6 SUNSET RD - BUILDING INSPECTION (2) 30L4 q 4- zsgq
The Cornmonw alth of Massachusetts
�- Board of Building Regulations and Standards CfrY OF
�� � Massachusetts State Building Code, 730 CNIR SALEM
Revised.L&tr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Da .Applied:
Building Official(Print Name). Signature. 7 - Date
SECTION 1:SITE INFORMATION
1.1 Pr 1 rty-address: \lL 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(It)
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 ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owncrt f Rccard.
1 a Ea.1.l�
Ante(Print) City,State,ZIP
/� �;� WA k �ZZ�'
i .mid Slrcel _T rclephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) Cl Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descripti of Prjjoposed Worka:
rl n462
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item - Estimated Costs: Official Use Only
Labor and iblaterials)
I. Building S 1. Building Permit Fee:S Indicate how ree is determined:
2. Electrical .S ❑.Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S h
4. Mechanical (FIVAC) S List: ��(]
5. Mechanical (Fire —
Suppression) roed All Fees:'S
Check No. Check Amount: Cash Amount:
C.Total Project Cost: J�a ri !•� 0 Paid in Full 0 Outstanding Balance DLIC:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) — '0 `
License Number Esp' ation ate I
Nanit of CSL holder r
� �r foie List CSL"type(see below)
No.and yet T _ Description
��GG��
���r��,yQ/� Unrestricted(Buildings u to 35,000 cu. I
n I4A AS t't/ ' R Restricted 1&2 Family Dwelling
Cityll'own, ult ,LIP M Nfasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
SI Insulation
'fele one Email address D I Demolition
5.2 Registered Home Improvement Contractor HIC) �d
TOkOV HICHIC Registration gumber E. irn on Date
111�50i 'my Nmne r l C iegistr i -un
i
No.al eet ivy Email address
CiC�wn,State,ZIP "fele 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...........❑
SECTION7a:OWNER AUTHORIZATION,TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT'
I,as Owner of the subject property,hereby authorize &/7 (x Tr)
tg act on my behalf,in all matters relative to work authorized by this building perm' application.
& /D
'Aim r s Nine( Iecoonic nature) 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.
Print hvner's or Audi rite r gent's Name(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
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty turd under i�LG.L.c. I42A.Other important information on the HIC Program can be found at
www.mrss.got �''OCa Information on the Construction Supervisor License can be found at wwnv.nctss. oe%'dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. fl-) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) 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"Tot i Project Cost"
a�aa„c»,a„eaerrl�/r r/'piaJJ2C�rrJ��j 4 Massachusetts -Department of Public Safety
Office of Consumer Affairs&Business Regulation BOdrd of Building Regulations and$tandar{is
OMEation: CONTRACTOR 12OME IMPROVEMENT tton: Construction Supcn'i+ur
131319'E Type License: CS-058o40
xpiration 10/25/2015 OBA< sitti r,
M.R.JOLY CARPENTER/B - �UILDER ]VIARKRJOL]z�� -
3B COOLIDGE RD '
DANVERS
. MARK JOLY lYJA 01923
38 COOLIDEGE RD.
DANVERS, MA 01923
- Undersecretary, J�^•� rtstt"
Commissioner Expiration
—, 01/1612014
AC"MY CERTIFICATE OF LIABILITY INSURANCE 10/8/2013
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(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 ELLEN FREEHAN
NAME:
Dooley Insurance Agency, Inc. PxONE (978)356-0581 FAX .(97W356-9609
2 Central Street DD RIE :Ellen@Dooleyine.cont
PO BOX 264 INSURE $ AFFORDING COVERAGE NAIC0
Ipswich MA 01938 INSURERA Vermont Mutual Insurance Co 26018
INSURED INSURERBAIM Mutual Insurance Co.
JOLY BUILDING S REMODELING INSURERC:SafQtY Insurance Co.
MARK JOLY INSURER D:
38 COOLIDGE RD INSURER E:
DANVERS MA 01923-2358 INSURER F:
COVERAGES CERTIFICATE NUMBERCL1310842338 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.
INSR rypE OF INSURANCE POUCYEFF POLICY EXP
LTR POUCY NUMBER MMID MMID UMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 50,000
A CLAIMS-MADE OOCCUR BP11028035 O/3/2013 0/3/2014 MED EXP(Any one person) $ 5,000
PERSONAL a ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000"000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000
X POLICY PRO- LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea amtlem
BODILY INJURY person) $
D ANYAlITO 250,000
ALL OWNED r-,-1 SCHEDULED 6213429 6/01/2013 6/01/2014 BODILY INJURY(Par accident) $ 500 000
AUTOS AUTOS
HIREDAUTOS AUUTOS�ED PPar-aacddTmDAMAGE $ 100,000
DNBUNDERINSURED $ 10DR 30D
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTIONS $
B WORKERS COMPENSATION VrC STATU- OTY LIMIT
-
AND EMPLOYERT U ABIUry Y I N
ANY PROPRIETORIPARTNERIEXECUHVE❑ NIA E.L.EACH ACCIDENT $ 100 000
OFFICERNEMBER EXCLUDED? 0/2/2013 0/2/2014
(Mandatary In NH) C 5003576012009 E.L DISEASE-EA EMPLOYE $ 10D DDD
It yes,describe under -<
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Sch sluts,N more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TOWN OF 1.9RAT.F.j-]EAp ACCORDANCE WITH THE POLICY PROVISIONS.
7 WIDGER RD
MARBLEHEAD, MA 01945 AUTHOW-ED REPRESENTATIVE
Jay Dooley/EFREEH
ACORD 25(2010/05) C 1988.2010 ACORD CORPORATION. All rights reserved.
INS025 mmnns)nl ar-nPn
a
CITY OF 5.'1LE�i -A-1SSACi IUSETTS
BUILDING DEPARTSIFINT
120 WASHNGTON STREET;3sc FLOOR TEL (978) 745-9595
FAx(978) 740-9946
IC1%LB Rt FY DRISCOLL TmohscsST.PSEM
LL$Yop. DIRECTOR OF PUBLIC PROPERTY/BUaDNG CO'CdISSIONER
Workers" Compensation Insurance M idavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(0usincsuOryanizatiuNlndividuai):
Address:
City/StatetZip: ['}tone tt:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with_/ 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.: 7• modeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No worker comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ Iran a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions
myself. [No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.)1 °mployces. [No workers' 13.0 Other
comp. insurance required.!
•Any applicatn tlur C11eek6 box#1 must all'fill out the section below showing their workers'compensation policy inhumation.
r I hunco.mrs who submit this affidavit indicating they arc doing all work and then hire outsida contractors must submit a new affidavit indicating such.
:c,mincwts Ihut check this box must attached an additiored sheet showing the natne of the tub-contradom and their workers'comp.policy information.
lull?an employer that is providilig workers'conipeu�n insurance for my employees. Below is the policy and job site
inrance C.
insurance Company Name' S
Policy a or Self-ina. Lic. H: �.IJCG�L� �� tamp Expiration Date:
Job Site Address: � �� r`✓�
City/State/Zip:outn �V
Attach a copy of workers'compensation policy declara(Ion page(showing the policy nbor 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
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.
Ida hereby certify m er dm airs d p lairs of perjury that the information provided above is true and c'orrec4
S' nu Ire' Date:
Phonc ti:
OJficial use only, Do nor write in this area, to be completed by city ar town officiuL
City or Town: __.._ Permitfr.lcense#
Issuing Authority(circle one):
1. Board of Ilealth 2. Building Department 3.C.'ilylrown Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other .____. ...__....__._
Contact Person: .__ ... - _ __.._.._ Phone#:
<, �" �1LE1 t, NLkSSACHUSETTS CITY OF S
BL:II.D4\,G DEPARTMENT
\ 120 WASHNGTON STREET, 3iD FLOOR
T EL (978) 745-9595
F.m.K(978) 740-9844
Kt1tBERLEY DRISCOLL
INLAYOR T'HONW ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUI DNG COWMISSIONER
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 NIGL c
111, S 150A.
The debris will be transported by:
(name of h er)
'rhe debris will be disposed of in
(name of facility)
(address of facility)
Asignature of 4apcant
date
dcbriiaii:,l,x