t c. ) 13 Otber 1 U&K] 1'I 693
employees. [No workers'
comp.insurance required.] °
*Any applicant that checks box#] must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they urn doing all work and then hire outside contractors most submit a new affidavit indicating such.
tContmetors that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities lliive-,
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 n+y e+++playem Below is the policy and job site
information.
Insurance Company Name: l h p t/d B _,
�7 n 1
Policy#or Self-ins.Lic.#: U� �Si��i 3P t Expiration Date: JY
Job Site Address: 5 City/State/Zip:�,JJA I"bTJ
Attach-a copy-of-the wor-Ieer-s'—eompensation poliey-deelar-atioa-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$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 ver fication.
I do hereby certify tit der thl a airs and penalties ojperjnry,that the information provided above is true and correct.
Signs re: a� Date: I b IZa 113
Phone#
fficial ase 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
1,Other
Contact Person: Phone#: