7 RIDGEWAY ST - BUILDING INSPECTION l�
I'hc C'ummunsve;dlh ulNiassaclntsclts
y, Board ul Building Regulations and Standards CI'I'1' OF
' 14assachuscifs State Building Cute. 780 C NIR S,\LI:,XI
t
Hrrieed I hu•_'ill/
Building Permit \ppii,cation 'ro Construct. Repair. Renovate Or Demolish a
One-or rtrn-kamill• Dive/ in,gr
This Section For Ofriciai Use Only
Building Permit Number: Date A pHad;
lluilding 01111cial(Print Nwric) Signature I al
SECTION I: SITE INFORIIIATION
1.1 P tr Address: 1.2 Assessors flap St Parcel Numbers
7 /�irJae CVLLM 5T _
L la Is this an❑cce ted street?yes no Map Number 'Parcel Number
I.1 lonina Information: 1.4 Property Dimensions:
Luring District Proposed Ilea Lot Area Isq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40,§54) 1.7 Flood lone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ tuna: _ Outside Flood Zuni Municipal❑ On site disposal%)stem ❑
Check if cs❑
SECTION1. PROPERTY OWNERSHIP'
2.1 Ownvtppf gecord� 9 l]
e liC0.rlG N>° t—f214NC\ .����� !�''1 A O l
Name(Print) City.Slate.ZIP
7 k( a 97 -7 S-D7.77
Na.and relcphune Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied ❑ Repairs(s) O 1 Alteratlon(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Cher ❑ .Spccity:
Brief Description of Proposed Work':
y nsv�,a�o
SECTION 4: ESTI,SLATEO CONSTRUCTION COSTS
Item Estimated Costs: C)Mclal Use Only
Il.ahur and \laterialfl
I. Building S I. Building Permit Fee: f indicate how lee is determined:
❑Standard City+Tossn Application Fee
uleelrical S r
❑Total Project Cost (Item 6)x multiplier
1 I'lumhinq S ?. Other Fees: S
4. \Iech.ulical ill\ \('1 5 List:__ ._—__
�u + rcsimnt rota) .\It Fecs: _--_—
Chcck No. ( heck Aonaun: C'.nh \uunmC
a rulal Prnjecl Cost S Gr 0G v 0 Peid in Full Q UwsLmJing Hahurcc Due:
SECIA N 5: ONSI'R I ("PION SFRVl( FS
5.1 ('onstructioil Supervisor License((Sl,I
I icoic Numhcr
1 01, I')IV)See llol&r Jjj
PC Description
No u1J street
-70 11 1 ftircs1rictcd i It...ldiovi ub it)35 1)(11)ol It I
Restricted
L itlirollll. kfa.svil
RC R,xiiiii
\4 S %A indimm.,
di.S--,u-L rn'ng
�SF Solid I:uvI flurninvAppliji'ves
I Insulation
I I.civP111111c Email address D Demolition
5.2 Registered Home Improvement Cont or(1111C) 1114,17
MA 111C 14villwation Ntinitivir Fkpiration I)JI9
I 11C 01111
UqeN nil is JIIC I =t Nang "Azh` 3
N!�q Slnelg4* &It 7(11Tq/f
City,frown, State,ZIP fete hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 2SC(6))
Workers Compensation Insurance affldavit must be completed and submitted with this application. Failure to provide
this aflidavit will result in the denial of the issuance of the building permit.
Signed A ffldavit Attached? Yes .......... No ...........C3
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner of the subject property,hereby authorize AC'J4PrK'V
to act on my behalf,in all matters relative to work authorized by this building permit application
e
X Vf
Print Owner's Nmic(EIccirunic Signuture) t 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.
