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5 UGO RD - BUILDING INSPECTION Jt� The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revlsed Mar 2011 D/ Building Permit Application.To Construct,Repair,Renovate Or Demolish a One-or Tivo-Family Ihvelling ._. This Section For O ial Use Only Building Permit Number: D Applied: Building Official(Aim Name) Signature Date SECTION 1:SITE INFORMATION 1.1 opUty�ldddress�,.�^ - 1.2 Assessors Map&Parcel Numbers L la Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimeasions: Zoning District Proposed Use Lot Area(sq R) Frontage(it) 1.5 Building Setbacks(it) Front Yard Side Yards Rem Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G-L c.40,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zme?'' Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY 9OWNERSMP�'/� - [{/„ e © 1 ( 1'O Name(Aim) City,State,ZIP _ ` S 0G� ` �. Vt- 5ga4d64 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) Nev,Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description ofProp U Wodr': u w C©0°r G'r (g 6 x 1��— F-Ck O T- 14 o US-5 O J -p cprl A-ri Co SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only abor and Materials 1.Bulling $ g,5� — 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/roan Application Feew ❑Total Project Cost'(item 6)x multtpleer 'x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (1IVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) 6.Total Project Cost S 3 Check No. Check Amount: Cash Amount:_ ❑Paid in Full ❑Outstanding Balance Doe: 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor Liceuse(C1SL') 374-0- -x--p--- License Number Expiation Date Name ofCSL Holder List CSL Type(see below) F A, Type Description Unrestricted(Buildings up to 33000 cu.ft. R Resnicod 1&2 Family Dwellinst Cityffown,State,ZIP M Ma%onry RC Rooting,Covering WS Window sad Siding SF Solid Fuel Burning Appliances "�(- ?6 j �8�3 te`f lc'l T]W^.✓w� I Ivsvlation Telephone Email address D Demolition 5.2�Rleglsterrd Home]lmprovvetoe-nptpContraetor(HIC) 1(r((/�s/' �1�9eH/mot ,.1S�lt�Zy+<7'� hII(Ci Registration lNumber Expiration Date - HI Com MOC Rra amemHlC itnt Name �lS p7c��S - � � 1 {,l p A([)�S—+ *1_QP 1`3 Emil address Ci frown,State ZIP J /t^� ll 7 i V lTelephoonee Q� - SECTION 6:WORKERS'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...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as O r of the subject property,hereby authorize to an behalf,in all matters lative m work authorized by this building permit application Pnvt�a(El Date SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION By entering my time 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.Qm rAuthorized Agent's Name(Electronic Signatme) Date NOTES: 1. An Owner who obtains a building permit to do hisdier own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(RIC)Program),will nothave access to the arbitration program or guaranty fund under MG.L.c. 142A.Other important information on the HIC program cart be found at www.mass.aov/ora Information on the Construction Supervisor License can be found at www.mass.gov/dns 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.fQ 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 t 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" CERTIFICATE OF LIABILITY INSURANCE DAEIMMDDWYy) THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. 2" CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OTHIII R ALTER THE COVERAGE AFFORDED CERTIFICATE 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 cert)flcate holder is an ADDITIONAL INSURED,the policy(I must be endorsed. If rs SUBROGATION IS WANED subject to ,the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certlflcate does not WAIVED rights to the certificate holder in lieu of such endoements. PRODUCER cow NAM A P&C Department Small Business Insurance Agency, Inc. PHONE (508)795-0635 FAX 542 Main Street E—" .1508)e33-5006 IN INSURERS AFFORDING COVERAGE NAIC R INSSUREDURED Worcester MA 016D$ INSURER A:WeSterII WOrld NSURER 8: HraD�er Builders Inc. INSURER C: Attn: Olga & Dietrich INSURER D: 115 Tedesco Street INSURER E; Marblehead MA 01945 INSURER F; COVERAGES CERTIFICATE NUMBER:GL REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOR BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS DED BY THE POLICIES DESCRIBED HEREIN IS 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 MPOUCY El(P GENERAL UABIU UNITS EACH OCC URRENCE g 1,000,0 00 X COMMERCIAL GENEAAL LIABILffY PA $ 50,000 ArGENL CLAIMS-WOE X OCCUR P1331140 /16/1011 /16/1013 MEOEXP IM me pgaon $ 1,000 PERSONAL a ADV INJURY 3 1,000,000 GENERAL AGGREGATE F 2,000,000 GREGATE LIMIT APPLIES PER: PRODUCTS-COMPAJPAGG 8 1,000,ICV P1�11RO- LCC AUTO101091LE LIABILITY COMBINED SIN LE LIMN E ANY AUTO �. ALL OWNED SCHEDULED BODILY INJURY(Pm person) E AUTOS AUTOS NON-OWNED BODILY;N URY(Par accoonl) S MIRED AUTOS AUTOS PRO R OAMAG 3 UM LA OCCUR E EACH OCCURRENCE E EXCESS UAB CLAIMS-MPDE OED RETENTIONS AGGREGATE s WORKERS COMPENSATION E AND EMPLOYERS LIABIL Y YIN WC STATU- OTH- ANY PROPRIETOP/PARTNERIFXECUTVE OFFICERIMEMBER EXCLUOEDP ❑ NIA E.L.EACH ACCIDENT (Me,Watory in NH) E H pas d;g.be onEer E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACacp ACORD 101,Additlonm Remarks ScM&W,N more apace k raquinw) Workers Compensation policy is written with an Assigned Risk Company, certficate has been ordered sad will be sent separately. CERTIFICATE HOLDER CANCELLATION (781)631-2617 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Marblehead ACCORDANCE WITH THE POUCY PROVISIONS. Attn: Building Inspector Widger Road AUTHORIZED REPRESENTATIVE Marblehead, NA 01945 1 ACORD 25(s)DI, ? INS026(zoloos).o1 5) ©1988.2010 ACORD COR TION. All rights reserved. The ACORD name and logo are registered marks of ACORD aight.fax C3-1 10'^3/2012 4:57:28 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATEIMMlDDINYY`fY! T RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS' CERTIFICATE DOES NOT AFFIRMATNELY 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(SU,AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER, IMPORTANT:lithe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. ItSUBROGATION IS WgNEO,subject tO he terms and conditions of the POLCY,certain Policies may require and endorsement. A statement On this certificate does not confer rights to 4 he certif!cale,holder in lieu Of such andotsement(s). 1 PRODUCER CONTACT NAME: 3M.ALL BUSIN5SS PW;A[P 1Y PHONE 5.4^_N4AFN SITZRjI T IA/C.Nal: L IA!c,NP,Extl: �j 1 EMAIL \b'O?;Ccs;TL•R.\L\ ()I CfI� ADDRESS: '_OP.'J IL INSURERIS)AFFORDINGCOVERAGE NAIC N INSl/RED �V•---yv—���-- INSURER A: ,V4E4[rgN Z'.1RIrp C!SURnN'.-E-nMPrtNS 1.iRAM11MGli(I[IILD(:I:'t a�. INSURER B: '- INSURER C: -- II INSURER U: i FTiiTIHA �IRHil'I AdgP RI..P.H}LAT),MA DIOJs INSURER E: -- -�i INSURER F: -! COVERAGES CERTIFICATE NUMBER: REVISION NUMBFFr HS A N NC tJ5 IMVE 0ETN 65VE0 TO WSURED RARE,ABOVEFO THEpoticyP 1 OICATEO PIERTANOT'MTHSTANONG ANY REQUIREMENT,TERM OR CO M)mOM OF ANY CONTRACT OR OTHER OOY.UMENi MRTII RESPECT TO WHICH THIS CERTURCATE MAY BE ISSUED OR MAY HAVE THE DUCED BCEAMClAi AFFORDED By THE POLICIES DESCRIBED HEREIN BSUaJECT TO ALL THE TERMS.EXCWSIONSANO CONOITIONS OF SUCH POLICIES. LWSSHDYINMAY HAVE BEEN REOIICEO BY PAFFORDED RISK ADD SUB POLCYEFFOATE POLICYE%POATE LIP TYPEOFINSURANCE L A POLICY MUNRER INRTAO[VYVy) IMM OD'YYYI DMps GENERAL LIABILITY ACHOCCURRENC E 1 CO3;NERCIAI.I:FFIFRAt LIAFTI "i i8 CLAIMS MArX- ®(COT AMAOF 1 ORFtITFO !q• EM!SES(Ea acwrrencel ED EXP(An,mw palzanl $ �- GEN'L ACGRFGAI}1_IM!' Apf'I'f-:i!'FF' _RSONAI.E ADV IIJJIIRY ,g 7-1 POLICY MPROJFC! EDIOt_ obNER.AL.AGGREGATE IS ornn;r;-COMP/OPa[;G IS AUTOMOBILE LIABILITY ANY.AI)Tq - OMBINFD SINGLE IMU fLa acadael ALL OWNFI`ALTOS ODILY INJURY SCHEI (Ak AUTO-- ,Pia pe"OH) ly HIRFDAUIOS OD!LY!NIL%R IS HC-CWTJFG Air O, FW amda t? ?ROPFRT'YOAVACF ----- Pz,acodan[! V AHRKI ALIAH Cx Y.IjR -ACH OCOURREICCE •s F-XCF.SS LIAR [I!.AIM`-MAOI- GGREGATE. y DEDI};T-PLE S RF rENrILYT S T ,T WORRER'SCOMPENSATIONANO LVC STgTU!ORY ally.u• EMPLOYER'S LIABILITY YIN [ATl)d9AM3'IA42 IOPPWID12 tO!?B/3753 LIMI`5 NiY F'RY'ERITGI:PAHINHLe::PI*.I fl>F ^cFlCFR:x1ENBFR EXcI.',AP";: �WF E.L.EACH ACCIDENT �% IJUU.000 (MgnNmorymlR[I FL D!SF.ASF- ttyct.n-a,nc,anu FA FMf\OYFFi3 1.CHID 69J DFSY;an*I UfI te, ',wm",11,een. E.I_DISEASE-POLICY U4nr S 1,CgU,WC DESCRIPTION OF OPERA TWNSLOCATIONSNF1fif,LESIRESTRiCT10NS15PEC1AL HEMS I'I uI{PI,A�'IFF,ANY RI:'d? 1! '.,"::.I: .I J,1 11 1lefA?