53 SUMMER ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts TY OF
Board of Building Regulations and Standards RECEI
° INSPECTIOt ALL
Massachusetts State Building Code,780 CMR Revise���r
Building Permit Application To Construct, Repair,Renovate Or Dlish.� '
One-or Two-Family Dwelling AAU A ID S 9
This Section For Official We Only
Building Permit Number: Date A lied:
Building Official(Print Name) signature Date
t SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
��'� S441 tia rh Ls� CT
I L la Is this an accepted street?yesJG 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:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal stem ❑
Public❑ Private❑ Check if yes❑ P P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
G�H-►zr�;-oL��
Name(Print) —�— City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ,� Alteration(s)X I Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Descripf n of Proposed Work":
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:
2.Electrical $ El 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
Su ression $ Total All Fees;$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 2 3 Oba ❑Paid in Full ❑Outstanding Balance Due:
PAS rnn, � �. 3 �LY•r, �l,�c.� M�ti� �t��fs
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) � �
R - �d&92— MDik fA/—n License Number Ex ,ion ate
Name of CSL Holder
List CSL Type(see below)
No.anrStreet "Type Description.
�� n.�e . U UnrestrictedFamily
(Buildings u el 35,000 cu.ft.
City/fown,Stale,ZIP (t/V�— R Restricted 1&2 Famil Dwelling
M Moo
� y S RC Roofing Covering
WS Window and Siding
I Solid Fuel Bum noting Appliances
icy I Insulation
Tele hone Email address D Demolition
5.22 Registered
+,-Rome Improvement Contractor(HIC)
!� r -eI� � L,[s-z � z6eo am' C Regis r it ,on ate
C Company Name or Registrant Name
C� oeo L-1 b2ot f�� cDt�rl vT
No:an Street Email ddress
i /Town State ZIP Tele hone
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 BUILDING PERMIT •.
I,as Owner of the subject property,hereby authorize � l�.(�iind�skL�2 DA424.4'
to act on my behalf,in all matters relative to work authorized by this buildi gg pi�lication.
Print Owner's Name lectronic Signature) ate
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 myknowledge and understanding.
Print Owner's or Au rized Agent's Name(Electronic Signature) —data
NOTES:
I. An Owner who obtains 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
wM1vw.mass.gov;'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"
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DRAWING TITLE: CLIENT:
15'O p 6.p01 ®E PROPOSED RENOV CMRI9 AND STACEY NORKNN
= 1 r C. Raei FEOOR Pun�B�
3/Su
008 LOCATION:
53 SUMMER STREET
Doiewne Sew�a m ee ao.o .9ALEM MA 01 970
Office of Consumer Affairs&Business Regulation
1 OME IMPROVEMENT CONTRACTOR
egistration 110t 47 Type:
UVEXpiration: 1912015 Partnership
G-I ��
MONACO JOHNSO�}J'ORp P,,,���... l=�
CHRISTOPHER MONil✓
3 ELM PL4 ,2,.�v/ gam_
MARBLEHEAD,MA 01945—' Undersecretary
t
Massachusetts'-Depaatmedt of Public Safety
Baartl of Building Regulations and Standards
Constructien Supervisor
License CS-013075
-4,
CARIS' O HER As,IyI0,
3.ELM PLACE ,,.� t "
MARBLEMAD 41 �
. Expiration
Commissioner - `!D/26/2015`�,
,s
Client#:65359 MONACOJOHN
ACORD!. CERTIFICATE OF LIABILITY INSURANCE DATE(MMND YYVI�
8M 212015
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 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 this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME Certificates Dept
HUB International New England P"M Es,):978 657-5100 Ati ne:866 475 5959
299 Ballardv A
ale St ADDRESS.
nee.certificates@hubinternational.com
ADDRE
Wilmington,MA 01887 INSURER(S)AWORDING COVERAGE NAICIf
978 657-5100 INSURER A:Travelers Indemnity 25658
INSURED INSURER B:
Monaco Johnson Group LLC
INSURER C
C/O Christopher A. Monaco
INSURER D
3 Elm Place
INSURER E
Marblehead,MA 01945
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 CONTRACTOR 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.
INSR TYPE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS
LTA INSR WVD POLICY NUMBER MWD M/D
A GENERAL LIABILITY 6803647N8841542 4/10/2015 04/111/2016 EACH OCCURRENCE $1 000000
X COMMERCIAL GENERAL LIABILITY PREMISES REaa'ur ante $300000
CLAIMS-MADE F_x1 OCCUR MED EXP(Anyone Person) $5 000
PERSONAL&ADV INJURY $1000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE UMIT APPLES PER: PRODUCTS-COMP/OP AGG $2,000,000
X POLICY M" LAC $
A AUTOMOBILE LIABILITY BA3649N64415 10/2015 04/10/201 6COMBBIINa DSINGLE LIMIT
(EaANYAUTO BODILY INJURY(Per Person) $500,000
ALL OWNED X SCHEDULED SCHEDUL BODILY INJURY(Per actident) $500,000
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $100,000
X HIRED AUTOS X AUTOS Per scdd.rd
A X UMBRELLA LIAR )( OCCUR CUP303OT6601542 4/10/2015 WO/2016 EACH OCCURRENCE s2000000
EXCESS me CLAIMS-MADE AGGREGATE $ 00D000
DED I X REfENTON$5000 $
A WORKERS COMPENSATION IOUB3887N32115 0/2015 04/10/201 X wO YUM oTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNEPJE ECU11VE YIN EL EACH ACCIDENT $500000
OFFICERIMEMBER EXCLUDED? 51 N/A
(Mandatory In NH) E.L DISEASE-EA EMPLOYEE $500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $500000
1 1 1 r _____ I
DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLFS(Attach ACORD 101,Additionol nonsense;Schedule,it more space Is raQuired)
Workers Comp Information"
Proprietors/Partners/Executive Officers/Members Excluded:Chrisopher Monaco, Member&Peter Johnson, Member
Blanket Additional Insured status applies to certificate holder only when required by written contract and
prior to any loss/claim.
CERTIFICATE HOLDER CANCELLATION
RE
Christopher&Stacey Norkun THE EXPIRATIONDATE THE ABOVE EREOF,DESCRIBED NOTICE I WILL ES BE CBE CDELIVEREDELLED OIN
53 Summer Street ACCORDANCE WITH THE POLICY PROVISIONS.
Salem,MA 01970
AUTHORIZED REPRESENTATIVE
@ 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) 1 oil The ACORD name and logo are registered marks of ACORD
#S1436761/M1360749 CW001
The Commonwealth of Massachusetts
Department oflndustiialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Vworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Organizatiorybdividual):
Address: :�, atlil ��"���
City/State/Zip: ////(�1 Phone#: D
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with employees(1411 and/or part-time).- 7. ❑New construction
2.n I am a,sole proprietor or partnership and have no employees working for mein g. Q Remodeling
any capacity.[No workers'comp.insurance required] -
3.Q I a a homeowner doing all work myself.(No workers'comp.insurance required.]t 9. Demolition
m
10 E]Building addition.
4.❑I ain a homeowner and will be hiving contractors to conduct all work on my property. I will
eruure that all contractors either have workers'compensation insurance or we sole 1 LO Electrical repairs o7 additions
proprietors with no employees.
- 12.E]Plumbing repairs or additions
5.❑I sm a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs
These subcontractors have employees and have workers'comp.insurenrmt
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a l4.Q Other
1(4),and we have no employees.[No workers'comp.insurance requited.]
-Any applicant that checks box#]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.
lContractors 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.., -
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: `MA-t/ir—t. ol& fitil"J�WC -t�-
Policy#or Self-ins.Lic.M IoCW 15 :3 7 f9/3; Expiration Date: (D
Job Site Address: ' 37_3 Y-si S City/State(Zip: <>7 - . ,t/N`'`t� G(5
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ce/ryfpytnder the pains and penalties ofperjury that the information provided above'is true and correct.
Sitmature 1 ( e��• .-----.---->y'ate r�/ ��Z��
i
Phone#: 4a(7 '71�219 9gg2
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
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017.
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
QTYOF SALEK MASSAMUSE7 S
{ BtatDiNG DEPARTMENT
120 WASHINGTON STREET,3'0FLOOR
7kL(978)745-9595
KIIv18ERLEYDRISQ7LL FAX(978)740-9846
MAYOR 7 If M STY ERRS
DIRECTOR OF PLMIXFROPERTY/BUIDMCOMM .STONER
Construction Debris Disposal Affidavit
(required for all demolition and,renovation workj.
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit 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) -(address of facility)
Signature of applicant
Date