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7 SUMMIT AVE - BUILDING INSPECTION
1 The Commonwealth of Massachusetts Board of Building Regulations and Standards CfCY OF Massachusetts State Building Code 780 CNIR SALEM Revised bfar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Divelling This SectionFbrOfficial Use Only,. / Building Permit Number:;. Date et Building Official(Print Name) $tgnatuie Date SECTION 1:SITE INFORNIAT ON 1.1 Property Address L2 Assessors blap& Parcel Numbers -7 — /h Yn.'f7— A- , 1.1a Is this an accepted street?yes L-' no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided PLaquired Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Flood Public Er� Private❑ Zone; _ Outside Check if fyes es❑Zone? Municipal EVISn site disposal system ❑ " SkCTIONZ:; PROP.ERT11'OWNERSR17. '.. 2.1 Ownert of Record: 2?£jzi/,_ Jon 2n/ tl r 5r✓l Name(Print)�"�� City,State,ZIP -781 -631 -4dJ3 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW'(checic all that apply) New Construction ❑ Existing Buildingg Owner-Occupied Pr R'epairs(s) O� Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number ofUnits,2_ I Other Cl Specify: Brief Descriptionof Proposed\Vorka: z � 2lc o F r1l t142 / h -/-f/Ui✓/ �40/2 c-� KCip� ,S/�/N�c jS S U'rJ C/Nfc SJGL�� SECTION 4: ESTINL4TED CONSTRUCTION COSTS- Estimated Costs: [ten Offtdal Use Only. Labor and Materials) I. Building 3 j�jcuv 1.,Building Permit Fee.5' Indicate how fee is determined: 2. Electrical S ❑Standard.Cityll'own Application Fee. ❑Total Project Costa,(Item.b)x multiplier. x 3. Plumbing S 2. Other Fees:k %1echanie;d (IIVAC) S List: i, Mechanical (Fire S inp Lression) _ Total All Fees: S Chcck No. . Check rinwunt. _ L'ash :\mount. A fatal® Project ('o;C S" / L] Paid in Fnll ❑Outstanding Balance 1)1w: V O(j4r r , r SECTION 5: CONs'TRUCTION SERVICES 5.1 Construction Supervisor License(CSL) OrG hGi✓Cf /��ON.� ,� License Number E.epiratiun Data Name of CSL I lolder List CSL Type(sae below) U,v ✓Css/-Xicrsa C?1,ZC ryeM Description No. and Street - / ted Duu to 3i000cu. tt./'✓)'L G!�'( o� R d 15c2 City/Town, State,LlP M RC Covcrin1VS and 9id SF el Burning Appliances (�VS e i ZGN.0 I nrein hone Email address D on 5.2 Registered Home Improvement Contractor(H(C) /Odl �� 7_3 HIC Registration Number Expiration Date I IIC Company Name or IIIC R/egutraut Nmne /� W AlN�2 No.and Street Email address City/Town,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 Issuance of the building permit. Signed Affidavit Attached? Yes .......... Ij--� No........... O SECTION la: OWNER AUTHORIZATION TO DE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize 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: 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, 5_a 9 — /3 Print Owners or Authorized Agent's Name(Electrunie Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program),will nor have access to the arbitration program or guaranty fund under M.O.L. e. 142A. Other important information on the HIC Program can be found at www.m;uc.�uv%oca Information on the Construction Supervisor License can be found at www.mas.UaLdL 2 When substantial work is planned,provide the information below: rood floor area(sq. It.) —(including garage, finished basement/attics,decks or porch) (iro;; living area(sy. d.) Ifiabituble room count _ Number oftireplaces Nuntberofbedrooms _-------------_____-- Number of bathrooms "„--_ u umberof halBbaths fvpe of he.ttil1g syetem ----_-- Number of,lxk.,'porches I)pe of cooliw, iy<tcm Enclosed pen 4 —' I ildl I'rot.'iI lyutrd Knot iqa" w rY b� ,nbstitnt: l f,r"I,d.il IRijdct 11, I -- ---- — — a CITY OF s v E4Nf i�iL1SS:�CHUSETTS v 13t:LLD LNG 0FP.%1T.NMNT 2 120 C(/,13HLNGTON STRSfiT, 310 FLC)Oit TFL (979) 745-9595 f<11[Lj&UEY DRISCOLL RLC(')78) 7•Id 9315 ,bUYOR TEIO16t3 ST.PIEAlLS DIRECTOR OF PLOUC PROP EATY/aL IWLYG COSattSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accords nee with the sixth edition of il ia State Building Coda, 730 C,tifR section l I 1 Debris, and the provisions of tb(GL c 40, 5 Building Permit# p 3 54• 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 tll, S 1SOA. The �debris will ,be transported by; / L (,ONNC✓L (�Ll'!r) 5 my2uc�[rYla,ty (name ut'haulcr) The debris will be disposed of in : (nnmo of facility) (addres.t of taalhty) >r pant d re ut permit applicant d,t� DAM(MMIDDNYYY) ACORq CERTIFICATE OF LIABILITY INSURANCE 07/11/2012 07/11/zolz 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: H the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. R 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: CPCU,CIC,VP, Stephen Tarpey Tarpey Insurance Group Inc Ert: 9050 791.231.81S1 PHONE 781.233. AK No (Alc,No 36 Main 5t ADDRESS: PO BOX 990 INSUREFyS)AFFORDING COVERAGE NAICO Saugus, MA 01906-0304 INSURER A: Holyoke Mutual Insurance Co 14296 INSURED Robert P Connor INSURERS: Republic Franklin Insurance Co 11247S 15 Joel Circle INSURER C: Lynn, MA 01904 INSURER U: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 12-13 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 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. JNSR POLICY ItFF POLICY EM LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YYYY) (MMtCqiYYM LIMITS GENERAL LIABILITY C890S8973 06/13/2012 05/13/2013 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY PREMISES Ea accwrence) $ 100,00 CLAIMS-MADE OCCUR MEDEXP(Any one person) S 5,00 A PERSONAL BADVINJURY $ 1,000,00 GENERAL AGGREGATE S 2,000,00 GEN'L AGGREGATE UMIT APPUES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PECry LOC S AuronoBILE LIABILITY CA90579980 05/13/2012 05/13/2013 (Ea amde S 1,000,00 ANY AUTO BODILY INJURY(Pa,person) $ A ALL OWNEDX AUTOESULED BODILY INJURY(Per amidw) $ HIRED AUTO$ AUTOS Peracadmt) $ S UNBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED REM I $ WORKERS COMPENSATION 431379 04/28/2012 04/28/2013 X H- AND EMPLOYERS'UAB11JTY YIN TORV LIMIT$ ER ANY PROPRIETOR/PARTNER/EXECUTIV E.L EACH ACCIDENT S S00,00 B OFFICER/MEMBER EXCLUDED? � NIA S00'QQ (Mandatory in NHl E.L DISEASE-EA EMPLOYE 4 Dy SCRIPTION OPERATIONS btlrnv es,describe under E.L.DISEASE-POLICY UMIT S 500.00 DE DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Alhch ACORD 101,Ad6lAnal Remarks Scheduk,H mom space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELAIEREO 11 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOM7 REPRESENTATIVE To Be Furnished Upon Request Stephen Tarpey, CPCU,CIC VP 9)1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD 9 9 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supcnisor License: CS-068989 ROBERT P CONNOR �'- 15 JOEL CERCLS iwx Lynn MA 01904 Expiration Commissioner 08/30/2014 ✓lie 7s,mcr Afzu/e� oy✓2aooa��ueella Office of Consumer Affairs&B siuess Regulafion _ HOME IMPROVEMENT CONTRACTOR Registration r 102844 Type' Expiration M12014 DBA CONNOR HOME IMPROVEMENT Robert Connor 15 Joel Cir - g � Lynn, MA 01904 Undersecretary i Date: 5/30/2013 Time: 10:58 AM To: Michael Lutrzykowski ® 9,1-978-740-9846 Page: 001 ACORD CERTIFICATE OF LIABILITY INSURANCE 05/2DILFE W°2013 rm OS/29/2013 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(iesi 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 CONTANAME, CPCU,CIC,VP, Stephen Tarpey Tarpey Insurance Group Inc acN E„t: 781.233.9050 (ac,Nq 781.231.8151 38 Main St ADDRESS' PO Box 990 INSURERS)AFFORDING COVERAGE NAIC# Saugus, MA 01906-0304 INSURER A: Holyoke Mutual Insurance Co 14296 INSURED Robert P Connor INSURER g: Utica National Insurance Co 15 Joel Circle INSURERC' Lynn, MA 01904 INSURERD: NSDRERE: NSURERF: COVERAGES CERTIFICATE NUMBER: 13-14 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MWDD/YYYY) (MMIDDM'1'11 LIMITS GENERAL LABILITY CB905887305/1312013 05/13/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,00 CLAIMS-MME I OCCUR MED ENT(Any one person) $ 5,000 A PERSONPL X ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 YEN L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO $ 2,000,00 POLICY JECT 7 LOr' $ AUTOMOBILE LIABILITY CA905799803 05113/2013 05/1312014 (Ee eoedert) $ 1,000,000 PNY AUTO BODILY INJURY(Pa peson) $ PILL)ms To SCHEDULELI BODILY INJURY(Poi acddenq $ A AUTOS X AS NON OWNED HIRED AUTOS AUTOS (Per ecciderit) $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MPDE AGGREGATE $ DEP I RETENTION $ $ WORKERS COMPENSATION 43137990412812013 0412812014 X AND EMPLOYERS'LIABILITY TORV LIMITG ER ANY PROPRIETOR/PARTNERIEXECUTIVE YIN EL EACH ACCIDENT $ 500,000 B OFFICEWMEMBER EXCLUDEDI N(A (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 500,000 I yAs.desonbe Linder DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS WEHICLES(Al ACORD 101,Additional Remarks Schedule,it more space is required) Job location: 7 Summit Ave, Salem, MA 01970 CERTIFICATE HOLDER CANCELLATION FAX: 978.740.9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WrTH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE City of Salem At n. Michael Lutrzykowski Stephen Tarpey, CPCU CIC VP ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD