23 PRESCOTT ST - BUILDING INSPECTION _ --- I he C'onununwe:dth of,blctssachusetU
CI 1'1'OF
Board of IluilJing Regulations and Standards
Massachusetts State Building Code. 7SO CMR lt,•ri. ALE 'n//
Building Permit Application To C'onsruct, Repair. Renovate Or Demolish a
One-or Tmu-Pitnfih Un vllinq
This Section For Olrcial Use Only
r1his
t Number: Uate. lie :
Zial tilling Mane) Signat Dolt
SECTION 1:SITE INFORM ATION
ddress: 1.2 Assessurs .$lap dt Parcel Numbers
accepted street?yes no Mall Number Purcel Numtwr
IJ Zoning Informatlon: 1.6 Property Dimenslonsr
Zoning District Proposed Use Lot Arco IN 11) Frontage(11)
1.5 Building Setbacks(R)
Frank Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.V. 40.§54) 1.7 Flood Zone Informallont 1.3 Sewaga Disposal System-
Public❑ Private❑ Zone: _ Outside Flood Lund? Municipal❑ On gild dispusul s)slem ❑
Check if yes❑
SECTION2. PROPERTY OWNERSHIP'
2.1 wrier of Record:
r�.r'el L r ��S 4'•epr .9. ✓vrr .�
Mane(Print City.State.ZIP
2�3 dvcsla2;/S� q Z 7 IOU? .,
Nu.and Street 'lephuna Et uil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ TAltermlon(s) C3.1 Addition 13
Demolition ❑ Accessory Bldg.❑ Number of Units_ r ❑ Specify: o-
Brief Description of Proposed Work-:
SECTION J: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs: Official Ust Only
(Labur and \latcrials)
I. Ouilding $ Ste, O v I• Building Permit Fee: f Indicate how fee is determined:
:. S
❑Standard Ciry,Tusvn Applicalian Fee
FIVctrical
❑Tutal Project Cost'I Item O x multiplier
1 I'lunihiny I
•. Olher Fees: S_ -
J. \Icch.ufical ill% Lim
S \Icch.mic.d (Fire '---- — ----•- ----- . . .
ti.. +n•siionl rotal .\II Fccs: SCheck Nu. ( hcek :\n-uout:n 1'ntul Project Cnf . -. — _._..
C.�O Qv ❑ Paid m Full OOuistandiny Bal.mcc Duo:
SEX-1I IN 4: C ON5TRUC ION SFRVU FS
i.1 C'onst rue tion Supen isor I.icenso(CSI.)
/� _ // Q.�Q� s I icen�e Nmnhar I��piretilm I);ne
N:uneul'l'S1. Iloldcr IisCN. l'\petsechelussl.__.j
Dcicriplian
No. and Str•ct
� p I nrcslriaeJ tltuildin s li pt 1<,002 eu. 11.1
Re trictcd I,*! Famil Oncllin
C�i loan,Sta' .L11' SI SlaSuu
RC' Rautin Oncrin
\1'S W'indow,mdSidin
SF Sulid Fuel Darning Appliances
Insulation
1'ek hone i?nnu addrrsi D Demolition
51 Registered/ lome Improvement Contractor(IIIC) j�y$y3 &- 3Da013
% IIIC•Rcgisuatiun Numhur Fxpiruliun Data
I IIC C'nmQJ it Nome or IIIC I c strum wn i
7cY fr QZjg )Asre e-2 /i -eO Gv7
Nu. rid Svvyy A Email address
�erbo� fie'
Ci Rown.Susie ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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 Issuance of the building permit.
Signed Affidavit Attached? Yes ......... 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 by this building permit application.
#3ai aru /J tiers /?�• ' Z
Print U+vner's Nwne(Elcctrunic Signature) Oate
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contain in this applicaI is true a d accurate to the best of my knowledge and understanding.
C erg d //
Print 0mier'i or Authorircd Agant's Name 1 ectruntc Signature) Data
VOTES:
I =obtainsobtains a building permit to do his.her usvn svurk,oran owner who hires an unregistered contrictur
n the Hume Improvement Contractor IHIC) Program),will nu have access to the arbitration
mly fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
+ I information un the Construction Supervisor License can be found at ++q`+ uLl.+ •�.,k Ips
2. \then substantial Durk is planned, provide the information below:
fatal Iluor area Uy. IT.1 . ____.-_1 including garage, finished basement attics,ducks or purchl
Grosi liv ing area 1 sy. it.I __.._ _ Habitable ruum count -
\unther \'unnhar of bedrooms - . .
