33 WARREN ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 201
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 Applied:
' -' y
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Num rs
33 MARREN ST
I.l a 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard "
Required Provided Required Provided Required Provided
I :T:
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 ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1I er'of Record:
SOSEPV KAYE _SALE
f M , t'IA SS O 1970
Name(Print) ' City,State,ZIP
33 WARREN 5T 781- 933 y /emd
To.and Street Telephone I Email Address
SECTION 3:DESCRIPTION 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': &1,)�Odel if;'fCke .�05� 4� 6r1
DoO R WAy cr a--t Q PI P w -door )ee l s C_vwt're ,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ A5 00 Q 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical f ❑Standard City/Town Application Fee
$ 3rJo�
_ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ R5CO 2. Other Fees: $
4.Mechanical (HVAC) $ 0 List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3) QQ� ❑Paid in Full ❑Outstanding Balance Due:
MdIL I o
SECTION 5: CONSTRUCTION SERVICES
51I on�sttrztction Supervisory License(CSL) 591 O6 59 q O G 7 5 a.
y
11 1 1 CFFA-e,L R W I KO N License Number Expiration Date
Name of CSL Holder
. _-} List CSL Type(see below)
/J Nart U
No.and Street SI Type Description
{Z r�.l� YV�ass O 1 1 U Unrestricted(Buildingsu to 35,000 cu.ft.
City/fown,Stale,ZIP t I R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
-ff+B k,3 u i lrW trl d 171- SF Solid Fuel Burning Appliances
q r0-9a2-9963 Co. Cowl I Insulation
Telephone Email address D Demolition
5..2 I Registered Home Improvement Contractor(HIC) 6/ T(
8 3
1-�e AOUSC?W it I Q ht Cf� HIC Registration Number xpva on Date
HIC Company Name or HIC egIm t Name
ys N�4tzt s�I- hllk2@ ttiousewriul,Tco covet
No.and Street Email address
6e✓eR1 V� .4ss g78'-9�2-9963
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 ..........W 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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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 applii5 ion' true an orate to the best of my knowledge and understanding.
it
Mot Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
l 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
I Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Hnclosed Open
3. `Total Project Square Footage'may be substituted for"Total Project Cost"
X The Commonwealth ofMassachusetts Print Form,
Department oflndustrial Accidents
Office of Investigations
it l Congress Street,Suite 100 t
^J Boston,MA 02114-2017
Y www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organ fion/Individual): The Housewright Company
Address. 45 Hart Street
City/State/Zip: Beverly MA 01915 Phone#: 978-922-9963
Are you an employer?Check the appropriate box:
3 4. I am a general contractor and 1 Type of proconstect r coon d):
1.❑� I am a employer with ❑ g 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. ❑ Remodeling
ship and have no employees These sub-contractors have g_ ❑Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp.insurance.* 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 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.❑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.
lConuactors 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.
I am an employer that is providing workers'compensation insurance formy employees. Below is the policy and job site
information
Insurance Company Name: Guard Insurance Group
Policy#or Self-ins.Lic.#: HOWC219708 Expiration Date: 12/10/12
Job Site Address: 33 Warm 51 City/StatePLip: ytt2h l MM9 5' 01970
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 ofMGL 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 statementmay be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the pains aad enalties of pedu!Zthat the in ormalion provided above is true and correct
Simture: Date
Phone#: 978-922-9963
Offwial 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
Contact Person: Phone#:
ACORDoATE(MMIDOIYY)
CERTIFICATE OF LIABILITY INSURANCE,, DA
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
THIS CERTIFICATE 004S 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 pollcgfhis)must Ire endorsed. H SUBROGATION IS WANED,
subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certiticate
does not confer rights to the certificate holder In lieu of such endomme s.
PRODUCER COMPANIES AFFORDING COVERAGE
PAYCHEX INSURANCE AGENCY,INC. GUARD INSURANCE GROUP
150 SAWGRASS DRIVE A
ROCHESTER,NY 14620 caeeANr
B
INSURED
HOUSEWR16HT COMPANY ww�
PO BOX 247
BEVERLY,MA 01915
meaaev
D
COVERAGES .';CERTIFICATE NUMBIM 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.
O TYPE OF INSURANCE POLICY NUMBER WY) DATE(�EI�BIADON LIMITS _
GENERAL LIABILITY GERERALAGGREGATE $
COMMERCIAL GENERAL LIABILITY
PRODUCTS-COMP/OP AGO $
�I.AIMS MADE�JCCUR _
PERSONAL 8 ADV INJURY $
OWNER'S B CONTRACTORS PROT EACH OCCURRENCE $ -
DREDAMAGE(AWry fte) $
MED EXP ore persm $
AUTOMOBILE LIABILITY
ANY AUTO -iI GDMiHINED SINGLE LIMIT $ .
ALL OWNED AUTOS
SCHEDULED AUTOS BODaY RHJURY $
(Per Person)
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY $
PROPERTYDAMAGE S
GARAGE LIABILITY AUTOONLY-EAACCDENT $
ANY AUTO
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM
AGGREGATE $
OTHER THAN UMBRELLA FORM - $
WORKER'S COMPENSATION AND EMPLOYERS'LIABILITY HOWC219708 12/10111 12110112 X we srATo- m>F
EL EACH A1,C10@IT $ 100,000.00
x,�mom�erow
PARTNERyF%T<IINE INCL ELDISEASE-POUCYUW s 5W.000.00
(41Y sN EX)EXCL EL DISEASE-EA EMPLOYEE S 100,000.00
OTHER
DESCRPTIONOFOPFJtATION$ILOCATIMSIVEMCLES(Aemn ACORDf01.Addido,W Re=Sdedole,ff. spPm is repuloa)
CERTIFICATE HOLDER CANCELLATION
HOUSEWRIGHT COMPANY SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E194PAMM
PO BOX 247 DATE THEREOF.NOTICE WILL BE DELIVERED BI ACCORDANCE WITH THE POLICY
BEVERLY,MA 01915 PROVISIONS,BUT FAILURE TO MAR SUCH N07ICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
AUTHORED REPRESENTATIVE
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