38 WARD ST - BUILDING INSPECTION co v►cF
The Commonwealth of Massachusetts ►N CIA
Board of BuildingRegulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR 4�
t. Wa 0 l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date A ied:
Building Official(Print Nune). Signature - ate
SECTION 1:SITE INFORNIATION'
1.1 Property Address: t� (� l —d ( 1.2 Assessors Map&Parcel Numbers
L i a Is this an accepted street?yes no Mop Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tl) Frontage(11)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yesE3
SECTION2: PROPERTYOWNERSHIPP�!
2.1 Owner of Record: Z U t JL � "'M11b
�(✓ii4NA 14YN � � � �
N), (Print City,
City,Slate,ZIP
� C-n 41s� 9 �g- rya -WV/'S-
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied Cl I Repairs(s) ❑ I Alterntion(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
6AJ /_rv4 It r
-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(item 6)x multiplier x
3. Plumbing $ P Other Fees: .S
4.Mechanical (NVAC) $ List:
5. i\Iechanical (Fire S Total All Fees:S
Su «ssiunl
Or/ Check No._Check Amount: Cash Amount:_
6. Total Project Cost: $ �J �d ❑ Paid in Full ❑Outstanding Balance Due:
Aoj� �i�D �k 1 0� �fl �Y c��,�P �-►-t� a
v-�i NET L,-) -V Lb (Z3
+ I
M1 e .
I- SECTION 5: CONSTRUCTION SERVICES
i�p .S -5.1 Construction Supervisor License(CSL) 06r f ber 6z Z�
/OAA,i'//�c- K (�(/�(/� License Num Expiration ale
Nanic of CSL Holder LL"`--- v,
/� )7!L List ype(see below)
No.and Snect /�) ` (/ fy yna _. .' - Description u
/ CJ U Unrestricted(Buildings to 35,000 cu. It.)
�J -- �/!/ �//' Restricted I&2Famil Dwelling
Cityfrown,State,ZIP ,vt Masonry
RC Rooting Covering
y ! !! WS Window and Siding
SF Solid Fuel Doming Appliances
[� I Insulation
Telephone Email address I U I Demolition
5.2 Registered Home I/m-provverr[�'ent Contractor(HIC) Id-1 (l�l� ! 6
/'t I L L" C HIC Registration Number F.. piru ion Date
f IIC C n my_NR it Name
No. and Y S A/ �*/1- D/4.Q� Email address
City/Town,State ZIP , Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. I52.§ 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 Is§uance 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 Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's None(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate t Ke best knowledge and understanding.
copw ✓N� lQ/QiF O (� l
Not Owner's or Authorized Agent's Name(Elccu c mture Date
O.
I. An Owner who obtains a building permit to do t er own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will nit have access to the arbitration
program or guaranty fund under M.G.L,c. I42A.Other important information on the HIC Program can be found at
www.mass.� iv'oc;n Information on the Construction Supervisor License can be found at w%i %v.mass.gov!das
2. When substantial work is planned,provide the information below:
Total fluor area(sq. R.) ' .(including garage, finished basemenUattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/batlis
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Ibinl Project Square Footage"may be substitute.) tor"rued Project Cost"
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�r QUALITY EXPERIENCE
SERVICE - l tgInsulano s 3 `.,
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LICENCE#101444 ' q`s" ,i+ `` Roo g ff
'CONSTRUCTION SUPERVISOR H®meS I.L.C. "" „ �, Repla ement w
y" LICENCE#064068 ''� -. y 479 BROADWAY, LYNN 01904 %{ck t" r � Wlndow3 Speclalt$tS
,. LYNN BUILDERS LICENCE#470 ® ,+ *y ,,�,'» : ", ` '• ''
' (781) 592=5900
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nv CONRAD McKINNEY,President «. Estabhslied 1964' s'"'b rc.+ a
Member'Better Business Bureau® www•hallmarkhomes.net �" a °�°A
up a
t Serving Eastern Massachusetts MEMBER OF THE LYNN&PEABODDYAREApCHAMBER OF COMMERCE��
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V I �lfl�t/,4 m zPut �.
} Owner home
zPhone ^''' "1•,� .r'�. 'srsv'..'t'
Job addiess.
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a .Cash price of goods and services:................ .....................,...,.........,...............................
Down payment or payment at commencement ..............................................................
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Payment when 50%complete: ... d `
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t,Balance upon complet' n: .. .. .. ...............................................I ........:. V.
