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9 TAFT RD - BUILDING INSPECTION (2) A GK� dd-a� >, The Cununomveahh of Massachusetts -- / Board of Building Regulations and Standards CI 11'OF Massachusetts Slate Building Cole, 730(AIR SALE\I Building Permit Application To Construct, Repair, Renovate Or Demolish a One-fir Tu o-Farm(- Du'rllln,\r This Section For Official Use Only Building Permit Number: ate Applicd, Building DBicial(Print N;unc) Signaluro Dale SECTION I: SITE INFORMATION 1.1 Pert�ld� 1� 1.2 Assessors Nlap& Parcel Numbers I.la K this an accepted street?),es no Map Numher Parccl NusnWr 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Arca(s4 It) Frontage(11) 1.5 Building Setbacks(11) Front Yard Side Yards Rear Yard Required Provided Re4uircd Provided Required Provided 1.6 Water Supply:(M.G.I.c.40,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Ihrblic O Private❑ Zone: _ Outside Flood Zone?Check it'ycs0 Municipal O On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner,of ecord: Nnnse(Pri ) City.State.ZIP �I No.and Street Telephone Email Address SECTION d: DESCRIPTION OF PROP ED WORKs check all that apply) New Construction❑ Existing Building❑ Owner-Occupied CliRepairs(s) Alteration(s) O Addition O Demolition ❑ Accessory Bldg. ❑ Number of Units_ 10ther O Spl " : Br' f Description of Proposed Work=: T ea jr- UGH .P2 S v4 O r° SECTION 4: ESTIJIATED CONSTRUCTION COSTS Item Estimated Costs: official Use Only ILabur and ..\lalerialsl Y I. Building S I. Building permit Fee: f Indicate how fee is determined: '. Electrical S ❑Standard City,Tuwn Application Fee ❑Total Project Cost'(Item 6)x multiplier j 1. Plumbing S �. Other Fees: S 4. mcch:mic 11 ill\.\(') S List: ' 5, . .\lecltanical IFirc -- ----- --------- —._.— . . . . tiu�trcssion) S TutaI .VlFees: S --- -- ('heck `o. ('heck:\nunmt: _ ('ash \mount: n Total Project Curt: S ��� ❑ Paid in Full ❑Outstanding 1)alance Due: SECTION 5: CONNTRUCTION SERVICES 5.1 ('onstructioli Supervisor License((S[,) I icciiv Number lsyiiratioo 1);Ilc Nallico(CS1. Holder I Ist('St. 1)[W(,cc belms) PC Description No, .111d SIrvet lrited I llui ld iogs L�io to311000 of it 'tricted J&2 F.J111ily D%w1liog RC Roolin Onerin A'S window;Ind Sidon S& Solid Fuel Burning AppliancesI InSulaLiOn fdc hone himil addircs.4 D Demolition .4.2 Registered Home Improvement Contractor(HIC) ZS79,?S0 / 111C Registration Number I 611-11t Oulic 111CCompall istrantNan'14 CAN C 0. eI 171111 Iddre.'s i /Tow n, State, ZI fele bane 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 atTidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... 0 No...........Cl SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FO R 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 O%l,ocr's Naine(Electronic Signature) Date SECTION 7b:OWNEWOR 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 (Flecvonic Signature) Dail: NOTES: I. An Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered;;uniractur (not registered in the Hume Improvement Contractor(HIC) Program),will au) have access to the arbitration t .r M.G.L. I G L a t n on the 10 o d under area .6 planned, .provide I program or guaranly fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at 10orniation on the Construction Supervisor License can be round at 2. %k lien substantial%wrk is planned,proOde the information below: rL,t a I Moor a r ca(, n ) ___ .4 r0tal 11001'area(� - n ) (illcluding garage. finished basement.attics,decks or porch i Gross h%ing.irea i sq. it.) Habitable room count \omberol'11relflaces Number of bathrooms Number of Half hallis 11 1w of heating S)item Number ot'decks, pordies r' pe of l:ooliliq Stela Flicloscd -.01wil be ob.,titutcd llir-kital Project('list" r CITY OF S,V-&Ni, Akss.kcFjusETTS Jt;am VG OEP-imm`T 110 WAS)INCTON SrugT, }'O FZOOIt I1L. (978) 745-9599 KIMBERLBY DRLSCOLL P,Vt(978) 740-984 .titAYOlt mo-%W ST.PmXAX DIASCTOI OF PLSUC PROPERTY/gL•QDCqC CO.%0jjSS(ONEIt Construction Debris Disposal Affidavit (required for all demolition and renovation work) Ii accordance with the sixth edition otthe State Building Code, 790 CM section 111.J Debris, and the provisions of MCL c 40, S 34; Building Permit At is issued with the condition that the debris resulting from this work shall be disposed of in a properly 1 If. S I JOA. licensed waste disposes facility as defined by NIGL c The debris will be transported by: (name of hauler) Thedebriss wiiIf be disposed of in (name of r�) �oi.���s/n � 1 Jddnff or raa� y) u lna Nte Urpermif� sun, _. 4'C OP ID: Bs `.� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DO/YYYY) 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 poncy(tes) 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 endorsements . PRODUCER 978-744-4540 CONTACT M.R. Shaw Insurance Agency Inc PHONE P.O. Box 4428 978-745-8584 AIC No EXt: FAX No: MAIL Salem, MA 01970 ADDRESS: PRODUCER I ATUST7 M.R. Shaw Insurance Agency Inc CUSTOMER ID, INSURERS AFFORDING COVERAGE NAIC# INSURED Steven C. Latulippe INSURER A:CNAICIGNA 35 Sunset Drive Beverly, MA 01915 INSURER B:Patrons Mutual Insurance Co. B INSURER C: Y 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 INSURE"persom $ BOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF YYYY MM%DD/YVYYLIMITS GENERAL LIABILITY RENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY CTR0008810 11/17/11 11/17/12 occurrence $ 50,00 CLAIMS-MADE OCCUR one person) $ 5,00 PERSONAL S ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,00 POLICY PRO_ LOC PRODUCTS-COMP/OP AGG $ 2,000,00 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ SCHEDULED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS PROPERTY DAMAGE $ (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR $ EXCESS LI ,B EACH OCCURRENCE $ CLAIMS-MADE g DEDUCTIBLE AGGREGATE _ _ RETENTION $ - WORI(ERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/N WC STATU- X OTH. A FR ANY PROPRIETOR/PARTNER/EXECUTIVE 6S59UB4209P57610 04/28/11 04/28/12 OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ 500,00 (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $ 500,00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (AUach ACORD 101,Addltlonal Remarks Schedule,I/more space Is required) CARPENTRY CERTIFICATE HOLDER CANCELLATION SHOULANY THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Beverly _ THE N DATE THEREOF, NOTICE WILL BE DELIVERED IN Beverly building Dept ACCOITH THE POLICY PROVISIONS. AUTHORIZENTATIVE ce In ©1988-2009 A ORD CORPORATION. All rights reserved. ACORD25(2009/09)- The ACORD name and logo are registered marks of ACORD CITY OE S:u Em, tiL1SS:1CHl:5ETTS BUILDING DEPART.,LENNT 130 Cl/ASHL�I(:TON STREET, 31D FLOUR �baaf, ' TEL (978) 745-9595 F.k-x(978) 7-R)4844 M.%lB Rf FY DRISCOLL NLAYOZ THo%L%5 ST.P1ERR13 DIAECTCROf PUBLIC PROPERTY/BUMOI?IG C0161,SSI0NE1 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electr)c)ans/Plumbers lopplleant Information Please Print Legibly V;II11C lllueitw,.�Urganiration.IndividualG �T�G����`� ���5i�'j/�yd Address: City/State/Zip: / Phone Al: Are ynu an employer?Check thqKapproprlate box: P ype of project(required): I.❑ lam a employer with 4. ❑ 1 am a goneral contractor and 1 b. ❑Now construction employees(full and/or part-time).• have hired the sub-contractors 2. am it sole proprietor or partner• listed on the attached aheoL t 7• ❑Remodeling ht •nd have no employees These subcontractors have 8. Demolition working ror me in any capacity, worker'comp.insurance• 9, Building addition (No wurkcrs',comp. insurance S. ❑ We are a corporation and its required.) officers have dxercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[,No workers'sump. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required./ t employees. [No workers' 13,❑Other comp. insurance requir d.) O\ny upphsam der chucks bon rl must aho fill uul the sretiva haloes showing(hair waken'romPenultun Policy inrnamutfon. '1 hvnauwnws whu,uhntii this aMdavit indicating ihry,an doing all wurlt and then hire uunide eamneran most nthmlt a now aMdavit indicating suck r' mrxtun that chuck this box It anachod an additiun l.harl showing the owns of the mbauntnctun and chair wanton'comp.policy Info notion. l ran an employer flout Is provJdling ivorkere'compensation huuranee%r my empluy,at Below Is die pol/qr and Jab sire information. Insurance Company Nmne: � �+q S' ==rr�U� ��-•r Policy 4 or SelGins. Lie.th 9 �U / U�� ! —on _ _ ^Expiration Data: tub Site Address: �Ct�'T-- �2 city/state/zip:— Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration data). Kiduret to secure wvcrge as required under Rection 23A of NIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,300.00 and/or one-year imprisnnmen4 as well as civil penalties in the form of a STOP WORK ORDER and a line ar up to S250.00 a day against the violator. Ile advised that a copy of this.,taicment may be furwardcd to the 011icd of I raresligalions of the MA 11dr insurance covcragc veriticatiun. /du hereby evrtijy ar r d pat ad provided above itv irat and earreet. ii,•, 1 hard: ��/�/� � OQroial see only. Oa nor write La t/tier area,td be completed by city or town n��Iria[ CiryfirTutrn: __. VotrmitiLlcense.i l,vtinK,\Whurily (circle unc)o I. hoard of licalth '. lluif ling Dcpamitem .1. f'ityi ratvn Clerk J. Glectric.11 In,pector i, Phnubiriv Inspector h. Other Cunl.let 1'ennu: