96 SWAMPSCOTT RD - BUILDING INSPECTION (20) t
The Commonwealth of Massachusetts CITY OF
�> Board of Building Regulations and Standards
S
Massachusetts State Building Code,730 CNIR
Revised
H d�lrar
u 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section ForOffieial Usa Onl
Building Permit Number':;..:
Building Official(Print Name) $tgnature Date -
SECTION I:SITE INFORMATION.
1.1 Property Address: 1.2 Assessors Nfap& 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 tt) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(KILL c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: Outside Flood Zone? Munici al❑ On site dis orals stem ❑
Public❑ Private❑ _ Check if es❑ P P y
sECTIONi. PAOPERTY'OWNERSHIP'
2.1 Own rr of Record:
Name(Print) City,State,ZIP—�
No and Street Telephone Email Address -
SECTION 3: DESCRIPTION OF PROPOSED WORW'(check all that apply),
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Cl Accessory Bldg. ❑ Number of Units_ I Other. ❑ Specify:
Brief Description of Proposed Work': .)e o a X S G
SECTION 4: ESTIDLATED C..ONSTRUCTION COSTS-
[rem Estimated Costs: Official Use Only>...
Labor and Materials
I. Building $ L.Building Permit Fee.-S rhdicatehow fee is determined:
�. fhctricat $ ❑Standaid,CityCPownApplicationFee.
❑'Fowl Project Cast'(Item 6)x multiplier x
3. Plumbing S 2. Other Foes: $
i. M.eh:mical (IIVAQ S List:
5. Mechanic.il (Fire S Total r\ll Fees:.S
Suppression) _ -
/ pro Cluck No.._Chcck r\uw :\n
unt: ---Cash rounC_
r, I'ntal Proicct Cuss: S f ❑ Paid in Flill ❑outstalidi fig Iia1:1nce 011a:,
r� 5-
r
SECTION5: CONS'l-RUCTIONSERVICES
5.l Cunstnutimt Supervisor License(CSL)
License Number Gepiration Date
Name of CSL Ifolder List CSL a see below
No. and Sueet Type Description
U Unrestricted Duildin s u to Ii,000 ell lt.
_ R Restricted l&2 Famil Dwoltin
City/Town,State, ZIP II \lasonr
RC Roofin Covering
WS Window and Sidin z
SF Solid Fuel Burning Appliances
[ Insulation
Tele hone Email address D Demolition
5.2 Registered Hone Improvement Contractor(IIIC)
25- I/e l t S /C� ItIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Ny
N .and treat Email address
dew !� 9'�P- 5'�5-S0`3
City/Town,State,ZIP rele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 Issuan5p of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
O WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize :z9� '&e
to act on my behalf, in all smatters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: 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 th best of my knowledge and understanding.
F-rint Owners or Authurized Agent's N.ane(Electron-le Signature) Data
NOTES:
I. :\a Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
(nut registered in the Honte Improvement Contractor(HIC) Program), will Prot have access tothe arbitration
program or guaranty rind under M.G.L. c. 142A. Other important information on the HIC Program can be found at
uww.mai9.sw%uc�a Information on the Construction Supervisor license can be round at www.mas .,,_,v.AIL
2. When substantial work is planned,provide the information beluw:
rued flour area(Sq. It.) _(including garage, finished basement/attics,decks or perch)
t rosi living au'ea(sq, (t.) _ 1labitable room count _
Nnuiberottireplaces-.___----- NUmberofbedromns
Number of bathr,)m ni Number of ImIt'batths _---_— —
' rcpooChe.ttiug ;yirem .. —_ -._-- Number o(deeks/porche.S _---.. ..--- ___--
f}peofc,inlin� ;y;tem _-.,--- Enclosed..--- )pen --_---_—__-
1, l oral 1'101"Cr F„ort.i e"m.ty be iiibitinit:d t,1 1'„4.11 l'rnjtr( (',r-t----
r-,.ee�,.•( - A -....-g.F,.a .. - rw..-.....� e �a..r� o..:e,.�..rr-": '�""r""-�"�,^
CITY OF S u,&%15 IN &A'CHUSETTS
�/ BtiILDL�JG DEPtRTJtE,�iT
• 120 W.NSHINGTON STREET,r FLOOR
TEL. (978) 745-9595
F.tix(978)740-9846
KIJIBERLEY DRISCOLL T'HONW ST•PWAU
R
MAYO
DIRECTOR OF PUBLICPROPERTY/HL'IIDL`7G CO\12MISS[ONER'
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumber
4nnlicant infirrmotion ��JJ !/ C Please Print'LJepi4i1
Vatne(0usitxsOrganizatiordIndividual): //�B✓�G� 7�Dr�.�T�6Yn� -LAr- a4a . �✓2K S �� iz�"
Address: L/Co
City/State/Zip Dig (,0 Phone#:
t
Arc you employer?Check the appropriate box: 'Type of project(required):
1. am a employer with 4. 0 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2. 1 am a sole.proprietar or partner
listed on the attached:9heet.t 7. ❑,Remodeling
ship and have no employees
These subcontractors have S. ❑Demolition,
working;for mc.in any capacity. workers'comp insurance. 9, 0 Building addition
[No worker;comp.insurance 5. We are a corporation,and its.
ruq 10.0 Electrical repairs or additions
uired.j officers Have exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL 1 I.[]Plumbing repairs or additions
myself.[No workers'comp. c.,152,§1(4),and we have no 12,0,�oof repairs L
insurance required.)? wo employees. [No rkers' 13.(�Other fit°nT
comp.insurance rcquired.j
* Any applfram that chucks box9l must also rill our the seciioo below showing their worker'comperieadon polity rm intoation. f
I hun:owners who submit this affidavit indicating they are doing all work and then hiro vurido contracum;most submit a new affidavit indicating such
=Contrxton that chuck this box mews otlxhe4 an additional shut showing the name of the mluoninetor and thek`workmit'comp.pulicy_information..
I am an employer that is providing workers'conipensadon htsurance for my.employeez Below/s the policy and Job site
information:
Insurance Company dame: /�+/r t� — t-��t rr. Q �'- -1�5 •
Policy 4 ur Sclf-ins./Lis.M. 1,( )(' r��-' O - 7 �J�/� `r! Expiration Date: /I
Job Site Address: %!J City/State/Zip: 1la- N.(t "f 01 p70
.lttach a copy,of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section25A of MGL a 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER'and a Rae
of up to S250.O0 a day against the violator. Be advised that a copy oC this statement may be forwarded to the Office o,f'..
Investigations ul'the DIA for insurance covcrage,verification. '
I do hereby certify under the pa and penalties ofperjury that the bil'armati in provided above untrue and correct.
t a Date' S �3
Ojjic hd use only. Do not write it/his urea,to be conspleted by city or town ofjlclaC
City or Town: Permlt/IJcenxe#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
_.__... .....,.....,... ,K.___-__..._.__..�.�.a.._..... .._.._._..�.__.._n...n._,.___ .....__.. _-._T______.___..._,..___._._..
[
,laco v' CERTIFICATE OF LIABILITY INSURANCE 03/25n�o3"
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: N the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,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 endorsemen s.
PRODUCER CONTACT
NAME:
Tom Honan do Hays Companies of NEW England PHONE 617 723-7775 M Nu): 617 723-5155
133 Federal Street .MNL
Second Floor ss;
Boston,MA 02110 MVJ"SI AFFORDING COVERAGE NMCf
INSURER A: Zurich-American Insurance Company 16535
INSURED INSURER B:
Aileglant Management Corp.
300 Lafayette Rd. wsuREa c
Rye,NH 0387G-M INSURERD:
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER:12NHOO2780696 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.
ILm TYPE OF IN ADOL SURA m NUMBER Pol1C'/EFF POl1CY E%P uWnTB
GENERAL UMIBLLTTY EACH OCCURRENCE $
D RE!
COMMERCIAL GENERAL LIABILITY PREMISES a rn $
CLAIMS-MADE ❑OCCUR MED EXP(AM aria perem $
PERSONAL S ADV IWURY S
GENERALAGGREGATE $
GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $
POLICY °RO' Loc E
AUTOMOBILE LIABILITY
Ee ecskart
ANY AUTO BODILY IWURY(P pareoe) S
ALL OWNED SCHEDULED BODILY IWVRV(Per acddent) E
AUTOS AUTOS
HIRED AUTOS AUTOS
PRp.OPEA 1 nDAMADAMAGE $
E
UMBRELUA LIAR OCCUR EACH OCCURRENCE _ f
EXCESS LIAR o.cwR-MADE r AGGREGATE $
DED RETENTION$ f
WORKERS COMPENSATION X WC STATLL OTH-
AND EMPLOYERS'LLL m YIN BIL
A OFFlCERe.1EMBERMXUUE CUT`-"
NIA WC 50-90-735-04 - 11/01/2012 11/01/2013 Et.EACHACCIDENT $ 1,000,000
(M.W.W,y In NMI E.L DISEASE-EA EMPLOYEE $ 1,000,000
I yyes,Eesaiba uMer
DESCRIPr10N OF OPERATIONS below El.DISEASE-POLICY LIMIT $ 1,000,000
Loearlm Co/era0s Ponied: 11/01/2012 11/01/2013 COentif 821
DESOtWTDNOFMERATIONSILGCATIdf1 ICIES(AIxT ACORD ie1.Atl®BVW Wmarlu selwNhlM,Nmans apxebrpuiM)
Coverage is provided for North Shore Rental,Inc.dba:Events for Rent
only those employees 464 Lowell St
leased to but not Peabody,MA 01960
subcontractors of..
CERTIFICATE HOLDER CANCELLATION
North Shore Rental,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
dba:Events for Rent THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
464 Lowell SI ACCORDANCE WITH THE POLICY PROVISIONS.
Peabody,MA 01960
AUTHORMED REPRESENTATIVE
--7
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010I05) The ACORD name and logo are registered marks of ACORD
Apr. 10. 2013 8:32AM BEKKY MUHAMU %Ulh 4o- 051 r.
_ NORTH 4 Op iD:DEB
CERTIFICATE 4F LIABILITY INSURANCE 04110 3
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TF9S
CERTIFICATE DOES NOT AFFIRMAIWELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THEEPOU��
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADOMONAL INSURED,the policylie5)must be ondorsed t SUBROGATION 18 WANED,subject to
Me terms and condibore of the policy,certain poticies may require an endomment A statement an this certificate does not confer rights to the
certificate holder in Lieu of such endorsemefft(SIL
PRODUCER Phone:617-479.6500 ""Ann4We Kahanowilz
DPS Insurance Group,Ina FaX:617�f79-6761 f°'� •E065263200 r -508.520 6914
6 n,MA Suds 3
MilliMR A akahan rryilt8tlrattce.com
Daniel P Sullivan INSUPSMIARA10RDINUCOVEPIA0111 a
dsurme A,St Paul Fire$Marine Iris.Ca
,xSURFn re Rental Inc- madma,SafelyInsuranceCompiNnY
Chris Leblanc mpjfotc:Ohio CasuallyiLiberty Agency
464 Lowell SL
Peabody,NIA 01960
q�DRFRE:
INEI1PEn P:
COVE GES CERTIFICATE NUMBER: REVISION NUMBERt
THIS IS TO GERTIHY'fF1AT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
TO Y4eCH ITOS
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY COMPACT OR OTHER DOCUMENT WITH RESPECT
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.
UDLPOLICY P Umry
L TYPEOF munANOE I POLICY xUS@E
GENERAL LIM111T- 71 EACHOCCURRENCE S 1r�0,00
Eu
A X COMMERCALOENEPALtABIt1TY CKOOYt3358 10410112013 04/0112014 PREMISES, ommm�v S 100.
CWMa#NDE CX {OCCUR I NED EXP(A- one era== S 4,00
j PERSONAL&ADVINJURY S 1,000,
I GENERAL AGGREGATE S 2,000,E
OEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPAPAGG S 1,�s
Y PRO- ! LCC f
AUTOMOBae LAelOTr MBIN'ED 1 1 1,000,
ntl
B X ANY AUTO 6217480 0410112013 0M0112014 BODILY INJURY(Perpe,Ev'J f
HALLOS ED SCHEDULED e001LY INJURY(Pereoddwd} E
AUTOHIREDALTOS AA UOSMED T Per
E
1 S
X UfaPilAA UA8 X IOCCUR EACH OCCURRENCE Is
C &AM LAB ;CLAIMS-MAOE W01365084426 0410112013 OGUi12014 AGOREC,aTE s
CEO X 1 RErENYIONE to 000 TNGBTATU-
wORKERs h:ahPExxnox
!AND EW94AV $'MELriY
I ANY MOP RIETORIPAR'rt,ERrE%ECUrIVE YIN NrA £t.EACH ACCIDENT 5
OFFICERIMEMaER FJtCiUCEtY! £L DISEASE-EA EMPLOYEE S
tMenDatary In%10
Ryca,iewbe weer E.L.MEASE•POUCY UMR f
E8 RIPTI FOPERATION below 700,000
A EgWpment Floater IIM00201610 04101/20/3 p4W1ra114 Unlit
j Ded. 6,00
pESCRIPTION t>F OttiRnrmNs/LhxAnolsr vexl,a»1Aaecn ACCRD 1DLAVCRanOrmv,ks sd.aw,a mmnaowem,r_mEcdl
party Goods Rmtal
CERTIFICATE HOLDER CANCELLATION
NORTHSH
SHOULD ANY OF TN6 ABOVE OE POLICIES 06 CANCELLED BEFORE
THE EX➢IRATION DATE THEREOF,EOF,EOP. N N OTICE Mull BE DELIVERED IN
North Shore Rental Inc. ACCORDANCE WITH THE POLICY PROVISIONS-
464 Lowell Street
Peabody,MA 01960 AUTHOFWXD Rei,M MA"A
0 1986-2010 ACORD CORPORATION. All rights reserved-
ACORD 25(201OMS) The ACORD name and logo are registered marks of ACORD
AT
m.werftftrate of atne .e
REGISTERED is
ISSUED Br
APPLICATIONANCHOR INDUSTRIES INC. Date of Manufacture
NUMBER EVANSVILLE,INDIANA 47711 4/24/97
MANUFACTURERS OF THE FINISHED Order Number
F121.4 TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated
(or are inherently noninflammable) and were supplied to:
PAUL W. GRILLO CO. #3728
464 LOWELL ST.
PEABODY MA 01960
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant
approved chemical and that the application of said chemical was done in conformance
with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 109
The method of the FR chemical application is:
Serial#:
8025300 (0003)
Description of item certified: �
F1 EXP MID 30W X 10 vL W W
i
I
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
i
r Name of Applicator of Flame Resistant Finish Signed. ysaw
i ILNL AFITMENT—ANCHOR INDUSTRIES INC.
�..
11!It
C�Ertifir P of lttme All i, t rtx�
REGISTERED ISSUED BY
APPLICATION p : ANCHOR INDUSTRIES INC. Date of Manufacture
NUMBER 0 EVANSVILLE,INDIANA 47711 4/24/97
MANUFACTURERS OF THE FINISHED Order Number
F 121.4 TENT PRODUCTS DESCRIBED HEREIN 157146
This is to certify that the materials described have been flame-retardant treated
(or are Inherently noninflammable) and were supplied to:
PAUL W. GRILLO CO. #3728
464 LOWELL ST.
PEABODY MA 01960
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant
approved chemical and that the application of said chemical was done in conformance
with California Fire Marshall Code, equal to or exceeds NFPA 701, CPAI 84, ULC 109
The method of the FR chemical application is:
Serial#:
8025000 (0001)
Description of item certified:
FI EXP TOP 30W X 30 VL W W
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
Name of Applicator of Flame ResistantFinish Signed: ,,� 12
TENT ARTMENT—ANCHOR INDUSTRIES INC.
a