27 PICKMAN RD - BUILDING INSPECTION / I The Commonwealth of Massachusetts
CITY
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7 h edition ReOFSALEM vised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: / d
Signature:
Building Comp ' sioner Insp ctor of Buildings Date
SECTION 1: SITE INFORMATION
4pertyf �Address: � 1.2 Assessors &Parcel Numbers�'�
,r -
1.la 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 II) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yazd
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Diissposal System:
Public n Private❑ Zone: _ Outside Flood Zone? Municipal: site disposal system ❑
Check ifyesGl--'�
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
e Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz: S�cCp t 2F—( � \2 Se►.�o..+2 i,IS�YI�. 3C1y1"•
r S �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (11VAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
e Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 6��� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number E nation ate
of CSL-Holder List CSL Type(see below)_��
s Art .m T Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Si�ggnnature pp M MasonryOnly
CA-9 �� 0� RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5. Regtstere Home Improvement Contracty (FIIC
ecil n � 1 �� Inc_ / It q , i.D i Dr1�
HI C pany Name or H1C egistrant Names AA Number
Expiratioonn—Gate
' ature 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 ofthe 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
and � QKf— \Or\ to act on my behalf, in all matters
relative to work authorized by this building permit application.
ature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I, 2a i� lzec\(N"A ,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.
Tint N
`Siature of Owner or Ahhoriz6d Agent Date
(Signed under the pains and penalties of perjury)
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(111C)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 I 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"maybe substituted for"Total Project Cost"
CITY OF S.U.F.\I, 2UNSSACHUSET17S
• BUMDLNG DEPARTMENT
130 WASHNGTON STREET, 3" FLOOR
'ICI_ (97 745-9595
FAX(978) 740-9846
KI�{gFRi RY DRISCOLL
MAYOR
IHOMAS ST.PIERRE
DIRECTOR OF Pumic PROPERTY/BI:ILDLNG CO\MUSSIONER
Construction Debris Disposal 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 c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of auler)
The debris will be disposed of in
QMyNd p �U5cnsa
(name of faci yl )
C (address at facility)
signature or-permit applicant
I C) b /t]
� date
a�nr�,Jtrdw:
i CITY OF SiU.E.`I, 2UNSSACHUSETTS
BUMDING DEPAR E&NT
• j 120 WASHINGTON STREET, 3w FLOOR
as TEL (978) 745-9595
FAX(978) 740-9846
KIMBERt FEY DRLSCOLL
;MAYOR T IE�1oMAs ST.PRRR6
DIRECTOR OF PtBLIC PROPERTY/BL:LLDLNG C01MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �� Please Print Legibly
Nattie (Busi� siOcrrganizatioNlndividual): SkeAc ) �^��-Y!-A L>C "E' c—:>r Inc,
Address: ZS NY�ornct3 \�\Tt1 \�l 2_�n
City/State/Zip: Phone #:
A an employer?Check the appropriate box: Type of project(required):
I.re 1 am a employer with 9—,3— 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.] officers .
have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 5Pjurnbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12. repairs
insurance required.]t employees. Wo workers' l3.❑Other
comp. insurance required.)
•Any appgcam that checks bon 91 most also fill out the section below showing their workers'compenurion policy information.
'1 heneowrtrn who submit this affidavit indicating they are doing all work and them hire outside contractors must submit a new affidavit indicating such
=Gontronors that check this has must anachod an additional sheet showing the name of the subconnacors and their workers'comp,policy infetnmtimt.
l am an employer that is providing workers'compensadon insurance for my employees. Below Is the pollcy and job site
information.
Insurance Company Name: vdvtc-v--
Policy#orSeif-ins.!��Lic.q� 14ay1 5 Expiration Date:
!, t2 Job Sire Address: ('YYKVL. KZO(3L-& City/State/Zip: R
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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
l do/sere certify ad e t palrts and nail s ojperjury that the Information provided above is tr and correct
. i+nat ue• �9 ri I Date: v
Phone
Dfricial use only. Do not write in this area,to be completed by city or Iowa official
City or Town: Permit/I.1cense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityifown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Massachusetts- Department of Public Safctr
Board of Buildin! Rcgulations and Standards
Construction Supervisor License
License: CS 102921
Restricted.to: 00 -
.PATRICK REDDY ' _ it•
8 PHEASANT RUNDRIVE -
NEWBURYPORT, MA 01950
Expiration: 11/29/2012
('nmmissioncr Tr#: 102921
__—
W— Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration• , 164675 Office of Consumer Affairs and Business Regulation
Expiration 10/27/2011 Tr# 290056 10 Park Plaza-Suite 5170
Type: Private Corporation Boston,MA 02116
REDCO CONSTRUCTION INC
PATRICK REDDY
8 PHEASANT RUN DRIVE
NEWBURYPORT,MA 01950 Undersecretary J4
Not valid without signature
FRO" <THU)OCT 7 2010 12:OO/ST. 12:06/Ho. S003404076 V 3
MASSACHUSETTS ASSIGNED RISK POOL
REQUEST FOR CERTIFICATE OF INSURANCE
Use this form to request a Certificate of Insurance from an Assigned Risk Pool Carrier.
Please provide all of the requested information, including the facsimile number(s)of the person or persons to whom the
Certificate of Insurance should be issued. If this form is fully and accurately completed,the Certificate of Insurance will be
issued and distributed by facsimile to each fax number provided below, within two(2)business days of the carrier's receipt
This Form may be mailed or faxed to the Assigned Risk Pool Carrier. To obtain each tender's contact information refer to the
Certificates of Insurance section located in the Producer Community section of the Bureau'swebsite,(www.wcribma.orn).
1. Name,address, telephone number and facsimile number of the INSURED:
Name: Redoo Construction Inc.
Mailing Address: 8 Pheasant Run Drive Newburvoort. MA 01950
Physical Address: same
Phone: 978-270-8740 Fax: 978-255-2489
2. Name,address, telephone number and facsimile number of the CERTIFICATE HOLDER:
Name: Albert Bonaiuto
Mailing Address: 27 Pickman Rd. Salem. MA 01970
Physical Address: Same
Phone: unknown Fax: none
•3. Name,address, contact person, telephone number and facsimile number of the PRODUCER:
Name: Arthur S. Page Insurance
Mailing Address: P.O. Box 391 Newburvoort MA 01950
Contact Person: Kate E. Quill
Phone: 978-465-5301 Fax: 978-462-0890
4. Policy Number,Policy Effective Date and Policy Expiration Data
If a Certificate of Insurance is needed for more than one policy term, provide the Policy Number,
Effective Date and Expiration Date for each policy term.
If the policy has not yet been issued, you must attach a copy of the Notice of Assignment
Policy Number. WC002011897
Effective Date: 03/05/10 Expiration Date: 03/05/11
5. List any special requests for optional coverages/endorsements(a"Page 2 for listing of coverages available
In the pool and the conditions of availability)or additional information(including changes In exposure not yet
reported to the carrier)that wid assist the carr/erin the Issuance of the Certificate of Insurance.
NOTE: An additional Insured(s) shall not be listed on any Certificate o/Insurance unless such additional
Insured(s)Is a named insured on the policy.
FROM (THU)OCT T MOIO 12: 1O/ST. 12]O0/Ho.0000484070 P B
OP ID:KC
,�a`oav CERTIFICATE OF LIABILITY INSURANCE ioro71 �
THIS CERTIFICATE 13 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 INSUREMS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the ceMftate holler Is an ADDITIONAL INSURED,the pol"Ies)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 corder rights to the
certificate holder In lieu of such endorsem s.
PRODUCER 97"S-5301 NAIVE;ACY
_
Arthur S Page Insurance Agency 978-462-0890 tp&%_ Na
37 State St.
Newburypott, MA 01950 REDCO-t
None
NISUPARSI APPORDIMG COVERAGE NAG
INSURED Rodeo Construction,Inc. INSURER A:SCOtbdale Irla CO
Erice Reddy INSURER B:
8 Pheasant Run Drive
Newburyport,MA 01950 INSURER c:
IMsuREa o:
IIKIIRER E:
NSumnF-
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 POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR nreoF sauRANesma JIM rovernums PGporrym "awoonnna LAIrS
GENERAL UMMUTY EACH OCCURRENCE S 1,000,00
A X COMMERCIAL GENERAL LIABILITY CPSIIB5773 0"W10 owmil ES Ee PWurrcnm S 50,00
CLAIMS-MADE r7x OCCUR MEDEXP aMPRfRJrI S SAM
PERSONAL 6 ADV INJURY f 1,000,
GENERAL AGGREGATE S 2.1100.0010
GEN'L AGGREGATE UNIT APPLIES PER: PRODUCTS-COUPWAGO S 1.000,0
POLICY PRO- r I LOC i
AUTOMOBILE LU1UM COMBINED SINGLE LINK S
lERw0de l)
ANYAUTO
BODAY INJURY(Px Pecan) 7
ALL OWNEDALROB
BODILY INJURY(PV MAiOMU i
SCHEDULED AUTOS PROPERTY DAMAGE
HIREDAUTOS (PRr=iMM) i
NO""ED AUTOS S
i
UMNIELLA WIB �y EACH OCCURRENCE S
EXCESS me =uR. AOE AGGREGATE I
DEDUCTIBLE t
RETENTION $ 1 S
r MRS OOMMMSAWN WC STATU- I OTH-
AND EMPLOYERS'LAIM ITY Via
AfVr PROPRIETORRARTNERIEMCUTME E.L.EACH ACCIDENT a
OFFN:ERMENMR EXCLUDED? MIA
OScnacSMr In IN) EL.DISEASE-EA EMPLOYEE S
OMypC,aRWaw IRMM
OESGiIR10N OF PERAIrONS Dcrow EL DISEASE-POLICY LIMIT i
DESCRIPTION OF OPERATIONS I LOCATIONS I YEIOCLEa(AUceT ACORD 101,A00NM,r RM.1a,Se1N01Mc,ff.yse N rRBlraal
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION GATE THEREOF, NOTICE WALL BE DELIVERED IN
Alpert Bonaiuto ACCORDANCE WITH THE POLICY PROVISIONS.
27 Pickman Rd.
Salem,MA 01970 AVTgMFD REPARVWATIVE
Nona -0
10 198 -2g09 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are regislaed marks of ACORD