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12 RAND RD - BUILDING INSPECTION (2)
The Commonwealth of Massachusetts ' Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM {<.i< Revised Mar 201 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling „WAIR ,, ._ §&! W—This Section For Official Use OnlyWo, v, Binding Permit Number:__ s "_ _,.,Iwo,.; l `Date Apo Ited:'iH'`d " .C3 ' ,13 x 4 Hnp wra...W r 'iv'. s BuddmgOf Hui at(Prm Napte) r-` �-�` `�� ..,.,Signature : � ;. � t+ to �. .m. t__.. ; SECTION 1-SITE INFORMATION L' y 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers i L l a 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: Zone: Outside Flood Zone? Public Q Private Q T Check if yes❑ Municipal❑ On site disposal system ❑ . .,; WIN0 ° ..:w :).,,U, ' _:max, :°�SECTIQN2::PROPERTY OWNERSFIIPt.. .:. iN .m sw : 2.1 Owner o14 ©AIf Record: K / Si�Z`�/ ' � Name(Print) �— City,State,ZIP Or No.and SNo.and—treed Telephone Email Address . CTION 3:DESCRIPTION OF.PROPOSED W ORW,(chick a'lt tha apply) HmgAA 5' New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ _ Other Specify: Brief Description of Proposed Workz: D SECTION 4;ESTIMATED CONSTRUCTION COSTS°'l Estimated Costs: ar$ " yX�r �{& � "e't Item i Qfffeial Use Only Labor and Materials __. 7 ,,,_,•. , ,.,r., " � 1. Building $ 1 Building Permit Fee $ Nam: -sIndicate how fee is determined:i 2.Electrical $ ❑Standaid+ CrtylTwn Applre tton F er�, w gSS' y ❑Total�rolect Cost (Item 6)x muihphe` iir ��*�x4i � � 3.Plumbing $ 2arOtfieiFees r$ .: . : i _ 9; 4. Mechanical (HVAC) $ 5.Mechanical (Fire Suppression) $ Total All Fees $f � `, ' r 6. Total Project Cost: $ Check Novi Check Amourn a CashAmount 0Q' ,❑Paid in Fult s" 'O Outstanding Balance CTION5.^COlNSTRUCTIONSERVICES� ., +r ._ _ , .7 wmrc ��7'fir�p 5.1 Construction Supervisor License(CSL) License Number Expiration Dale Name of CSL Holder List CSL Type(see below) p No.and Street +_� -.Type ,. a- +,,,.,.,,,4tDescnpnon",.. ,irxg . T P; / / �/ Unrestricted Huildings u to 35,000 cu.ftJ /1 S R Restricted 1&2 Family Dwellin City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding r• q p /� / n Y SF Solid Fuel Burning Appliances Insulation Telephone Email address Demolition 5.2 Registered Home Improvement Contractor(HIC) Go ' (,) Q 7 Z Q HIC Registration Number Expiration Date HIC Company Name or Registrant Name No.and Street Email address Ci /Town State,ZIP Telephone + S GTTQIY b r WOI2TCE){tS'COWENSATION INSURANCE AFFIDAVIT(M G I jja 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 Issu a of the building permit. Signed Affidavit Attached? Yes.......... No........... ❑ :=$ECTION,7a: OWNERAUTHORIZATIONTO BE COM I) ETED WHENg� --. » OWNER'S'AGEN l OR CONTRACTOR APPLIES FOR BUILDING PER�MIt M. T .IMP .. 1,as Owner of the subject property,hereby authorize Ima d n . to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owne ' Name(Electronic Signature) Date t p cF ., t,,,,,;,F $PCTION7b OWNERt,OR'AUTHORIZED'AGENT:DECLARATION4. . By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contamed&this application is true and accurate to the best of my knowledge and understanding. P Owner's 6r Authorized Agent's Name(Electronic Signature) Date xW.. ., , s?v. n 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage, finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths 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" i CITY OF S��LBiLI, XLA.SSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET,Sae FLOOR \ TEL. (978)745-9595 .'; FAX(978) 740-9846 KIMBERLEY DRISCOLL T MAYOR HoMAs ST.PwjM DmECCOR OF PUBLIC PROPE /BU ILDING CO\L�tISStON RTY ER Workers'Compensation Insurance AftidavIt: Builders/Contractors/Electricia"Plumbers Agglicant Information Please Print Legibly dame(Busineavownixatio vimtividual): Address: to City/State/Zip: �/ 1�19 i Phone #: Are y an employer?Cheek the appropriate box: Type of project(required): I. 1 am a employer with Z 4. ❑ 1 am a general contractor and I employees(f dl and/or pan-tittte).e have hired the subcontractors 6. ❑New d construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodebteling ship and have no employees Thew subcontractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance S. ❑ We ate a corporation and its 10.❑Electrical sus or additions required.] officers have exercised they repairs 3.❑ 1 am a homeowner doing all work right of exemption per MGL t 1.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.