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4-6 PRESCOTT ST - BUILDING INSPECTION
t The Commonwealth of Massachusetts CI"fY OF Board of Building Regulations and Standards I Massachusetts State Building Code, 780 CNIR RED h_� tli INSP d t��t l`&I ES Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only5 Building Permit Number: Date Ap 'ed OuilJing Olticiul(Print Name) Signalpre a e SECTION 1:SITE INFORMATION 1.1 Property ddress: 1.2 Assessors Map 8r Parcel Numbers �/-t' /02,eIr- .S� I.I a Is this an acce ted street?yes_ ❑0 Map Number Parcel Number 1.3 'Zoning information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yams Rear Ynrd Require) Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: I Zone: _ Outside Flood Zone? Municipal l"On site disposal system ❑ Public� Private❑ Check if es❑ P P SECTION2: PROPERTY ERSHIP, —it�Ownerlo(Record- VYI✓t i 4nfitJ SRSAIi XfI UOstJ City,State,ZIP Telephone " Email Address No. mtJ Street SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) rAccessory Existing Building❑ Owner-Occupied ❑ Repairs(s) 6( Alterntion(s) ❑ Addition Cl ry Bldg.❑ Number of Units Other ❑ Specity: oposed\York': r e 'U ''Q r SECTION d: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Rent Labor and Materials) I. Building S .5 Va I. Building Permit Fee:3 Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costa(item 6)x multiplier x ). Plumbing S ?. OtherFees: .S t. ,Mechanical (HVAC) S List: 5—Mechanical (Fire S Total All Fees:S . Skip r scion) Check No. _Check Amount: Cash amount:_ (. Total Project Cost: S ❑Paid in Full 0 Outstanding Balance Due: 01 %6 b SECTION 5: CONSTRucTION SERVICES 5.1 C'unstruction Suporvisor License(CSL) d6304 5 r/ License Number Expiration bate Name of CSSL[folder List CSL'rype(see below)—J,) _ '1 .0 t. !'eblv`✓ bdocl ,type Description No. ;aid Street U unrestricted(Buildings tip to 35,000 cu. Il. 171 401111't Rd —9 It Restricted 1&2 Family Dwelling Cityfrown,State,ZIP hl Masonry � 2 o Covering fir[ f S WS Window and Siding SF Solid Fuel Burning Appliances (/7 k3.2 f3Pt(xcx 5 So) CC I Insulmion 1'ele hunt Email address r :(,�C D Ucmolilion 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date [IIC Company Name or HIC Registrant Name No. eutd Street Email address 4 cit rrown,State ZIP 'Cole Ionia SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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 Is§uance 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 PP X 1,as Owner of the subject property,hereby authorize Y'i i-\ 2iCkbcm?d_ OhnS- t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owtmr's Name(Electronic Signature) Date SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION By et Grin my name below, I hereby attest under the pains and penalties of perjury that all of the information cunt,ute in this a no 's true and accurate to the best of my knowledge and understanding. Print wncrS r A c r gent Name(Electronic Signature) Data NOTES: An Owner who obtains a building permn o Jo Iris/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program),will LLi have access to the arbitration program or guaranty fund under IM.G.L,c. 14'2A. Other important information on the HIC Program Carl be found it www.mass.i ov'oca Information on the Construction Supervisor License can be found at www.mass.sov'dL 2. When substantial work is planned,provide the information below: Total tloor area(sq. P.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. it.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Typcufcuulingsystcnl Enclosed Open_ i. "Iblal Project Square Fuutuge"may be illbbtltnted liar Total Project Cost" ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 04/02/2014 PRODUCER (978) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ARCHER INSURANCE - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 271 CABOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BEVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A.Western World Is. Co. John Babcock Construction INSURER8: 77 Sohier Rd apt 6D INSURERC: NWUR D: lBeverly MA 01915- INSURERE: - ' COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR D'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MMIOO DATE(MM/DON() LIMITS X GENERAL LIABILITY NPP8184730 - 01/17/2014 01/17/2015 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED lOO,OOO PREMISES Ea occurrence $ CLAIMS MADE I—XI OCCUR / / / / MED EXP(Any one arson) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMP/OP AGG $ 2,000,000 17 POLICYF-j JEC LOC AUTOMOBILE LIABILITY - / "/ / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY $ SCHEDULEDAUTOS (Per Person) HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per amideM) $ PROPERTYDAMAGE (Peraccident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ $ WORKERS COMPENSATION AND / / / / TRY LIMITS ER EMPLOYERS'LIABILITY ANY'PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ - OFFICERIMEMBEREXCLUDED4 / /' / / E.L.DISEASE-EA EMPLOYEE$ H yes,describe under SPECIAL PROVISIONS below El.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE,ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTENNQCETO THE C/EEPqX1J1FICAT OLDER NAMED TO THE LEFT,BUT TANIN SASALUXANON - FAILURE TO DO SO L I PO NO OJoL(�A'I L�IA�pITYY ANY KIND UPON THE /MM.-EE ""'may';. 4-6 PRESCOTT ST - INSURER ITS AGE TA S. AUTHORIZED REPRESE TIVE SALEM MA 01970- '-"'' ACORD 25(2001108) O ACORD CORPORATION 1988 INS025(olmfw Page 1 of 2 CITY OF SIV-EM, A-1SSACHUSETTS j ©LUMNG DEPARTMENT 120 WASHNGTON STREET, 3'4 FLOOR TFL (978) 745-9595 RUC(978) 7.10-9&4S KISIHERLcY DRISCOLL &LAY01' Irto.%As ST.J'tERRs DIRECTOR OF PUBLIC PROPERTY/SL:=NG CON WI55IOVER COnstruction Debris Disposal At'tidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section l 11.5 Debris, and die provisions of NIGL c 40, S 54; Building Permit is is issued with the condition that the debris resulting from this work shall be l l 1, S I SOA. disposed of in a properly licensed waste disposal facility as defined by vfGL c The debris will be transported by: 1 (n�ntr of hauler) The debris will be disposed of in 4C�w T��, s v 5 � n (ume of facility) (`AA O '7 0 (address of(aeility) s of igrtwtur IMiCappfi""t .. ---- Luc -- —, 9