47 SUMMER ST - BUILDING INSPECTION (2) op
The Commonwealth of Massachusetts
°uld Board of Building Regulations and Standards RECEIVED �\� )CESCITY OF
Massachusetts State Building Code, 780i1CI)!�'ACjIOt(�E ` SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demo ish� '
One-or Two-Family Dwelling Im 01 1
This Section For Official Use Only
Building Permit Number: Date Appliedc'
Building Official(Print Name), 'Signature Date
SECTION 1:SITE INFORMATION
- _ 1.1 Property Addre 1.2 Assessors Map&Parcel Numbers
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(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 O WNERSIUPr
2.1 Ow,g` oLf RecojtdL-/,?
Name(Print) l"J/3'�c'PT CJ City,State,ZIP
. 'l9 Svvmsz� S� 77Y —zJt7 C�2o Z
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number fUnits Other ❑ Specify:
Brief Description of ProposedWork2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offieial Use Only
Labor and Materials _
1.Building $ qY00 1. Building Permit Fee:$ Indicate flow 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 Cost: $ 2,0v 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CSl���'�lo z-` �Ll Ito
�,�y�Ut �1QJ��-7/ ry v License Number Expiration Date
Name of CSL Holder
"ram n_ ln/ D" S` List CSL Type(see below)
No.and StreetT/ Type Description
r{� U Unrestricted(Buildings u to 35,000 cu.ft.D
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�i j�y SF Solid Fuel Burning Appliances
3 7 - o l o U I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contracpr(HIC) ,Z " 5 4 f7/,�
4h�/oG t i'// t `-mZ °� C Registration Number GExpiration Date
HIC.G,oMany orFSC 1&gis[rapt Na&/1
Email address
City/Town,State,ZIP !�J Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c,152,¢ 25C(6))
Workers Compensation Insurance affidavit must be comple ed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of a building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
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 eltt l(.c<(G(` i✓di1 /.�—�(
to act o�n/myy behalf,in all matters relative to work auth zed by this building permit application.
E9
Print Owner's Name(Electronic Signature) Date
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
l to the best of my knowledge and understanding.
'il C
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 HIC Program can be found at
www:mass. o>s v;oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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 halfibaths
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"
[WORK ORDER
COASTAL ❑ ADDENDUM
WINDOWS
& EXTERIORS, INC. i
too Cummings Center,Suite 236-H•Beverly,MA 01915
978-304-0495 • 888-812-2783 - Fax:978-304-1928 JOB # 1 1 }./•' -
www.mycoastalwindows.com
Owner's Name County
Address City State Zip J_ 's
Construction Site �. City State Zip
Home-Ph e� _ _ Work Phone(M) Work Phone(F) Email
You are hereby authorized to perform the following specifically described additional work:
TERMS OF FINANCING r'f=`-ifVl t O 1
Amount Financed Ly�` _ '
Interest Rate -`' (t�} y":a-'�p ^j'f t 2'C " y I I
r-I.SC f'1 lA i s
Amount of Payments `♦f''AS. Wig *�ca� "{"`7,:'r'l 'L 'S -,ti7f
Number of Payments , Da r E
Secured ❑ Yes ❑ No
Total of Payments r
ALL CONTRACTS SUBJECT TO APPROVAL
TERMS OF CASH PAYMENTS
Total Cash Sale
33%Deposit To Order Materials
Balance Due Upon Completion
Jet
ADDITIONAL CHARGE FOR ABOVE WORK IS: $
S� ax $ �f^ - r
Payment to be made as follows: �J t
Total $
COASTAL WINDOWS&EXTERIORS is not responsible for any painting,staining,or condensation problems resulting from preexisting conditions.
Above additional work is to be performed under and shall be subject to the same terms and conditions contained iu the contract unless otherwise stipulated
Date �) 2 '1 Authorized Signature
(owner signs here)
Date 2 Authorized Signature
(owner signs here)
r
f
We hereby agr ci 1f rf'nish la r ma 1-compl e In accordance with the above specifications,at above stated price.
Authorized Signature �, Date 2 2
/ indows&Exterio s Representative
THIS IS CHANGE ORDER NO. NOTE:This Change order is an addendum to the existing contract.
WHITE-OFFICE YELLOW-CUSTOMER
ne Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,M4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician:;Tlumbers
Applicant Information Please P;:int Legibly
Name(Businewowntzation/lndividual): n,,�' �G� tQ�/ J' / [• r S�'�UICQ
Address: 116—
Ci /s e/zi : C/ l � Phone#: 17�— 7Z 3 '�7
Are y as employer?Check the appropriate box: Type of project(i equired):
i.W1 am a employer with -` , 4. I am a general contractor and 1 6. ❑New consb Iction
employees(full and/or part-time).* have hired the sub-contractors
2.(] I am a sole proprietor or partner- listed on Use attached sheet' 7. ❑Remodelin
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers 9 Building ul iition
[No workers'comp. insurance comp'insurance=
required.] 5. 0 We are a corporation and its 10.[]Electrical repairs or additions
3.❑ J am a homeowner doing all work officers have exercised their 11.[]Plumbing r i pairs or additions
myself.[No workers'comp. right of exemption per MOL 12❑Roof repair i
insurance required]t c. 152,§1(4),and we have no
employees. [No workers' 13.[3 Other_,
comp.insurance required.]
*My sppik at thd checks boa YI swat alto ea out the seedon below showing their worms'eompematlee Policy Wennotiod
t Hsmmwam who submit this atBdavh ie they am doles ell wak sod than hhe etmide mnascom mad submit a new atHdn 1 t Wkstleg=1L
konhseton that Cheek this hog seed muchad an additional shed sbowtag tha mime of the seb-oonosctas end date whether of not the 10 aaatla have
employees. If be sob-000ememn have eawtoyea,they,most VVYWe their wortm'ton*pollay number.
Iam an employer that is providing workers catttpensadon hourancefer ray employees Below is the poi,.y and fob site
la 0moadom --�
Insurance Company Name: �� �
Policy#or Self-ins.Lic.#: -
Y3 �!� �2 3 on at l�5
41 SU —
Job Site Address: ——City townp• --
Attach a copy of the workers'eompensintlon pokey declaration page(showing the pokey uhmber and i spirstbn date).
Failure to secure coverage as requited under Section 25A of MOL a 152 can load to the imposition of Brim:"d penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil paruaides in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to tb 0 Office of
Investigations of the DIA for imanuae coverage verification.
I do hereby coo ender the pairs and pen aide a ofpe that the tnfornwdon provided above is out mi d correct
Phtasa# 17Y- 7 Z& 3aY7
Offlelal use only. Do not write in this area,to be completed by city or town ofjfetal
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbs tg Inspector
6.Other
Contact Person: Phone#:
AeoRa CERTIFICATE OF LIABILITY INSURANCE °�'�`"�°""""'
6/8/15
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 CER71RCATE OF INSURANCE DOES NOT CONSTITUTE 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(ies) 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 thi a certificate does not confer rights to the
certificate holder in lieu of such endorsamen s.
PRODUCER CONTACT
NAME:
George Gath Insurance Agency, PHONE 978 454-7728 FAX No: 197q) 458-6300
703 Chelmsford Street nDD Ess: susan@georgegathinsurance.com
Lowell, MA 01851
INSURE SAFFORDING COVERAGE NAIC•
INSURHRA:Atlantic Casualty Ins Co
INSURED INSURER e:
Rocco Carter DBA INSURER C:
Rocky's Maintenance service INSURER D:
45 Dunstan Rd INSURER E:
Chelmsford, MA 01824 INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 NAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS ANDCONDITIONS OFSUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE JUM VWD POU CY NUMBER MNDDYYYYY) (MMA)QfYYYYI LIMITS
A CENERALUABILITY y L143002023 6/21/14 6/21/15 EACH OCCURRENCE $ 1 000 000
X COMMERCLALGENERALLtASILITY PAMASESiE E ED $ 100,000
CLANIS, ADE [ilO(CUR MED SP tArM oro pars ) $ 1,000
PERSONALSADVINJURY $ 1 QQQ 000
GENERALAGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 1,000,000
POLICY PRO LOC $
AUTOMOBILE LIABILITYCOW INED SINGLELNI
(Eaac.ti q) $
ANYAUTO - BODIL Y IN JURY(Per Person)
AL OWFED SCHEDULED BODILYINXRY(Rereacid.il, $
PA1T05 ALITOS
NON-01ANED PROPERTY DAMAGE $
HIREDAUTOS _AUTOS _ er acddent
$
UMBFELLA LIAB OCCUR EACH OCCU RRENCE $
EXCES S LIAB CLAIMSMACE P.GG RE CATE $
DED RETBJTION$ $
WJRKERS COMPENSATION WCSTATU- OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETORPARTNERJEXE-CUTIVE � NIA EL.EACH ACCICENT $
OFFICEWEWER EXCLI-DED?
gftndalory In NH) E L.DISEASE-EA EMPLOYEE
If yes,de Gibe under
DE SCRIPTIONOFOPERATIONSbelaw EL.DISEASE-POLICY LIMIt $
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACOR0101,Abffitonal Remarks Schedule,It more apace is m qu.d)
HANDYMAN
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TOWN OF WINCHESTER ACCORDANCE WITH THE POLICY PROVISIONS.
71. MT. VERNON ST
LOWER LEVEL AUTHORIZED RE PRESENT0
WINCHESTER, MA 01890
-A7-
O 1988-2010 ACORD CORPO ON. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
Phone: (978) 454-.7728 Fax: (978) 458-6300 E-Mail: susan@georgegathinsurance.com
MassachuseCs - Deparfrne-;y
Board W 3uif c.,c 3aiei'-
ding .RaguiaYSz!�,
License: cs wS210
KRrMTH G B$DBO$lq�
44 BEDppgD�
CARMLE MA 01741
Crna,Z;ssio�t�r .04%2irAls
--------------------
I�
Oftlee of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR '
x Pegistration: 173195 Type:
l Expiration: 9/17/2016 DBA
ROCK'S MAINTENANCE SERVICE
ROCCO CARTER
._ 45 DUNSTAN RD
CHELMSFORD,MA 01824 Undersecretary '
License or registration valid for i
before the expiration date. g. ndividid use tinfy
i Office of Consumer found return to. "
10 Park Plaza_ Affairs and Business Regulation
Boston,MA 02116ite 5170
t
y4
Not v ---- .
alid without si --
gnature