/I
ct --7 Dutu
PrintNi6riatura)
NOTES:
I. An Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered cuittrictur
'.1'tor
toot registered in the Home Improvement Contractor IHIC) Program). will 1U) have access to the arbitration
program or guaranty lund under M.G.L. c. 142.A. Othcr impuriant information on the HIC Program can be l'ound at
%%\11% ni.n, 1,0% " I hiriarniation on the Construction Supervisor License can be found at
2. k%lien substantial %sork is planned, provide the infurinatiun bclo%v:
rota) (lour area 114. R.1 , t including garnge, limisbcd basement attics. decks or porch I
I Gross It%ingarea IS4. It I Habitable rouill oitint
i \anther of fireplaces . Numher ol'bedrooms
Numberol hathrounis
I %11cot heating ik,lein porches
I�Jlvol":oollllg '."Mil
loi.d Ilroivo Squxc Foot�jcc m;IIN 1,c uh,twitcd our IlrojcCl (',"t-
DATE(MM/DDIVYYV)
Acid CERTIFICATE OF LIABILITY INSURANCE
6/4/2012
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 CONS71TUTE 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(les)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 endorsements.
PRODUCER NAME:
Eastern Insurance Group LLC -Main PHONE 508-551-2700
A/C Ns _ _
233 West Central Street E-MAIL
Natick MA 01760 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC0
INSURER AWeStern World D�W[EunCe CO
INSURED 37667 INSURER B:
Mass Weatherization Inc INSURER C:
3 Ocean Avenue INSURER D:
Salem MA 01970 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1317026687 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.
POLICY EFF POLICY EXP
ILTR TYPE OFINSUflANCE S PODCYNUMBER MMIOD/YVVV MM/DO/VVVV LIMITS
A GENERALUABWTV NPPOO85980 /28/2012 /28/2013 EACHOCCURRENCE $1000000
DAMAGE TO ITEN
X COMMERCIALGENERALUABILITV PREMISES Eaoccurrerie $100000
CLAIMS-MADE ILI OCCUR MED EXP(Any.. son) $5000
PERSONAL A ADV INJURY $1000000
GENERALAGGREGATE $2000000
GENt AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2000000
POLICY PRO- LOC $
B AUTOMOBILE LIABILITY BA46SH7036 10/4/2011 10/4/2012 Eaamldent 1000000
BODILY INJURY(Per Person) $
ANVAUTO
ALL OWNED x SCHEDULED BODILY INJURY(Per ancient) $
AUTOS NON OWNED PROPERTY DAMAGE $
X HHEDAUTOS X AUTOS Per PERT nt
C X UMBRELLA DAB 'OCCUR XBS0022678 28/2012 /28/2013 EACHOCCURRENCE $1000000
EXCESS LIAR CLAPJS-MADE AGGREGATE $
DED RETENTION$ $
WORKE RS COMPENSATION WCSTATU- VIM-
AND EMPLOYERS'UASIUTY YIN E L EACH ANYPROPHIMWRIPXCLUDEE%ECUTIVE NIA q -r A(` y 1 �� EL.DSEASE ACCIDENT EA EMPLOYE $
ANY PRORJEMRFREXCLUDED9 W / 7 G 11
(Mandatory in NH)
If yes describe under E.L.DISEASE POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPE RATIONS I LOCATIONS I VEHICLES (Attach ACORD lot,Additional Remarks Schedule,if more spare is required)
UDR, lnc.,UDR/Met Life Master Limited Partnership;UDR Texas Ventures,LLC;DCO Realty,Inc;K/UDR Venture,LLC;RE3,lnc. and all
subsidiaries,communities, and partnerships are Additional Insured with regards to General Liability as their interests may appear where
required by written contract or agreement.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
UDR Inc. ACCORDANCE WITH THE POLICY PROVISIONS.
c/o Compliance Depot, LLC
1800 Preston Park Blvd,Ste 220 AUTHORIZED REPRESENTATIVE
Plano TX 75093
® 1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
10 Massachusetts - Department of Pu GiiC Safety
�-- Board Of Btnlding Regulations and Standards
('onsnvction Super%isui Spucialt\
License CSSL-102293
RICHARD LAMB}` ,
y 3 OCEAN AVENUE 'a
SALEM MA 01970
6xp"auOl,
8ommis stoner 05/03/2014
;J� T/Jry/YYYRNKlCr86� 6��% /ldO�A/6P.�.J
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: 111617 Type:
/f' Expiration 1/1,2/2013 Private Corporation
s.:✓
MASS WEATHERIZATION INC
RICHARD LAMBY
3 OCEAN AVE
SALEM, MA 01970 Undersecretary
CITY UN SAL.Eml NWSACHUSETTS
' [3t.IIDtNG ❑EP.\RT\tENT
l_'O CQ:\SHLNGTON STREET, 31s FLOOR
TEL 973 745.9595
(978) 710.9844
,Lj%113EftL.EY DRISCOLL THoat►sST.PIER"
L�Yoz
DIRECTOR OF PC9LIC PROPERTY/8CI1DtNG COSt31ISStUNER
Workers' Compensation Insurance Affidavit: I)uilderg/Contracturi/ElectricianeJPlumbers
16nplicgnt Informutinn y�t�t Please Print Leeihly
V;IInk:(I)ufitws Orggrnnlinn)ndividtlat): fIA45--, _j �••+&1K_
Address: 3 Q ifCA-r\l y9-kJ' �r
City/Sratc/Zip: LSskt4M rll4 Phone M r ` 7VI— L3 y
Are you an employer!Cheek t a appropriate boat Type of project(required):
I.❑ I am a cmploycr with J. Q I am a general contractor and I (a. ❑Now construction
dmployees(Hall and/or part-time)." have hired the sub-contracrs
2.Q 1 am a sole proprietor or partner. listed on the attached shearmt 7. ❑ Remodeling
.,hip and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. warkars'camp. insurance. 0. Q building addition
(No workers:comp,insurance 5. Q We are a corporation and its l0.❑ Electrical mpair or additions
required.) oflIcers have exercised their
3.ElI mn a homcuwnur doing all work right of oxamption per MOL I I.Q Plumbing repairs or additions
myself.(No workcra'sump. c. 152, 11(4),and we have no 12.Q Roof mpairs
insurance required.l a employees.(No workers' I S.Q Olher
comp.insurance inquired.)
'.any ipplkkira due vhaeks but rl mime atw flit uul thv w•elioa beta*Allowing their waksa'csmrunudun pulley inAl"Allom
'I hvnail%m"who mhmit this Affidavit indiealiny they an doing all wore and then hit*wiside eontraliam mime suhmli a new anldavil ind(eeiny tuck
l'omractao that cAak this btM mime aaaehud an ntWtnutml.htat,hawing the nwnv olthe tub.aumnetws mJ their wnhttn'wmp,paltry InRxmaaeq.
/atn an anpluyer that/r pruvidlnx workers'campeeratlon insurance jar my employees: Bdu w/a the pally and job site
injorrll"dore. ` kG' i.
lommince Coflipany .Name: y✓. _)......
Policy 4 or Sal(ins. Lic. 4: ('(l G / 9�L Z 7 Eapirition Date: l 2-,
Jule Site Address; RtdSG (.✓RM CirylState/2ip: 5W N4
.\ttacb A copy of tha worker' compensation pulley deelarallan page(showing the policy numbor and expiration data).
Fsiluro(u,ecure coverage as required under.Section 25A of MGL e. 152 can faad to the imposition of criminal penalties of a
tine up to il.500.00 and/ur one-year imprisonmcn4 as well as civil penalties in the form of it STOP WORK ORDER and a line
0f up to 52i0.00 a Jay against file violator. Ile advised that a copy of this.t Atemcni may bit furwordcd to ilia 011ice of
larc,tig.niuns of ilia DIA for insuranca eovcmgc verification.
/du Jrerr crrri/y alyder rhr =ills mud pen=/rler n erjary Ihut the Ltfurnrudon pro aided above iv uua rmd corrvre.
_,.,t•.tl,trd bard: � iy 1
rr,1e,r 77q- 7`li- ay7f
17//iciu!r�tr.nJy, Oa nor write he dhi.v area, table cmupJ�ted 6y riry ur rown.r/jJriu!
City of sown:._-- _ _ - I'ermitAlcense
Ltuiay.\ulhurily (cireld oac):
I. Ilo:trd ul IA•alth !. Iluildint Dcp.trtmcnt 1. ('ityiruon Clerk t. Vldctrical hrtpcclor i• I'hunbintz futpecotr
G. Other
I Kona l: