Loading...
2 RIVERBANK RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF 1QV Massachusetts State Building Code, ALEM CMR Revised Mar SdMar 1 2011 - Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section EatsOfficial Use Only Building Permit Number: Date Applied: Building Otticial(Print Name) Si re ate SECTION 1:SITE INFORMATIO 1.1 Pr efty.�Address• 1.2 Assessors Map& Parcel Numbers tiYN I.1a 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(it) 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Cheek if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Recor I W 1co Lam' J ft N 'SACM I MAI 0 ! 7 C Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 01 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Nu her of Units Other ❑ Specify: Brief Description of Proposed Work': LI SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2.Electrical $ [3 Total Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ r6T ression) Check No. Check Amount: Cash Amount: otal Project Cost: $ 1—T9 ,99, ❑Paid'in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) n I ^ a U/3 License Number Expiration Date Name of CSL Holder �p List CSL Type(see below) -RC) _ -A RC)<1 mA rJ Il �No.and Street Type ;, Description C.` , C C') U Unrestricted(Buildings up el ing cu. ft.) W l C.JC 'C1 Q A_Q V. J 25 R Restricted I&2 Family Dwelling City/Town,State M Masonry RC _ Roofing Covering WS Window and Sidin ( SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5..2, Registered Home Improvement Contractor(HIC) (, Q C'1q-QK� �- \l-���1���� - HIRegistration umb ( r E p atio Dateo J HIC Com ny�T ame o, r HIC R�gistry��me L�1�(lH-0y N�o�and,S U Email address City/Town,State,ZIP 1 0., 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 ........ . No ...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR ByUUIILDING PERMIT ! � 1,as Owner of the subject property,hereby authorize I C ucc )5u,4-bc� to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner'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. Qko2..c-� 5 - 2. 77-Zo(J Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I,r 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Otherimportant information on the HIC Program can be found at www.mass.aov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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 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 Cosy' CONTRACTOR WORK ORDER Conservation Services Group Printed: 06/13/2011 Contractor_Information I ( customer/site Details Geoff Chapin NICOLE BUXTON Phone(eve): (617) 852-2317 Next Step Living 2 RIVERBANK RD Phone (day): (617)794-4419 25 DrydockAve Bostonton,, Me 02210 SALEM MA 01970 5313 0 Site ID: $10004019023 Ma Appointment Details Completion Deadline: __.__._. Location Descriptlon Quanta __ Unit$ Total S NotWlPtevislons Work Order : IAPNS21_20110613 Replace Bath Fan Hose 1 22.00 22.00 AFL Attic Floor 6.25" Fiberglass Batting 4 1.51 6.04 AFL Densepack Cellulose-6" 510 1.91 974.10 BEDROOM Door: Polylsocyanurate 2" 1 49.45 49.45 OTHER Sheathing access 1 32.52 32.52 — HALLWAY Wall Ins Interior 4"Cellulose 18 2.00 36.00 HALLWAY Wall Ins Interior 6"Cellulose 27 2.16 58.86 Total for Work Order IAPNS21_20110613 : $1,178.97 Grand Total: $1,178.97] Road Blocks Asbestos Possible Asbestos Containing Material Observed OLD PIPES IN BSMT, POSSIBLE W BASEMENT CEILING TOO - c nationalgrid C The power of action, Conservation Services Group This service is brought to you through s pport irorn your local utility IF This Agreement is made by and among and MassSAVE NICOLE BUXTON Conservation Services Group (CSG) 2 RIVERBANK RD 40 Washington Street,Suite 3000 SALEM MA 01970 5313 Westborough, MA 01581 • Customer ID:S10004019023 Contract ID: 1442011C • I. DESCRIPTION OF WORK TO BE PERFORMED e (;SG will perfonu or cause to be performed the following work on the"Premises" known as _Z IC 1✓ef ��'+��AO( ,in a professions manner turd in a(,ord;ince with the terms of this Contract, including the attached order describing the work in detail (the"Work")which are incoq) irated herein by reference: a Description Qua" Location Densepack Cellulose-6" __.510. ..- AFL $1,203.60 6.88 Attic Floor 6.25 Fiberglass Batting 4 AFL _. ._—... ---- $39.96 Well Ins.Interior 4"Celiulose _ 18 HALLWAY 27 HALLWAY Wall Ins. Interior 8'Ceilubsa - - ---- � - - _ Door.Polylsocyanurate_2" _- 1 BEDROOM --.-. . OTHER $37.05 1 Sheathing access _..__ —__.. Replace Bath Fan Hose 1 ._. ... . � Building Perfo. rmance Padwge _. _ 1 ___ __.. _ _- E132.00 - - --- -- --- $1.579.03 a Sub Total: • Energy Efficiency Incentive -$1,184.27 Net Sales Tax After Incentive $0.00 a Total $394.76 • 1.CUSTOMER affirms that they have received no incentives during the past 12 months.initial here_'( 6 2.The Incentive is dependent upon the package purchased andlor prior incentive utilization. Changes to individual line Items anti/or previous incentives may increase or decrease the size of the Inca - 3.CUSTOMER ai8rms that their electric provider is National Grid.Initial here • it. PAYMENT CI ItiT(IMF.H:egress In pay l'.tih for the. Work as follows: Printed 0512412011 Page 1 of 1 - Paynunt#1: -Deposit upon signing the Contract(Not to exceed 7/3 of the total reptil custc or act ual costs of special onletti, wldchmvr is greater) • Additions Pavmentsand Final Invoice: A__ Z6y _ -Additions payments for the Work stiall be due:ill hays 1i7uui c date shown(.oil the Invoice. Final payment for the Work still be due 30 days from the date shown oil the Final Invoice. You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller, which may be his main office or a branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Custono-s Signature Uau- i;SG Signal.ure - Ilau• Name of CgG F:epnsenLnlice The Terms of this Agreement are contained on both sides of this page Conservation$emces Group-40 Washington Street• Westborough, MA 01581 - 800-480-7472 Licensee Details . Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety Department of Public Safety Licensee Complaints License Type Construction Supervisor License# 81022 Restriction 00 Name George S Garwood City,State,Zip W Brookfield,MA,01585 Expiration Date 7/16/2013 Status Current No conrpFaints found for this Licensee. Back To.Search littp://db.state.ma.us/dps/licdetails.asp?txtSearchLN=CSL81022 7/28/2011 9 � Office� o Sumer f»rs& emulation p TGE HOME IMPROVEMENT CONTRACTOR Registration:,f.,136253 Type: Expiration: .6/26/2012 Individual S. GARWOOD�;, .. j�- i GEORGE GAR OD,, _J 29 RODMAN RD. � W.BROOKFIELD,MA 01585 / - <t y Undersecretary I A'lassachusetts- Uepai tmenf of Public Safety Board of Buildin_ Regu lilt ions and Standards ���YYYJJJ .-Construction Supervisor License i License: CS 81022 _ - Restricted to: 00 ' GEORGE S GARWOOD BOX 538/29 RODMAN RD W BROOKFIELD, MA 01585 _ t Expiration: 7/16/2011 ('ununissioncr. Tr#: 17306 />=D`b`LO®91�*a CENY111 � Will/-V tl E O LS�/T BUT Il �01S1�'D1d11NCE DATEIMMIDDMNY) 1 v1 vaol o PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION William GaBlayher Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Insurance Brokers, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 470 Atlantic Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Boston, MA 02210 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Federal Insurance Company 20281 NextStep Living, In 25 D INSURER B: Great Northern Insurance Compan 20303 5t h Floor or ock Avenue INSURER C Safety Insurance Company 39454 Boston, MA 02210-2600 INSURER D. INSURER E: COVERAGES 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 MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 4SR ADD' POLICY EFFECTIVE POLICY EXPIRATION .TR INSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDryYYY) DATE IMMUDD)`YYYY1 LIMITS A GENERAL LIABILITY 35904463 11/1112010 11/11/2011 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED�ccri $1 OOOOOO CLAIMS MADE ®OCCUR MED EXP(Any one person) $1 O 000 _4 - PERSONAL BAOVINJURYV OQo GENERAL AGGREGATE000 GEML AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMP/OP AGOOOke;LICV PRO- LOCJECT C AUTOMOBILE LIABILITY TBD9444611/11/2010 