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6 RAWLINS ST - BUILDING INSPECTION i . 'file Commonwealth of Massachusetts ` ` � CI F i Board of Building Regulations and Standards SALEM q �I Massachusetts State Building Code, 780 CNIR 16Ib NOV —9 4040e@tfar 2011_ Building Permit Application To Construct, Repair, Renovate Or Demolish a ^ One-or Two-Family Dwelling ^�Ji This Section For Official Use Only \ , Building Permit Number: Date Applied: i Building Otticial(Print Name). Signature - - Date t SECTION li SITE INFORM1IATIOW L I Pro erty Address: 1.2 Assessors Map& Parcel Numbers I ' 1.1 a Is this an accepted street?yes Lino Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(It) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required . Provided Required Provided Required Provided 1.6 Writer Supply:(M.G.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP" 2.1 Owners of Record: 14 ;me(Pnn) 14 C1 y,State,ZIP No.and Street Talep one 796 Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Altemtion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief DescAtt n of Proposed Work-: L S �s LA ri4 �L wv au, SECTION a:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labpr a id`arterials) 1. Building ; G 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cose(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S _ )_ i d.Mechanical (IIVAC) S List: 0__C 5. ,Mechanical (Fire 'total All Fces:3 Su ression) Cheek No._Check Amount: Cash Amount:_ 6.Total Project Cost: S n ❑Paid in Full ❑Outstanding Balance Due: it VYlfd t utm Tp G SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Sppervisor License( 65v l L lu ` � / i yQ� ��� License Number E. motion Date Nani 'CSL ilu''ld1er /� List CSL'rype(see below) Description No.; td Street n O � / rl U Unrestricted(Buildings u -to 35,000 cu.It-)[, )/ r n� 1� �tV Wd' _ Restricted 1&2 Family Dwelling CiLyfro%ffl,State,ZIP M Masonry RC Roofin Coverin WS Window and Sidin 1 v SF m;ng r\p Solid Fuel Hupliances 1 Insulation Tele hone Email address I Demolition 5.2 Register d Home wrovement Contractor(HIC) a ism L HI eg wn umber Exftationgati 5e<unipahy Name or HIC Registrant Name No.and Street Email address CityiTown,State ZIP Tele hone 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 Istuuance of the building permit. Signed Affidavit Attached? Yes ..........6 nc No...........❑ SECTION 7a:OWNERAUTHORIZATIONTO BE COMPLETED WHEN: OWNER'S AGENT OR CONTRAC'PORAPPLIES FOR BUILDING.PERMIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized b this building permit application. l Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,) 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 Otvncr s or Authorized Agent's Name(mectrome Signature) Dute NOTES: I. 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 rrof 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 .aww mass cov'oca information on the Construction Supervisor License can be round at www�ns 2. When substantial work is planned,provide the information below: Total floor area(sq. R.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. R.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of healing system Number of decks/porches f ype urcouling system Enclosed Open 3. "Total Project Square Footage"may be substituted ror Total Project Cost" QTY t7F SALm MmAaffmn Bm�Dsras�r : W WAMOMS�T,3DAoat 7>;t. Mro- 99. $�F.RIBY L FMMV 74D-" MAYM 9MMUSUISM ae�rc /arn��a�oo� Con struction Debr is Disposa/Affidavit (required forall demolition andrenovation work) In aomr&nm with the sbA edition of the State SuHAwCode, 780O, Secdan 111.5 Debit; and the provtions of MGL coo,S S4; Bulkow Permit S is issued with the condition that the debris resuf ft from this work shall be disposed of in a properl y licensed waste depas(t fadlity as defined by MGL c lily S 156A. The debris will be transported by. T qnS aY (name of hauler) The debris will be disposed of in: ' (name of facility) (addriess of facility) Sign t re of applicant Date The Commonwealth of Massachusetts Department of lndustrialAccidents a I Congress Street, Suite 100 Boston,MA 0211 4-2 01 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: J Address: r ) / 6 o(e�� City/State/Zip: `— c(�)-Phone#: Are, o employer. Check the appropriate box: Business Type(required): 1. I am a employer with_��employees(full and 5. ❑Retail or part-time).* 6. ❑RestaurantBar/EatingEstablishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers'comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑ Health Care with no employees. [No workers'comp. insurance req.] 12.0 Other `Any applicant that checks box#I most also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy"is required and such an organization should check box 01. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D insu2l c verage verification. I do herW71 W. the a an enalties of perjury that the information provided ab ve i true and correct. ,� Si natur Date: Phone#: 2 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.imss.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax# 617-727-7749 www.mass.gov/dia Form Revised 02-23-15 t ... A`o CERTIFICATE OF LIABILITY INSURANCE DAT o 6/24/2/za/2DII'YYY) 016 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 have ADDITIONAL INSURED provisions or 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(s). PRODUCER CONTACT NAME: Peter Lim Friendly Insurance Agency PN"�NN Eat: (781)593-0344 FAX No: (781)596-7142 471 WESTERN AVE Ms.—LPete—r@Tri:dlyins.com dlyins.com INSURE S AFFORDING COVERAGE NAICN LYNN - MA 01904-3317 INSURERA: ESSEX INSURANCE COMPANY INSURED - INsuRERe: LIBERTY MUTUAL INSURANCE WILLIAM C ELLIOTT _ INSURER c: PROGRESSIVE' 72A High Rock St INSURER 0: INSURER E: Lynn MA 01902-3851 1 INSURER F: COVERAGES 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 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. INSRLIM ADDLSUSR TYPE OF INSURANCEJUM POUCYNUM13ER MMND EFF MMID YDIYYYY UNITS LTR COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR PREMISES Ea occurrence $ 50,000 MED EXP(Any ane person) S 1,000, A 3EE2377 03/21/2016 03/21/2017 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 2,000,000 POLICY PRO- LOC PRODUCTS-COMP/OP ADD $ 1,000,0()0 ECT OTHER: I $ AUTOMOBILE LIABILITY BINDSINGLELIMI $ EOaBINEI ANY AUTO BODILY INJURY(Per person) $ 50,000 C OWNED SCHEDULED 02838563-0 01/15/2016 01/15/2017 BODILY INJURY(Per ecdtlent) 8 50,000 AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ 100,000 AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ "CEss LWB CLAIMS-MADE AGGREGATE It DED I I RETENTION$ I $ WORICERS COMPENSATION AND EMPLOYERS'UABILITY STATUTE ER B ANY PROPRIETORIPARTNERIEXECUTIVE Y� NIA WC5-31S-613060-016 06/17/2016 06/17/2017 E.L.EACH ACCIDENT $ 100,000 OFFICERddEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 It es,describe under 500,000 DESCRIPTION OF OPERATIONSbel. E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached a more space Is required) CARPENTRY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 - PETER LIM ©1988-20T8 ACORD CORPORATION. All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD tj® Massachusetts Departrhent of Public Safet Y Board of Building Regulations and Standards License: CS-109791 Construction Supervisor WILLIAM ELLIOTT-�` 72A HIGH ROCK.STr LYNN MA 01902 : i r - /IL"'� CA— Expiration s1 commissioner - 03/21Y1020:� -- -'•`-��V�r� tOmnrr000uiseal�o��a�or.�ivael7a.. Office Of Consumer Affairs&Business Regulation U'VExpirationi OM E IMPROV&ENT CONTRACTOR Regis n it i/201 Type: 12728l2017 DBA DEPENDABLEEHOME'S T r't � WiLLIAM ELLIOTT 72A HIGH ROCK ST. LYNN{ MA 01902 --' Cudersecretary'. I J- 1 ry ------------------------- NOTES REC_EIP DATE ll/ NO. 527260 r� RECEIVED F O � c ADDRESS '�� r '-9 `.^AGC NT i.., ''".`:3✓x-" WPAI + aryry�c. .s dAM l OFe ` -ACCOl1NT w'R DOES tt ORDER"^ ... .. ...�Y�SVPl6n` '`..'aN3'�9' `'•era'-"'. ?.�.a�f`msw "!ati v ._....+..:z n.._ucyst?avi^�su:rvuvv'.;�ilwo.�.+add4u rt '4 1