17 SABLE RD WEST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
B
W
oard of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
(� Revised Mar 2011
�{1 Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: d Date ppli :
I c4 t•1 L oStCJ! 6
Building Official(Print Name) Signatur Date
SECTION 1: SITE INFORMATION
1.1 J r- pTdlrfss: + I 1.2 Assessors Map&Parcel Numbers
Jt
L I 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(ft)
1.5 Building Setbacks(ft)
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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Record:
rj�c� S a iyl�a 0 n 'L
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIV(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Des, 'P�pio,,n of5roposed Work :
lr`SIr(a LAAp mc elf
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ p 0 z ) 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees:$
6.Total Project Cost: $ (0)\30 J
Check No. Check Amount: Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
t
SECTION 5: CONSTRUCTION SERVICES
5.1 ConstructionSupervisor Licensee(CSL)
I yV�jPvA 11'2YhLJ� .. �'' C 1
License Num er Ex iration Date
Name CSL Holder
w� -Ave,
List CSL Type(see below)
ng
No.and Street {10t / Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
1 \ R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
INS Window and Siding
SF Solid Fuel Burning Appliances
CJ �[ I Insulation
le hone Email address D Demolition
5.1 Registered Home Improvement Contractor(HIC)
emh, GM G rlic Sn,, 1y537 i 1 1
HIC Registration Number xpi lion Date
C mpC� y Name or IC Re istrapt Te
� Cm o i KO ,�U�y--
N and SVeet ,��
�^ � rn WW o lC'iJ C9 � ���� Email address
�C_ity✓/Tlown,State,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 JIssuance of the building permit.
Signed Affidavit Attached? Yes .......... 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 -UA Ve"61 C-7
to act on my behalf,in'all matters relative to work authoriz by this building permit application.
4 ac
C1.J4�7 " L q 2-7 2
Print ner's Name(Electronic Sign t e) I Pale
SECTION 7b: OWNEW 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.
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(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the IBC Program can be found at
www.mass.eov/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 Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers
Applicant Information Please Print Legibly
Narne(Business/Organization/Individual): ✓ 66, 4 "
Address:
t ,
City/State/Zip:
Are you an employer?:Check the appropriate box: Type of project(required):
1,��I a i a employer with Z a , 4• Q I am a general contractor and I 6. ❑ New construction.
("employees(full and/or part-time). have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑.Remodeling
ship and have no employees These sub-contractors have g_ ❑ Demolition
workingfor me in an capacity. employees and have workers'
y p n'• 9. ❑ Building addition.
(No workers'comp.insurance comp.insurance.t
.red.) 5. ❑ We area corporation and its 10.0 Electrical repairs or additions
requl
3.❑ I am a homeowner doing all work officers have exercised their.
11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,.§1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees.:they must provide their workers'comp.policy number.
lam an employer that is providing workers'c pensadon insurance for my employees. Below is the policy and job site
information
Insurance Company Name: rI
Policy#or Self-ins.Lic. #: II uU +Jtt 4 3L5 � � �� I Expiration Date: � t �Z
Job Site Address: 1-7Sf✓� J U"e� City/State/Zip:
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 DIA for insurance coverage verification.
I do hereby certify under the pains9 and penalties 6f perjury that the information provided above is true and correct.
Signature: /3 - / 1 Date: I 1 2l I► Z
Phone#:
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.Electrical Inspector 5. Plumbing Inspector
6.Other
rnntart Person: Phone#:
,4co d CERTIFICATE OF LIABILITY INSURANCE 1DATE OMMDA'YM
1/10/2011
/1ooll
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANDCONFERS 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(Sh AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER
IMPORTANT. N the Wittiest'holder Is an ADDITIONAL INSURED,the poNcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the tsrms.and conditions of the policy,Certain policies may require an endoreement A statement on this certificate does not confer rights to
certificate holder In Neu of such e s
PRODUCER N°A� Construction
Eastern InsuranCe Group LLC ° EEad, (308)651-7700 LAM Mm(508)655-11e53
233 West Central Street DOREss•
° OU R 0033507
Natick Mh 01760 - MORE AFFORDlN000VERAOE MNAIC
INSURED - OSURERANautilus Ins. Co.
INsuruaedLrlDella Protection Iae. Co.
ROGER A TREMBIM CONTRACTORS INC msuRERcilartford Und.-WC Pool
10 COLONIAL RD - - WMDmRo:
SUITE 4 IN E:
SALEM IAA 01970-2943 - hNE F•
COVERAGES CERTIRCATENUMBEP34UTER 2011.5 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 NTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUGES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -
Dart IEFF ppLICY UP
LTR rPEOFINSUMNCE eassi VIVO POIICVNUMM M MIO umirs
GENERAL LUOUTY EACH OCCURRENCE $ 1,000,00o
X COMMERCIAL GENERAL LIABILITY P S Ea a ce $ lob,000
A CLAIMS-MADE X❑OCCUR 41196529 1/08/2011 1/0111/2012 MED EXP none on $ 10,000
PERSONAL a AM INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000,
GEN'L AGGREGATE UNIT APPLIES PER: PRODUCTS-COMPIOP AGG S 2,000,000
POLICY rZ PRO- LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E 11000,000
(Ea acciden0
ANY AUTO
.B ALLOWNEDAUTOS 9013400004 /15/2011 /15/2012 BODILY INJURY(Pr Pel9en) $
BODILY INJURY(Par aztldem) $ '
X SCHEDULEDAUTOS - PROPERTY DAMAGE
X HIRED AUTOS (Per mddenO S
X NON-OWNED AUTOS _ Medical paPrreme $
PIP-Bask $
UMBRELLA IMB OCCUR. EACH OCCURRENCE $
EXCESS JUAB CUIMSJIAOE AGGREGATE' $
DEDUCTIBLE $
RETENTION $ 0 E
c WORNFAS COMPENSATION X WC STATU- OTW
ANDEMPLOYERS11ANLRY -YIN
ANY PROPRIETOPJPARTNERWZCUTIVE - E.L.EACH ACCIDENT g Soo 000
OFFICERG¢MOM EXUDED? N/A
(Mandatory In Nlq 860UB4735P96211 /1/2011 /1/2012 E.L DISEASE-EA EMPLOYE E 500 000
N yyees dew be under
DESCRIFTION.OF'OPERATIONS below E.L.DISEASE-POLICY UNIT S 50O OOU
3ESCRIPTION OF OPERATIONS I LOCATIONSIVEHICLES tllNach ACORD 101,Additional RemMb SNuduk,IT more space Is reduilM)
:ERTIFICATE 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
Rosemary Fulham/EJN,
,CORD 25(2009109) - - ®1988.509 ACORD CORPORATION. All rights reserved.
4SO25(200M) The ACORD name and logo are registered marks of ACORD
Massachusetts- Departmient of Public Safetl
Board of Budding Regulations and Standards
���SSSlll Construction Supervisor License
License: CS 53e93
'ROGER A TREMBLAY JR i
29 HATHAWAY AVE
BEVERLY, MA01915
Expiration: 51W2013
<'unmrissnmer Tr#: t5182
i
Aq 71.
"�imxanoouireall�i o�.�,tu
S .-X Office of Consumer Affairs&BJsiness Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 145375 Type: Office of Consumer Affairs and Business Regulation
Explrabon 1FI3/2013 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
RO ERA.TREM$p,'EY'C.ARt--Mt .T,�ORS, INC. -
r
ROGER TREMBLEY>
0 COLONIAL RD I7,€Jl4, -
IALEM, MA 01970
Undersecretary Yot valid without signature