23 PHELPS ST - BUILDING INSPECTION -fhe Commonwealth of Massachusetts
t Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
"'wwwsssrrr Revised Janitor
lit Building Permit Application To Construct,Repair, Renovate Or Demolish a /. V0
One-or Two-Family Dwelling
This Scqrlonyor Qfficial Use FI
Building Permit Number: I I pie App ' d:
Signature:
Building Commissioned Ins of Buil ings Date
SECTI N :SITE INFORMATION
{ 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
93 i'144�P5 -Sr
I.I 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 tl) Frontage(A)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 nertofRecord: p73 r'fi£G�5 5 Si�Gf y
No Pri Address for Serves• .
/ .7 7A 76/N d 90 9
'Signature 7/elePhone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': £MOVE 0(-0 tZ 0 i=. SA3STA tL- P 4-i•s 906 F
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S $ 00.a: I. Building Permit Fee:S Indicate how lee is determined:
2.Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (it VAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 8 �je�D• D� ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7d N7
Q r ( Itle V e 'Q� S License Number Expiration Date
Name of CSL-I l 5
7 Lisl CSL Type(we below)
T Description
Ad U Unreslricud(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwellin
Siynalu p� -7 M Masonry Only
( 4 RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Bumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 Issuance of the building permit.
Signed Affidavit Attached? Yes..........M-' No...........O
SECTION 79: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 rk horiz this building permit application.
lima re n
Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 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.
Print Name
Signature of Owner or Authorized Agent Date
(Sijtncd under the pains and penalties of 'u
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 Improvement Contractor(HIC)Program),will Vj 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 110.116 and 110.115,respectively.
1 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"
CITY OF S.U.E.`I, NL%ss kcfit;sETrs
BI:DDLNG DEpmtTslL%iT
4
D
1'_0 WASNL�IGTON STREET, 34e FLOOR
TEL (978) 74S-9S9S
Aut(978) 740-9846
KI,%®EP EY DRISCOLL TNobfASST.PmM
.MAYOIL
DIRECTOR OP PL Ruc PttoPERTY/Rt:DDLYG coSL�nssrov El
Workers' Compensation Insurance ABldavit: BYilderslConlraC[Ors/EIectrlelans/Plumbers
Anallcant Infnrmatlon Please Print Legibly
Nainc(9usine,rotpnttanonlro4vidual):_IR4AT650-0556 Cnn57"CT—Q0
Address: a S 13'" S i
1 ofsaSd
City/StatdZip: W/Uk4Fyf10 /1?!!. Phone 770
.ere you an employe!Cheek the appropriate box: Type o/project(required):
1.❑ lam a employer with Itenerl conowwr and 1 6. ❑New construction
employees(full and/or part-time).• haw hired the srbcaratruton
2.❑ 1 am a sole proprietor or pam er. listed on the attached share.: 7. ❑Remodeling
;hip and have no employees Then subcontractors have X. ❑Demolition
workingrot me in an capacity, workers'Comp.inwnace
Y an c ry• 9. (]Building addition
mq worker'comp. insurance S. ❑ We ors a have
and its 10.❑Electrical repairs or additions
r�gtaired.) officer have exercised their
).❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs at additions
myself.[Na workers'comp. C. 172,91(4),and we have no 12.0 Roormpairs
insurance required.)t employees.INo worker' l�,(�Older
comp.insurance required.)
-Any appli_carl tM a chacks ban al mum m fig out the eafiao talon abowiq their working-canmpwadtw polity idmnan on
'I Gamwowmaa who suhnil this aMdavk imitation they we doing ell oak pot thin kin maaida datrtaI da mar aMak a now aMbvi indic ainn mmak
:'.mdranon that ubwk this bin mug anwhod an 3"liwwl slur chewinn it,amain items ,boa"Unno Vol nuk wakrn'comp.policy information,
NOW
f una ant amployer that bOrovidbeg workers'eompa sedan/nsaruaaif jar any as►plicit"a gdow/s the paslttIli eadJoh SAW
injoraeruioat.
Insurance Company Name:
Policy t or Self•ins.Lie. M: Expiration Data:
Job Site Address: City/StatetZip:
.tttach a copy of the werltars'cootpeassides policy deelaratlos pep(showing the policy another and expiration tlotej6
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
fine up to S 1.300.00 and/or one-year imprisonment,as wall as civil penalties is the form of a STOP WORK ORDER and a Brae
of up to$250.00 a day against the violator. Ile ativisod that a copy of this statement may be rorwarded to the Office of
Inveaoaations ofilia MA for insurance coverage veritiealion
/do hereby con'y aJa t op a r/ary than tha i tiffs, o%w provides/ubow is true and Caned
�"• i 5 Matt: �-/a -In,
P'nre a'
O/Jlciai sae an/r no not write in this area,to be cump/ered by city or raw•n w/flvva! �
City or fwvn: PrrmiN.lcrnu M
i
Issuing Aurhurity (circle une):
1. Huard of Ilruhb 2. nuilding Department I City/rown Clerk 4. Elrelriul Inspector S. Plumbing Inspector
6. Other
Lomlacl Person: ._ Phone N-
lD
MaSSachUSCttS- Department of Public Safet%
Board of Buildiroy Regulations and Standards
Construction Supervisor License
License: CS 72475
Restricted to: 00 r
CARL NEVEJANS
4
37 RED GATE RD .
TYNGSBORO, MA 01879
v— r
Expiration: 12tii/2011
t'ommiscibuer- Tr#: 10609
it
Irs
� OfficeC�aor�mer xu!ra�(�°�✓�amac�ir��
-HOME IMPROVEMENT C&Ba51ness Regulahuu
Registraho,��.. CONTRACTOR
. ExPlrabon�3/23/--2
TYPe;
012
NE Indrv�dual-3!_VEJANS CO �rti � '` 292229`
CARL NEVEJANSU
37 RED GATE
TYNGSBORO,
Undersecr��. ;
Z�
L _
I _ Restricted to: oo '
00- Unrestricted
1G-1 2 Family Homes
' I I
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer to: WWW.MassCmv/DPS
1
License or registration valid for individul use only I
before the expiration date. if found return to:
_ Office of Consumer Affairs and Business Reulation
10-Park Plaza-.Suite 5170 g
Boston,MA 02116 -
} Not valid without signature
E
RD,„ CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDD/YYYy)
(781) 245-2292 03 12 2010
on Insurance Aqen THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
cy, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
bion Street HOLDER. TXIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ox 349 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOld MA 01880-
INSURERS AFFORDING COVERAGE NAICOSSO CONSTRUCTION INSURER A:NAUTILUS INS
ST INSURERB:GRANITE STATE
INSURER C:LD MA 01880- INSURER D:
COVERAGE INSURER E:
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE UIU BE ISSUED TH MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD'L
LTR INS TYPE OF INSURANCE PoLICY EFFECTIVE POLICY EXFRATION
A GENERAL LIABILITY POLK:Y NUMBER DATE MMIDDIYY DgTE MMIDDryy
NC896821 06/23/2008 O6/23 LIMITS
/2010 X COMMERCIAL GENERAL LIABILITY EACH OCCUR 30
RENCE $ 0,000
DAMAGE TO RENTED
PREMISES oceurreme $ 56,000
MED EXP orre rson $ 5,000
PERSONAL S ADV INJURY $ 300,000
GENL AGGREGATE LIMIT APPLIES PER: / / GENERAL AGGREGATE $ 400,000
POLICY Pam-
J PRODUCTS-COMPIOP AGO 8 600,000
ITY LOC / / / /
AUTOMOBILE LIABILITY
ANY AUTO / / COMBINED SINGLE LIMIT
ALL OWNED AUTOS (Ea accident) $
SCHEDULED AUTOS
/ / / / BODILY INJURY
HIREDAUTOS (Par person) $
NON-0WNEDAUTOS / / BODILY INJURY
(Per accident) $
PROPERTY DAMAGE
GARAGE LIABILITY
(Peraccieem) $
ANY AUTO / / AUTO ONLY-EAACCIDENT $
OTHER THAN EA ACC $
EXCESSIUMBRELLA LIABILITY AUTO ONLY:
AGO $
OCCUR CLAIMS MADE / / / / EACH OCCURRENCE $
AGGREGATE $
DEDUCTIBLE / / / / $
RETENn 8 $
B IMORKERSCOMPENTy AND WCO05-09-3558 08/13/2008 08/13 2010 $
EMPLOYERS'LJABILITY / X TU. 7H_
ANY PROPRIETOR/PARTNERtEXECUTIVE OMITS Eq
OFFICENMEMBER EXCLUDED7 E.L.EACH ACCIDENT $ 100,000
IfYss.SPEC AL PR a undePROVISIONS
/ EA EMPLOYEE 8 100,000
SPECIAL PROVISIONS bebw E.L.DISEASE.
E.L.DISEASE-POLICY UNIT $ 500,000
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLcwEXCLUSIONS ADDED BY ENDGRSEMENT/SPECIAL PROVISIONS / /
CARPENTRY
CERTIFICATE HOLDER
( _ CANCELLATION
( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WALL ENDEAVOR To MAIL
ROGER PIED 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUr
23 PHELPS STREET FAILURE TO DO SO SHALL IMPOSE NO OBUDA N OR LIABILITY OF ANY KIND UPON THE
INSURER ITS AGENTS OR E An
AUrHORQ PRESE AT
SALEM MA 01970-
COD 26(2007108)
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