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Apwr Est yStart a Est. Comp;J I SUBJECT TO MASSACHUSETTS SALES.TAX_
ConMactor will do all o said work in a good workmanlike manner he owner agrees to notify the contractor in writing signed by the owner,ojony deject in: -ai
-; w kmanshi' or material The contractor shall be liable only if it jails to repair any specified deject,including defective repairs,mithin thirty days ofreceipt ojr.�q
i nollee�¢ui)adt otheqvise and in no event sholhhe contracior be liable"be'yond the cost to it of labor and material required for any repair work. • i,.� , '
rThe�con"'lraorshall be paid by the"awner(s),`qll reasonable costs attorney fees and expenses in addition to the amount due and unpaid that shall be"'incurred
rn enforcing the termsgnd conditions ojthis contract and/or any lien,in connection therewith. ' - < p +.' y�
You pray cancel this-agizemeirt(if it has been consummated by a party thereto at a place other than at.address of die seller which may be his main office
:g ibraneh.ihereoj,by a written notice directed to the seller at his main or branch office by ordinary mail posted,by telegram sent or by delivery,,not later than :n`
midnight ojlhe third business dayfo(lowingdie signing of Jtiis agreement
,,No worktlo,be done'mi this property other than species in this contract without additional charges , 1, t, ,
• This contract contains the whole agreement with its.Companywdl furnish'warranty adjusted to the type of work dare on above property upon campleaon of
this con ract zh « z - ' " .. ., .: , . v„
5l Oavhrer agrees this in event of his breach of this contract before work is started 5%)per cent of Contractor may demand hventy-five(2 the contract price as its
f a snpulated dam agesjor'the breach A r
conh' s , r t,
.l
y ' ' Company furnishes insurance coverage`
k ,Uwe.'the+owner(s)of the premises mentioned above,hereby contract with and authorize you as contractor,to furnish all necessaryjmatenals, e
Fesced, all,construct and place the improvements according to th specific tion�Seown
rms and conditions,on premises ,
�bo m ss whereof the which
hawe ve
and represent that we have good local recor/Q britl�e t�as own
s In name
labor and wrkmans pip,parties
install,hereunto signed their nines on this dote.................(. Y �:.(.. .. /.... .. .:.. ^.. ... .....,. !�
- CO D KIN RESIDENT,. SigrnedX. .. ... O;vu •" N !'� .... T
U Owner I ly
it \/ P
OR ...... .p.... I. SignedK..... ........ ......... .....
.- Representative _ Owner
'CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DDrmY)--I Q211n/2nI4 �.
FlCATE ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS �t
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOWWJ
r
F/S CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INS URER(S),AUTHORIZED w _ 1
D THE CERTIFICATE OD
,di PORTANT:"the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to `
r'+S he terms and conditions of the policy, IS
policies may require and endorsement A statement on this certificate does not confer rights to
he certificate holder In lieu of such endorsemen s.
PRODUCER " CONTACT. - s
NAME:
DAVID E 7131 1 R INS AGCY - - PHONE FAX mj
370 LYNNWAY (A/C,No,Ext): (A/C No):
.;, LYNN.MA 01961 ( E-MAIL
ADDRESS:
• 25U6D_ INSURER(S)AFFORDING COVERAG E NAII y
INSURED , INSURER A: TRAVELERS INDEMNITY COMPANY OFAMERICA 1 n q
RASMUSSEN EXTERIORS INC INSURER B: -
INSURER C: '.
z
39 SOUTH STREET INSURER D:INSURER E
LYNN.MA 01904 _ INSURER F:
COVERAGES - - CERTIFICATE NUMBER: REVISION NUMBER:
TNIB ai O HAT THE POLICIES OF NSU ANCELISTEOEELOW HAVE IEENISSUEDTOTHE INSUREDNAMEOABOVEFOR THE POUCYPERNJDWDCATED
NDTNTn1STANDNO ANY REQUIREMENT,TERM OR CONOGION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE EISUED OR MAY _
PERTAIN.THE INSURANCE AFFORDED BY THE POLOES DESCRIBED HEREIN td SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY
HAVE BEEN REDUCED BY PAID cLAal&
NSR ADO SUB 'POUCYEFFDATE POLICYEXP'DATE
LTIR _ .TYPEOFINSURANCE L R POLICY NUMBER .(MMOMYYYY) (MMw M,YYYY) LIMITS ;
GENERAL LIABILITY CH OCCURRENCE
COMMERCIALGENERAL LIABILITY
DAMAGE TO RENTED
CLAIMS MADE OCCUR. $ :1
REMISES(Ea ocmrrence) -
ED EXP(Any one parwn) $
ERSONALS ADV INJURY. $
GENL AGGREGATE LMIT APPLIES PER: ENERALAGGREGE $
POLICY E]PROJECT❑LOG RODUCTS-COMPATAT AGG $
AUTOMOBILE LIABILITY' COMBINED SINGLE $
AWAUTO LIMIT(Ea accident) {
ALL OWNED AUTOS $
BODILY INJURY
SCHEDULE AUTOS (Per Person) a
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per mcidem)
PROPERTY DAMAGE $ £!
