13-19 TANGLEWOOD LN - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards
CITY
OFSALEM
Massachusetts State Building Code, 780 CMR, 71h edition RevvisedJanua ry
(� Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
`� This Section For Official Use Only `
Building PermitNum r: Date Applied. i
Signature:
Building Commission nspectorofBuildings Date-'.
SECTION I.SITE INFORMATION j4;
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
13- hi Ta n!:�Yewco l Ln
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(sit 11) Frontage(ft)
1.5 Building Setbacks(It)
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'.'.
2.1 Owner of Record:
F T rrst propcarhos LfUU Hi�11/tinc� Ave S<,lru, MCA Qtt7o
Name(Print) Address for Se ice:
�7 -7g1-2ov3
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED•WQRK' (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) l9Y Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description Of Proposed Workz: — ( A
�/Prr ®nF�.
SECTION 4i ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only °
Labor and Materials °T', , . •' ,
1. Building $ 1. Building Permit Fee:$ , Indicate how fee is determined:?
2. Electrical $ Q Standar& City/Towit Application Fee .
❑Total Project Cost;(Itein 6)k multiplier x�
3. Plumbing $ 2' .Other Fees: ,$
4. Mechanical (HVAC) $ Ltst:
5. Mechanical (Fire
Suppression) $ Total All Fees: $
6.Total Project Cost: $ b ��
Check No. 'Check Amount: Cash Amount
9� El in Full ❑Outstanding Balance Due:
SECTION 5 CONSTRUCTION 5.1 Licensed Construction Supervisor(CSL) CC5 &L I D I DD-Z,
License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
ylie
Address T :I , e7t7lption,��
* Unrestricted(up to 35,000 Cu.Ft.)
* Restricted 1&2 Family Dwelling
Signature M Masonry Only
,?7 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor
), e !(HIC)
1514 326
-J L Co
HlCcafinp-m time or HIC Registrant Name Registration Number
I / Ly//,/s T < la MA C")IQ 7D
Address -2 -27 - 11
&s Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE,AFFIDAVIT(M.VIL.c'AS'L§ 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 .......... Sr" No...........11
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERWAGENT 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.
Signature of Owner Date
SECTION,715�OWNER. 6R,AUTHORIZED,AGENT DECLARATION
A Lpine- Avpej-'Tz as Owner or Authorized Agent hereby declare
that the statements and i;ficrrAtion on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
-s L v co s Plculsat,,A;c
Print Name
6 -2L.-
f Own-of ol'-Aut4orzed Agent- Date
(Signed under the pains and penalties of perjury)
NOTES:
I An Owner who obtains a 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 not have access to the arbitration
program or 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 I IO.R6 and I 10.115,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"
j 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 Legibly
Name (Business/Organization/Individual): At i�4a ja,, Ty Services,
Address:
City/State/Zip: [51e110 Phone M `l 7Y-99 7 5 E 10
Are ou an employer? Check the appropriate box: Type of project(required):
1.LI am a employer with-0 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed 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.❑ I am a homeowner doing all work right of exemption per MGL ME]Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp, insurance required.]
'Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ��qq
Insurance Company Name: 3�C h l r'(I ra.,
Policy#or Self-ins.Lie.#: C1 i�,n SZ Expiration Date: 03 %/(, //j
Job Site Address: 13 - 11 l6rn 61e WA.2d Za City/State/Zip: So%.. /014 /p/,9-D
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 andpenaldes ofperjury that the information provided above is true and correct
,Simature: Date: 6 - 23 40
Phone M 9 - 997 - 53 70
Official use only. Do not write in this area, to be completed by city or town ofciaL
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#:
RP;I ) '13: 05 UDorley Hgency (FRX)401 696 9622 P. 001/001
c ' CERTIFICATE OF LIABILITY INSURANCE oPu) IA
_ � .. '
ALP32; Od ld 10
r + k! + TH CERTIF CA IS ISS AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Dao=1• Inc. HOLDER THIS CERTIFICATE DOER NOT AMEND.EXTEND OR
yyg°� ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Ea£eta LLRI 02818
?h`bnerb„ , fi 9'600 Eax:401-886-9622 INSURERS AFFORDING COVERAGE NAILS
wsuRLwA: Beacon Mutual Ins Co
;C OtBZy R4eBo61ix 4 INSURER
INsuRet D
8`�ytivats RI 02857 '
I�f�t�'� xTrus" Xi9UREN E•
i 'Y.. u4r®DcIow HAVSOFENISSUEDTO THE INSURFAWIMEDABMFORTHe POUCYPEMOU INDICATED.NOTWITHSTANDNO
CQNIITIONOFNIY CONTMLTOR OTHER DOCUMENT WITH ROSPSCTTID WHICH THIS CMIRCATE MAY BE ISSUED OR
.v )IMOGDOYTHEPOUGlESDESMWDMEREINISSYSIECTTOALLTHETEnM%WCLLt 10NSANOCDNxnmOPSUCH
V;81]OIN WAY HAVE BEEN ReDUCEDBY PAID CLAIMS.