*t n•.LDIN A'rT"!'IN"0.-NICH3"OM r,V 1 t CERTIFICATE - 'IOWNOF'\'LARB1.!it 1EA1) a SHOULDANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED 7:VJJG.ER.RG Y BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED TAC'-- ACCORDANCE WITH THE POLICY PROVISIONS H0RRED REPRF�yTA VE 'vLARBL-1Bi-A i),MA 1)1!)TS t-f,�..,.� 1 ' ACORD 25(2tN(UO5) The ACORD name and IOgO are registered marks of OR — t96g-2010 ACORD CORPORAitO 1. qlj ijghts received. j CITY OF S.UZNf2 NL1 &wHUSET s OUILDLYG DEP.IftTSLE.VT I?0 CV.ISHLYGTOt4 STREET, 3i°FLOCA v`. y TFIL (978) 745-9595 F.V<(978) 740-9346 ;UJ(DE4LEY D2ISC0t1. ,�rUYOit T'FIOSU3 ST.PlERRB Drm rca of pI 3LIc pROFERTY/sumnLNG COSL%,,ss,O.VER Construction Debris Disposal AftIdavit (required for all demolition and renovation work) In accordance Will, the sixth edition of the State Building Coda, 730 Cm section 111.5 Dcbris, and the provisions of IMGL c 40, S 54; Building permit t! is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal 111, S 150A. facility as defined by I%YfGL e The debris will be trnnsportcd by: per OW 4) (V-ocC �Orr / (nama ut'haulur) ✓ The debris will be disposed of in : 1 (name of tacilily) (.nldress ut'fatilily) cant s m ignaro ut permit appli yr u . CITY OF S1UX1%4 ixWS't,CHUSETTS BUILDING DEPARTMENT • 120 WASHING TON STREET, 3"'F100R +� T L (978)745-9595 Fix(978)-7404846 KIMBERi 13Y DRISCOLL MAYORTHoetAS Sr.PTERRe DIREC[OROPPL:BLtcPROPI?B1Y/BU DINGCONMUSSIO,iER' Workers' Compensation Insurance Affidavit:Builders/Contraetoi*WE]ectricians/Plumbers 4nplicant tnfirrtnation r- { Please Print Leg tii Name(BusinesslOrganizatiorvindividual): Address: pp ^^ : City/Statc)Zip: )Lr E��A� Nv`- Phone ll: � 3 0 OZ T Arc you an employer?Check t]te appropriate box. •type of project(required): 4 4. ❑ 1 am a general contractor and I 1.� I am a employer with g b. ❑New construction sin to ees(full part-time).* have hired the sub-contractors P y P listed on the attached sheet 7• ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8.,❑ Demolition workers'com .insurance. P 9. DuilJin addluon working,formein;nlycapacity, ❑ 8 [No workers'comp..insurance 5. ❑ We are a corporation and its. _ oi'fcers have exercised their ll).❑ Electrical repairs or additions required.] . right of have ion MGL 11. 3.❑ 1 am a homeowner doing all work 8 P� per . ❑plumbing to or additions `.myself.(No workers'comp. c. 152,§1(4j,and we have no 12.❑ Roof re ies _ insurance required.)t umployees.[No warners' 13.ESOther comp.insurance required.) 'Any applican that checks boa of most also rill out the s¢ctiee below showing their waken'compensation policy mlbmtadon. t 1 L.meowneis who submit this iffidavit indicating they am doing all work and that him ouuide cantmaors must submit anew amdavit indicating such. :Comrautnn that check this box most attached an mWitional sheet showing the.name of the subaontraraon and their`worken'comp.policy information. I am an employer that it providing workers'compensation Insurance for my employees: Below Is the policy and job site information 1 w... . insurance Company Name.,— Policy a or Self-ins.Lic.N: _ Expiration Date: Jub Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to sueurc coverage as required under Section 25A of MGL c. 152 can lead to the impositionof criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.D0 a day against the violator. lie advised that a copy of this statement maybe forwarded to the Office of - Investigations o(the DIA for insurance coverage verification. i do hereby certify and - s and penahles ofperjury that the bil'armatioe provided a bve is it a gad correct Official use only. Do not write in this urea,to be completed by city or town official. ' City or'ruwn; Permit/License# Issuing Authority(circle one): 1. Board of health 2.Building Department J.Cityirown Clerk d. Electrical Inspector S. 6.Other. Contact Person: _— Phone#: