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43 SUMMIT AVE - BUILDING INSPECTION (2) US c.K � 5 3 g RECEIVED i RVICEsrhe Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY M : MAR �� ed thw 8 A sachusetts State Building Code, 780 CMR RevisrJ ti/ur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling d This Section For Official Use Onl ` Building Permit Number: Date Applied- Building Official(Pont Name) zSignature,: . 3 e SECTION is SITE INFORMATION: 1.1 S PIT perry Add opL res�(T Ajk ZA 1EL 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street9 yes___ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Aaa(sy lt) Frontage(it) 1.5 Building Setbacks(R) . Front Yard Side Yards - Rear Yard Required ProvidniRequired- Provided Requited- 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? MunicipalO On site dis sal system 13 - Public(i9 Private 0 — Check If a0pa 9 SECTION Z: PROPERTY OWNERSHIP'` 2. Owna er-ofR ord: s Q Sy�(krc �f- PAC P—A(, I ,� uE. O,�tE K 1Trme(Print) City,State,ZIP l78 S21� R�S � No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Existing Building❑ Owner-Occupied 0 Repairs(s) ❑ Alteration(s) C3 Addition 0 Demolition 0 Accessory Bldg.O Number of Units Other 0 Specify: Brief Description of Proposed Work : rEV i SIAJi d ct o µ/ �i -p (mot ( N 2 P�/J F( - iL T (A i/ � t SECTION a: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Ofllcial Use Only Labor and Materials I. Building S `,3 Qpp 1. Building Permit Fee:S Indicate how fee is determined: 0 Standard City/Town Application Fee 2. Electrical S 0 Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2�Qther Fees: S ( x a.Mcchanical (I-IVAC) S List: U 5. Mechanical (Fire ,� Total All Fees:S Su ressiun) Check No. Check Amount: Cash Amount: 6. Total Project Cost: CX�, / ❑Paid in Full ❑Outstanding Balance Due: t " `( kx-C OU �.dh t e 0 GlJ h�IL N rat �l�S :3�,"a ti6v,et•, t:t SECTION5: CONSTRUCTION SERVICES 5.1 Constructimt Supervisor License(CSL) C _ O Uo 2?2 07 16 17 T� 1r f�Q I ) p ov o aA License Number �- ;J E:rpira�ton stet Name of CSL Holder _ List CSL Type(see below) U tv P (.a,(c l I o Jj E C t A JAG TYPe. - - . . Description . No.and Street U Unrestricted(Buildingsa E� �!JCAAAMt rVY Q0D R Restricted 1&2 Family Dwelling City/rown,State,ZIP M Masonry RC Rooting Covering WS Window and Sidin ) SF - Solid Fuel Burning Appliances �2j/' a9 (,('rLtp,dli 1 Insulation Tcic hone Email address 6 D I Demolition 5.2 Registered Home Improvement Contractor(HIC) 14 (-)S 0 51I2 I'c njA, CC>N C, al C't L m` l A/C HIC Registration NumberE:rprmtion Date f IIC Company N�v ( t411 oRX u'ran(.J4M. 2/4 _ (�>��.t,�✓ TL(9 a No.and Street n( �. . ) IT(2,1 �( A f J, Email address' — Ci /town State ZIP V vGt[ Tel e hone SECTION 6:WORKERS'.CONIPENSATION INSURANCE AFFIDAVIT(M.G.0 c.151.f 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 Is✓;uance of the building permit Signed Affidavit Attached? Yes....K-_.O 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 t9 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,) h by attest under the pains and penalties of perjury that all of the information contained in this application is t d accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agc s Nmne(Electronic 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 registered in the Home,Improvement Contractor(HIC) program);will no have access to the arbitration program or guaranty fund under M.G.L.c. 142A. Othcitimportant in-forination on the HIC-Program be of trod rt www mass eov:'oca Information on the Construction Supervisor License can be round at www.nm� 2. When substantial work is planned,provide the information below: 'total floor area(sq. ft.) '% ,(including garage, finished basemenVattics,decks or porch) Gross living area(sq. ft.) Habitable room come Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches 'type ofcooling system Enclosed Open ]. "total Project Square Footage"may be substituted for"rotal Project Cost" CITY OF SALSA MASSA(H.SEM BuzDm DEPAFmem 120 TAsiwqG7cTTS7nET,3IDFLooR 7>?L(978)743-9595. BII FAX(978)740-9846 vJBF.RLEYDRISO�LL MAYOR SAS STPIRM DIREclaR oFr[sIIcrRoFmY/BLLmDma mossiomit Construction Debris Disposa/Affidavit (required for all demolition and,renovation work) In accordance with the sixth edition of the State Building Code, 780 CAM, Section 111.5 Debris, and the provisions of MGL c40, S 54; Building Permit d 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. F1AkLj pl,Sbsk& (name of hauler) The debris will be disposed of in: NALAWS Ors Po SYL (name of facility) (address of facility) Signature of applicant 015 Date The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 w www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information � Please Print Legibly Name (Business/Organization / /Individual): P (� C,D ill `- ' /d / L.L rp s, t �_ Address: Q( f J/12�� A-✓ F City/State/Zip: e/XAt r 1, Ci c1A 4'IA Phone M C ( ? G ( 3 ?