26 SURREY RD - BUILDING INSPECTION GK_ C? � S �5 �0
The Commonwealth of Massachusetts
Board of Building Regulations and Standards RE'y4F �y CESCITY OF
r Massachusetts State Building Code,78g1 �S�� lad SE ,,,SALE
Mar 2071
Building Permit Application To Construct,Repair,Renovate Or pem_v}lishf'a 1111
One-or Two-Family Dwelling L"' Be
This Section For Official Use Only
Building Permit Number: Date A plied:
Building Official(Print Name) Signature - Date
SECTIONI:SITE INFORMATION,
l 1.1 Pro �ddress: (( 1.2 Assessors Map&Parcel Numbers
X SUI'Y`Zf f/ 1`
1.1 a Is this an accepted street?yes if no Map Number Parcel Number
1 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 Wate 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 OWNERSHIP'
2.1 Own�:of Record: / /��n
,ate of-If/�- /�`4
Name(Print) City,State,ZIP
�6 f rr c5-6'J' 6-1,;'6-1,;' Paqd
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied [IRepairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Voposed Work :
r�
SECTfON 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 $ ❑Standard City/Town Application Fee -
❑Total-Project Costy(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Supression Total All Fees:$
00t� Check No.. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full 13 Outstanding Balance Due:
Fri Ta t t t"sp a o 1-l•O . i o
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Sup/e'yrvisor ice a(CSL) 04 010k,
y /� f 9 _ /�
/ Q i ense Number (t Exxpiirraation Date Y
Namee o`f�CSL Holder �_�j' �//
lJ 7 ( 4'yel> L;Iti /"qJ List CSL Type(see below)..
No. d Street Type Description
/t nf.w�� �� iy/C�� U Unrestricted(Buildingsu to 35,000 cu.ft.
N� V < R Restricted 1&2 Family Dwelling
—cifyfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
ele hone Email address D Demolition
5.22 Re/gist gyredNome Impro77 m-ent Conttrraactor( IC) N/�"���y Q(��j y�_�
L.V',y� C HIC'Registration Number Expiration
HI Comp3 a or f Re i/str�anyName
33 L /C
No. id Sneer/ �„ // Email address
wiCi /Town,SSta-te,ZIPP Telephone
SEC77ON 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 Iss rT the building permit.
Signed Affidavit Attached? Yes .......... V 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
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: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
containe /n�,,this application is tru an ccurate to the best of my knowledge and understanding.
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
w•vvw.m&ss.eov/oca Information on the Construction Supervisor License can be found at www.mass.Gov€ /dos
- 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 halffbaths
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"
�1 ®
CERTIFICATE OF LIABILITY INSURANCE 411612`°°°oi5
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), AUTHORDED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. N SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsemelrL A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsemeld(s). - -
PRODUCER NA TACT Jeremiah Laois
Bernard M. Sullivan Insurance Agency PHONE 978)356-5511 FAX
0.(999)356-0214
12 Market St. E-MaL : jewis@sullivaainanrance.com
P.O. Box 568 _ _ INSURER(S)AFFORDING COVERAGE NAIC0
Ipswich - MA 01938 INSURERAEssex Insurance Co. XSB003
INSURED - UisuaiRei•GM Insurance Company 4788
O'Keefe Brothers Construction, Inc. nLguRERcACE American Ins-ARWC
397 Linebrook Rd. - INSURERD,
INSURER E-
I awlch MA 01938 INSURERF:
COVERAGES . CERTIFICATE NUMBERCL1541603830 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.
WIR TYPEOFINSURANCE _ POLICYEFF POUCYEXP
POLICY NUMBER Mm LIMITS
GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY - PREMISES Me oPaarelwe $ 50,000
A CL0UMSd1ADE rX I OCCUR /15/2015 /15/2016 MED EXP(AM one Paton) S 10,000
PERSONAL aAUV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GENL AGGREGATE UMIT APPLES PER PRODUCTS-COMP)OP AGG $ 2,000,000
Fxj POUCY PRO, LOC I
S
AUTOMOBILE LIABILITY e8BI CIS LIMIT11000,000
BIANY AUTO . . BODILY INJURY(Perperson) $
ALLOONTIED X AUTOS BODILY TBSSOM /3/2015 /3/2016AUT BODILY INJURY(PaacdOad) S
HIRED AUTOS X NO 5�� PRO DAMAGE $
F - Medool ems $ 5 OOO
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE $
I $
C WORKERS COMPENSATION WC STATU- OTH-
ANDEMPLOYERRIMBIDTY YIN -
ANYPROMETORIPARTNERIEXECUTNE EL EACH ACCIDENT S SOO OOO
OFTiCEReJEMBER EXCLUDED'1 NIA '
(Mandarory In NH) SOB-2962614-7-14 2/23/2014 2/23/2015 EL DISEASE-EA EMPLOY S 100 000
HIM
yyeeee desonbeaMer
DESdMPION OF OPERATIONS below E.L.DISEASE-POUCY UMR S 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(A1 wh ACORD 101,AddNional Remalm ScAalule,N more spate is squired)
CERTIFICATE HOLDER - CANCELLATION -
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION .DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORQED REPRESENTATIVE pp
Jeremiah Lewis/Cfii2IS �Q�p"'u"�"
ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
INS025 rxirm5l m Th.Arnon noon and Inns aro roniafnrod madre of anon
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street, Suite 100
Boston,MA 0211 4-2 01 7
www.mass gov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FH.ED WITH THE PERMITTING AUTHORITY.
Applicant Information - Please Print JAgibly
Name (Business/organization/Indi
vid
ual):
Address:
City/State/Zip: �&k hone#:
Are you an employer. eck the appropriate box: Type of project(required):
mmployer with employees(full and/or part-tam)." 7. New construction
2.0 I am kinds proprietor or partnership and have no employees working for me in 8. E]Remodeling
my capacity.[No workers'comp.insurance required]
9: El Demolition
3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition.
4.❑I sm a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
Proprietors with no employees.
12.Q Plmnbing repairs of additions
5.❑I sm a general contractor and I have hired the subLoontiactors listed on the anacbed sheet. 1•• epaffs
These sub-cantractors have employees and have workers'comp.insarancet �1
6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other -
152,§1(4),and we have no employees.[No workers'comp.insurance reguhM.]
'Any applicant that checks box#1 must also fill out thesectim below showing their workers'compensation policy inimmatim. -
t Homeowners who submit this affidavit indicating they are doing all work and th®hue 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. ifthe sub-contractors have employees,they must provide their worken'Gomp.policy number..
I am an employer that is providin workers'compensation insurance for my employees.-Below is the polity.and job site
information. -
Insurance Company Name: '
Policy#or Self-ins.Lic.#: �JtJb '�(. tOiC(d 6 �l�Expirafion Date: {(('�//Z� ��f—
Job Site Address: ✓,r c/�t1� �� City/State/Zip: .J frh
Attach a copy of the workers'compensa64 policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required ender 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 certify der the pains and� i fperjury that the information provided above istr true
-and correct
Si ature:' v Date: !�(/
Phone#: ��� 44( d3L
Official use only. Do not write in this area,to be completed by city or town gyciat
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. Y
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 writtep."
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 thari 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 pemruUlicense 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 narked 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. # 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
e
(STY OF SALEM, MASSAaiUSE M
i BummNGDEPARTAENT
' 120 WASHNGTOHINGTON STREET,3"0 FLOOR
TILL.(978)745-9595
FAX(978)740-9846
KINIBERLEYDRISC�OLL
MAYOR THomm STYiERRE
DIRECTOR OF PUBLICPROPERTY/BU[LDING a:)mwSSIONER
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 c40, S 54; Building Permit fi 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:
(Ame of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature o applicant
Date