Loading...
14 PLANTERS ST - BUILDING INSPECTION (2) I 7 the C'onintonsae:dth of M:usaehuseus -_ y, Board of Building Regulations and Standards CI'i'N' OF tr Massachusetts Slate Building Code. 730 CNiR Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Tivo4li ni(s' Du ellin,kr This Section Fur 01)Mcial Use Only ! Building Permit Number: Dam� p '•d: 37 Building 011icial(Print N;unc) Sigts arc Date SECTION I:SITE INFO IATION I.1 Pro p�ty Address: 1.2 Assessors Map,fr Parcel Numbers 4 Y la lr ress..S ' 1.la Is this an acre led street? -es no Map Nunther I'urccl Number 1.3 Zoning information: 1.4 Property Dimenslons: Zoning District Proposed Usc Lot Area Isy R) Frontage 0l) 1.5 Building Setbacks(ft) Frunl Yard Side Yards Rear Yard Required Provided Reyuircd Provided Reyuircd Provided 1.6 Water Supply:(M.G.I.c. 40.§Sa) 1.7 Flood Zone Information: 1.8 Sewnge Disposal System: Public❑ Prk ate❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal s)stem ❑ Check if yeso SECTION2. PROPERTY OWNERSHIP' 2.1 Owner'of Record: Nmne(Print)n City.State,ZIP ly VLAtA's'E(LS M C17T CA-11-T15- W No.and Street Telephone Email AJdrcss SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ .Spccil'y: Brief Description of Proposed Work=: 9p 2°° La. typ'ev. 1J\n5 r\ SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: 0111c1a1 Use Only (Labor and Materials) Official I. Building S �5 coo — I. Building Permit Fee: f Indicate how fee is determined: LL l eclrical S ❑Standard CityiTown Application Fee ❑Total Project Cost'(Item 6)x multiplier 1. Plumbing S 2. Other Fees: S J. \ICChaniC.tI ill\' \(') S List: t. \ICChallli al tFirc .—_ -- ----- _--____- - - - - - �u++ressiom S Total .\II Fees: S Check No. ('heck Allioum: 0 Total Project Cost: S ❑Paid in Full 11 Out tetan g lalance Doc: SE(JION 5: CONSTRUcriON SERVICTS 5.1 ('unstruction Supenisur License(CS1.) 2j(� LI-1 b^U1Z -- - — i ^ I iansc Nunlhcr I�,pn;uion Datc Nane of(Sl I Iulder (( I ist l'S I. f l Pe I see bolus) C\ T2•N(� /\JC - -- --- - -- 1ME Descripuun�outJ Street .triM(Ih1ilJin Is a to 15,001)nl. It.l©, O icted IR2 F.unil D+wllin—.—.. .Ci1sil"mil.Slat,/III nn Cnd Sinuw and SiJinFuel Iluming Appliancestion Tcic hone Ifmuil address D Demolition 5.2 Registered liume Improvement Contractor(HIC) ICi l sc IIIC Registration Wunher lapir;aiun Bute I IIC Co pan) N;une ur I IIC' I(egistrum Nanw t' (l�T r Nu.and Street - �js� Email address City/Town.State,ZIP felcithone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 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 ..........o No...........O SECTION 7s: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 y this building permit application. �(�� � Soffit.( Q�MEe�tnLT �- ��-an►� Print Owner's Nane(Electronic Signature) Dale SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 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 l)++nur't or Authorised Agent's Name 11•.lectrunle Signature) Ditc NO'f ES: I. .\n Owner who obtains a building permit to do his her uwn work,or an owner who hires an unregistered contractor Inut registered in the Hume Improvement Contractor(HIC) Program).will Mil have access to the arbitration program or guaranty fund under\I.G.L. c. I42A.Other important information on the HIC Program can be round at \1+1,1 m.n. O% ,11.1 Information on the Construction Supervisor License can be round at ,+wt n1.1,: i�:,1 -Ip, 2. \\'lien substantial lwrk is planned, pruside the information below; total flour area(sq. R.) . ____1 including garage, finished basenlentattics,Jocks Or porch) Gross lis ing area(sy. It.I - _ Habitable ruun)count N unhbcr Or lireplacas Number of bedrooms Nunlherofhathrounls . . _ . . . Numberul'halfhallis .. is pe of heating s)item N'unlhcr of decks, porches + i Il pC al io011llg i)item I�ncloseJ . ..()1 do i 1. Total Project S,ittwe Footage 'IllaI, be uh,totacd tlhr"rowl Project Cast" i rl"; ` � TL`Ci'I'Y OE s7.�r .r.aYt, 1�[.15S.1CHl:5ETTS BUILOLNG DEPARTNLE\T 120 WASHIINGTON STREET, 31D FLOOR T FL (978) 745-9595 Fla(978) 7.10.9846 Kl%tBE R[ RY DRISCOLL A-%YO Z THO.%us ST.PIERM DIRECTOR OF PLBLIC PROPERTY/8Un.DING CO\L.IISSIONER Workers' Cmnpensation insurance Afl7davit: Builders/Contructorq/Electric(ans/Plumbers A 1 illeant Informatlnn PICAse Print Leaibl .Vati7c lflu�ioes.rr Urgantratinm lmlividu^al): � .uoli f\ gull _s lw, Address: RaNt� I AA. UA r{ �y� 7 City/State/Zip: fNt� AA• 0�gOl Phone Al! �I S12-c.t�! 7 Are lu an employer?Check the appropriate box: Type of project(required): 1.91 am a employer with 7 1, ❑ I am a general contractor and I 6. ❑ v construction elllpioyces(full and/or part-time).• have hired the sub-comnctors 2.0 1 am a sole proprietor or partner. lived on the attached sheeL t 1• watmodeling .chip and have no employees These sub-comrectors have 8. Cl Demolition working for me in any capacity. workers'comp. insurance, 9. Cl Building addition [No workers',comp.insurance 5. ❑ We area corporation and its required.( officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself. (No workers'sump, a152, §1(4),and we have no 12.❑ Roormpairs insurancerequired.l t employees (No workers' l},❑Other comp, insurance required.) •.nay erPll,unl raw cl1mks bee el must also rill aW the saction below showing their"kao'e,,Ponudun pulley inAimrailon. 'I ll nvuwnun who.obeli this uTMvil indicaine they am doing all wort and then hire outside aunrmctm M141 althmii ARM aOfJavil;,diming muck :tlmnxtur that check this box must itful od in Aldaiu"aborl showing the nume orlhe wit commct m and lhair woAM,mmp,pulley intwmanan, f tun un rnrpluyer that/pruvfdlnx rvorkers'campeuratlun insurance jot my empluyars Below la du pulley and fob s!!e irtjorarrutlnno I nsurance Company Name: Policy 4 or Selr•ins. Lic. to: Expiration Dote: Job Site address: CityiBtute/Zip: Altach a copy of the workers'camponsatloe policy declaration page(Showing the policy number and expiration data), Failure to secure coveraga as required under Soelion 25A et'bIGL e. 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 corm of STOP WORK ORDER and d line ,If till to S_M.00 a day against file violator. lie advised that a copy of this.statement may be rurwurdcd to ilia Oflica of lurrsligmiuns�dfhe Dla for insurance alvuage vcritiealiun. 1,10 hereby earl/' a!t hw pubes r ad/ tell ajperjury that the injerarm/mr pro v/Jed above it-true cud correct clime,,: 771- 5 L3 —vo7r Ojjh iol rue wdy. Oa not write in tYn:r area, to be completed by city ur/own njf/ciuf i City nr Town: -_ I'ermitiT.lcense.d I %ding Atlillurity (circle one): I. lluard of Health !. Iluildlnt., Mpurlutent .1. ('ityi roan Clerk J. PYeetrical Inspector 5. Plant bins; Lupdetor ri. Other Conlad Pvrsno: , I hone d: CITY OF S,v-&Ni, Akss.kaiUSETTS ©LILDNG DEP.IRTIE.`T 110 WASHNGTON STRFBT, 3"FLOOR I'M k973) 143-9595 P.tx(971) 74a98U K .1GmAL.EY DRISCOLL MAYOR Nomu ST.PMXAS DIucroHOPPLaEicPnOPERTY/StADLYGCO- MISSIONER Construction Debris Disposal At'ttdavit (required for sU demolition and renovation work) In accordance with the sixth edition of the State Building Code, 790 CMR section 111.3 Debris, and the provisions of MGL a 40, S 54; Building Permit a is issued with the condition that the debris resulting from this work shall be disposed of in a properly licemed waste disposal facility as dofincd by NIGL c 111, S 150A. The debris will be transported by: t (name of hauler) The debris will be disposed of in (name of raciblQy)� Jcu nQc (Aldrar oericd+ty) + enamra ofperm+t rpphcmt 2361AI�2—:J(e '+=` �lassachtisetLv--Dcp:u'hncnf'ut Public 7:11Ms:� 3} Board of Buildimg./tc{ulations and Stand W(6 `�•-- ? Construction.Supervisor- License - License: CS 95367 Restricted to: 00 - DEREK PETERSON 9 TRINITY AVENUE s LYNN, MA 01902 Expiration: 411WM12 b, (•lnm�iwionrr.' .i'r#: 20399. '. 4' ��se -lJomvmanwea�c a G/o.6wg,l Office or Consumer Affairs&B smess Regina li _ HOME IMPROVEMENT CONTRACTOR TYP`, Registration: 151859 - f Expiration 7113f2012 Private Corp, SE CIA BUILDERS-INC}� A tl GLENN PETERSO_.._ _ 1 9TRINITY AVE LYNN. MA 01902 Undersecretar•;— 03-06-' 12 17: 03 FROM-Phil Richard Ins. 1-978-774-1318 T-114 P0001/0001 F-181 �►(�aRo CERTIFICATE OF LIABILITY INSURANCE v nATE(MMoomrY) 03/06/12 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 policy(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 confer rights to the certificate holder in lieu of such endomemen s. PRODUCER 978.998-6896 NAME:CONTACT MasSPay Insurance Services,LLC 978-998.6897 NN an), PAx - 27 Garden Street Unit 1 B PNO Beverly, MA 01915 ADORIESS: Kenmore Commons INSURER(SI AFFORDING COVERAGE xAN:# INSURER A:ChertlS Insurance INSURED Sequoia Builders,Inc INSURER B: Derek Peterson INSURER C: 9 Trinity Ave Lynn, MA 01902 INSURER D: INSURER E MSURER P COVERAGE$ 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 MAX PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR TYPE OF INSURANCE POLICY NUMBER MM/GDn'YY MM/ODM ,LLIMITS OENERAL UABILRY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMIS $ CLAIMS•MADE OCCUR MED EXP An o11B afeonl $ PERSONALBADVINJURY 'S GENERAL AGGREGATE S GEN'U AGGREGATE LIMIT APPLIES PER: '• PRODUCTS-COMP/OP ADD $ POLICY PR LOC $ AUTOMOBILE LIABILITY COMBINEp SINGLE LIMIT $ ANY AUTO BODILY INJURY(Par pars=) S AALL UTOS OWNED SCHEDULED 1 BODILY INJURY(PerS &nt) $ NON-OMED PROPER.dTY AM4 $ HIRED AUTOS AUTO$ I 8 UMBRELLA UAS OCCUR EACH OCCURRENCE S EXCESS I.IAB CUAIMS-MADE AGGREGATE S DED I RETENTIONS 7 WORKERS COMPENSATION WC$TATU- X O7H- AND EMPLOYERS'LMINUTY A ANY PROPRIETOIVPARTNPRJSXECUTIVE Y/N NIA C009A4.7932 10122l11 10/22112 E.L.EACH ACCIDENT $ 500,000 OFFICERNEMSER EXCLUOEDI (Mandatory in NH) El,DISEA4E-EAEMPUOYE $ SOO,000 Iryes,desclba under DESCRIPTION OF OPERATIONS below El DISEASE•POLICY LIMIT $ 500,000 DESCRIPTION Or OPERATIONS I LOCATIONS I VEHICLES (AIMM AO0R0101,Additienel Raman¢Sohadxb,a men spa oIp n,.Lrsd) Evidence Of insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL Be DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington St. AUTHORIZED REPRESENTATNE Salem,MA 01970 �GGeR.lcl.a �yG+Xxd•n•Or��. ®1938-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 03/06/2012 TUE 16:15 FAX 0001/001 Ae Ro O, CERTIFICATE OF LIABILITY INSURANCE MTE(wroo I 3/6/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATWN ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE 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. N the certificate holder Is an ADDITIONAL INSURED,the pol eyfies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an emlolsement. A statement on this certificate does not confer rights to the Certificate holder in ieu of such endorsemenXs). PRODUCER CONTACT O Benevento Insurance Agency IncPHONE - FAi- (781) 599-3411 . (781) 581-7200 497 Humphrey Street 1AML DlmFss: Swampscott, MA 01907 INSURE 6)AFFORNNOCWERAGE ,- mice IN9URERA:Patrons Mutual USURP .....-- INSURER B: ._.---.._. ........,..._ .. .. Sequoia Builders, Inc. INKIRMC: _ 9 TrinityAve. ---'" A INSURED:—_ Lynn, MA 01902 INeulset E: -- . IISIIRHt F• ..— COVERAGES CERTIFICATE N UMBER: 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 AINDCONOTIONS OFSUCH POLICIES.LIVIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR _-, AmL$UBR POLICY EFF LTR TYPEOF INSURANCE I WVD POLICY Wh®ER AM=IYYYYI hNrDDYYYY UNITS A OEHatALLIABILIY CTR0008946 2/5/12 2/5/13 EACH OCCURRENCE a 1,000,000 X COWAERCWL GENE PAL LMBILITY DAMAGE TO RENTED _ mmmw) i 50,000 C(AIMSMADE ❑X OCCUR NIED EXP(Awom Posen) a 5,Q00 PETtsONALS ADV INJURY a 1.000.000 GEHERALAGGREGATE S 2,000,000 GBI'LAGGREGATELNITAPPLES PER PRODUCTS-cowtOP AGG S 2,000,000 X POLICY 'CT LOC S lW1GMOBILE INABILITY a mN E ANYAUTO BODILY INA/RY(Per Me ) S ALLOViEO SCHEDULED BOOILYIWURY(PeTe enU S ANTICS AUTOS NON-0M1ED pftOPERTY DNAAGE S HIREDAUTOG _AUIOB (PeramdeaR S U MB�IJ.N DAB OfTUR EACH OCCURRENCE $ FXCEee 1.1 CWMS.MADE AGGREGATE ...-- S DEC RETENTIONS $ WORKERS COMPENSATION X WC STAT OTH- ANDFNPLOYERSDABAUTY YIN ANYPROPRI:TOR.PARTNERIE)F=TNE E.L.EACm6p_t� NT OPPICERA'EMGE R OCCLUDED? N/A . 01111bW1 I-NH) EL.DSEASE-EA-BAP_ VEE Nyyeee Rd a Remdar DESCI"ONOFCPERATIONSIob E.L.DISEASE-POLICY LIMB tl Ip, t fE6CRIPTIDN 11FOPERATIOHS/LOGIWNS/VE3tl ClES WBrgt ACOIt01P1,Atlmtl(mal RPtNON Letloaup.IT mwa spew kmq,q,d) � CERTIFICATE HOLDER CANCELLATION City OP Salem SHOULD ANY OF THE ABOVE DESCRIBED PO1-ICIE$BE CANCELED BEFORE THE FXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N Salem Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street Salem, MA 01970 AUIHOR®REPIES@17ATNE Bryan Benevento ®198E-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010185) The ACORD dame and logo are registered marks of ACORD Phone: Fax: (978) 744-9327 E-Mail--