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1 TANGLEWOOD LN - BUILDING INSPECTION l�kO qW 37y The Commonwealth of Massachusetts _ Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM (� Building Permit Application To Construct,R �ued�2011 Repair,Renovate Ca Demolish a One or No-Family Dwelling 4 1L`ra:Sectrat.Foret7 cialU ,OnIY� - r• .. p , �1. y ••. �`_'z`. Lr-1x.5 ,?="-`.^+ bF1�T� tfi ding O,ff1C'�Bl�( fNerlle � '^""'�-�- - :� SEGTION lE S1TE IIVFORM�►TIUN - — _ � 1.1 Pro party Address: 1.2 Assessors Map&Parcel Numbers 1 Tanglewood Lane al rn Mn ol970 1.1 a Is this an accepted street?yeses_ noMap Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zonhrg District Proposed Use Lot Area(sq R) Ftontege(ft) 1.5;Building Setbacks(ft) Front Yard Side Yards Rear Yard Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information; 18 Zone: _ Outside Flood Zone? Sewage Disposal System: Public Private O _ Check if es13 MuoicW 13 On site disposal system O "�. • �`� ; --, ,]�SECrION2 �P,ROEER1iY OW -�'�� 2.1 OwoerrofRecord: Bernadette Lue Salem MA 01970 Name(Pnny City,State,ZIP 1 No.anndd Street Ttrednnd I ana 97R-F94_1805 _.bPrmlue(p�anl om .-- - -- - — Telephone Email Address -' pN3:DESCRIPTION�OF•PROPOSED WORKR ebee ,all, appy!t New Construction D Existing Building Y Owner Occupied of Repairs(s) 4 Alteaation(s) f] Addition ❑ Demolition O Accessory Bldg.O Number of Units_ Other Specify;Replacement Brief Description of Proposed Work-: Raola .ins 3 dnnrsr nn structural chsnmas `•, " , ' _-a. �*�.> . SEC'TIONA:E9TIMATED�CON$TRUCl'ION/CQ3_TSIv„-'�-�-T'a--�""'r'"` �1:'-- _' Estimated Costs: " `"' `" Item eod Materials � �*�a� Oflicitl UserOaly� r t ` �s `� a: 1.Huildmg $ 7,507 11�B��,giP�eumitFea+i$ _, Irtdtc`ate�howfcersdetermnted't 3.Plumbing $ TJ costa(Item 6)x'mnittplia 7.507 a Lam=O 2x,OlherFees:4$ -- 4.Mechanical (HVAC) $ Lrst e 5.Mechanical (Fire S ion) $ Total All Fowl;,$58, . r + s t f$ �,- 6.Total Project Cost: $ Check No ��CheekAmmmt �CashAmotiiit, 't` ` 7,507pPaid'mFull' _ O0utstandmgrBalstceDue f i 1 �3 tvlAtt�,p IN SfaS� S Construction Supervisor License(CSL) 90125 Jamie Moirn 10-06-18 Name of CSL Holder E17=5c—Number Expiration Date 86 Gardiner St List CSL Type(we below) U No.and Street 1 . -!V Lynn, MA 01905 U Unrestricted Ullman 22 to 35,000 cu.ft.) City/Town,State.ZIP R FRmflv 1wefflnv M M RC Roo Covcdgg - WS Window son 508-351-2214 SF Solid Fuel Suring A—I;--- Insulation Telephone Email a as D Demolition 5.2 Registered Home Improvement Contractor(HIC) Renewal by Andersen 170810 12-23-17 RIC Company Name or HIC Registrant Name MC—Registration Number Expiration Date 30 Forbes Rd No. MA 01532 508-351-2214 Email address S ZIP Tel one SEGI 16-:WORKERS'COAFPEKSATION 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...........13 OWNERA I II0PUJ'ff111 i E11111`,111c,1011-m—F -7, hk it -FORLBUAb ]PAW VW L as Owner of the subject property,hereby authorize Jamie Morin to act on my behalf,in all matters relative to work authorized by this building permit application. SEE CONTRACT 10/27/9 Print Owner's Name IC Date A je 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 understandling. JAIME MORIN PuOwner's or Authorized Agent's Namc(Electronic Signanne) 10127/9f)16 Date 1- An Owner who Obtains R 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 nor 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 www.mass.aomtm Information on the Construction Supervisor License can be found at 3MME.milUjayLU 2. When substantial work is planned,provide the information below-. Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.i) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halFbaths Type of heating system Number of decks/porches Typeof cooling system Enclosed —Open 3. "Total Project Square Footage"may be substituted for-Total Project Cost- CITY OF SALEbI, NtAsSACHUSEM BtunIlG DEPARTMENT 120 WUH N=N ST EST.Ya FWoR TEL (978)745-9595 K1�fBERI EY DRISCOld. PAX(978)740-9846 MAYOR THOMAS ST.P11111111lts DIRECYOR OF Pl'MX PROPMY/Ht:QDING CG&Qa SIGNER Construction Debris (Disposal Afndavlt (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code,780 CMR swtion 111.5 Debris,and the provisions of MGL c 40,S 54; Building Permit# is issued with the Condition that the debris this work shall be 111,S 150A. disposed of in a properly licensed waste disposal facility as defined y Mg L cLc The debris will be transported by. Renewal by Andersen (Z;ofba er) The debris will be disposed of in Renewal by Andersen (Dame of facility) 30 Forbes Rd, Northborough, MA 01532 (address of facility) signaftm of pemtit applicant date �ebrissR.bc The CentateAWeBM ofAfanschureo Depardaenrofln ofAftUww Offlee eflaff5 ig 1dons W&%Wnjpn Sbw soatoa,MA 02111 d Workm' Compensation Insurance Affidavit:BoBdere/ConhmctorsMWt idrne/pl Auniles stuforuemb" Bmbera PI a Print �aet.mb RENEW Name ). AL BY ANDERSEN Address.- 30 FORBES ROAD . NORTNBORO,MA 01532 Pho le#, 508.351 2214 Are you an am~Cheek the appropriate box: 1.o I am a empbyar with 30 4. ❑I am a ganeral contractor and I Z�Pe of ( ): �picyces(falland/or part t®o).• have hired the sob-conpndas 6. ❑New omotmeton 2.❑ IBM a solo proprietor orpartms- listed an the numbed sheet 7. g]Raemdelmg ship and have m amployeas These sub-contractors ban wmldeg for me in any capacity. employees and have workers' 8. ❑�O [No workers'tamp.iostmnae comp.insmanca t 9. ❑BuildiaB additio requited.] 5. ❑ We aro a ompmaton and its 10.❑Rwhical repass or add!*= 3.❑ I an a homeowner doing all work cffiaers have exeroised thea 11.❑Plumbing repairs or addltom mynX INo wodtom'campright of moulptimperMOL hmm ace rogahcd]t o. 152,(11(4),and we have no 12.❑Roof repairs empla4'ces.[No wo$as' 13.❑Odw cammp-irtsuaoce required.] f�WHoug an dmb tea#1 MM AW 811 ad geowatlm belowshowlug tharwodeae- 1Bemeowocswboaabma8daa�vsmdiaEmggryamdaugdlwadc'ad&ao hbe Omer toomatom oumpenuabo umeil laaew ledboolog kl�aomw dot obeck 66 box amt.mohed an 2ma®d.hex mwiag momaecM.xcb4owncun a ad ditwboaaof�,�a aoployem. >eMaob•eoatm0000 trace ,t5eymottaovtdea>eb wotmaax'wmR Paley camber. adilleshwe 109 411 dfirbyer tbaf bpmrr<ft warArcra'coalpo+sotlmr dfamrsmta for gafoty 4 dmepoAfiy eudjob rEte bAlu ceCompanyName: OLD REPUBLIC INSURANCE COMPANY Policy#or Self ins.Lic.#: MWC30823100 Bx1010112017 paetio Dano: Job Site Tang wood Lane Attaehacopy ofthe workers,compensation pdky CRYMWOMip: Sale #A01970 Failure to eeeme IaP(��the Palley number and axptratlon date). up to 81500. under Safina ZSA of MOL o.152 can lead m the impoe t m of crit"pestes of n Sao Y�impalsammny ere we11 m CM peaaltee in the fans of a STOP WORK ORDER and a fore of up m 8250.00 a day sgaiam mho violator. Be advised that a copy of this statimbe for insurance coverage variBcato• �Y fiuvvarded to the Off=of Ido cff* dkepabstandpanmNuofpgdmy00&g (.`—• 10/27/2016 B-351-2214 tib use=&6 Do am wrble in m&mrer,m be compAwd by atry or eaww*Alda[ City or Town: pwmwucem# kurfg Authority(eirrle ansa): L Otter Board dUsel tb 2.Beading nspseboust 3 Ckytrawn Cleric 4.Lle &kd Iropeetor i Plamhke hmpee6ar Contact pen®• phone �C R ANDECOR-81 SALWANjv �.� CERTIFICATE OF LIABILITY INSURANCE DATEMwODIY" LTHIS CERTIFICATE IS 188UED A8 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H 1TMg;TIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVFFAGE AFFORDED BY THE POLICIESOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AU1'HpRlgpRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.RTAT: H the cermosisholdw ls M ADDITIONAL INSURED.fheonna Md Conditions of the policy,Certain policies do1�ient A t b0 Mtloant NSUBROGATION IS WANED,subject toiCe4 holder In Ileu Of Meh arLdoreeme a require an endorsement. A tdalement on Ihfe corORgts dose not Corder rights to do ERb�r�p�e, Willis of yry BNd Inc Nes a WPIlls Towers Watson Cal Cate Center P.O.Sox g21911 10771945-7378 Not fS88)467-2978 NeshYllle,TN 3723MISI •Cal... Bis.cwn APPORmNOaovmuGE NAlce IMSUM wauR mauR® WSUMERA:OId Ra ublk IItsuranoa COM an 24147 EN e Renewal by Anderson RSURER C 30 Forbes Read Northborough,MA 01332 YIBURenn. INSURER E: COVERAGES - INSURER P: CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUGES OF INSURANCE LISTED BEL OW HAVE BEEN ISSUm TOTHE INSURED NAMEDABOVE FOR THE POLICY PERIOD ICERnFICATENDICATED. NOTWITHSTANDING BE ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECTTO WHICH THIS EXCLUSIONS MAY BE ISSUES OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POIJCIES DESCRIBED HEREIN IS SUBJECT TO ALL WHICH THIS EXCLUSIONS AND CONDITIONSNCEOF SUCH POLICIES.UMTTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY Nw®ER HE A X COrsPACIAL OENFMAL LuwanY Lam Cavus-MADE ❑X Occua WZY 808231EACH OCCURRENCE S 11000,00 1O/01P2018 10ID1k077 $ 500,00 _ jEXP a,a $ 10,00 OENLAGSRECATEUMITAPPUES PER: PERSOMALarovauURY M 1.000,00 X mm=❑JPECr ❑Loc I GENEFUil. REGATE $ 4,000,00 OTHER PRODLICTS-COMRaPAcm s 4,000,00 AMMORU Lmwtm g. A X ANYym com ZgWNED MWTB 38311 ar� S SCHEDULED 0101Y2018 10TOth017 eoaLYlNn (P5.000,00 PRaon) S AUTOS HIREDAUTOS �M BODILY IWURY(Prleodtlap)I g i s LaMAELLA Lum I - g OCCUR EXCESS Lute CLAIMS-MADE EACH OCCURRENCE g .I DEO RETEtnONM , Ar3GREGATE g WORKERS COnRRaLTNDI S ANDEaPLOYOWLtA9ERY YIN I X A EIRE UERm D N❑NIA 030823100 toro1f2016 torot2017 EL��� � If "mo I I $ 1,000,0 PTpN OF OPERATIONS babes EL DISEASE-FA L31PLo S 1,000,00 EL DISEA$E•POULY Uwr g 1,000,00 DESCRIPTION(OF OPERATRNa/LouTmNS/VEHICLES IACORD 101.Aaabnrl Rmsaa&heap, mqr ba aervlRa enwra apawy,equtraAl CERTIFICATE HOLDER i CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POtJCa:B BE CANOELLEDBIXORE THE ErG1RATIWI DATE THISMOF, NOTICE WILL BE CANCELLED IN ACCORDANCE WITH THE POLICY PROYI&O TI AUTHORM!D REPRESMAT" P of Insure A7 14�` ACORD 25(2014/01) ®1988.2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered mart of AC0RD Massachusetts Department of Public Safety j Board of Building Regulations and Standards_ License: CS-1190125 — Construction Supervisor ,. JAIME L MOAN ... M 4ARONfER ST ;; 2;/ LYNN MA 07!06 • l""� CA, Expiration: Ctm7missioner "i2078 Construction Supervisor Restricted to: Unrestriafed-Buildings of any use ggroup which contain Mess than 35,000 cubic feet(9191 cutiic meters)of enclosed space. s Faaise M possess a tunnel edition of the Messaohusaft Stalls ill He g Code Is cause for revocation eftMs kwee. OPS LicensMg iMOmrBon wait.WNiW.1111A86A)MI fPS �i a�ammaam�.ea!/�i o`a�aaaa<✓ueeUa t #of Coaeomer Affain&Bodeen Regulatloa ME IMPROVEMENT CONTRACTOR FRe `-` ,Type: SPI Supplement Card RENEWAL BY AN JAIME MORIN 30 FORBES RDS` NORTHBOROUGH,MA 01532 Uedereeentary .1 n--E rn AP ag � ? � ® �, � re � � � Lk i8 Bi a,, at 13 CI !s W L7 L•1 i7 e n , � I� BI IL u L J ed WWh.i a. I I Is Ia0'tA' Y�1 BI Lfi E1IBd�I L.�C# U U.SIL �: �� 'I I ItL E+i L III r O N li SPP L mal Agreement Document and Payment Terms: gaoaoof 'i .awrtaw reo�Ramer Retial by ArxleesedLLt`.. 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