13 SYLVAN ST - BUILDING INSPECTION fhe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
a ('J
Massachusetts State Building Code, 780 CMR SALCh1
Building Permit Application To Construct, Repair. Renovate Or Demolish a /lt1.i,.e,1 t/ur 10/1
One-or Two-Fumily Dwellh g
This Section For Of7icial Use Onl
Building Permit Number: Da Applied:
Building Oflicial(Print Name) Signature Dal
SECTION 1: SITE INFORMAT
I.I Proper Add ess: 1.2 Assessors Nla Parcel Numbers
I.I 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 fl) Flowage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifycs❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'oCIA rf�qo"/vA 7�0b 2r (�W—Am v(p
N;mie(Prit I ,L "'/ Ciitfy,State,ZIPO", /C
f 3 a.1V61-1 M--- 99 -
No.and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
r�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
' Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:__
5. ,\lechanical (Fire S
Suppression) 'fowl All Fees: S_
p,1 Check No. Check Amount: Cash Amount:
G. Total Project Cost: S 19 ❑p,tiJ in Full ❑Outstanding Bat;mce Due: --
�� aw
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Licensee(CSL) 06 ((6 CX
,9 �c— /YaL. .icense Numher /, 1.. iratiun I ale
NamcofCS1. 11ol n LNi _
�l / p� v( ,�\ �, /�' /, ' � List C'SI_ I)PC(see below) _
No. and Street /e-t1 Ul(,}^}y L 7)Vpe Description
A/A J U l InrestrieleJ Buildings u' to 35,000 cu. 11.)7 R Restricted 1&2 Family Dwcllin
Cily/I' wn,state.ZIP M Alason
ry
RC RoolinR Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
"fete hone Ismail address 1) 1 Demolition
5.2 Regis a ed Home Improv�tent Contractor(HIC) / d � V V
/X r `" � Z— L C I IIC Regislration Nun her .spiry m Uatc
I II('Contpan) Nan a or I IIC Registrant Nan r 7 _ -- �,y
No.and Sir.LcX'jul q y Email address
Ci /Town;State,ZIP Telephone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes ......... 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
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, 1 hereby attest under the pains and penalties of perjury that all of the information
contai this agplication is true an ccurate to the best of my knowledge and understanding.
I'rin ttner's or�\uthorizeJ, I's ante(I(lectnmic ignauve) ale
NOTES:
I. ;kn Owner who obtains a bu ding a to do his her own work,or an owner who hires an unregistered contractor
(not registered in the Hume I rovenient Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 1 q'_A.Other important information on the HIC Program can be found at
;ok oc,i Information on the Construction Supervisor License can be found at Jg;
2. When substantial work is plumed, provide the information below:
Fotal floor area(sq. R.) (including garage, finished basement'altics,decks or porch)
Gross living area(sq. 11.) Habitable room count
`umber of tircplaces Number of bedrooms
Numher of bathrooms Number of halfbaths
F%pC of heating systern .-----_--_--_-- Number of decks,porches
T)pCofcoolimge)stcm Enclosed Open
t. Total Project Square Footage'may be substituted for"road Project Cost..
CITY OF S,VZNf, AASSACHUSETI'S
BLILDLNG DUART1tENT
120 WAsHLVGTON STREET, )iO ROOA
I-EL (978) 745.9595
KI.AMERLBY DUXOL L FAX(978) 740.9846
MAYOR I)40.uu ST.PMRU
DIRECTOtt OP PUBLIC P0.0PEATY/8L'QMLNG CONNISSIONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 1 I.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit M 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
111, S 150A.
The debris will be transported by:
(nrma of haular)
The debris will be disposed of in :
(name of raolily) _
(iddress or raeility)
e orper ant
CITY OF SALEM
I' PUBLIC1)RUPRERTY
..�
DEPARTMENT
MV.v:a rJml+4 U11
41
12.'WnHUAt:It^i1ytL•f a Sat 1•.u,Ms U.N.a II vc I It J197.�
I'm.971.715-vi95 e f lx. YIM•.'IC•'txM
\Yorkers' Compensation Insurunce :UJidavit: Builders/CuntractursiClectricians/Plumben
\ 1 )llcant Information
t/ / Plcu.� Prfnf le 'AI
V;IIT1l:111ua,y;t(vt�)r;tutlr�tinNlnJniduull:_ hh4 ` (AV JZ4 �t�l' 1 C
1Jdre.cx: f �� 6/ 4 f)
Ciry,Srtrc,%ip X�t//CJ Phone iiv u
Itre s an employar?Chu If the approprture box:
I. I am a cmpluycr with 4. 0 1 ;fin a general call, or and I r)P@°f prvlieet(nqulrrJ):
Lrv
uyccs(full anJ/ur part•tinte).• have hired the soh-cuntracwn ff Kew cwutructiun
a Iola prnpricntr ar punnet• listed fin the anached.vhcet : y nleling
nJ lava ne umpluyc,s Thee sub contncton hoveng tin Ine in any capacity wvrken'comp, msursnce. Ihmoliriunorkers•comp. insurance 5. 0 We are s eo,poretinn and its 9. ❑ Ouidingaddition
J.) otTicen have exumiscJ their10.0 Electrical repairs or additions
holrlCnwner doing all work right ofe'1cnlplion per NICE 11.0 Plumbing rcpuirs or additions
.(No wnrkun'com e. 15I,§1(4),and we have noca required•) t :1nploycem.(No workers' 12'0 RolifrcpairY
comp. insurance n yuinvJ.l 1 J•0 other
•t n>.glphcav nIW d:ccb Oon rl mua:dw lilI act,ho v:cwum heluw thuwul tAuir.'Il�m,n,wnvre why,ddlmit this vmdavir indiealin a Y wwkai eellllletwien lv,tiey anrinmsoi,Ir�
Y h'are auimY all work and them him Outside"Itmew",ova,•Any a row at lldavil injiud;ng ylek•
•r,Mimll .also check ibis boa mum aaachwl an addiliwul.AM d uwit'l the name o/tivl luk•commcturs and them wultent'comp.Imply In111rmnt 4
/Ian fill tnrployrr Igor/.r proMr/!nx rvurkrr►'ru/npenrnNon luturnnra/or tmy r/np/uprre. Br/mv/r for pugvy und/ub vile
infwr/rlutiwrt
InsuranceC'umpany Vvne:_S -
1'04y y fir Sulf-ins. Lie.0:�-_ /
�'' Expiration Date:
)ul)Jlfe -
11y'slate/Zlp: �)
Attach it copy of tho workers'cumpetnallnn pulley Jaelarullon page(showing the policy number and cxplratlun data).
1+allure to sucura cuseruge as required uodkr Scctiun?JA ul'JIGL c. I
IL,c„ 51 can lead to t 1 na.S o r he im
I LJ 0.M antLur one-yea inlprivunancnr,ar wall as civilrin Position of criminal penalties of a
of up ro i250.IM a Jay.aguiaal the viulatnr. Iic adirmed shut i copy urllhial"Jivinu I may be urw/a JmdUu he URK R'IDf if and a fine
III1'�all�al101if ul lllu 1)L\ 1bf I111wg1tcc�ovcMfC\ul'ilivill,ln.
/du hereby certify wider the p,r wwd pro i• n
itrfurrnullon prvviJrd fib ee ix vfir and correct
�a •::w re n
r)/1lc'hil live an/y. O I evade in dtLr urea.lu Ae ruwrplelyd b tit
Y Yurlownu//lriuL
a
fir -fawn:
Pcrinit/l.iccnvc Y
Issuing.\ulhurity (cirrlo and);
I I. lli,1liv of IAahh !. Ihuldin, Ikgc,rhnea
1)Iir J f G. her ll 1. Cil)r'I'uou Clerk 4. Llccirie. lspc m
rtur 5. plumbing lanpceror
Information and Instructions,nt„rth:,rcn,Qloyeca
non in the service of a whir under any contract of hire.
�L,»a:IlaSell)V:nefal Lawx:hapter 172 1'egUtfex all e111plJyer7 IO QfOY,de Workers' compensation
I'ursuaal w tiux aiatute, an rmplus•ee is detineJ as"...!very Mt
:%Press or unQlicd, oral or written.
of other
.Nn employer is des;ncd as"all individual,
ival, rt er hivladillg the legal corporation
Ives of la deceased employer,or the
rere
..I the loregou,g engaged m a enterprise, vm to eea. HOwivcr the
ccerver Jr trustee of.tit individual,plainer ship,assoetatiuo or other legal entity,employing ' P Y'
owner of a dwelling house having not more than three one to o nain coon ents and
unhuu lion Or(cpuirwurk oo resides therein,or the rs such dwelling house
dwelling house of another who employ. Qe
or on,he-.,rounds or building appurtenant thereto shall iiot because of such employment be deemed to be an employer."
�IGL chapter 152, �'_SC(6)also states that"every state or local licensing agency shag withhold the Issuance or
renewal of u Ilcenu or perntit to Operate a busln#ss at to construct buildings In the the commonwealth
cGvf wgo required."
e for any
npplicaat Nho has not produ,ed acceptable states esr'Neuce of her they om nonw�lth tar any of u poIAOCIT withli cal{tubJivisrJns shall
\dditiuntilly, %IGL chapter I S_, �_ l
enter into any contract Cor the perfumwnca of public work until acceptable evidence ufwnipliwice with the insurance
requiramcnis of this chapter have been presented to the contracting authority."
Applicants { xes p to our situation and, if
piea.•ie rill out the workers' compensation affidavitcompletely,
yl�oJ phunn mm�btner(the
ong with heir)enificute(s)of
necessary.supply sub-contructor{s)name(s), with insurance. Limited Liability Companies(LLCworkers'Limited
com compensation insurance.(If an)LLC atOLLP does have
er than the
members or partners,arc not required to carry
employees,a policy is require 6e advised that this atfldae suirsy be gis gad Cd le the of fide il. of In I11dava
ld
aliment of
:\ccidenta for confirmation of iruutarlco coverage- Also be sun to sl{p nod dote the tifndavlt. The attiJavit show
uestioaa regarding the low tar it'you era required to obtain u workers'
h! rclslnted to tl,a city or town that the application for the pon>ut or license is gain{requested,not the a w
Industrial Accidents. Should you have tiny y umber listed below. Self-insured companies should enter then
I the n
compensation policy,please call the Deportment At
self-insurance license number on the a ro fiat*line.
City Of,rown Officials
the a licant
Please be suro that the affidavit is complete clod printed legibly. The Department has provided u space at the Uora
Of die affidavit for you to till nut in the event the Office of Investigations has to contact you regarding an PD
Pl:osu b!sure ro till in the pCreniuliccnse number which
any
be used
ee�e geedonlyrencsubmitunlf. l:ntfidnvit ndica applicant
current
Y g y pit or
that must submit multiple per V)Inditinder"Job Site n alp provided to the
policy illtorrejlio he abides l thNhas bCCn OfflC ally tamped or marked tby�the city or town may be p o .(city
town).'.�copy
Out each
applicant as proof a home t a valider of affidavit
is s on file for a license or pecan trnot relater)to any businessior comiuse mercial of venture
Y
(i.e. a dug license or permit to burn leave{etc.)sail){faun is NOT required to complete this affidavit. uuous,
�I he f li:e of Iuvesliyatiuns would Ilk#to thank you in advance for your cooperation and should you have;tnY 4a
picas{do not hesitate IO gIVC us a call.
f he U:parnncnt'+address, relcphone and Th C Mponwealth Of Ma&wchusetU
Department of Industrial Accident
OMCS of Invadgadons
600 Washington Street
Boston, MA 02111
'rel. N 617-727.4900 ext 406 or 1.877-MASSAFE
Fax M 617.727.7749
d 1o.ns www.mam.gov/dia
„ tr
QUALITY - EXPERIENCE t - Insulations
SERVICE Hallmark - Siding
HOME/,bIPR06'Ed-IEl\'T w
- Roofing
L/CEAC'F_ = !01444 �� Homes L.L.C. - Replacement
COA G`STRC
TION SUPERVISORWindows Specialists
LICENCE064068 Im 479 BROADWAY. LYNN 01904
LYVA BUILDERS LICENCE 4 470 (781) 592-5r0
CONRAD McKINNEY, President Established 1964
Member Better Business Bureau® wvvw.hallmarkhomes.net
Serving Eastern Massachusetts N1F:\1BER OF THE LYNN d PEABODY AREA CHAMBER OF COMMERCE
rqL
�� r oic4
ail a n add, ,., -
pecifications
� t r
' C
Cash pi ice of oods and set ices. . ....................... .. . . .... ., ..
Donn payment or paanIcn at conamrncemcn['. .` ' �'.�'. �.�' Q .a
� ?
Pucnxm tchen �0`vb complete: ................._........ ....._........... ....................................... . -............ �..��.
p !
Balance.uponeampletion: ._.................._............................................................................................... 5/..7.t,S�.O..E...
Est. Start Esi. Comp. SUBJECT TO NIASSACHUSETTS SALES TAX
Cams:,I i ill do all nlikc,nannu. 71r uwnc'l'ngr cep o-,uatiJl d,e amtrr,el<l m ,siring, signed hi the numc,;oLam d l'CI in
nnrAuumrhgI -rrr n r,al. The,VoI)l(9o, skunk liahlt. aeh it it laila la repair urn spe(IfiCd dV/c('I iuc lu:w d<.fecri re,,,pairs, within rh„m da„r Id u,ripl uT
o dlrr, but a l c th ,u'i,e uu.l in nu event Jud!Ihr cone a'nu'hr bobl, herond oh , ,.If ,,it of lahor and tyro¢ual required for urn',epuu k.
The rano'ucfill nbull he Paid hr Ihr ov„ ,Itl.all,"Immable cosh', rloowl f"I I11111 ecpcnae+'in odduion m dm amount due one!unpaid, d al.d,all hr al,I,I I
w cnWretnt the t r ne.,uul ,,nlilian.+n/this I ow,uc'I web"', an li ll m ronncrnon[he,ewidl.
ILu uwr rune,I this ag,nimu,l Ili it ha:barn ea„s,uanmred hr u p n'n'd,creta at a place odic,Ikon at add,exs aflhe seller which mar be hie'main ulticr ur
ham,h dna'eai. hr a u,iudn noliee rGrrcIed ro the srllrr at his moon nr Ili n( uJrire br ,,thnaPp nmil posted. br Icicgram sew or br dein elY nul l(re,Bran
nibn,hl"i d) uw lh,nm . In'1��llu, r_r d, ,,,'pour flbi. /Yru.umt
\n ,n A'(a h, dam un till n gr,n'uNi r d,an o'pec,/, a,tiles'on!,1,,1 n id,an,addilianul ch trgrs.
T/rIc ruuvutl unlduo,e 1h, ,i,ul u,1,eruunl 1, lk,,r. C umpanr:rill lo,ni.vh vur,owl adj,ared to the rope of I, ,,k done on"how property',qun,complcnan of
till cane o,I.
01 nel ap,eel Ili'., in.....nr of h,9ln'cud,a11h,5 cony uu helidr work i,started. Curl,aclu,'mqr demand c rl❑ /iru(15 of per-('C,n of dw Iontr Ill'I it)1('e III ,IV
dlip,JmdJ du,no,'.�,lur thl hrrurh.
77ria t'unll'oi t,.,.v,hirn¢, Iu',kr, ,,I;dow, ,,-olhr,orcio,r beru,rcl n„r r"'llm/.
Company furnishes insurance coverage
I ece, the owner(,)of the preinises mentioned above. hereby contra,,( with and authorize You as contractor,W furnish all necessary m let als.
labor and workinanship,to install. construct and place the improvements acccY'or ing to the specifications, terms and conditions.on plemues
/ �� d,iedole.._ SC Ile s�o�neis nouro�snname.
above described. which ete o brain and represent that w` l� G
iu l` 1 PRF SIUE\I St n
A � have ooc ova i�c r t1
. n �lu,umtr ,w,ctl lh�b'name,, ,m � �q� )f�/�-�y.�,
lhr nit VIC I' X ea..�"""«• �/. �. ” """""' . .......
Owner
OR ... .. .... . .... ... . . ..... . ....... ....
... .. Signed... ...... ..... ..... ...... .... ..... . . .... . . ..... . . . .
. .emndre Owner
07-05-2011 01:32PM FROM-CLOENT ARCHER INS. AGENCY 978-922-9276 T-6T7 P.001/002 F-666
A�QRD� CERTIFICATE OF LIABILITY INSURANCE DATE("DMNYM
06/05/2011
PRODUCER (978) 922-4900 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ARCHER INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
271 CABOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BEVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERAESSEX INS. CO.
Hallmark Homes, LLC INstiPER Bt LIHERTY MUTUAL
479 Broadway INWRERC_
msuRr=R D:
iLynn HA 01904- I„LS E.
COVERAGES
'fHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSL RED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMEI IT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUSIECT TO ALL THE TERMS, EXCLUSIONS AND CONDMONS OF SUCH POLICIES
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR AWL POLICY EFFECTIVE POLICY EfpRwTl ON
L TYPEOPINSURANCE POLICY NUMBER DATE(MWODM') DAIS INWIOW T) LIMITS
A [tEr>FrRAL LIABILITY 3DaB694 06/07/2011 06/07/2012 EMN OCCURRENCE T 300,000
X
COMMERIXAL GENT3TAL LIABILITY E TO RENTED
-PREMISES EP PccUxron T 50,000
CLAIMS MADE FX-1 OCCUR / / / / MED EXP evie vmrr S 1,000
PERSOAIAL aADViNJURY S 300,000
GENERAL AGGREGATE 5 600,000
GBPL AGGRE(.ATE tIMT APPLIES PER: PRODUCTS-COMPMP AGO T 600,000
POLICY P LOC / / / / NOktM
AUTOMOBILE LIABILITY COMBINED SINGLE UWT
ANY AUTO IEe etc o f
ALLOVA913AUTOS eOaLVINJuRY
SCIIEDULEDAUTOS (Per Pe ) f
wRFD ADS BODILY INjuRY
NONaweDAuTOS M&& n s
PROPERTY DAMAGE
(Pee xc 0 $
GARAGE LIABILITY
NlTO ONLY-EA ACq DENT T
ANYAUTO I / OTHER THAN EAACC T
AUTO ONLY- AGG T
E)WZSSIUUBRFL1A LIABILITY EACH OCCURRENCE S
OCCUR ❑CLAIMS MADE AGGREGATE f
f
DEDUCTIBLE
RETENTION f
T
B WORKERS OOMPEFSAY10N AND WC1 31S 332794 019 02/09/2011 02/09/2612 X VIC STATLL OT+.
EMPLOYEW UABILTTY TORY LIMITS ER
ANY PROPMETOWPARTNERDQCLITIVE E.L.EACH ACCIDENT T
0MCEFRMEMBER EXCLUDED?
Hye.,.d—= Whet / / / / E.L.DISEASE.EA EMPLOYE s
SPEMALPROMSION6[le EL DISEASE•POLICY LIMIT T
OTHER
DEBCRIPTON OF OPERATIONSAI=TION&VERICLE%4=LUSIONS ADDED BY ENOORSEMEN /SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EIOBRATION DATE THEREOF, THE ISSUING INSURER 1MLL VOR TO MAIL
10 DAYS WRITTEN NOTCE TO THE CERTTfTCA7E MOID ED TO THE L67.BUT
CITY OF LYNN FAILURE TO DO SO SHALL IMPWU NO OBUIGA LIA LI ' OF qND UPON THE
CITY HALL. INSURE ITS AGENTS OR REPASS TI
1 CENTRAL SQUARE AUTHORIZED REPRESENTATIVE
LYNN MA 01901-
A{ACORD 25(2001108) RPORATION 1988
J,,r INS026(0108),05 ELECTRONIC LASER F RMS,INC.-(8D0X7-0565 Pepe I of 2