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12 RAND ST - BUILDING INSPECTION fhc Comnwmvealthpxh y, , hoard of Building Regulations and Standards CI I'Y OF t klassachusetts State Building Code, 7SB CNIR S.\Lli\I ; l 13ttilding Permit Applicalion 'ro Construct. Repair. Renovate Or Demolish a One-or Ton-Plurnily Dn rllonq This Section For OI'rieial-V-se i id Building Permit Number: _ i D t Applied: MIC44-� �'T1�ZZ I Koro514ft — Iluilding 0117cial(Print Mena) Sigtta urc Date SECTION 1:SITE INFO ON L1 Proper AJ es��� ram' essors Ivlep eft Parcel Numbers r -J _ L la Is this an acce ted scree . -es no binp NwnMr Parcel Number 1.1 Zonlna Information: 1.4 Property Dimensions. Coning District Proposed U.46 Lot Area(sy 11) Frontage(11) 1.5 BulldIng Setbacks(R) _ Front Yard Side Yards Rear Yard Rayuircd Provided Reyuircd Provided Rquimd Provided 1.6 Water Supply:IM.G.I.c.40.§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: Riblic O Private O Zone: _ Outside Flood Z me?Check if cs(3 Municipal O On site disposal s)stem O SECTION3: PROPERTY OWNERSHIP' 2.1 wnert gf Rel1J/UG� N;mse l PrinU City.State,ZIP /t9l RYIX'i0 No.and Street relephune Finail Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction C3 Existing Building Owner-Occupied ❑ Repairs(s) O Alteration(s) C3 I Addition t7 Demolition O Accessory Bldg. O I Number of Units_ Other Specily: s�Ct Brief Description of Proposed Work-: WIIO �j SECTION J: ESTIJIATED CONSTRUCTION COSTS heat Estimated Costs: I Labor and.\Lnerialsl Official Use Only I. Building S Qd D I. Building Permit Fee: S Indicate how lee is determined: '. l:'learica( S O Standard City?uwn Application Fee O Total Project Cost'(Item O x multiplier t. I'lumhiny S 1. Other Fees: S_ J. MIvch.mical ,I I\ %C) S List:._ ' � \ledtaniad iFne ------ �u +rassioni S rotal .\II Fces: S_.__ I.'haANo. Check :\maunt: l'.uh \moon:: a Tntal Project Cnvt: i G� _...__ /�uL! C3Riid in Full ❑Outstanding Ilal,utce Ouc: ., Ova V✓ V o� � SECTION t: ('ONS I'Rllf'rION SF.RYI('F.S S.I Constructimt Super isor Lirrnsr(C'Sl.) -�i�.�5.��_ � �3_v`�/� 1 icenee Number I:\pkr.L11011 Date N•mty ul'01, l ialdcr .. .....---- I Ist CSI. I)Pc hec _._0101 �3e�1�_4. �f _.----.-- --- 11 , Ihxripliun Na. ,ulJ Slrcct it I1,iresiricicd illuildin s ti w 15,000❑l. Il.) It l Driellin Cilii fawn.S6ue,LIP �I Sl;nun NC R,anin C'uscrin _ N'S Window an SiJin SF SuliJ Fuel Ihuning Appliances Iluulutiun l'ak bony Enulil addrasi e D Demolition S,2 Rrglstrred Ilume Improvement Cuntrnclor IFIIC) IIIC I(egiiu;niun Numhcr liepinuiun Data 1IIC'C 011 an) N unv nr I IIC' I(egistrunt tnv �r lL frriav7@ �Ii�GSCIr fGri i`) NoN�trcet Emuil address Ci !Town,State ZIP Rh hone SECTION 61 WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52.1 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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENTORCONTRACTOR 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. Print Umier's Nwne(Electronic Signature) Date 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 contained in this application is true and accurate to the best of my knowledge and understanding. c_ Prins omicr•.t u1 %m1�,N Numu l l IVVtrMl Signature) NOTES: I. .fin Owner whu'obtains a building permit to do his her uwn work,or an owner who hires an unregistered cuntrnow (nut registered in the Hume Improvement Contractor(HIC) Program),will t have access to the arbitration program ur guaranty fund under\I.G.L. v. I421A. Other impurtant information on the HIC Program can be l'ound at ii,,,i me.. �;„ .•. 1 Information on the Cunstruction Supervisor License can be found at,,,,,, ill-; �;o% •Ili' 1 W hen substantial twrk is planned,pros ide the informatiun below'. rota) flour area t iy. III_ _—__.._I including garage. finished bascnsent attics• decks or purch) Uruii liv ing arra 1 iy. Il.l _-_... Habitable roust count \unlhcrof lircplacei .. .._ _-._ \'umher kit*hednunns .. _ . . \unlhcrofhathruollls \unlherofhalfhalhi i)pe of ha,uing i�;lern _ \lonbvr of daki. porehcs I\1wof oolingi)item 1:116,Ncd (tlhll 1. "I octal Project Square fPal.lga Ill111 he iuh,titutcd tbr"fal,d Prajat Cast" 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 121604 Type: DBA Expiration: 5/24/2014 Tr# 223332 QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RD. DRACUT, MA 01826 Update Address and return card.Mark reason for change. .- Address ❑ Renewal ❑ Employment Lost Card SCA 1 Ca 20M-05/11 C%& ((iC1MW10)8(ieQlr/,:o/b,/,&J;ad./roett License or registration valid for individul use only Office of Consumer Affairs&Business Regulationy - ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _ /egtstretion 121604 Type: Office of Consumer Affairs and Business Regulation c - - !re,,. 5/24/2014 DBA 10 Park Plaza "Suite 5170 Boston,MA 02116 QUINN's CONSTRUCTION THOMAS QUINN - 868 MAMMOTH RD. gin DRACUT,MA 01826 - �— � �� • E �A�J�,� Undersecretary Not valid without signature :Ni tssachusetts - Department of Public S:tfen Board of Buildin-.Rc_uhttion.s and Standartls i Restricted to: 00 Construction Supervisor License 00- Unrestricted - t ,License: CS 39732 - iG-1. 2 Family Homes Restricted to: 00 THOMAS J QUINN t 868 MAMMOTH RD. Failure to possess a current edition of the DRACUT, N1AQ1826 L j Massachusetts State Building Code - - is cause for revocation of this license. Referto: WWW.Mass.Gov/DPS Expiration: 3I252012 (lnnmisSianer Tr#: 18330 V 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 121604 Type: DBA Expiration: 5/24/2014 Tr# 223332 QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RD. DRACUT, MA 01826 Update Address and return card.Mark reason for change. - Address ❑ Renewal Employment Lost Card $CA 1 0 20M W11 V/ae CeavV1101 Ver' "n�C�/171nJJfFc�uJe�lJ Office of Consumer Affairs&Busi ess Regulation License or registration valid for individul use only -'rME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 121604 Type: Office of Consumer Affairs and Business Regulation Expiration: 5/242014, DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 QUINN'S CONSTRUCTION - THOMAS QUINN 868 MAMMOTH RD. DRACUT,MA 01826 - - Undersecretary Not valid without signature - 1 CITY OF S.UZN fe ttiL1SS.ICf-iUSETTS at.:tLDOM OVIA TtE`T I'0 W.li'1LNGTOM Srtj8r, 1'O FtCCjt 1`+L (973) 145.9591 K!»FJtLeY 0Iti1COLL FVt(978) 7 0.9&4 MAYOR DIAB I}Iosw ST.PMUS L-Cpfl OP Pl'S UC PII0PlA7y/8(,•Qpa4C C0JOItSS,0.N Eft Construction Debris Disposal Attldavit (required for all demolition and renovation work) In accordance with the sixth edition of the Stats Building Coder 7s0 CUR section 111.1 Debris, and the provisions of MQL o 40. S 54; Building Permit M is hie work shall be disposed of in issued with the condition that the debris resulting from I 11, 3 I JOA. a properly licensed waste disposal racility as defined by,blCL c The debris will be transported by: The debris wilt be disposed of in (nam@ o� �--- �JsiU.c) .,dare„am„t„r) +yn+mreufpermit ,ppt —' CI-I•Y OF S:ULE.%is NL1SSACHusE-[TS UL'IIDING DEP.WMENT 120 W.ISNLYGTON STREET, 3'o FLOOR 1EL 978 745-9595 F.kX(973) 74&9844 �lNeBE.RI•EY DRISCOLL T �tL�Y01 HO�L\S ST.PtE.iAB DIAECTOROF PUBLIC PROPERTY/BUR.DING CONNISSIONER Workers' Compensation Insurance AflTd•avit: Buitders/Contructorv/Electrlcians/Plumbers Itoolicant information Please Print LegihlX NainC Address: CityiState/Zip: Arc yn in employer!Check appropriate boss Type of prrr)cet(required): 1. I am a crap Ith 4. 0 I JIM a gcnl•a1 cuntrsetor and 1 6. 0 Now,construction anlployc (Ni ndlorpert-time).• have hind the sub•wntractors 2.0 1 am a solo oprictor or .partner• listed on that uttachcd.rheet t 7• ❑ Remodeling ,hip and have no employees These sub-contractors have V. 0 Demolition working for me in any capacity. workers'comp. insurance. y. 0 Building addition (No workers:comp.insurance J. 0 We are a corporation and its 10.0 Electrical repairs or additions required.) officers have exercised their 3.❑ 1 am a homeowner doing all work right of conniption per MOC I Lq!Ptjambiniti repairs or additions myself. (No workers'sump. C. 152,11(4),and we have no 12.Ealtoof repairs insurance required.) It empluyees.[No workers, 13.0Othet sump•insurance required.) •,tny appllu:ue nW Omits boa/I must also all uul the aeaiue bulaw showing Ihair wabn'comprnudun pulley inalnnutton. Of Lvnuuwlw+n who.ubmil Ohio aMdovil indicating ocy an doing all week and Then hire wui4e wnlmetde maul ruhatll a new anJdavll indleuine weJ. $1�mmcluo Thal chuck this boa mall mxhud in adduiunol.hal showing the Mules of the suktionlrienn sad Ihair workers'watts.policy Inrerrnadon. /atn un anpluyrr that/t provldlnx Ivorbn'cumprnradun/nsuruneejor my empluyerse Below Is du pollq and job site iujornrurinm � J / �/� In,urtice Company Name: Policy 4 or Self•ins. Lie. d: Expiration Date:__ yJ lab Site Address: /� /Yl�'y/= S% CitylState/2ip:��Lr Altaeb a copy of the workers' compensation policy declaration page(showing the policy number and espinlion data). F.tiluru to secure coverage as required under.Section 23A ul'3tGL c. 152 can lead to the imposition of criminal penalties of a fire up to S1,500.00 undlur one-year imprisonment,as well as civil pcnalties in the farm of o STOP WORK ORDER and a lire Of op to S_'iQQO a day against dte violator. Ile advixed that a copy of this atatcmenl Inay bo forwarded to the 011ico of In vc,l i g.n ions,dole DIA Ibr insurance caveragc veri licaliun. l Its It're by certify rutdrr III pales Olt d prnoldes of perjury drat the injunnutlmr provided above it true•rtrd curreet 11air > U//ieiul u.re only. /7,s nor Iwitr in this area, to br completed by city ur tawn lfitiaL . Ciry or I'1nnl: ,. Pcrmitil.lecme i__. Main;,\olhurily (circle one): 1. L'u.Ird of llcahh !. Iluildirt. Ucparinlent 1. ('fly,I'olrn C'icrk J. lileetricil bl,l tbir i, Piomhin4 Iolpector 4. Ihhcr C11111ac1 Pirillll: 1 hnlll l: 311 OP ID: JP CERTIFICATE OF LIABILITY INSURANCE o1roorvvey} 3112/12 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 PRODUCEN,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the POlicy0e9)must be endorsed. If SUBROGATION IS WAIVED,subject to the tans 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 endorsemen s. PRODUCER 978.975-1300 ONTACT Segrevs&Hall Insur,Assoc.Ino NAME: 305 North Main St. 978.975-7596 PHHCONE pAX Andover,MA 0181E E: iNin Edward Ramirez ADDRESS: cu U ER 10 4:7HOMA-3 INSURERS AFFORDING COVERAGE NgICk INSURED Thomas Quinn INSURERA:Distel Group dba QUinn's C.Onstrucl:fon 868 Mammoth Road INSURER B:Hartford Ins Co.Dracut, MA 01826 INSURER c: INSURER D: INBUR£R E: NSURER F: COVERAGES CERTIFICATE NUMBER; REVISIONNUMBER: 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 NS TYPE OF INSURANCE Y POLICY NUMBER M/DD MMtoo LIMITS GENERAL LIABILITY EACH OCCURRENCE 3 1,000,0E A I X I COMMERCIAL GENERAL LIABILITY M021000227 O V15l12 01116/13 PREMI , $ 100,004 CLAIMMADEFRI OCCUR MED EXP(My me peram) $ 5,0EO — PERSONAL.ADV INJURY $ 1,000,0E GENERAL AGGREGATE S 2,000,0E GFN'LAGG.REGATE LIMIT APPLIESPER PRODUCTS-COMPIOPAOG $ 2,000,0E POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (EE amidnM) ALL OWNED AUTOS BODILY INJURY(PEr Pemn) F SCHEDULE?AUTOS BODILY INJURY(Per dx21M11) S PROPERTY DAMAGE MIRED AUTOS (ParncNnnt) S NON-OWNED AUTOS $ F UMBRELLA LIAR I OCCUR EACH OCCURRENCE. $ EXCESS LIAR CLAIMS-MAD'_ AGGREGATE $ DEDUCTIBLE S RETENTION $ S WORKERS COMPENSATION VJC GTATU- AND EMPLOYERS'LIABILITY YINI X IMF OTN• B ANY PROPPIETORIPARTNEWEXECUTIVE 116P704 0V15/72 01195/13 OFFICERIMF-MSER EXCLUDED? CI NIA E.L.EACH ACCIDENT $ 100,00 (Mandatory In NH) If dnecntie under E.L.DISEAS=_-EA EMPLGYEE $ 100,0E yyos OE RIT(014OFOPERATIONSmlow EL.DISEASE-POLICY LIMIT I$ SEE,EE I DESCRIPTION OF OPERAMON91 LOCATIONS I VEHICLES (Attach ACORD 101,Addibanel RomgriM Schodule,It more epaCt It ruqulrad) Sale Proprietor Thomas Quinn is Excluded underWorkers Camp CERTIFICATE HOLDER CANCELLATION 1 LOWELLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTTKORRII,ZILED�DJREPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. 4CORD 26(2009/09) The ACORD name and logo are registered marks of ACORD