11/1112011 COMBINED SINGLE LIMITANY AUTO (Ea accident) 000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNEDAUTOS (Per accident) $ PROPERTYDAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ 4 EXCESS/UMBRELLA LIABILITY 79870050 11/11/201.0 11/11/2011 EACH OCCURRENCE $3000000 X OCCUR CLAIMS MADE AGGREGATE $3 QQQ 000 DEDUCTIBLE $ RETENTION $ $ 3 WORKERS COMPENSATION AND 71733288 11/1112010 11/1112091 X WC STATU- OTH- EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE 11tL, E.L.EACH ACCIDENT' $5QQ OOO pp�pFICER/M�MPFHR EXCLUDED? N (Mandatory,n I E.L.DISEASE-EA EMPLOYEE $SOD OOO If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$500,060 OTHER ESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS (Star Gas Company is included as an additional insured on general ability as their intersts may appear per written contract. ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION EFI -NStar Gas Residential DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL '40 DAYS WRITTEN Weatherizatlon Rebate Program NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL 40 Washington St.Suite 2000 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Westborough, MA 01581 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE CORD 25(2009/01)1 of 2 #S185635/M185611 © 1 8 -200 CORD CORPORATION. All rights reserved. Tho CCORn names and Innn am mnicter4d marks of ACORD RAD 11/16/06 TRU 17:04 FAX 617 393 2415 MEDFORD BUILDING DEPT. 0005 The Conuwnwea/lh of Masaaehase&Y Deparinwail efrndaslrialAccdde)W v.. „ f_ : ,ali3 office ofrn,resrtgaldoas 606 WashiagMst Street Noslolt,MA 02111 'A4-�' rvw►wnaasxgov/dia Workers' Compensation Insurance.Afidavit: Builders/Contractors/Electriciams/Plumbers Applicant Information C , riewe Print Le>ably Nance(BusinesstOrgaoixetionAndividuw):p-� J Fr. i Ne vN a rt L Address: O-r v 7�e c.�� AV— dy/Statemp: 01"I_1 O Phone#: CMG 4, ,q 6 ) - c%7a-4 Are you an employer?Check the appropriate box: 'type of project(required): I.IN I am a employer with, 91 4. Q I sun a general ommacaor and 1 6. Q New construction employees(fill and/or part-time).* have hired the sub-oont airs 7. Q Remodeling 2.0 lam a sole proprietor or pofinery listed on the attached sheet ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 0. ❑Building addition [No workers'comp.insurance 5" ❑ We are a corporation and Its mq�j officers have exercised their 1 O.Q Electrical repairs or additions. 3.Q 1 am a houreown�r doing all work right ofexemption per MGL I I-0 Plumbing repairs or additions mysaal£(No workers'comp. c. 152,§1(4),and we have no 12.Q Roofrepairs insurance,required.]t e:mptoyecs-(Naworkers' 13.®Olt comp.insurance required.] 'Any applicant that cheeks box#1 must also fill not the sonion below stiowing their workers'lion policy informmion. t Homoowneswho arbmh this affidavit indicating they am doing all work and then like outside comem s must submit a new affidavit imucning such. klouunttoa thatrhockthis bor mutt attached an addhional sham showing the name ofatc sub•ranhaclun end their workers'comp,policy ikknoncim6 lane an argdoyerChad&providing worker'eompewallon rnsrrrnncefor my mr/oyett Below is tkePOW7 mrdjob sole mformallon I1 Insmuance compatry Name: r C< ,2, 1 Policy#or Self-ins"Lic.#: ") I -) J3Z Sr 1S E,puation Date: I I t i 5 Job Site Address: city/State/7rp: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required Imder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties;of a fphe up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine Of up to$250.00 a clay against the viol Be advised that a copy ofdds statement may be forwarded to the Olrce of Investigations of the DIA for rifiration. I do hereby wry aader rh p ofper/'ary thae the information provNed above a fare and core ut i i curse: Phalle# �� GG �647 - 517a.q Q0ledaf use only. Ao nor#wire in rhls area,to be eompldedby cfry or town g0?cdal City or Town: Permid/l.ioeose# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityf town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Cooled Person: Phone#: i