quIMNea POLICY NUMBER fIA O Ia7t0 umn
k✓'",� EACHOCCURRENCC i
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CyOM�B�WyE�O�SDIDLG IYGIf i
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AUTOS
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DRIER THAN
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AUTO ONLY; AM •i
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AGGREGATE i
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R� YIN 39008 03/16/10 03/16/11 ILL EAC IACaDENT i 500 000
M DISEASE-FAEMPLOYEE $500 000
"Al PiD19EWe•PoucruMrt 3500;000
r .
iLDF10IONi/YENN:LES/QCL{ISIONSADD6D BY ENDORSEMENTI SPECIAL PRI"JONa
Eax to 978+887-5875'
CANCELLATION
A . y+..w:...'•• SHOULD ANY OR THEABOK DESCRIBED POLICIES 06 CANOELLEO=FORSTHE EXPIRATION
RICONM DATBTNEKCPTHEIWWNONBURMWRLENDEAVORTONIM 10 MAYSWRRTEI
NOTICETOTmecwIFN:ATENOLDERNAMSDTOTNE LER•BUTPAXLRETO COCO jKALL
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F '•�.41 axd IMPOBS NOOaLIORTION ORLWENTYOPANY NEiD YPOd THE INSLINER..TTSAOEN180R 11 REPRESS TATNES`
` 12I',02908 AY RDxD REP A L
Y
01988.2009 ACORD CORPORATION. All rights rosormd.
�. ` Tho ACORD nano and logo are plitstared marks or ACORD'
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.'a 0•Inxxuchusctts- Dcp:utmcnt Df Pulllic SaleC�.
Bon"' of Building Refvintions and Stuntl.11.,ConstructlonSupervisorSpecialtyLicensLicenseorreistratlon valid License: Cs s _. - g v d furindivldul use only
L 101003 _ ` 11MOre-the-expiration date. If found return to:
Restricted RF,WS '" Board of Building Regulations and Standards
q� IOne Ashburton Place Rm 1301
STAVROS"NIOLITSOULA'3 iBoston
11 WILSON STREET. ..:
.:.:SALEM, MA 01970
----�f�, Expiration: 12/1q/2pi1 I Not without signature
CununLvzinnur .
Trg: 101003- '
. :. J
foaorvldlzol%�Igl�ons`"i2nd�ta
One Ashburton Place -Room 1301
Boston. Massachusetts 02108
Home h proveme Contractor Registration
Registration: 164326
;'-. ' •�:'ra- -."': Type: Pdvete Corporation
. :4^s%�-�'�;:?`=�'-•=C-_=:-_,' '' Expiration: 2272011 Trd 279846
ALPINE PROPERTY SERVICESECsFJ __:
STARROS MOUTSOULAS a': °=' ;
11 WILSON STREET `. =
SALEM, MA 01970
Update Address and return card.Mark reason for things.
•• O Address ❑ Renewal Ei Employment b Lost Card
B o[go8letl6m sod License or registration valid for Individul use only ;
before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR
Board of Building Regulations and Standards
Regist�jl0n, 154326 One Ashburton Place 16 1301 ,
I 6, -ro 2272011 Tr# 279846 Boston,Ma.02108
PilSate Corporation
ALPINE PROP ;" . •fA,INC.
STARROS MO
11 WILSON _ ``'Y �""�""'�' Not valid without signature
SALEM.MA 01970 '� "' Administrator ._.