-4 2- Are you an employer?Check the appropriate box: FLE] f project(required): 1�I am a employer with employees(full and/or part-time).* ew construction 2.❑I am a sole proprietor or partnership and have no employees working forme in emodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t emolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on m property. I will uilding addition Y P perry ensure that all contractors either have workers'compensation insurance or are sole lectrical repairs or additions proprietors with no employees. Q 5.❑I am a genera]contractor and I have hired the subcontractors listed on the attached sheet. 12. Plumbing repairs or additions These sub-contractors have employees and have workers'comp.insurance3 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§](4),and we have no employees.[No workers'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 subcontractors 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: CA wA t -o N A L Policy#or Self-ins.Lic.#: .4 W Expiration Date: D I 2 6 Job Site Address: -4 3 f s k k c A,; At City/State/Zip: S�-(..ft.*I'� Attach acopy 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 imprisonmen '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 c ylof this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t 7dohereby certify under r:s and penalties ofperjury that the information provided above is true and correct. re: Date: / Phone#: tG 0 A0 24 Z 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 dog 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 Massachusetts -Department of Public Safety _ Board of Building Regulations and Standards Crnstroctinn Svpervi:or ' License: CS4)86272 VT I S I)FA ARTHURGPOK to ,y'•�\ Ilk 18 WAYSIDE LANE g I ASIH AND MA 0172 e r r Expiration _pry'e_ppir-s,a-��..i.,"/o,L Commissioner 076/20.1-'7 Wlegis�Etrea"Mtj',ROVEMENT ffiCoasamerAfair sand CONTRACul atioo re OR iration: r d 5/12112016 Type: ABA-CONST. INC. _ Private Cerpora(i; ARTHUR POKOR4 18 WAYSIDE LN ASHLAND MA 01721 Under,CrOary CERTIFICATE OF LIABILITY INSURANCE 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: M the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. H 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 endorsements. PRODUCER c SANDRAPOWELL 22 M llas-CorseBi Insurance Agency,Inc. PHorEie FAx 22 Mill SL (781)641-3300 (A/c,No):(781)777-1402 #410 spowdl@doulraHscarsetti.corn Arlington,MA 02476 INSURERS AFFORDING COVERAGE NACO IN9IRER A: STATE AUTO INS COMPANY INSURED ABA General Contracting Co.Inc. INSURER B: UTICANATIONAL 18 Wayside Lane INSURER c: Ashland,MA 01721000 INSURER D: INSURER E: 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 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. LLTTR TYPE OFINSURANCE J=IivaR POUCYNUMBER MMNOtt� MMNO LIMITS A GENERAL UABILRY BOP2735406 04/M15 04/26/16 EACH OCCLRRENCE $ 1001X100 COWIZRCW.GENERA LMLITY PREMISES Eeoccunence $ 50� CLANISMADE � OCCUR MED EW An one person $ 5000 PERSONAL&ADV MURY $ GENERAL AGGREGATE $ 2000000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRo- LOG $ .IFGTAUTOMOBILE IJABRrrY COT rae SNGLE LIMIT Ea aedaenr ANYAUTO BODILY INAIRY(Per person) $ KL OWNED SCHEDUAFD BODILY IN,URY(Per acCde,d) $ AUTOS AUTOS NON�OWNED PROPERTY DAMAGE $ HIREDAUTOS AUrO$ P ra E UMBRELLA OCCUR EACH OCCURRENCE $ EXCESS U1LIAB C MADE AGGREGATE $ DED RETENTION $ B WORXERSCOMPENSATION 4615822 04Y1fa115 04/Wl(i WC STATLL OT4 AND EMPLOYERS LIAINUITYRY UNITS ANY PROPMETOWPAMNETbDECUINE YIN E.L.EACH ACCIDENT $ 100000 OFFIO=RNIEMBER EM].UDED] ❑ N/A (Mandatoryln NH) E.L.OLSEASE-EA EMPLOYEE s 5W000 $yyea,describe under 100000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UNIT s DESCRIPTION OF OPERATIONS LOCATIONS/VEHICLES(Mach ACORD 101,Additional RemarSs Schedule,if rears apace is required) CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 93 Washington Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem,MA 01970 ACCORDANCE WITH THE POLICYPROVISIONS. AUTHOR®REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD soon 3p? r