8 VISTA AVE - BUILDING INSPECTION (2) 01/21/2007 18:07 FAX �rD Cd002
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR, 7'h edition MUNICIPALITY
USE
�\ Building Permit Ap tion To nstruct, Repair, Renovate Or Demolish a Revised✓anuary
NN e-or Tw -Family Dwelling 1, 2008
This Se tion For Official Use Only
Building Permit No r Date Applied:
Signature: IO Qb
Build gCo missio of Buildings paw
SECTION 1:SITE INFORMATION
1.1 Property Adder ss 1.2 Assessors Map& Parcel Numbers
Ss l//SI :FUC
I.la 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(sq R) Frontage(I)
1.5 Building Setbacks(ft)
Fran Yard Side Yards Red Yard
Required Provided Requited 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❑ Zone: Outside Flood Zone?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rggeeord: /_ _ Y Name Print) f
/N !3 za—lae S �/F'�IhaLP/ _� Ul /j �L/ C� �(/(
j �7— X Address for service:
'Y\ Signaturc ` Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction M Existing Building❑ Owner-Occupied O Repairs(s)0 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Speca:
Brief Description of Proposed Work-2: 7 - o
SECTION 4: ESTIMATED.CONSTRUCTION COSTS
Item Estimated Costs:
bor and Materials Official Use Only
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ Q Standard City/Town Application Fee
3. Plumbing $ ❑Total Project Costr(Item 6)z multiplier x
2. Other Fees. $
4. Mechanical (14VAC) $ le17• V 6 List:
S. Mechanical (Fire
Su ression $ Total All Fees: $
6.Total Project Cost: $ Check No. Check Amount: Cash Amount:
❑Paid in Full 0 Outstanding Balance Due:
- 01/21,12007 18: 07 FAX [a003
SECTION 5: CONSTRUCTION SERVICESJ
r��5.1 Licensed Construction Supervisor(CSL) JQO92Z �y -�-
license Nwnber E ateN me of CSL-Holder /� di`!EGList CSL Type(see below) FF Dm7e ionA es U Unrestricted u to 35 .Ft.R Restricted I&2 Fainilinigna ure M Mason Onlbd RC Residential Roofin Celcphone WS Residential Window aSF Residential Solid Fue A liance InstallationD RcsidcntmI Demolitio
5.2 Re ister Home Improveme Contractor(HIC) y l/n0 l 8 TK
# 7--, ,crib
�_� L t< e /E.VHN 1 - _ Registration Number r r n
HIC Company Name or HIC S tgstrant�emet S n {10
Address f 712 —f U
(/ -77 Expiration Date
LWorkers
ure "FtIt one
SE TI 6: WO ERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. C. 152. § 25C(6))
Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
ffidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... a No ........... O
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.
Signature of Owner Date
p SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
„ A/Q as Owner or Authorized Agent hereby declare
that the stitements and information on the foregoing application are true and accurate,to the best of my knowledge and
Print Name q/ -/O p
Signature of wn or Authorize Agent ' Date C
(Signed under the pains and penalties of per u
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 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"
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Board of Budding Regulations and Standards
N= One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
ReOistration: 160988
Type: Private Corporation
E)piraban: W1712010 Tr# 274646
NEFP INC. -
PHYLIS RYAN -
140 SO. MAIN ST ----- -- ---__-- _ __
MIDDLETON, MA 01949
Update Address and return card.Marls reason for change
j Address '- j Renewal - Employment Lost Card
s c * ., scev;rer-rCsav:
Board of Bolding Regulations aad Standards License or registration valid for individul use only
HOME IMpROVEmENT CONTRACTOR before the expiration date. if found return to:
r Board of Building Regulations and Standards
Rogistati0m 16M One Ashburton Place Rm 1301
Expiration: 91171200 Tr# 274846 Boston,Ma.02108
F�
Type: Private Corporation
NEFPINC-
PHYUS RYAN _ �.. ..`}.
140 SO,MAIN ST .� - No slid without si ature
MIDDLETON,MA 01949 Administrator
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01/21i2007 18: 08 FAX Boos
AOOR QN CERTIFICATE OF LIABILITY INSURANCE oa/02008
FROGUN;§R (979)922-2299 FAX (979)922-2731 THIS CERTIFICATE IS 9SSUE1 MIATYER OF INFORMATION
c ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Appleby 5 wyl^*n Insurance Agency Inc. HOLDER.T14I8 CERTIFICATE DOES NOT AMEND,EXTEND OR
152 Conant St_ ALTER THE COVERAGE AFFORDED BY TH IES BELOW.
Beverly, MA 01215 INSURERS AFFORDING COVERAGE NAICA
INBURERA National Ora Inauranaa CO. 14799
INauReD XLFP, Inc.
140 South Main St. wnuRER B:
Middleton, MA 01949 ""PER C:
ESURER D
INSURER E:
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ANY REQUIREMENT,TERM OR CONO ION OF ANY CONTRACTOR OTHER DOCUMENT WITH REBEEN 19P COT TO WHICHITHIS CERTIFIICATETMAY BE 3UBD OR DING
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS-
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-_]Q_DAY$IAIRTI-TEN NOTICE'TO TILE wRTInCME HOLDEN NAMED 10 TN!LEFT,
BUTFAB.URE TOMML SUCH NOTIw$HALL NPOSE NO OBLI04TIONORL1 BOM
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01/21/2007 18: 08 FAX (a 006
p i ne c ommonweattR of Massachusetts
Department oflndustrialAecidems
Office of inves"gations
-i 600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
�j Please Prin bl
Name (Business/O%wizatiorOndividual): - ,!5' 'f-1�0` iF F P G
Address: / D S . /U S j•-
City/State/Zip: A,444t A V 6'f Phone#: 79 a 3 "/3 O
Are you an employer? Check the appropriate box:
Type
Pe of protect(required):
1.❑ I am a employer with 'o ❑ I am a general contractor and I ff-— 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 7. [3'temodeling
ship and have no employees These sub-contractors have g, [] Demolition
workingfor me in an capacity. employees and have workers'
Y P ty• 9. Building addition
[No workers' comp. insurance comp. insuranee.t
required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11,[] Plumbing repairs or additions
right f exem exemption per MGL
self. o workers' cono p p 12. Roof repairs
nU P4 ❑ P
c. 152 i and we have no
ins required.]
t . ?3 O.
insurance employees. [No workers' 13.[3 Other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy inforvration.
t Homeowners who submit this affidavit indicating they are doing ell work and then hire outside contractors mast submit a new affidavit indicating such•
tContraaors that check Oils box must attached an additional sheet showing the name of the sub.contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the polle and job site
information. _
Insurance Company Name l P t -,t'� InA 19 w>~ N C— -
Policy#or Self-ins.Lie.#: 41 C Expiration
Job Site Address: 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 S250.00 a dayophist the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the IA brinsurapRe coverage verification.
I do hereby cert' under c pa s a d p naltles perjury that the information provided above is t e and correct
Signature,- D • O
Ofjlclal 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 S.Plumbing Inspector
6.Other
Contact Person: Phone#: