2-12 TANGLEWOOD LN - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7"'edition OFSALEM
Revised January
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This,Section For Official',Use.Only
Buildind06nnit Nom
IF i�],.'Paic ApjJfied:
'
Sig
logoeto fB
Inspector Buildings
.,Building Commissioner/ ate' I
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2- lanele, Zq
1.1a Is this an accepteYs'treet?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yesO
I
SECTION 2,:,PROPERTY OWNERSHIP[,,,,_ 7 2.1 Owner'of Record:
Ave
Name( Address for Se ice:
2003
ignature Telephone
96.0 1 2
SECTION 3. DESCRIPTION OF PRO SED, RK
ecle aq that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) V Alteration(s) 0 Addition 0
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other 0 Specify:
Brief Description of Proposed Work': S c C,)i(A Rpm f �YN a iA SLLk
kei.1 ano
SECTION
4. ESTIMA
TED CONSTRUCTIO
N N COSTS
Item Estimated Costs:
(Labor and Materials) Official Use 0.
1. Building L Building'Per miffec'
$ $ Indicate ItOW fee is;detennine. &
— OrStandard' City/To,"Application Fee
11
2. Electrical $ -Total'to
6 Costa1 ,'(hero 6):k 9 multiplier-I
X
3. Plumbing $ 2. '6ther Fti
4. Mechanical (HVAQ $ ,St:
5. Mechanical (Fire
Suppression) $ Total All Fees:r
6.Total Project Cost: $ Check rN 9 0- ltlhe�k'Annount: Cash Amount:
, 1 _5 P Paid.4hrFoli D.Outslanding,Balance Due: x"
SECTION 5: CONSTRUCTION:SERVICES
� .
5.1 Licensed Construction Supervisor(CSL)
�
GS S L if)10(�-�
h
!:Jewres /'10df!5--V/e. r License Number Expiration Date
Name of CSL-Holder _
List CSL Type(see below)
Address - " Type, :Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 154326
Al n;ne �� err S�(V\ 'P< CO InC
HIC C— mp�p ] or H Registrant Name Registration Number
1I Wi/sr n Sty < la MA t_71ei7t) "27 - ��
Address
7 -s870 Expiration Date
Signature Telephone
SECTION 6: IVORKERS'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 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
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.
Si nature of Owner Date
SECTION,76: OWNERr OR AUTHORIZED AGENT DECLARATION
1, A 1. in l?,ro i[cis as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
sTavrus '17cyiscul,<
rOwner
b -23 - %O
uthnzed Agent Date
ams and enalsof e ' NOTES: ,
ho obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
red in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 half/baths
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" '
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual): kpiu_ 42p,.+ SLf V1c e
Address:
City/State/Zip: Phone #: q d-8Y 7 - -S 970
Are ou an employer? Check the appropriate box: Type of project(required):
1.0I am a employer with . ❑ I am a general contractor and I
�� 4 6. ❑New construction
employees(full and/or part-time)." have hued the sub-contractors
2.El am a sole proprietor or partner- fisted on the attached sheet. t �• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp.insurance required.] 13.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeownera who submit this affidavit indicating they am doing all work and then hive outside contractor:most submit a new affidavit indicating such.'
tContmctom that check this box must attached an additional sheet showing the name of the sub-contmetms and their workers'comp.policy infmmation.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �l
Insurance Company Name: 3t,C.o In lO UTbl,a 1 /ns
Policy#or Self-ins.Lic.#: S G/i7 Q g Expiration Date:
Job Site Address: .Z -12— /q t G.(o w Lan 2 City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). -
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: 4 - 23 -/O
Phone#: _ 997 - 5,S 70
Official use only. Do not write in this area, to be completed by city or town official.
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#:
qP11713: 05 OoorleY HgencY (FRX)901 00b 96ee P. 001/001
CERTIFICATE OF LIABILITY INSURANCE
04 1d 10
THIS CERTIFICATE IS ISS ED AS A MATTER OF INFORMATION
ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOYIL
�15 02818
Phones d �1"6 9600 Sax:401-886-9622 INSURERS AFFORDING COVERAGE NAICs
INSURMA: Beacon Mutual Ins Co
INsuRmt a
{ 'ey4Fit z r Sav es Ina R IrafuRERa
�tezy Rd Hbx 44b
tom' Oa tizate RI 02857IN91fRER E
5
r. BELOW HAW SEEN ISSYEDTO THE INSURED NAMED ABOVE FOR THE POUCYPERIOD RmIcATEO,NOIWIHSTANOWG
NOF ANY COMRACTOR OTHER DOOIMENT WITH RSSPECTTOYJIUCH TIES CEWIRCArr MAY BE ISSUED OR
AT;'FORDED BY THE POLRXES DESORISED HEREIN 13SUSAECTTOALLTHETERM%ENLXUSIONSAND CONDITIONS OF SUCH
,81]O!NN.WAY HAVE SEEN REDUCED BY PAID CLAIMS. �p
is '�� •.��` IRANCa POLICY NUMBER IMMI FEbTWB 011 IN 0 O man
� ,. � EACH OCCURRENCE _
BDKcRAL WOum S
k
(( ►ibDE,�OCCUR 1a.SIa>6L one Pesonl 2
b' Jd R.41
PERSONAL{ACV E•LURY S
ODIERALAOOREORTE $
�. LUYgYAPSLRSPETt PR000M-COIIPWWA S
mid:t LDC
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„o, C'tY��Irtlt- COMBINEOSINGLO LeAR a .
c• � lPAaatldeAJ
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PantMO
SOOu.YDOIIRY.
mo Y A1nOa _ IPMamq S
ti= PROPERLY DAMA0r
yy yt.S� AUTOOI4Y-EAACCIDENT 3
OTHERTHAN eAACC S
AUTOONLYI AM .S
�;'r'd' r RE PLKeineszrn
EACH OCd1RIa:NCe _ {
k ?',`CLAIMS YAOE ASMOATE {
v;<<y YIN 59008 03/16/10 03/16/11 GA- ACHACMDEW ISSO0 000
ELDISEASE•EAEMPI.O SSO0 000
'FLOWAm-poucrLoar 13500'000
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F �jLfiGTI0N9/Y91p-La9f plgMfUDIpADDED eY 6NOO115EY0i{f aPBCYU,PROYIS10N8
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CANCELLATION
SHOULD ANY OP THBADOYE OSSCRI8ED POLI410 aE CANCELLED ONFORETHa EXPIRATION
RICONTR DATE THEREOF.THE ISSUINO INSURER WILL ENDEAVOR TOMAR DAYswmrm
Nm=To THE CERIIFICATH MOLDER RAMED TOTIIB LEFT.BUT FAalOtaTO 1O50$HALL
re Registration IMPOSE NO OBMOATON ORLWa1UTYOPANY RIND UPON THE INSURER rMADD=Olt
Board
REPR6aENTATNPS.'
ItL,L(02908 AYTHOR A
I e
®1986.2009 ACORD CORPORATION. All rights rooDWOd.
e' The ACORD name and logo are leglatered marks of ACORD'
n:
i4lnsxach Else[is- Department
Bna'dofBuilding Regulutions
ndards
Construction Supervisor Sp Specialty License _
-License or registration valid forindfvidul use only
License: CS SL 101003 _ - " lb-1101`e-th0mxpiration date, If found return to:
RestrictedJOL RF,WS Board ofBuilding Regulations and Standards
,T. I One Ashburton Place Rm 1301
STAVROS MOUTSOULAS I...iBoston
11 WILSON STREET...,- .
- SALEM,MA01970
--�� Expiration: 12114t2011 Not w"ltloutsignatureC
Trg: 101003'
m
fi
oj o m e ions an War
One Ashburton Place -Room 1301
Boston- Massachusetts 02108
Home ImprovemeffEContractor Registration
'-" Registration: 154326
Type: Private Corporation
Expiration: Tr0 2f9646
ALPINE PROPERTY SERVICES ( ( r=
STARROS MOUTSOULAS
11 WILSON STREET
:. _.
SALEM, MA 01970 - r_.-•, -
- Update Address and return card.Nfnrk resson for ehenge.
Address Renewal Employment 0 Lost Card
DPa-0M o sm-07W-FCa490 - - -------
Bo of BoOdin ddm and 5 License or registration valid for hedividul use Doty
HOME IMPROVEMENT Co.NTRACTOR before the expiration date. If found return.to:
t, Board of Building Regulations and Standards
Registf%ydn; 154326 One Ashburton Place Rin 1301 -
Ex i�tl_p .i22712011 TrI 279646 Boston,Ma.02108
e`f '`•-6rh eta Corporation
ALPINEPROP6r iS:fi.O,INC.
STARROS M c.
11 WILS .- Notvalid without signature
SALEM,MA 01970 ^•� Administrator
i