[] 0a6f repa' insurance required]t employees. [No workers' "t comp. insurance required.] l3. Other •Any applicnm that c mkt ball►1 MUM Was fill out the sectim below showing their workps'compntaarion policy infumtatim. . llnmaownM who submit"affidavit indicating they use doing all work and than hie outside contractors must submit a Crow affidavit indicating such Cwmawan that shack this boa must attached an additional sheet showing the name of the seb.contmears and their wmams'comp.policy infotnmiton. lam an employer that Is pravidhtg workers'compensation insurance for my employees. Below is the polley and fob site Information �J q Insurance Company Name• AArrYI„%// Policy#or Self-ins.Lie.#: Q Expiration Date: Job Site Address: . ' L Z (1/ / City/State/Zip: ,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 S 1,500.00 and/or one-year imprisonnuink as well as civil penalties in the form of a STOP WORK ORDER and s fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance covcrage verification. l do hereby certify ande %�% anitiu ojperJorq that the information provided t above]s true and correc Sispa_t_u Date- Phone#: 7 — 9-1-Z" 6200 Official use only. Do not write in this area,to be completed by city or town oj/'iciot City or Town: Permit/License# IssuingAuthority ty(circle sae): 1.board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Otber M' I Contact Person: Phone* CITY OF S.U.& . NLksSACHUSETTS • BUMDLNG DEPARxN[E2NT ,g ` 130 WASHINGTON STREET, 3*0 FLOOR TEL (978) 745-959S FAx(978) 740-9M KwBERLEY DRISCOLL. MAYOR THo&w ST.Pmm DmECCOR OF Pt is PROPERTY/BUILDING COMMMIONER ;a 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: TbI1(—name of hauler) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant date debdsalTdoc Massachusetts-Department of Public Safety Board of Building Regulations and Standards C'un.struction Supen isor License: CS-058181 `s tir-'ns of TODD A MAIDF� IO BEAVER$b1VD $EVERLYiffA •e VFW& .3 i Commissioner Expiration 11/30/2013 OfficeoOConao�B OMPROVEIAENT cONTRACTOR s4oe Regise"On: 419972 Type: Expiration: 9013 pgA IMA &cO TODD MAIN 10 Beaver Pond Id }; Beverly.MA 01915 .. Undersecretary From:<978-922.2731> To:19789226805 Page:2(2 Date:2121/201312,46:36 PM HC.VK►ACERTIFICATE OF LIABILITY INSURANCE 02/21/2013 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: R the caNfieate holders an ADDITIONAL INSURED,the poficy(ies)nnrst be endorsed. R SUBROGATION IS WANED,sldgeU to the temis and conditions of the Policy,certain poficies my require an endorsement. A statement on this cedi mate does not conifer d9ft to the certificate holder in Hsu of such endolsement(s). PRODUCER NAME: Appleby & Wyman Insurance Agency Inc. NOE : 978.922.2288 cNo: 97S.922.2731 152 Conant St. AODREss: Beverly, MA 01915 cu me 00008021 INSlIRER(S)AFFORDING COVERAM NAICr I+SURED INSURER' Main Street America Assurance 29939 MAIN CO INC MURERB: National Grange Insurance Co. 14789 10 BEAVER POND RD MURERC: Star Insurance Co. BEVERLY, MA 0191S-1203 MURERD: l URERF: COVERAGES CERTIFICATE NUMBER: 13-14 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. LDI fS LIm TYPE OF RISIIRANCE MR YWD POLICY NIAABER GENER ABaALU MPB3465 U2I08P2013 02108/2014 EACH OCCURRENCE f 1,000, X COM.EROAL GENERAL UABLIIY PREMSES Eaaca e f 500,00 CLAMS.MADE X'OCCUR MEDEXP(Anymepe ) E 10, AT PERSONAL&ADV tLURY E 1,000 GENERAL AGGREGATE E 2 000,0001 GENL AGGREGATE Leff APPLES PER PRODUCTS-COMP/OP AGG f 2,000,0 8 P OLICY PRO- OC LIABILm' M1B3465 0210612013 02I082014 'OMMED SNOLE LW E auddero 500, 000 D BODLYNAIRY(Perpersen) 4 D AUTOS BODIYNAM(Pwecodar0 E EDAUTOS PROPERTYDAMAGE S UTOS (PxecdOem) E Auros f X utmRla.uLue X occurs CUB346S 0210820'13 02MBt2014 EAaio.co-FAENcE E 1,000, E%CESSt-m CIAIMSMAOE AGGREGATE 8 11000,00( ODC B E DEDUCI�E X RETENTION E 10, E waNlmtscoeaeisATION WC068527 0&032012 081032013 X TORYLwfrs ER MID EMPLOYERS LIABILITY YIN E L.EACH ACCIDENT E 500,00( ANY PROPRFTOPJPARThEPJE)(ECUtTVE C OFFCERM-MBER EXCLUDED? NIA EL.D6EASE-EAENPLOYEE E 500,00( I wnxh o ytn NH) DESCPo TIWJ OF�RATONS W. L.DISEASE.POLICY UW E $00 DESCRPTIDN OF OPERATIONS I UO 7FTOFH IVEHICLES(Aft N ADDRD IOI,AEatlp RemarksS ckde,I nmm apace N r wndl CERTIFICATE HOLDER CANCELLATION FAX: 978.921.8534 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Beverly Armors®R RESENrATIVE �rs4le:la nt% Department of Public Services and Engineering 144 Park Street Lisa Marciano AL Beverly, NA 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD