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9 VALLEY STREET - BPA 13-881 The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY M Massachusetts State Building Code,780 CMR S Revised dMar Mar 2011 Building Permit Application To Construct,Repair, Renovate olish a One-or Two-Family Dwelling This Section For Official Us my Building Permit Number: Date App ed: 3_121 Building Official(Print Name) ^ignature Date SECTION 1:STTE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers eo 0 —!? k!�� aAl--e 1.1 a Is this an accept street?yes_&�no_ Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sit ft) Frontage(ft) 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 Laformation: 1.8 Sewage Disposal System: Public i3� Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ CTION 2: PROPERTY OWNERSHIP` 2.1 Owners of Record: Name(Print)SIAVWAj City,State,ZIP �! No.and Street S;e ` Telephone Email Address SECTION 3: ESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) -❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials 1.Building $ O9 . 00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical t $ ❑Standard City/Town Application Fee. , .0 0 ❑Total Project.Costa(Item 6)x multiplier x 3.Plumbing $ O 00. 0U 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees: $` Su ression Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ Q 0 70 .00 ❑Paid in Full ❑Outstanding Balance Due: T�a964 Ly14 PDSLARS n 1 1 SECTION 5: 'CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL F older List CSL Type(see below) 37 11 nn�v ems- t2 o f �L- No.and Street �./ Type Description Unrestricted(Buildings u ,000 cu.R.R Restricted 1&2 Family Dwelling City/rown,State,ZIP M Masomy t'l y 19 �� RC Roofing Covering . 7 9 ) WS Window and Siding . G 1Y01 L, Cp/y SF Solid Fuel Burning Appliances / I I Insulation Telephone Email adss D Demolition dre 5.2 Registered Home Improvement Contractor(HIC) 15,e 9 D 9 3- /3 —20/ /0 D R SAL/-y /79 /r T" HIC Registration Number Expiration Date HIC Company Name or HIC egistr t N e No.and Sheet _� X Email address k)r.o J /Y4 olyo5 70 99q) 155/ Ci '/Town,State ZIP Telephone 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........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMTr Las Owner of the subject property,hereby authorize A�lag Al 2 to act on my behalf,in Al mafteA relative to work authorized by i�ilding permit application. ts' 2D- t 3 Print Owner's N (Electronic Signature) Date SECTION 7b:OWNEW OR 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. �/fwn0—,Authorized ,QAu ,�ZO -/3 Print Oer's r Authorized Agen Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hives an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program), will not have access to the arbitration program or guaranty fund under MG.L. c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www mass ore /dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) .3 (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) 2 D D o Habitable room count Number of fireplaces i Number of bedrooms f _ 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" PDSLARS V F i n . r 7 ® DATE(MMIDD/YYYY) A�® CERTIFICATE OF LIABILITY INSURANCE 4/22/203.3 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 policy(ies) 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 endorsement(s). CUNT Thomas Thomas Quinn Jr PRODUCER NAME: Quinn of Lynn Insurance Corp. IPA NGNE (781)581-6300 FAX 0. (781)681-9070 152 Lynnway Suite 1D E-MAIL P.O. BOX 789 INSURERS AFFORDING COVERAGE NAIC# Lynn MA 01903 INSURERAMain Street America Ins. Co. 29939 INSURED INSURER B:Associated maployers Ins. Co. BIS003 Philip Brienze INSURER C: PO Box 54 INSURER D: INSURER E 1,YNN MA 01905-0054 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1342200688 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 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 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 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. POLICY EFF POLICY EXP IN AODL R TYPE OF INSURANCE POLICY NUMBER MM/DD V MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 DAMAGETO-TOTFE-D SOOT OOO X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurre ce $ A CLAIMS-MADE OCCUR CPT716511 /5/2013 /5/2014 MED EXP(Any oneperson) $ 10,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 X POLICY PRO LOC $ .IFCTGLE LIMIT AUTOMOBILE LIABILITY EO eBlc EeD SIN ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS UTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS pLITOS Pere ent UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAS CLAIMS-MADE AGGREGATE $ DEO RETENTION$ $ $ WORKERS COMPENSATION WC SLIMIT OTH - ANDEMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100 000 N/A OFFICERIMEMBER EXCLUDED? 5005946012012 6/25/2012 6/25/2013 E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory In NH) N yes,describe under CRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DES DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Addhlonal Remarks Schedule,If mom apace is required) - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REPRE I ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(2D1oo5p1 The ACORD name and logo are registered marks of ACORD - _„--- °e esKa on Omce oosm " ffil Vxpiretton:OME IMPROVEMENT CONTRACTOR Type. egistration 3/13/2014 DBA P. .REALTY MGMT -�� .PHILIP BRIENZE �+�} 7- 57 MURRAY ST APTy#2 '�, r, i LYNN,MA 01905 ndersecretary.- � � U, +-.. �l ssachu.uth- Department of Public Safc(, 9�X1 Board of Bmldim, RC ulalions and Standards Construction Supervisor License License: CS 100434 - PHILIP BRIENZE 57 MURRAY STREET APT 2 LYNN, MA 01905 Expiration: 11/11/2013 Tr#: 7260 (',rmmi.viuner �T,q._.,..s�.•.._.-.,.,--.�,a,.::