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35 PERKINS ST - BUILDING INSPECTION
zs C(--v -t; a q IN The Commonwealth of Massachusetts EA ICES Board of Building Regulations and Standards ?°rFGiF Massachusetts State Building Code, 780 CMR SAL rE,,Mr Building Permit Application To Construct, Repair, Renovate Or Demolish a 1 bR � � / 3, One-or Tivo-Family Dwelling This Section For Official Use Only Building"Permit Number, Date 4plied' -0uilding Official(Print Name) Signature,, Date 4 SECTION 1:SITE INFORMATION 1.1 P�%rtpp ss:� s yam, 1.2 Assessors Map&Parcel Numbers t13aZon1dg an acce led streetT yes S/ v`no Map Number Parcel Number Information: LJ Property Dimensions: strict -. Proposed Use - Lot Area(sy 11) - Frontage(11) - ingSetbacks(it) Front Yard - - Side Yards Rear Yard ed ProvideJ !eq - n Required Provided r Supply:(M.G.L c.40,§54) 1.7 Fne InforLA Sewage Disposal System: Zone: Outside Munieipol .On site Disposal system ❑- Private❑ Check if SECTION2. PROPERTYOWNERSHIP! rt of Record: S 9/t'�V✓7 ✓t�l si N G- [ I4me(Prin - City,State,ZIP . -; l5 G� ^i s s�«r7 !d7 39 K- 13S97 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing BuildingX- Owner-Occupied A( I Repairs(s) Of I Alteiation(s) ❑ 1 Addition ❑ Demolition ❑ Accessory BIDg.❑ Number of Units_ I Other Cl Specify: Brief Description of Proposed Work=: �AG iy%Q /21}i�S A "d nw h� - IF9e4S i"I ,. .. SECTION 4:ESTIMATED CONSTRUCTION COSTS hcm Estimated Costs: Official Use Only Labor and Materials - 1. Building S Q 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(item 6)x multiplier x J. Plumbing S 2'�Qther Fees: S 4. Mechanical (I'IVAC) S List: 5. Mechanical (Fire S Total All Fees:S Suppression) q o� Check No. Check Amount: Cash Amount:6. Tutai Project Cost: S /O Q ❑ Paid in Full ❑Outstanding Balance Due: M Pet l_ -FO ?.u.g . 40bS ©tC((,& SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) W60 3 /O/6 —/,> F, . • j�� t• �� J License Number Expiration Dale Name of CSL[folder List CSL'rype(see below) (J /67 /U �� S - : - Description , - No. and Stfect U Unmtricted B ildimis an to 35,000 cu. 11. Pe fJ(3G y !M y4 Gl o/�iO Restricted I&2 Ft unify Dwelling Cityfrown,State,ZIP M Masonry RC Roolinit Covering WS Window and Siding y— SF Solid Fuel Burning Appliances —ya/- 7o�us T�NPL(Vtr1•(1G1�1 /GtN7GIJ.GG>'h I1 Insulation -Telephone Email a ess D Demolition 5..2--Registeredd Home Improvement Contractor(HIC) /G��Y? go— L" p'FgrgT?i()AS HIC Registration Number Expiration Dade HIC Cump•.�/py Name/pr HIC rRegistrant Name 7 �/�/� -y )y7 15L) yp an Street Email address A f 0/-7;0� Cityfrown,Slate ZIP Tele home SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M:G,L,c.1SL$ 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 Isivance of the building permit. Signed Affidavit Attached? Yes .......... No........... 13 SECTION 7a:OWNER AUTHORIZATION,TO BKCOMPLETED.WHE OWNER'S AGENT OR CONTRACTOR kPPI JES`FOR BUILDING.P NERMIT 1,as Owner of the subject property,hereby outhorim��Vv Y Ar t�Ki r tS act on my half,in a afters relative to rk-authorized by this building permit application.s ZZ /6 int OmEr s Name ecru c Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under th ams and penalties of perjury that all of the information contained in this application is true an acc to t be v edge and understanding. Q'A�fl ' :✓ Z� /G Print Owner's or Authorized Agcat' me lectron Signature Dute NOTES: I. 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 ImRrovement Contractor(HIC) Program),will no have access to the arbitration program a guaranty fund under M.G.L.c. 142A.Other important information oo the-MCYrogiam can begin d at www mass cov'oca information on the Construction Supervisor License can be found at wwa•.mas� 2. When substantial work is planned,provide the information below: Tolal floor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. R.) 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 ofcoolingsystem Enclosed- Open 3_ "Total Project Square Footage"may be substituted for-rota Project Cost" . $'fie �`oxnrnonivealth ofldXassachaasatts . -Department ofIndusirial.f9ccidents Office o Iraves#igat8ons 600 Washington Sheet Boston;MA 02111 - ' www.mass.gov/dia Workers' Compensation Yusuranee Affidavits Builders/+Contractors/Electdcians/Plumbers AAppljeamt Information Please]Print Legibly Name (Business/Orgmization/Inaividual): 7oAM a/FJ j-,Y�2..9-f - City/State/Zip: PAP A 6 09 Y yn 11 O/ Phone#: Are you an employer? Cheek the appropriate boa; Type-of project(required): I.El I am a employer with 4. [] I am a general contractor and 1 6. ❑New construction employees (full and/or part-time).T have hired the sub-contractors 2Y I am a sole proprietor or partner- listed on the attached sheet. 7. Y•Remodeling ship and have no employees These sub-contractors have g- D Demolition employees and have workers' working for me in any-capacity. 9. ❑building addition [No workers' comp.insurance comp.insurance.? requited.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0.I am a homeowner doing all work - . officers have exercised their I I.[]Phm?bing repairs or additions . myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §l(4),and we have no 13.0 Other employees. [No workers' comp.insurance required.] Any appliceat that chwks box#1 must also fM out the section below showing their workeis'compensation polioy information. .� t Homeowners who submitthas affidavit indicating they arc doing all work and then him outside contractom must submit anew affidavit indicating such: �Conblactors that cheokthis box mustattaohed so additional sheet showing the name ofthe sub-contractoxs'and state whether or not those entities have employees. If the sub-contmetom have employees,theymustprovidetlreir workers'comp.policynumber. '• 1 am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site informAgdon Insurance Company Name: Policy-4 or Self ins.Lic.4/: Expiration Late: Job Site Address: . City/State/Zip, Attach a copy of the workers' compensation policy declaration page(showing the ptdicy.number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.15• can lead to the imposition of criminal penalties of a [j 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verificatioxl. I do hereby certi un er the lrs a d an of perjury t$at the information provided above is true and correct. 5i ' afore: q / Date: Z (o Phone 4: / ��'Z0�7,+OJ' Dfj4cial u:only. o not write in this area,to be completed by city or town officiaL City or T PermitUcense it Issuing Acircle one):' 1.Board2.BnildhigDepartment 3.City/TownClerk 4.ElectricaIInspector 5.PlumbingInspector6.OtherContact Phone#: rl CITY OF SALSA MWAaAEETP5 BEnzDm DErAramEw 120 WA9ff4G7MSVEET,3ADRDM 7kL(978)745.9595. PAX(978)740.9846 BIIvJBERLEYDRiSaDLL MAYOR 7}EAssSTAEW DmEcrcacrpua dcrRoFExT lBtuDnaGcommac*m Construction Debris Disposa/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 c40, S 54; Building Permit g is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: Qrrvvn`{E 7(Uc-� (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) %nature applica t Date CERTIFICATE 01F LIABILITY INSURANCE D05/311/2016 ) 05/31/2016 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(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 endorsements . PRODUCER CONTACT Brenda Cozzolino EA Kelley PANI A/C No, (401)431-9883 FA (401)431-9889 450 Veterans Memorial Parkway ADDRESS brendac eakelley.com Building 5 PRODUCER 216303 Fast Providence RI 02914 INSURAFFORDING AI INSURED INSURERA: Atlantic Casualty Ins CO 42846 John Pantapas INSURERS: 407 Lowell Street INSURERC: INSURER D: Peabody MA 01960 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 INSU RANCE 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 OF INSURANCE ADDL SUBR POLICYWOB NUMBER POLICY BEE POLICY EXPJ-TJL LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 KCOMMERCIAL GENERAL LIABILITY a occurrence) $ 50,000 CLAIMS-MADE OCCUR MILD ESP(Any one person) $ 5,000 AW-- L118001204-2 03/262016 03/262017 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENLAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 x POLICYF-JPIR9J- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALL OYMEDAUTOS BODILY NJURY(Perperson) $ SCHEDULEDAUTOS BODILY INJURY(Per sea dent) $ PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-CSMEDAUTOS UMBRELLAUAB H OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ RRDEDUCTIBLE $ ETENTION ESOMLSATION AND EMPPLOYRABIn W 7 - C H- V/N ANFFICP�RR/PMRIETqOFFRREXCLTMUDEEXECUTIVE N N/A E.L.EACHACCIDENT $ (mandatory in NH) EL DISEASE-EA EMPLOYEE $ If es describe under E.L.DISEASE POLICY LIMIT $ IPTIONO PAPPRATIONSbel, DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is requited) Carpentry Contractor. CERTIFICATE HOLDER CANCELLATION Me Nit Sin SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 35 Perkins St ACCORDANCE WITH THE POLICY PROVISIONS. AUiH�4fgb NTATIV€ E Salem MA 01970 Y J Cam\ ©1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) The ACORD name and logo am registered marks of ACORD