i (Per accident) :1
UMBRELLA UAB r7 OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $ ;
RETENTION $ . $
A WORKER'S COMPENSATION AND d
EMPLOYER'S LIABILITY YM USA E9782SI 01/102014 01/10/20I5 `Y uMITSATUTORY OTHER
ANY PROPERROWPAWNEWEXECUTIVE Y N/A E.L.EACH ACCIDENT "t OFFICERMEMBER EXCLUDED? ❑ $ 100 000 ')
(Manwuvym Nil E.1-DISEASE-EA EMPLOYEE $ 100,000 .I
DESCRIPTION OF OPERATIONS oebx E.L.DISEASE-POLICY LIMB $ 500,000 (
i
DESCRIPTOR OF OPERA710NSrWCA710NSNEHICLES/RESTWCTIONSSPEgAL ITEMS
TRLS REPLACES ANY PRIOR CERTIFICATE LSSUED TO THE CERTIFICATE HOLDER AFFECTING WORITRS COMP COVERAGE.
4
_.__-_..-_._...-.-.-.._._._...._.-..__..�..-___._._._._.___-__,� i..
CERTIFICATE HOLDER CANCELLATION
HALLMARK HOME LLC - SHOULD ANY OFTHE ABOVE DESCRIBED POUCIES BE CANCELLED +»
ATTN:CONRAD- BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
16 CASTLE CIRCLE IN ACCORDANCE WITH THE POUCY PROVISIONS.
AUTHORIZED REPRESENT VE
PEABODY,MA 01960
ACORD 25(2010/05). The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
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CITY OF S:U E.M, NWSACHUSETtS
T
p► i BuLum\,G DEPARTSIE.\T
3 9��8 is l 120 WASHIINGTON STREET, 3"FLOOR
f TEL (979) 745-9595
F.L.�t(978) 740-9844
jI.NIB Rt FY DRISCOLL
;MAYOR THoms ST.Frim s
DIRECTOR OF PUBLIC PROPERTY/Bt;RDt\G COAL assrONEit
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electr)cians/Plumbere
Applicant Information y� . L J n /Please Print Leeibly
(�/,r
NainC InueinusOrganiraGtiynm'Indivi�d�{ual/Y • // A111WA 1-- C_
Address:
City/State/Zip: hone
Are you an employer'.'Check the appropriate s: Type of project(required):
I.❑ I am a employer with 4. s general contractor and 1 6. ❑Now construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ fain a solc proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
,hip and have no employees These sub-contractors have S. C]Demolition
working Air me in any capacity. workers'comp. insurance. ), ❑Building addition
j No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑ New
repairs
insurance required.) t employees.[No workers' 13.0 0ther
cutup.insurance required.)
-Any applivam Ilwf cheeks bur e 1 must alsu rill caul the rucriun below showing their wodiea'compensation puliuy inrmmmlon.
'I Inmeuealne who.whmit this affidavit indicating ihey are doing all work and then hire outride contmctmer min)submit a new a(tlJavit indicating such.
10mrmetum thin Orml;Ibis box most anachoa in iddiaurasl sheet showing Iho name of the iabtiromacleia and theft warkea'comp.pulley infomiatica.
I unr can eurpluyer rbat h pruvidinK Ivorkrrs'rumpensmlan insurance for my employees. Below Is the pollcy uttd jab rile
iufurnretfan.
Insurance Company Nome:
Policy it or Sclf-ins.
' ,Y &;4LLic• it: //,�,�,�� /7j�, /
/ Expiration Date:
lob Site Address: � 9-� U Z City/Slate/Zip:
Attach a copy of the vorliers' compensation pulley declaration page(showing the policy number and explratlon date).
Failure to secure coverage as required under Section 25A ufSIGL c. 152 can lead to the imposition oferiminel penalties of a
tine tip to S1,500.00 undlar one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be furwarded to the Office of
Inve,ligotions of the DIA for insurance coverage verification. -
I flu lrerrby rrrrijy or tit p id Pend/des o perjury that the frJunau!!oa provided abu a is True rarrd correct
ii•'n 1 rc' Dare: _ /��T
P I al:
O%/iciuf use mfly. u nor ivrit ' ilt area, to be cumpkied by city or lown n/JleM
City or Town: Permitli.lcense q--•-.--. .__—. . .---
Issuing Aof horily(circle one):
I. tivard cal'Ilealih 2. Building 0epartnteut .I.('ilyrrnwn Clerk 4. Electrical luipecrur 5. Plumbing Inspector
6. Outer
('nnlud I'cnno: Phone g: I
CITY OF SALEM, MASSAQ-iUSEM
a
BUILDING DEPARTMENT
120WASMNGTONSTREET,31DFLOOR
TEL. (978)745-9595
KINMERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
( C-
(name of hauler)
The debris will be disposed of in:
� Co
(name of facility)
(address of facility)
Si re of applicant
D to