\umber of hathreunti . . _ _ \umber ol'Ilalt h;uhi
I\ lie Idhc.nting s)stcol _ _ \ltnther ul'decki p,lnhes
rip
I\l`u nl c0aliltg i)item L'nKlused
t, "I,n.tl Project \+ umv f ootage•Itna1 he <uhstitutcd fur"f.'t.d Project Cast"
CI"['Y OE: S:1 lm. ItiL1SS.ICHUSE"ITS
� t)t:llnlNG DEP.hRnf��r
),`;) ��:}+� 110 %V,%sHLNGTON STREET, )" FLOOR
K) .�. ,r T L (978) 745-9595
R� t
- F.+.r(973) 7 N1-98-36
:tI>IBE,'tI.EY DRISCOLL T"mus ST.PIER"
Nt{YOI DIRECTOR OF PULIC PROPERTY/OI:RDr%1G.COWNISSIONER
Workers' Compensation Insurance AMdavit: l)uilders/Contractor.v/Electrict•rns/Ptumbers
t illcant Inrormutinn t ase'P/rint Legibly
.V;1111C Illutina+oUrgtmnliatilndividu.dl:T//✓�'? c�G uo�r_ 4! ,fin/c—S'70T1�L
r '
Address: /
City/State/Zip: Phone N:
,fire you an umplayer!Check the appropriate bait Type of project(required):
I on a em to or with3 4. 0 1 am a general contractor and 1 6
D Y e have hired the sub-canlractors ❑Rem debt action
ittplayea(tLll and/or part-lime). 7. ❑ Remodeling
2.0 lama sole proprietor or purtnur• listed on the attached shout.
.hip and have nu amplayees These sub-contractors have 4. ❑Demolition
working lbr ma in any capacity. workers'camp.insurance. y, 0 Building addition
(No worker:comp.insurance 5. 0 We are a corporation and its 10.❑ Electrical repair$or additions
requirud.) officers have exercised their
3.0 1 ain a homeowner doing all work right of exemption per MOL I I.Q Plumbing repairs or additions
myself.(\a workers' Gump. c. 152,j1(4),and we have no 12.0 Roof eepairs
insurance required.) t vmployees.INoworkers' 15.0Olher
sump, insurance required.)
•.\ray appil.on dW alma boa rl mWt Asia all out the wetiea buhtw showing chair e,otitoo'comrsentallun putiAy inatmtaoon.
'I hen owm"who.ubmit this atrtdavil indiwlns they an doing as were and then hire uultide canlnabs mtat mhmlt a now,antdavil indicting tuck
t' mrwwn awl0mt this box mast anachod+n.ddlaurtilI ihuwing the nwnd of the rusronlnakn and their workers'comp,policy Infaneadon.
fain un rurpfuya slur la pruvlJLrX rvorke 'cumpeuraNun lnruruneejor my empluyrrs. Below Is the polky undjob slfe
inju/nruBna
Inaumncu Company Name
Policy 4 or Scif--itu. Lie. d: __ Expiration Date: 5
July Site Address: oily/Stateizip:
Allacb a copy of the workers'cam ponsutloa pulley declaratlon paps(showing the policy number and expiration data).
F tilure to wcuru euver iga as required under.Section 25A ut'%tGL c. 152 can lead to the imposition of criminal penalties of a
fire op to 5I.S00,00 ondlur one-year imprisnnmen4 as well as civil penalties in the form of it STOP WORK ORDER and d tine
of up to 5250.00 a Jay against the violator. Ile advi.ted that a copy of ills.datcmvm may be furwardcd to ilia Of tied of
I iv csti gat ions off lie 0IA for insurance coverage vcri iicaliun.
/du/rrrrby rrrtijy uuJrr die�ifruli difuhlra,, erjury//rut the lnjurarallen pruvideJ above;;.I ttrue/utrJ rdrreca
r
L=LL_
Otlhiul rue only. /lo nef roast Lr//v:r urea, to he coney/tteJ 6y riry ur/own ajj7riu!
Citynr fawn: ._. Pcrmit/Ucenm d__.
Liuin,,.huthurily (circid anc):
I. Lu.ud ut Ilcalih '. Iluihlln., Deli rtutem i. r'itp'rnwn Clerk 1. E.lectric.0 lnipuc tar i, Thumbing lutpector
L„tl.i.l I'e rind: I'hnnc .h
ClTY OF S.t[.E,N4 AISSACHUSETTS
JLMDLNG DEP-m-n .\t
I'0 A.UHLNGTON 5rxgjrr, }"FLOOR
172L k973J 145.9591
4.%IBFRf Y DRISCOLL P.�x(97� 1 98td
MAYOR 114CIM&!ST•FMAIA
011ECTC A 0/PL HUC PRC?LTATY/BC RDLYG C0.101ISSION E R
Constructloa Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 790 C,NR section 111.J
Debris, and the provisions of b1GL o 40, S 54;
Building Permit ,y is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by,bIGL c
I 11. $ 1 JOA.
The debris will be transported by:
(n,+me or' solo)
The debris will be disposed of in
(namsu%/a,-yj
/�n� /� (JJdrdr or fJcihry)
u 1nJNtC oI permit rppli.Jnf
�Jfp
ACORO® CERTIFICATE OF LIABILITY INSURANCE °"'-`MN°"`""'
1 23 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 poricy(tes) 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 endorsement( .
PRODUCER NAM : P ul T Murphy
Paul T. Murphy Insurance Agent PHONE FAX
781 321-9700 N ; (7e1) 324-4253
628 Broadway
Malden, MA 02148 Ass: ;>aul@ptminsurance.com
INSURE R(Sl AFFORDIN3 COVERAGE NAIC 0
INSURERA:Scottsdale Ins
INSURED INSURERS:Peerless Ins
Advanced Energy Solutions LLC INSURER c:AIG
28 Hamilton Rd. INSURER D:
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 NAMES)ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDNG 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.
POLICY EXP
TR TYPE OF INSURANCE ADD POUCYNUMBER POLICY
LI /YYYYYYI MMUDO/YYYY1 LIMITS
A GENIERALUABLnV CPSIO14919 5/7/11 5/T/12 EACH OCCURRENCE S 1 ODD QOO
X COMMERCIALGENERALLIABEJTY DAAIAGETORENTED $ ZOO 0
cLAIMSMADE ❑X OCCUR RED EXP(Any o.p m) $ 5,000
PERSONAL B ADV INJURY S 2,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LNITAPPLIES PER PRODUCTS-CDNPIOP AGG 3 2,000,000
POLICY PRO. Lac S
B AUTOMOBILE LIABILITY 8633314 3/19/11 3/19/12 aaadaDrt SNIDLELIMM 1,000,000
ANYAUTO BODILY INJURY(Pw person) S
ALL OWNED AUTOS X AUTOSCHEDS BODILY INJURY(Pe mcidwd) S
X
NON OWNED PROPERTY DAMAGE HIREOAUTOS X AUTO waccident S
S
UMBRELLA LMB OCCUR EACH OCCURRENCE T
EXCESSUAB CLAIMS-MADE AGGREGATE S
0ED RETENTION a S
C WORKERS COMPENSATION 006789459 5/14/11 5/14/12 WC STATLL OTH-
AND EMPLOYERS'ABILITY Y I N
ANY PROPRIERXT/PARTIERA:XE-CUTIVE E.L.EACH ADO DENT 1,000,000
OFFI ENMEMBER EXCLUDED? N I A
(Mandebry In NH) E.L.DIS EASE-EA EIAPLOYEE 111 1,000,000
lotyae,dlate ger
DESCRIPTION OF OPE RATIONS MNOW E.L.DIS EASE-POLICY UNIT S 1 000 000
DESCRIPTION OFOPERATIONS I LOCATIONS/VENCLES (ANeeh ACORD 101,Add10a,M Relreda Schetlub,Amore space b regd,ed)
Insulation-Coverage subject to policy terms conditions and exclusions.
3reater Lawrence Community Action Council, Columbia Gas of Massachusetts (Bay State Gas,)
\ction Inc. , National Grid Corporate Services LLC , d/b/a National Grid, Boston Gas Company,
:Olonial Gas Company, and Essex Gas Company are listed as additional insured on GL
>olicy per form CG20330704.
CERTIFICATE HOLDER CANCELLATION
GLCAC SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
305 Essex St. ACCORDANCE WITH THE POLICY PROVISIONS.
Fax M 978-681-4980
Lawrence, MA 01840 AUTHORIZED REPRESENTATIVE
19 -20 it ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered ma Of ACORD
'hone: Fax: E-Mail:
�l ns achusetty Department of Public
Board of Building Regrrl lions arid Standa4st
Cor"lstruction Supervism License s
License: CS 90902
RICHARD 13, BORGIES s
28 HAMILTON ROAD'
PEABODY, MA 61960 _
FRt x
Expiration: 11/1Y2012
C'nmmisvinner' - Trt: 5481
Aet'�r-64...F?`.• .F ....:i.rvw+a 5 .F..>s4.1 \Y
oReeofC0n,l.e prca�'xg,—
HOME IMP &B-ACT R�ulaliou
{ ROVEMEN7COt4TRACTOR I �
Registration:,-064893 > �tt
Expiration: A�/30/2013- - - TYPe: Ii
e AD ANCED Cowration
ENERGY 5 LO UTi ' _
ONS11-C.
RICHARD'BORG6iR
- II
28 HAMILTON -1' ._-- "''. RD _fin _
f, PEABODY, MA 01980
--' Undeneeretary _