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10 PICKMAN RD - BUILDING INSPECTION
The Commonwealth of Massachusetts (L/` Board of Building Regulations and Standards CITY OFM Massachusetts State Building Code, 780 CR SALEM \,J Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011 One- or Two-Family Dwelling This Sect on For Official Use Only Building PermitNumber:' f� AA Z? / ".Bulding Official(Print Name) ,`. .ate r.;- }gnat ? Date .F . =SECTION 1:SITE I RMATION 1.1 Pro,yty1A/ddress, ( 1.2 Assessors Map&Parcel Numbers .cjf Q.x 6C AsI L la Is this an accepted street?yes-1K 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 Providdd Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public f Private❑ Check if yes❑ Municipal's On site disposal system El I " ..SECTION 2;PROPERTY OWNERSHIP' 2.1 Owner'of ecord: - lavl� Name(Pri City,State,ZIP !a Y,Lj:�wta16 &J -2r31 aot-/3& 4 �erc'lo � ►rrk�Cri No. and Street Telephone Email Address rim SECTION 3c DESCRIPTION,OF PROPOSED WORKZ.(check all that apply) New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Propose Work 2: SECTION 4: ESTIMATED CONSTRRUCTION COSTSh Estimated Costs: ' Item k , OffieiaLCUse Only Labor and Materials , , � � y 1. Building $ 1 BtuldingPermi tFee $ Inchcatehow fee is detennine�l: ❑ Standard CrtylTown Application Fee 2.Electrical $ s a ❑Total Project Cost_(Item 6)xmulttpher x` 3.Plumbing $ 2 Other,Fees 4. Mechanical (HVAC) 5. Mechanical (Fire ` $ Total All Fees $ Suppression) Check No - Sr iounf dash-,,,Check Au o nt 6. Total Project Cost: $ �❑paid it lFull,, '� OutstandingBalance Duer. , "' , h SECTION 5:`CONSTRUCTION SERVICESF. 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No. and Street pe . 'Dascription" U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town, State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town, State,ZIP Telephone ;'SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.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 r 1 OWNER'S AGENT OR CONTRAC TOR'APPLI-ES FOR BUILDING PERMIT I, 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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER, AUTHORIZEI?,AGENT.DECI By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES. 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 can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov;'dos 2. When substantial work is planned,provide the information below: Total floor 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" rt . SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) �Op21'"1 �. I.(�1)I I�CIVI'ISCi1 License Number Expiration Date N2tne of CSL-Holder 1 �p U I Q�)lx S)�f SI .?e uboLIUt Ma )lq �t CSL Type(see below) A s —� T e Description U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 FamilyDwelling Si ature ��11 M MasonryOnl °t RC Residential Roofin Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 2 Reistered Home Improvement Contrasl�qyr(HIC) erlCcen CYithunelSu oSlne.Mbesf J 03i)[lanNA HIC Com any Name or HI a strant ame Registration Number aA 6 1910 0 41 !t !g. te Expiration Date Signature VTelephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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 I, 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 SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 1, ,as Owner or Authorized Agent hereby declare that the statements and information on the f egoing application are true and accurate,to the best of my knowledge and behalf,., C 1 JnQi�cvo Cl tore of Owner or Audhorized Agent Date (Signed under the pains and penalties ofperjury) 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 Mot 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 I I0.115,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" fie `C� Office of Consumer Affairs and Business Regulation b. 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Reqistration: 128463 Type: Private Corporation Expiration: 4/11/2013 Tr# 216164 AMERICAN CHIMNEY SWEEPS I(�C� rr =_ ROBERT WILLIAMSONi t 61 PULASKI ST PEABODY, MA 01960 Update Address and return card. Mark reason for change. Address ❑ Renewal ❑ Employment Ji Lost Card 'S{A1 0 S M-0 G10121e Offer ofaco9meu'�'ines""e" e9u`t6i'i'ao"- License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR Registration: before the expiration date. If found return to: 128463 Type: Office of Consumer Affairs and Business Regulation y Expiration: 4111(2013 Private Corporation 10 Park Plaza-Suite 5170 yy"" Boston, MA 02116 �A�rCAN CHIMNEY§W'4EPS.INC. ROBERT WILLIAM SON . . ` 61 PUTASKI STC7 Q PEABODY, MA 01960 - Undersecretary Not vali Vwithout signature Public Massachusetts- Dcn 1mcon!!ndSnu'dlards + - Buurd of truil n},Supervisor License Construction Sup License: CS 71638 FIT. ' 0AROBERTJ61 PuIASRM PEABODY tl A Q1��6 I 141i1{�d. ion: . ,ExPirat 11I2712013 Tr#: 7276 ('unun'us+uneK ®ACORN CERTIFICATE OF LIABILITY INSURANCE "'E'"`°8/15/ 8/15/12 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 pollcyQes) must be endorsed. N 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 endmsemen s. PRODUCER CONTACT NAME: Georgetown Insurance Agency PHONE 97 352-6000 FAX (97e) 352-7719 10 West Main Street ADDRESS: info@Georgetownlnsurance.com Georgetown, MA 01833 INSURE S AFFORDING COVERAGE NAICS INSURERA:Maiden SRecialty Insurance INSURED INSURERB:CoMMerce Insurance American Chimney Sweeps, Inc. INSURERC:Savers Property 8 Casualt 61 Pulaski St INsuaeRo:Tudor Insurance Peabody, MA 01960 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 POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWLSUB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INqR POUCYNUNBER MM ID)IY MMIDdYYYY LINTS A GENEEALLIASILITY NAX000612/1000 11/30/11 11/30/12 EACHOCCURRENCE $ 1,000,000 X COMERCIALGEWRALLIABUTY DAAWGETORENTEDEREMISES(Ea C $ SO OOO CLAIMS A1ADE OCCUR MEDE(P(A ore eron) $ 0 PERS01,ALSADVINURY S 1,000.000 GENERAL AGGREGATE $ 2 000,000 GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-cowtoPAGG $ 2,000,000 ][ POLICY PRO-CT [ LCC $ B AUTOMOBILELIABIDTY BCWxyC 4/27/12 4/27/13 C MIINEUSINGLE IMIT 1,000,000 ANVAUTO BODILY INJURY(Par person) $ ALLOWWO x SCHEDULED BODILY INJURY(Par accident) S AUTOS NON OWNED PROPERTY DAMAGE $ HIREDAUTOS _AUTOS erawdent $ UABRELLA LIAB OCCUR EACHOCCURRENCE $ IXCESS LtAB CLAIMS-MODE AGGREGATE $ DED RETENTION `+ WORKERS COMPENSATION AR0426062 10/2/11 10/2/12 }[ WCSTATu- OTH- AND BI PLOYERS-LIABILITY MIYPROPRIETOTLPARTNE(LEI�O.UTIYE V7 NIA E.L.EACH ACO DENT 500,000 OFFlCERMENBEAEXCLUAEDT QAaitlawry le NH) E.LDISEASE-EAEMPLOYE 500,000 If YYes describe under DESCRIPTION OF OPE RATIONS be low E.L.DISEASE-POLICY LIMB 500,000 D Errors a Omissions EOP0035967 8/24/11 8/24/12 each claim 11000,000 Liability Policy policy aggrega 11000,000 MSCMPTIONOFOPERATWNSILO TIONSIVEHICIE3 (AI�cN ACORO tO1,Adtlitlorel Ranerka SchetluM,Bmae sow 4reeJred) Certificate holder is listed as additional insured as required by written contract executed prior to any loss. Operations usual of a chimney sweep. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Janet Sherwood ACCORDANCE WITH THE POLICY PROVISIONS. 10 Pickman Rd Salem, MA 01970 AUTHORRED REPRESENTATNE Steven E. Mollohan ©1988.2010 ACORD CORPORATION. All rights reserVed. ACORD 25(2010/05) The ACORD dame and logo are registered marks of ACORD Phone: Fax: E-Mail: nsimone@cpnail.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Buaincc/Organication/Individul):'A YUQf 1 _QYl N 1A (Q J A2f-P 5, Ir G Address: &I ; OCiSKiS+. City/State/Zip: 2QGLbC)atj , MLl O(96p Phone#: 97E 53 `02 U 0 U Are 1'ou an employer?Cheek the appropriate box: Type of project(required): 1.F✓ I am a employer with S 4. ❑1 am a general contractor and 1 6. ❑New construction employees(full and/or pan-time)." have hired the sub-contractors 2.❑ 1 am a sole proprietor or parser• listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. 9. Y Pac Y� ❑Building addition [No workers'comp.insurance 5. ❑We are a corporation and its reqY11ed.) officers have exercised their 10.❑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,§l(4),and we have no 12.[]Roof repairs - C insurance required.]t employees.(No workers' 13.6 Other K)OD Cl U comp.insurance required.] *my applicant tha checks box at mot rasp all out the section below showing their workers'nompemation policy information. r Home nmer who submit this affidavit indicating they ace doing W work and then hire outside cootracton must submit a new affidavit indicating such lConaacbrs that check this box must attached an•ldhiond share,showing the mane ofthc subcontractors and their worker'comp,polity in:onmtiw. l am an employa that is providing worker'compensadon insurance for my employees. Below is the policy and job site iaformadan. insurance Company Name t� C ct sac T L'LL #: A Policy Nor Self-ins.Lic. QO Y2�>7OT12.Q—a, Expiration Date: �.0 n^ Job Site Address: i�ICiwva2 /t-A'. ` _CiTy/State/Zip: 3ftlt - mCi aiq /V 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 MGLc. 152 can lead to the imposition of criminal penalties of a fine u to$1,500.00 and/or one- imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine P Y�� 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. 1 do hereby y c tt a nd nahie:of nrj uyat th the information provided above is true and correct nh Sienamre . Date, Phone 4: 9-71k 5- (IZyo Ojj7cia/uu only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle am): I.Board of Health 2.Building Department 3.Cityrtrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: