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15-25 OLDE VILLAGE DR - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7h edition ReOFSALEM visedJanuary Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling This Section ectionF6r0fflciaI5Us&O Only Building Nrinit Numb 07 Date Applied Sig Aix Bui,iding oinmissi6net/'Ibsi)6ctor,6fBul'ldln' Date :li SITE INFORMATION FORMAT16N SECTION N 1.1 Property Ad 1.2 Assessors Map& Parcel Numbers 1 0 47s: _L1 , 5 V,'/Atie Lla Is this an accepted street?L./ 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 Required7T Provided Required Provided 1.6 Water Supply:(M.G.Lc.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yesO SECTION2- PROPERTY OWNERSHIP` 2.1 Ownerl of Record: E2 — CPosr aropqrT)'os Hie lAnd Ave , <&,t o,, pol N t) 1 nice:a7 y__7/ 2003 - - �Signature phone SECTION 3'DESCRIPTION-Ok'PROPOWORK'(ebeek all that no New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) M/1 Alterations) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 13 Specify: Brief Description of Proposed Work': —Z.)X6 CA 14 knc)-(� n :SECTION,4' ESTIMATED' CONSTRUCTION,COSTS. Item Estimated Costs: Official U§�q"Iy l (Labor and Materials) 1. Building $ 1.1 Building PermitFee., Indicate how.fee-is determined: 2. Electrical $ 0 Standard, City/Town App ication Fee 0 Total Project Costa(Item 6)x multiplier 3. Plumbing -------77--7- .2...OtheiFe6:."$ 4. Mechanical (HVAC) List: 5. Mechanical (Fire Suppression) Total All Fees:� C OU heck Amountash Am nt. Check No C 6.Total Project Cost: $ 95 ❑Paid in' Full, tanding,Bq.ance Due, SECTION Sc CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) S T GSL ,:jIGVCOS /hn ads,--Vl ! License Number Expiration Date Name of CSL-Holder _ S I , < ,p m List CSL Type(see below) Address Type, .Descri lion U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Signal: M Mason Only 9-14- - �� RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) Al n,ne 4�c�1[PS CO Inc �b4326 HIC C—bmpp�ny Name or HFC Registrant Name Registration Number 11 Wl/sn, 5n(a M/q toIQ-/D Address -2 -27 - !1 q)g-a -rg 70 Expiration Date Signature Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT( ,.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 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. Signature of Owner Date n/SECTION 7b:'OWNERr OR AUTHORIZED AGENT DECLARATION I, In 'L /?Ol1BlTY �sJi CPS ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. A� SjaVroS Print Name ;y —SignattrrUcof O er Au hori2dd Agent Date (Signed under the pains and penalties ofperjury) NOTES:-'"C, _. 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors 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 oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 40 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): AL,0,r12 4n d,,+ Sc3ryic es Address: City/State/Zip: ,��la M b E�1�1 t© Phone M 17Y-917 - -S 970 AI!,you an employer? Check the appropriate box: Type of project(required): 1.Ln I am a employer with 4. ❑ I am a general contractor and I 3 Q 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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 workingfor me in an capacity. workers' comp. insurance. Y P ty• 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.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp, c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *My applicant that checks box#1 most 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 most submit a new affidavit indicating such tContmctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: 3e_cA G.o n l r'A�qq UTuca l lns �o Policy#or Self-ins.Lie.#: S CI/I n g! Expiration Date: 03 //(,//i Job Site Address: /.rl'- 25 Valt5'ie )r- City/State/Zip: . fin& /01910 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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: l! - 23 -10 Phone#: 9 .- U-1 .- 53 70 Official use only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: ] u ) 13: 05 Uoortey Hgency (FRX)401 686 962t P. 001/001 c R 4 i CERTIFICATE OF LIABILITY INSURANCE oPID + °A'a'ummaw" „t ALPIIi-1 Od ld 10 THIS CERTIFICATE 13 ISSUED AS A6 MEATIER '".�"° T '$' i'a"t•*k°. ONLY AND CONFERS NO RIGHTS UPON THEFERTIFI TTION HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOK $eist eh�Itl 02818 ?hoiL�z r��6- 9600 Fax:001-886-9622 INSURERS AFFORDING COVERAGE NA109 r x \ INSURER& Beacon Mutual Ins Co INSURDR4 . �yE� Lty $et1r� a3 I O. INSURER C: TDlelanametery Ri( ENSx �d6 ni . $aitivate RI 02857 INSURER D: � •�'t'6 ` �t2F' IR911RER E• AHS L"TSI,1®OCIDW HAW BEEN ISSUE0T0 THE INSURED NMAEDABOVE FOR THE POLICY PERIOD INDICATED.NO1W11HSMNOWO 'Opj$WIpt1Of ANY CONTRACT OROTHER DOCUMENT WITH SUSPECT TO WHICH THIS CERTIRCATE MAY BE ISSUED OR AFFMrD BY THE POLICIES DESCRIBED HEREIN 0 SUBIECrTO ALLTHE TERMS•EXCLUSIONS AM CONDITIONS OF SUCH •1 '++,�••rr EI00"YHIIVESEENREOUCEDIrr PAIDt1AIMS. L i OFIIgI1RANCN POUCY WINNER ATE N FED'WNE POISIM 0 `wre OA EACH OCCURRENCE S _ 'w OISIGMLUAsuff F f 4 tMOE!�OCCUR f PERR1SS0NALSADYILURY S )� 0 "a14 yY 1 9L GENERALAOOREC ATE S 1"tl c TLIMRAPSLIESPFSC PRODUCTS-COMPIOPAGO S lift LOCI e � a COMBOIFASMOLULOW ,G• v �' F&eetlu- S '•F�, AUTOB' . ppp Iµryqy \ "yv" kr"uiraa •• der INNaaanl s 4 �tv SOMY N AM. FROMMOAMAOE _ ` r fi AUTOOKY-EAACCIDENT E u I OTHER THAN EAACC S .... AUTOONL'F. ACfi •S , y 11ARIM EACH OO"-IIW�NCE _ C T t �CiNA18 MADE AGGREGATE a t N Y. Yr" S9008 03/16/10 03/16/11 BLFACNACCIDENT s500 000 vE ILLIMSEASE-EAESOWYEE $500 000 l k ly?A' EL DISEASE•POUCVUMO 5500'000 ATA i LT7¢ATTCNS1VMIN: 1EXCUUWQXSADOSOIffvN ed KNITI NPECPIL PROVISIONS I A , Cam to 978�887-5875' '• 4p t " *> '• CANCELLATION SHOULD ANY W7HOAa0YP-OESCNSED POLNSEN NN CANCELLED BNFORNTHN BOVATW \ r „ }:4.::.,. RICONTR DATETHEREOF.THE ISSUINO INSURER WILL ENOEIVORTO MM 10 DAYSWRIR@I NOTICE TO THE CER IFIGTENOLONR EASED TOTHE LEFT.NUT PAILURETO DO SO IIHALL _ L'.-YOre ReQ�etSat�OII IMPOSE NO OBLIGATION OltUiUMUMOPANY IeIO UPON THE INSURER DSA0FJIT80R 7 - mBOal'Cl REPRNSSMATPJM . 1�N"all tl 02908 AITHORGEO A ti'n t ®19011-2009 ACORD CORPORATION. All rights ruserwd. ' •? y Tho ACORD name and Iog9 are j9glatered marks of ACORD' a Rlussx ell use ttx- Dep:utmcnt oFpttlrlir Sofen — Bon"(1 of Suildin„Ref,ulntions and Shurtl:u•Us Construction Supervisor Specialty License License or registration valid forindlvldul use only License: CS SL 907003 lb -the-expiratlon date. If found return to: jot RF Restricted � Board of Building Regulations and Standards :r t IOne Ashburton Place Ron 1301 STAVROS 'MOLITSOULAS 't iBoston 11 WILSON STREET;, _.:. .. SALEM, MA 01970 d' Expiration: 12Jiq/2017 Not without signature t-n111111tPPI1,11VP TnR: 10L003' •; - 1 ' I ,II p BOA o ui gAe, i ions an War One Ashburton Place -Room 1301 Boston_ Massachusetts 02108 Home Improveme Contractor Rep i stration Registration: 154326 ;��:• �. :'(`-' "°'�' Type: Private Corporation Expiration: 2272011 Trif 279846 !, ALPINE PROPERTY SERVICES!l(i�t_,_: STARROS MOUTSOULAS :,.ry .;�- ,:1�:-� ; •. 11 WILSON STREET SALEM, MA 01970 Update Address and return card.Mark reason for change. •• Address ❑ Renewal El Employment Q Lost Card oPB•ont 0 sahrorW-PMaa Board oB uildio�d as and Standards License or registration valid for iadividni use only ; 1 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registtapdn; 154326 One Ashburton Place Bin 1301 , 1 6orr:r-2272011 Tr# 279846 Boston,Ma.02108 :- i a"' te Corporation All ALPINE PROP O,INC. STARROS MO w. �L�>Y 11 WILS Not valid without signature SALEM,MA 01970 Admiaistrator ._.