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22 VISTA AVE - BUILDING INSPECTION t I V The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY SALE M Q 1 Massachusetts State Building Code,780 CMR Revised.Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date lied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&6re4vmlbers !Ji oAL,-c 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 D� Lot Area(sq ft) Frontage(fin 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided L6 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 ifyesO SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner[of Record: S"ee(' -�Y/ Name(Pont) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Addition ❑ Demolition. ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work 2: �'i bi-Yi -//, .P�a-•�+r / ��� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ j��y6L 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee �, ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ j—«s g 2. Other Fees: $ 4.Mechanical (FIVAC) $ A"����, z,� List: 5.Mechanical (Fire Suppression) $ Total All Fees: $ }` Check No. .. Check Amount: Cash Amount 6.Total Project Cost: $ 2 � rP ❑Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Y�r.� 6 /a;z aG•i License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description Unrestricted(Build in s up to 35,000 cu.ft.) c)e+ /YK> GPw R Restricted 1&2 Family Dwelling City/Town,State'ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances r'ir� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) �� Y Te�•--r��'� HIC Registration Number Expiraln D ioale HIC Company ame or I-IIC Regist ant Name No.and Street Email address ��<c.a� t �ss Cit /Town, ate,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 PERMIT 1,as Owner of the subject property,hereby authorize �eS..x�tto act act on my behalf, in all matters relative to work authorized by this building permit application. not OwncrNa ( Electronic Sign re) Date SECTION 7b: OWNER' 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. -2 .Z Print Ow is or Autliorized Ag is Name(Electronic Signature) Date 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 can be found at www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.eov/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" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):_ �py Address: City/State/zip: ," nV Are you an employer? Check the appropriate box: Type of project(required): am a employer with . 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction. 2.El I am a sole proprietor or partner- . listed on the attached sheet. 7• ❑.Remodeling ship and have no employees These sub-contractors have _8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. ❑ Building addition. [No workers'comp.insurance comp.insurance.: required.] . 5. ❑ We area corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t C. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp.insurance required.] !Any applicant that checks box#1 must also fill 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 state whether or not those entities have employees. If the sub-contractors have employees,.they must provide their workers'comp.policy number.. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ( �CI�.3C�� 2 [ ) Expiration Date: t 2' , \ i 7 Job Site Address: r;�� y, O✓t V`� 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$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 and penalties ofperjury that the information provided above is true and correct Signature: 44 ,l, r" ! Date:4 R Phone#: �'� 7 Y C' Official use only. Do not write in this area, to be completed by city or town official 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 Cnntact Pprsnn- Phone#: A d CERTIFICATE OF LIABILITY INSURANCE D.,A IN ,D " 11/1o/zo11 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: N the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endoreed. N SUBROGATION IS WAIVED,subjed 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 endorse s). CONT PRODUCER - NAME• ConatIcoatlon Eastern Insurance Group'LLC E (508)651-7700 PAX Na.1508)655-6053 233 West Central Street L PCUNRZFDO 0033507 Natick )`tip 01760 - MURERMAFFORDWO COVERAGE NAICIf INSURED INSURERAHaUtilUB Ina. CO. seuREReArbella Protection Ina. Co. - ROGER A TREb=M CONTRACTORS INC MsuRERC Hartford Und.-WC Pool 10 COLONIAL RD - - INSURERD: SUITE 4 INSU E: SAXM4 MA 01970-2943 - IMU COVERAGES CERTIFICATENUMBERSIDSTER 2011.5 - 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. - MSR TWEOFMSURANCE POLICY NUMBER YIWCY EFF omnoFffm POLICYEXP UNIT L1R GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 ' X COMMERCIAL GENERALUAMLITY. _PREMIS '.Me r0ene $ 200,000 A CLAIMSJAADE ❑X OCCUR 166529 1/OB/2011 1/OH/2012 MEOEXP .one cn Is 10,000 PERSONALaADVINJURV $ 1,000,000 GENERALAGGREGATE $ 2,000,000. GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO S 2,000,000 POLICY X PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE UNIT $ 1,000,000 (Ea emdeN) ANY AUTO BODILY INJURY(Per Pelson) $ B ALL OWNED AUTOS 901340000E /15/2011 /15/2012 BODILY INJURY(Per ecdden0 $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNED AUTOS _ - Medical pavnerda $ PIP-Bask $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DEDUCTIBLE $ RETENTION $ O S C WORKERS COMPEN5/1TION - X VLC STIMT I 101`1- AND EMPLOYERS I AOILTrvYIN ANY PROPRIETOWPARTNERIEXECUTIVE a N/A - E.L.EACH ACCIDENT $ SOO OOO OFMCERIMEMSER EICLIIOE09 S6OUB4735P9B211 /1/2011 /1/2012 (Mandatory In NNl E.L DISEASE-EA EMPLOYE S 500,000 Dyyae5,RIPtION under E.L.DISEASE-POLICY UNIT S 500 000 OESCRIPTION.OF OPERATIONS W. DESCRIPTION OF OPERATIONS I LOCATIONSI VEHICLES Which ACORD 101,AddNlonal Aemeb Schedule,B more nPace is rpulmd) NOIUrOOD HOUSING ADEEOAITT IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS TEE RZOUIPJ24MTS OF A SIGNED WRITTEN CONTRACT OR AGREffid@NT WITH THE MANED INSURED. 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 REPRESENTATIVE Rosemary Fulham/EJM_ ACORD 25(2009109) - ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2cfwl) The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 109171 Type: Private Corporation Expiration: 9/3/2012 Trill 203261 DANCO BUILDERS INC. Daniel Tremblay 2 Margin Ter Peabody, MA 01960 Update Address and return card.Mark reason for change. D'Address _E] Renewal Employment F] Lost Card ors-cA1 is s0u-0aroa-om0�tss2te y �� /' �a offlea`Coss art+f n&`Besiaes""s`Yt°gula--ifou- License or registration valid for individul use only _ HOME IMPROVEMENT CONTRACTOR before the expiration date. If foundrreturn to: Registration:., 1.09171 Type: Office of Consumer Affairs and Business Regulation Expiration 9/3/2Q12 Private Corporation 10 Park Plaza-Suite 5170 -, Boston,MA 02116 D O BUILDERS INC Daniel Tremblay 2 Margin Ter Peabody,MA 01960 —� Undersecretary 1 of valid without sign.lure '� Matti uhusetts Dcpartmc nt of Public S ifct% Board of ructio Rc Constructiogulutions and Standards n Supervisor License License: CS 43536 i DANIEL E TREMBLAY 2 MARGIN TERRACEW PEABODY, MA 01960 w, i Expiration: 12/2/2012 - r lniwiissinma Tr#: 7362