27 RAYMOND RD - BUILDING INSPECTION :- The Commonwealth of Massachusetts
Board of Building Regulations lations and Standards CITY OF
L
!` Massachusetts State Building Code, 780 CMR SA EM
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelli
This Section For Offi6al Use Only
Building Permit Number: a Ap lied:
i
Y /
Building Official(Print Name) S' Date
SECTION 1:SITE 6W6RMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
QGt.A r�ne�rCll. QQ
1.1 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(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
:
Name(Print) City,State,ZIP
No' t2yer�.rwt� Ra
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑, Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWorkZ: Ctp rr>~S r�U1 ccr,N d__`�r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials Official Use Only
1.Building $ _ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cast: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 CNnstruction Supervisor License(CSL)
I043>',1
���� �'Lb� D License Number Exin at on ate
Pe of CSL Holder
List CSL Type(see below)
3 P.-a- b 36 Type Description
No.and Street
Unrestricted(Buildings up to 35,000 cu.ft. '
C�t� Mq G�9.bt3 Restricted 1&2 Family Dwelling
City/Town,S ,ZIP M Masonry
RC Roofmg Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�,A..a ® GcncD- ftyn I Insulation
Telephone Em dress D Demolition
5.2 Registered Home Improvement Contractor(HIC)
nnr �`cw JK➢. 15yg,(r � H ti
C � C.v�n. �r�� HIC Registration Number Expir on Date
HIC Company Name or HI egisnant Name
� A.R
No.and Street Email address
City/Town,SWe,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... Rr No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Cam.0Nn r C"%Zc� .
to act on my behalf,in all matters relative to work authorized by this building permit application.
1�Q� seti_ S".QQG II /t /4/
Print Owriei's Name(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.
( cc.6 .'— X\Il jti,
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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(I-IIC)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.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
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"
ACORD. CERTIFCATE OF INSURANCE DATE
PRODUCER
- THIS CERTIFICATE IS ISSUE AS A MATTER OF INFORMATION ONLY AND
40ESPH PINTO INS AGCY IN. CONFERS NO RIGHTS UPON.THE CERTIFICATE HOLDER. THIS CERTIFICATE
142 PLEASANT ST. DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICES BELOW.
MALOEN,MA 02148 COMPANIES AFFORDING COVERAGE
27BSY COMPANY
A HARTFORD GROUP
INSURED COMPANY
ACTION SIDING B
3 PINEWOOD ROAD
PEABODY,MA 01960 COMPANY
C
COMPANY
A
COVERAGE
THIS IS TO CERTFY THAT THE POLICIES OF 11SURANCE LISTED BELOW HAVE BEEN ISSUED TO THE HSURED NAMED ABOVE FOR THE POLICY PERIOD
E4DICATED,NOTWITHSTANDING ANY REQUIREMENTS,TERM OR CONITIONS OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THB
CERTIFICATE MAY BE ISSUED OR MAY PERTARL THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM)D%YY) DATE(MMADD%YY) LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/Op AGG $
CLAIMS MADE OCCUR. PERSONAL 88 ADV.INJURY $
OWNER'S S CONTRACTORS PROT EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
MED.EXPENSE(Any ONE person) $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO BODILY INJURY(Per Person) $
ALL OWNED AUTOS BODILY INJURY(Per Accident) $
SCHEOULEAUTOS PROPERTY DAMAGE $
HIRED AUTOS
NON OWNED AUTOS
GARAGE LIABILITY
ANYAUTOS AUTO ONLY EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGREGATE $
EXCESS LIABILITY
UMBRELLA FORM EACH OCCURRENCE $
OTHER THAN UMBRELLA FORM AGGREGATE $
WORKER'S COMPENSATION AND
A EMPLOYER'S LUABILITY 6S60UB-0274N04- 03-20-11 03.20-12 STATUTORY LIMITS X
THE PROPRIETOR/ 9-11 EACH ACCIDENT $100,000
PARTNERS/EXECUTIVE 1NCL DISEASE—POLICY LIMIT $500,000
OFFICERS ARE: X EXCL DISEASE—EACH EMPLOYEE $100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR CARBONE ARTHUR R.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ACORD 2"(3I93) THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR
TO MAIL 10 DAYS WRFITEN NOTICE TO THE CERTIFICATE HOLDER NAMED
TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO
OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS
OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Ramani Ayer
I,
.. - • i. � i F� e
/�-
-s�
1
Invoice No.
Action ► wding 1028
INVOICE
Customer Misc
Name _ -- �>. „d/,�q Date
Address 2ze� ti >n� Order No.
City '7 Ma Rep
Phone FOB
Qty Description Unit Price TOTAL
S ?4 P f."C
Subtotal
Deposit
Payment Select One...
Comments TOTAL - .l
Name
Expires
Thank You
f CITY OF SM.EN4 NL-kS&A CHUSETTS
BL•IIDL%G DEPART\IMHT
• + 120 WASHINGTON STREET,Sao FLOOR
TEL. (978) 745-9595
FAX(978) 740-98"
KI\lBEjtl EY DRISCOIl
MAYOR TrIOAfAS ST.PtERR6
DIRECTOR OF PUBLIC PROPERTY/BCIIDLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 Please Print Legibly
Name(BusittasaOrganizationlindividual): C t \ 5\ 6;L-6
Address: 3 A �Zo
City/State/Zip: li .1
pb49
r C-- Phone i/: to
Are you an employer?Check the appropriate box: Type of project(required):
1.01 am a employer with�_ 4. ❑ I am a general contractor and 1
6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp. insurance. 9, ❑Building addition
[No workers'comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp. insurance required.]
•Any appliar tlat checks box#I must also rill out the section below showing their worker'compensaden policy inte matlon.
t Jr.
who submit this affidavit indicting they are doing all work and then him outside contractors must submil a new affidavit irdieging such
:Contmrxon that cheek this box must attached an additional sheet showing the name of the eub�coouaa r and their worker,comp,policy infomution.
I am an employer that is providing workers'compensaton Insurance for my employees. Below Is the pollcy and fob site
information.
Insurance Company Name: -, 56
Policy#or Self-ins.Lie.M Expiration Date:-312o/1
Job Site Address: f%t A VV0 City/State/Zip:3el
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 imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 coverage verification.
I do hereby certiify underikepaing and penalties of perjury that the information propided above is true and correct
. i Ln 1 ire• C./N� 4 40— Date:
P o #: &0- Fair -9�43,
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/lAcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone#:
CITY OF S,U-&Nfj Akss.kcFiL'SETI'S
9LILOLNG DEP.IRTTLNT
120 WASHNGTON STREET, J'FtCCIt
TttL (978) 743.9599
KIMBERI EY DRWOLL PAX(978) 740.9&W
MAYOR THosw ST.PtPx"
DtRECTOa OF PLBLiC PltoPeltTY/8L1LDNG CO-NnuSSION ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Cade, 78o CM
Debris, and the provisions of MGL c 40, S 34; R section 1 11.S
Building permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a p
111, S ISOA. roperly licensed waste disposal facility as defined by MGL c
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name offacdity)
111dresf of facility)
'Y '�ermit i pl��nr`�
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