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14 PICKMAN RD - BUILDING INSPECTION RECEIVED The Commonwealth of Massachusetts IMPEC l s Board of Building Regulations and Standards FOR V0281PALITY Massachusetts State Building Code, 780 CMR1015 Mj —4 USE Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date- lied: 4,4 Buddmg Official(Print Name) Signature Date 1 SECTION 1:SITE INFORMATION 1.1 Proper ddress: 1.2 Assessors Map&Parcel Numbers red I I.Ia 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 ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2r PROPERTY OWNERSHIP[ /�e1L 2,1 Owner'of Record: Lov HA No Name(Print) City,State,ZIP /N /° s 1— No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ 1 Existing Buildin Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work : �i>rnk SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials)- I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ 3 ❑Total Project Cost .(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) G Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ O Q 64 ❑Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICE$ 5.1 Construction Supervisor License ,(CSL) )8L29?J' 41711b �1 e�N19ap /V/T(�`7 p y License Number Expirat n ate Name of CSL Holder W S List CSL Type(see below) No.and Street v�f Type. Description S A44 C p�O U Unrestricted(Buildings toing cu.R. •T 1 R Restricted I&2 Family Dwelling City/Town,State,ZIP M Masonry qRRoofingCovering Window and Sidinr' ^ Solid Fuel Burning Appliances 7yi- ?y-1/ ti!� WK (6r-1ef/I' Insulation Tele hone Email address IVDemolition 5.2 Registered Home I�mp�rro,vem,�/en"�t Contractor 01C) Wtio, 9AV&l4b Z� C Registration Number _ HIC tympany Nam�or C egistyln5lj2�te. "#V 1#,k � COS c&j � w� No.angd C9eyI Q•,� M/�4NW9 _F6 i► E ail address City/Town,State,ZIP 7 Telephone SECTION 6:WORKERS' COMPENSATIONINSURANCE 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: OWNE AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby-authorize Rte.04MP 4*P1 " to aZony behalf,in all matters relattiive to work authorized by this building permit application. PrintOwner's fflame(Electronic Signature) ate SECTION 7.k.OWNERr OR AUTHORIZED AGENT DECLARATION: By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contajW,din this application is true and accurate to the best of my knowledge and understanding. Print Ow er's or Authorized a ectronic Signature) ate 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. og v/oca Information on the Construction Supervisor License can be found at www.niass.gov/dT)s 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" t Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Superi-isnr Specialh . : License: CSSL-102293 ^-x RICHARD LAMBY- . 3 OCEAN AVENUE SALEM MA 01970 4, Expiration Commissioner 0 510 3/2 0 1 6 ---° Office of Consumer Affairs& Business Regulation -ai AOME IMPROVEMENT CONTRACTOR *egistration: 1 j 1617 Type: �.r Expiration: 1/12/2017 Private Corporatic: F MASS WEATHERIZATION.INC RICHARD LAMBY 3 OCEAN AVE SALEM, MA 01970 g-- Undersecretary i Rightfax C1-1 10/22/2014 9: 20 : 19 AM PAGE 2/002 Fax Server ` CERTIFICATE OF LIABILITY INSURANCE DATE(MNI/DD/VVYV) T111ILS4,RRITIFICATE 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. HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE FAX 155E OTIS STREET (A/C,No,Ext): (A/C,Na): E-MAIL NORTHBOROUGH,MA 01532-2456 ADDRESS: 735HH INSURER(S)AFFORDING COVERAGE NAIL N INSURED INSURER A: TRAVELERS INDEMNITY COMPANY OF AMERICA MASS WEATHERIZATION INC INSURER B: INSURER C: INSURER D: 3 OCEAN AVE INSURER E: SALEM,MA 01970 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 REOUIREMFM,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 POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS. INSR ADD SUB POLICYEFFOATE POLICYEXPDATE LTR TYPE OF INSURANCE L R POLICY NUMBER IMM\DDIYYYY) (MIADMYYYY) LIMITS GENERAL LIABILITY -ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. REMISES(Ea occurrence) P1 ED EXP(Anyone person) $ ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICYPROJECT[DLOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) .HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTYDAMAGE $ (Per accident) UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ A WORKER'S COMPENSATION AND X WCSTATUTDRY OTHER EMPLOYER'S LIABILITY YINUB-5B4493BA-14 09103/2014 09/03/2015 LIMITS ANY PROPERITOR/PARTNEWEXECUTIVE N/A E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes.describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/RESTRICTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION ��.�.._m. C.S.G.(CONSERVATION SERVICES GROUP) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 40 WASHIN GTON ST BEFORETHE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT [' WESTBOROUGH, MA 01581 ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. ACi 1 ® DATE(MWDDNYYY) �tl/RO CERTIFICATE OF LI BILITY INSURANCE 6/3/2014 THIS (CERTIFICATE IS ISSUED AS A MATTER OF INFORMATICN ON I AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTAICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY r'MEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CO�ISTIT E A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HO 'DER. IMPORTANT: If the certificate holder is an ADDITIONAL INSU 'D, thl policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may reqL re an ndorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). _ PRODUCER CNTA Select Department X66807 _ Eastern Insurance Group LLC PHONE ' �. 800-572-4538 FAJC AX .TeL ses-9244 155B Otis Street ik�:'i;'c,-twork@easterninsurance.com INSURERS AFFORDING COVERAGE NAIC R Northborough MA 01532 INSURER A:Western World Insurance Co. INSURED INSURER B:SCO tts dale Insurance Company Mass Weatherization Inc _ INSURERC: 3 Ocean Avenue INSURER D: NSURER E Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER:CL146338558 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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL BR POLICYEFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MM/DDrfYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE OCCUR 4PPS236097 /28/2014 /28/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY - CEOMaBINEeDt INGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS ' Per accident X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTION$ rBA UMBR 2014 /29/2014 /29/2015 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETORIPARTNERJEXECUTIVE❑ E.L.EACH ACCIDENT $ NIA OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE EA EMPLOYE $ ff yes,describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Insulation Contractor CERTIFICATE HOLDER CANCELLATION (617)497-5538 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, Archstone 30 Cambridge Park Drive AUTHORIZED REPRESENTATIVE Cambridge, MA 02140 John Koegel/KAB1 ACORD 25(2010/05) ©1988.2010 ACORD CORPORATION. All rights reserved. INS02512o10Ds)01 The ACORD name and logo are registered marks of ACORD i ne uommonweatrn of iviassacnaseas Department of Industrial Accidents Office of Investigations 600 Washington Street _- Boston, KA 02111 u%,mv mass.gov/dia Vr'orkers` Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers :pplicant Ivio ration Please Print Legibly NamC (9usinc:: ::i zioon,flndivi dual): MASS WFATHFRDATIry l Info 3 OCEAN AVE address:_ _ Ciri/Stace.'7ic 978-Mbj d4- Arm e ou an employer'. Check the appropriate box: 77E] f project(required): 1 ] am a :mpluyct a ith 4. ❑ I am a general contractor and I have hired the sub-contractors New cons actionemployecslntlltuidiorpart-tune).` Remodelinglisted on the attached sheet. I' ❑ 1 am a snir ;11 anstor or partner- These sub-contractors haveship end 11 r� no employees Demolitionemployees and have workers'working 'lo.me in am' capacih'. Building addition comp. insurance.- req iru-1.:e comp insurance 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ 1 am a homoo'vii-i doing all work officers have exercised their 1 I.❑ Plumbing repairs or additions myself, ?yn v orLci s' comp. right of exemption per MGL 12.❑ Roof repairs in suranee rrt a fired c. 152, §1(4),and we have no t„ r.- _„-,I employees. [No workers' 13. Other — comp. insurance required.] I4 `Ann applicant[tiro chec.ls he:A'I must also fill out the section below showing their workers'compensation policy information. Homeowners v:ho Sni�rnu :hi� affidavit indicating they are doing all wort:and then him outside contractors must submit a new affidavit indicating such. 'Contractors the!citecJ;;hu:i+os must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have employees. if the sul-C;mtrzotors have emplovees,they must provide their workers'comp.policy number. _ I am an ernplrrcr lira: is providing workers'compensation insurance for my employees. Below is the poiicp and job site information. hisurance Compaq' l:are- �� Policy I` or Selo=ir,� i-ic_ �l -KB I � q 3 , -7� Expiration Date: 3 i` .lob Site Add,_l„y 1—f �p,�,,4 I m Cm City/State/Zip: S Attach a copy of the at orkcrs' compensation policy declaration page(showing the policy number and expiration date). Failure to secure _o,cr age as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fie up to ;l >-'.IQD(' a'Id%or one-year imprisonment,as well as civil penalties n the form of a STOP WORK ORDER and a fine of up to S25b1Hi;: dal against the violator. Be advised that a copy of this statement may be forwarded to the Office of IrivestiLations of dry 01 A for insurance coverage verification. I do heregn certi;j Ktder the ai rs and penalties of perjury that the information provided above is true and correct. 1 Date Phone t'` .1_ Official utC onA- Im not write in this area, to be completed by city or town officiaL Cite or Totl n: Permit/Licease# Issding Authurih (circle one): 1. Board of Flvelth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector �. Plumbing Inspector 6. Other _ Contact Prrcon: Phone#: i 1