34 SHORE AVE - BUILDING INSPECTION ,
The Commonwealth. ' golusetts
Board of Buildin eL�a 0 CMR# ds S CITY EM
� Massachusetts State utlding Code, 78
``,,
Revised Mar 2011
Building Permit Application To CIM%tr W I?e3aiPRe1oQ&Or Demolish a
One-or Two-Family Dwelling
(J This Section For Official Use Only
(" Building Permit Number: Date Applied:
1
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: V-e - 1.2 Assessors a M & Parcel Numbe s /
L l a Is this an accepted street?yes no Map Numbe ParceiNumber
1. Zoning formation: 11 /C 1.4 Prope�ty Dime ' ns:
+Zoning District Proposed Use (}` Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) T5 .
Front Yard J Side Yards Rear Yard
Requirqd Provided Required Provided Required Provided
1.6 Wat Supply: (M.G..L c.40,§54) 1.7 Flood Zone Informatio 1.8 Sew ge isposal System:
Publi Private❑ Zone: _ Outside Flo d one? Municip On site disposal system ❑
Check if ye
gS��ECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of RecordU�V (APAA"
Name(Pri t) qq City,State,ZIP
�� � /Vv ��. � �; j
No.and Street Teleplfne Email Address ki 6-447
SECTION 3: DESCRIP ION OF PROPOSE WORK'(che all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units _ Other ❑ Specify:
f set'ption f repose ork': dl In
\, J S
Y
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 'Z2 S 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ S � ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ \[ (� (1� List: -
5.Mechanical (Fire $
Suppression) 4 1 {.� J Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 9'76 01-b ❑Paid in Full ❑ Outstanding Balance Due:
� 7
cf- . --Q Lk
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C"s 0
License Number Expiration Date
Name of CS Holder /
/j � List CSL Type(see below) I
�J 00Description
o.a4d Street ` p
I\ I�i.^Jl✓�.�/t/ Unrestricted(Buildings u to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
✓Im �✓'� a t C 1 bka SF Solid Fuel Burning Appliances
sp G.c�L�•.v I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC R�eggistrat�Number J Expiration Date
HIC C a e or C gistrant Name t
Vt n
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS' COMPEN ATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6))
Workers Compensation Insurance affidavit mu t be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Nslance 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 authoriz t'Y vC Q
yjyNt
to act on my behalf, in all matters relative to woVath,,,edby- ' building permit application.
kJ
Print Owner's Name(Electronic Signature) Date
SECTION 7b: O R' OR A&THORIZED 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 ace e t the b t f y knowledge and understanding.
l 0
A^'Je-, 6,
24-/-K
Print Owner's or Authorized Agents No (E nonic gn re) 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 HIC Program can be found at
www.mass. oe v/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 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"
Massachusetts Department of Public Safety F
�j /��a�'Q,t(arxcluxl/a
' Board of Building Regulations and Standards �e mpam,�raaxwea
License: CS-104096Ofrice of Consumer Affairs&Business Regulation,
OME IMPROVEMENT CONTRACTOR ' -
Construction Supervisor #
n,,
egistration 1N1273 TYPeERICATOWNEExpiration: 3/18/2017 Ir>dividual{ONE MAPLE TERRACE.`- k'� 1 _ ERIC A.TOWNE i
NEWBURY MA 0195, i+j
/ - ERIC TOWNE
Sri n its"� ONE MAPLE TERRACE �...6r.-
,1�'/IL�� Expiration: NEWBURY,MA 01951 Undersecretary
Commissioner 0811712017 Qua
�+ Berkshire Hathaway GUAfi
BERKSHIRE HATHAWAY P.O. Box A-H • 16 S. River Stre,
INSURANCE Wilkes-Barre, PA 18703-002
GUARD COMPANIES 570-825-9900 (Toll-Free 800-673-246!
FAX 570-823-20=
www.guard.coi
October 12, 2015
R Agent: ROSE INSURANCE AGENCY
REAL ESTATE TO RENOVATE LLC
66 Loring Avenue
1 MAPLE TERRACE P.O. Box 958
NEW BURY, MA 01951 Salem, MA 01970
Phone: 978-745-6464; Fax: 978 745 7386
#: Note: A binder from the Workers'
r, which
R072735 20 Compensation Plan Administrato
Binder 1072735
Policy #: 16 you may have already received or will be
Policy Period: 10/07/2015 - 10/07/20 receiving shortly, serves as your proof of
coverage until cancelled or your policy is
issued.
erkshire Hathaway GUARD!
As the servicing carrier selected the ran erColmpanBy)ks pileasedre ht have the opportunity
away GUARD Insurance
Companies (specifically, our subsidiary, AmGUARD Insu
Workers'eCyou with the suerior ompensaton coveragecorthave a particular need, our usomer services ou deserve. 1proessio al staffsand automated
resources will be available to assist you.
Our Customer Service Department is available leave phone at 1-800-an a-2465 Monday through Friday,
8:00 AM t o 3 00 PM EST.59), or often ho s, You line form (a cessible a voice 'Ifrom send an
Customer �Service section Fof our
Policyholder Service Center at WWW-guard.com). Our mailing address is listed in the upper right
corner.
To make a oavment and credit card. Payments can be mailed to
We accept payment via check, bank check, direct draft (EFT),
PO Box 785410, Philadelphia, PA 19178-5410.
To report a claim or loss:
Call us immediately at 1-888-NEW-CLMS (1-888-639-2567) — 24 hours a day, seven days a week.
0
To repo fraud:
S Call our Fraud Special Investigative Unit via our Fraud Hotline at 1-800-673-2465, ext. TIPS — 24
t hours a day, seven days a week.
To reouest Certificates of Insurance
You can either fax us at 1-570 823-2059 or call our Customer Service Department at
1-Soo-673-2465. Either way, be prepared to provide the company name, address, fax number, and
contact person of the entity requesting the certificate.
To obtain service from a saecific discipline
You can feel free to address your issue to the attention of the following individuals.
Email Address Extension Fax Number
Departm ent Contact Name 1300 570-825-6211
Billing
Lori Decker csr@guard.com 1300 570-829-4587
Audit Dawn Aigeldinger csr@guard.com 1300 570-825-2990
Loss Prevention John Bohn
csr@guard.com 1300 570-820-7968
Underwriting Dawn Aigeldinger csr@guard.com 1300 570-825-0611
Claims Lisa Krzywicki csr@guard.com
We look forward to having this opportunity to serve your insurance needs. Please keep a copy of this
letter with your Berkshire Hathaway GUARD Insurance Companies policy for future reference.
HQ: MA/WC Your Business is our Business sm
RECTO I
Tire Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
If I Congress Street, Suite 100
Boston, MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A ltcant Information Pease Print Leeiibly
i
Naive(Business/Organimtiodlndividual): �--
Ad ss:
l r -��,�1 i Phone#: '1 f/ 1 f ; ��
City Skate/Zi : �`Jt'�1.J�1,--�� ',
Are u an employer?Check the a ' opriate ox: Type o project(required):
1. I am a employer with 4. I am a general contractor and I 6 ew construction
have hired the sub-contractors
employees(full and/o art-tim 7, modeling
listed on the attached sheet.
2.❑ I am a sole proprietor or partner- These sub-contractors have g, emolition
ship and have no employees employees and have workers'
working for me in any capacity. n , 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t 0-D
5 Q We are a corporation and its 10.❑Electrical repairs or additions
.
required.) officers have exercised their 1 l.[] Plumbing repairs or additions
3. I tun a homeowner doing all work tight of exemption per MGL 12.❑ Roof repairs
myself. workers' comp. c. 152, §1(4),and we have no
insurancee required.]t employees. [No workers' 13.❑ Other
comp. insurance required.)
*Any applicant that chocks box#1 must also till out the section below showing their workers'compensation poicy information.
t Homeowners who submit this aindavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tCommotors that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have
employees. If the sub•oontmctors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy ared job site
information.
Insurance Company Name: LA 1 Y'' ._ I Pqi k^ 6,L^
en
W C�S Tl, Expiration Date:
Policy#or Self-ins. Lic.#:_ r,
�`. i 2_ c�
7 r ' /� �/ �L'vvx'' City/State/Zip:��^i U
Job Site Address: J J 4G't "
Attach a copy of the workers' compensation policy decla on 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 cetYWY un a alas and penalties o a that the Information provided above is true and correct.
_. ..Pho a#•
Official use only. Do not write in this area,to be completed by city or town offlelaL
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
Contact Person' Phone#:
i CITY OF S.U.&%I, N'LkSSACHUSETTS
• BUII.DLNG DEPARTNIENT
130 WASHINGTON STREET,3'o FLOOR
T E1- (978) 745-9595
FAX(978) 740-9846
IVY(BFj F-Y DRISCOLL
MAYOR THOMAS ST.PIERR6
DIRECTOR OF PUBLIC PROPERTY/BUUMING com%aSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler) /
The debris will be disposed of in :
(name of facility)
e042:�L
(address of facility)
e of er applicant
date
dcbriulTJd