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9 VISTA AVE - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Ol Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 20I1 1 One or Two-Family Dwelling Q/ 1� This Section For Official Use Only Building Permit Number: pplied:-` --. Y m Budding Official(Print Name) :Date SE -TION'1:SITE gVFORMQTION ti 1.1 Propeddq //r � 1.2 Assessors Map&Parcel Numbers 1.la Is this an a Fccep�ted street?yes_ no_ Map Number Parcel Number 13 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(tt) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yazd 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? Check if yes❑ Municipal❑ On site disposal system ❑ `.a - SECTION 2: PROPERTY OWNERSE1TPr 2.1 Ownert of Record: in 1 Vl S Fq *ye - s V-4N _ city,State,ZIP No.and Street -2�. �2! 030 L Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': � C `SECTION 4r ESTIMATED CONSTRUCTION COSTS Item Estimated Costs bor and Materials ` Official Use Oaly I.Building $ 1. Building Permit Fee: $ 1 Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee 3. Plumbing $ 0 Total Project Cost'(Item 6)x multiplier. " .'x 2. Other fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Su ession $ Total All Fees: $ 6. Total Project Cost: $ Check No. Check-Amount: .. Cash Amount: -. ❑Paid in Full 40,4 ❑Outstanding Balance Due al9ds �� d Pd�Vv Lyh h '.SECTION 5:'CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) P4//j�Q /e a 17 Q License Number Eapvation Date Name of CSL Holder List CSL Type(see below) 5 7 /`1 ccR A2� s No.and Street _Type Description 1-4 N Al M6L o��+� S U Unrestricted Buildin s u to 35,000 cu.11 City/Town,State,ZIP R Restricted M2 Family Dwellin ��^^ masonry tr HN-1 RC Coven w and Siding' L lib /� uel Burning Appliances 78/ k9 t/ 9 b� on Telephone Email address Do. tion 5.2 Registered Home Improvement Contractor(YUC) e�HC7 /xG' 17 �� 3 -l3 �a/ HIC Registration umber Expiration Date HIC Company Name or HIC e�g�strant Name No.aad Email address City/Town,State,ZIP Telephone SECTION'6:WORKERS'COMPENSATION INSURANCE AFFIDAYIT(M G i.c.152. 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 •q,, - -. ;: SECTION.7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR'AQPPnLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize P�f1.,X t D �)I�^ t to act on my behalf, in all matters relatives to work authorized by this b i�ng permit a ication. Print Owner's e(Electronic ignature) 6�96 � 5 1 v//3 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. Print Owner's or Authorized Agent's Name(Electronic Signature) Date A�- 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 MG.L. c. 142A. Other important information on the HIC Program can be found at www.mass eov/oca Information on the Construction Supervisor License can be found at mnDy.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor 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" rlti .sue p{fice�on�me "."�'oesse ($nu" HOME IMPROVEMENT CONTRACTOR Type. " Registration 4158909 DBA Expiration: 3I43I2014 P. - ALTY PHILIP BRIENZE q� rj 57 MURRAY ST LYNN,MA 01905 ��. ' Undersecretary .�..,.-az-.�.Asa„s.:,.-P�.«r,�-.,..-..ter»h •. M*ssachusetts- Department of Public Safctc Board of Building Regulations and Standards �J Construction Supervisor License License: CS 100434 - PHILIP BRIENZE 57 MURRAY.STREET APT 2 a LYNN, MA 01905 Expiration: 11/112013 ('onm�is+nroei:` Tr#: 7260 CITY OF S.1 ZM2 AUSACHUSETTS Bt:'WLNG DEPARTS &NT 120 C11-"HWGTOv STREET, 31O FLOOR �h h T FL (978) 745-9595 i<!J(0E.4LEY D(tISCOIl. FAX(978) 7.10-93-15 NUY01 '1110AU ST.PIERR$ DI.1ECt'OROFPUOLIC PROP ERTY/8LmoL (;CONNISSIO,NEQ Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition ofthe State Building Code, 730 CAJR section 111.5 Debris, and the provisions of tbIGL e 40, S 54; Building Permit # is issued with the condition that the debris resulting firm this work shall be disposed of in a properly licensed waste disposal facility as defined by rVIGL c 111, S 150A. The debris will be transported by; L (na'm^e of hauler) The debris will be disposed of in ; (nama Of ticility) (�dJres.c of facility) signatnrc of permit applicant !0o..W !, 1 ® - DATE(MM/DD/YYYY) A�o CERTIFICATE OF LIABILITY INSURANCE 4/22/2013 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les) 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). PRODUCER CONTACT NAME: Thomas Quinn Jr Quinn of Lynn Insurance Corp. PNONE . (781)581-6300 FAQ . Heil sel-so?o 152 Lynnway Suite 1D E-MAIL P.O. BOX 789 INSURERS AFFORDING COVERAGE NAIC Is Lynn MA 01903 INSURERA.Main Street America Ins. Co. 29939 INSURED INSURER B:ASSociated. Employers Ins. Co. BIS003 Philip BrienZe INsuRERc: PO BOX 54 INSURER D: INSURER E: LYNN 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. AD SUBR POLICY EFF POLICY EXP ILA TYPEOFINSURANCE POUCYNUMBER MOD M /D V LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 DAMAGEED 500,000 X COMMERCIAL GENERAL LIABILITY PREMISES a..mance $ A CLAIMS-MADE OCCUR MPT7165H /5/2013 /5/2014 MED EXP one on) $ 10,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC COMI $ AUTOMOBILE UABIUTY Ea s..N�tSINGLE LIMB BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OAMED PROPERTY DAMAGE $ HIRED AUTOS H AUTOS Per cantl 8 UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UP CLAIMS-MADE AGGREGATE S DED I I RETENTION$ $ B WORKERS COMPENSATION VJC STATU- OTH- ANDEMPLOYERS'LIABIUTY YIN ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 100000 A OFFICER/MEMBER EXCLUDED? NI 005946012012 /25/2012 9/25/2013 E.L.DISEASE-EA EMPLOYE $ 100,000 (Mandatory in NH) if Y describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Rema&s Schedule,Ifmom 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 ACORD 26(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 poloos).o1 The ACORD name and logo are registered marks of ACORD