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33 WARREN ST - BUILDING INSPECTION (4) ga The Commonwealth of Massachusetts ## r y Board of Building Regulations and Standards " r Tt[`; ( FORS I Vp[ Massachusetts State Building Code, 780 CMR aka'w ��p�� USE Building Permit Application To Construct,Repair,Renovate Or 1J6't9Yo OO AyOW 2011 - - :One-orTwo-;F'amfly:lh+�lliPtg, �., _ ;' �TtrsSec7itln}rot'lf)"icsalVsg`auly = _ _ 13urldtuet<mtt=lJum"ber ate=APP� �- � -�,.�---E QH 0 ki Buz n al Ism am raw.,- MsF s OR— ME — 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers `3�3 u iA9tpr( S L l a Is this an accepted street?yes_ no Map Number Parcel Number 13 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 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ 2.1 wnert of Recor : S-J_ _ph Name(Print) City,State,ZIP , 33KA-2rtewl S'r St-" q 79- 3193S-c?2 -U No.and Street Telephone Email Address -- � I�TPTIOATO��I2�YYQ;SEIE'�-0IN ��g���=� _ New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Workz: �c cs2 2L�IS�"rng naw� Estimated Costs - 1.Building $ �-Burlditi��ettsuLF�$ �drdate hc �ee�s�eYermmetl Z.Electrical $ f1,5tau4arJ�. 11intv.Q-�pZteai4`o��e�. � t = � 1]TotaLPfo�zcT�os'���m�-li�x-nmlhplier �� 4.Mechanical (HVAC) $. _............ e _ ti 5.Mechanical (Fire Suppression $ Tatal All Fe s $ �r Cheek3lo ChefAmountashmount 6. Total Project Cost: $ �f�� p_PardwTulY ETC�u�stantirs Bala3ic��2u�� 12-1 5 CP4 m C'c `1115'/l� j `A 5.1 C uctio Supervisor C S License(CSL) t��9t7� O i 1-7 r� License Number - Expuation ate Name ofCSL Holder &r List CSL Type(see below) No.and Street T I}cya #toe s, ► aV I Unrcstricted(Buildings to 35 000 cu.ft. CityMwn,State,ZIP R I Restricted I&2 Family Dwelling M I Masonry . - RC RoofingCovens - - / WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registereo Home Improvemep�Contractor(MC) 13 7�1 p q (l_.Piny'rwe:Y/)i HIC Registration tFNumber VExpiration ate HI y Name or HIC Registrant Name No.and Stre�e� p (�i h't'r Email address City/Town, State,ZIP _ Telephone E I�i i� ITd >3 � 5"FkfiFA PG' Mel __ 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 ..........dF: No...........l7 I,as Owner of the subject property,hereby authorize to a my behalf,in all matters relative to work authorized)jy this building permit application. Ptint er's Name(Electronic Signature) Date By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained ' this�applica 'on is true and accurate to the best of my knowledge and understanding. Print Owner's o Authorized Agent's Name(Electronic Signature) Date 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 m .mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.$.) 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 Canwonwearth ofMassachreser£s 12eparftwnt oflndas&WAcdden& a Offlee oflnvesdgations 600 Washington Street Boston,MA 02111 www.m=goYMa Workers'Compensation hmrance Affidavit: lBuRdeasfContractonfflectrieMnat lumbers Avylleant Information / n Please Print L b Nme(gus ess/OrgauiaationRndividual):__�I a►{ - l�t�S • Address:_ /IS,>y`L�ETC�'✓� City/StaWZip:' ,St M 0,Z/(LV Phone#:AxA _ you an employer?Check the appropriate box: Type of project(required): KO I am a employer with 4• f] I am a general contractor and I employees(full and/or part time).* have hired the sub-contractors 6• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. f]Remodeling ship and have no employees These sub-contractors have g• Demolition working for me in any capacity. employees and have workers' COMP.insuraace.t 9. ❑Building addition [No workers' Comp. insuranceP• required.] 5. Q We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their I L Plumb right of exemption per � �repairs or additions myself.[No workers' comp. empti P MGL 12.E]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 fin out the section below showing theirworkers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating so& tContractors that cheek this box must attached an additional sheet shoving the name of the sub-conlractnrs and state whether or not those entities have employees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation ins7urwce for my employees Below is thepo&7 andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy.of the wor 'compensation policy declaration page(showing the policy number and expiration date), Failure to secure cover kne quired under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 an r -year imprisonmentas well as civil penalties in the form of a STOP WORKARDER and a line of up to$250.00 a day he viola . Be advised that a copy of this statement may be forwarded to the Office of Investigations of theD surance verageverificabon. I do hereeb fy an a aws penalties ofpedziry that the btformaiion provided above is true and correct. Si afore: Date: Phone#: OJYZC al use only. Do not write iR thigarea,to be completed by city or town ggrcmi City or Town: PermitUcense# IssaingAuthority(cirdeone): ' 1.Board of Health 2.-Building(Department 3.Citynown Clerk 4 Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone M. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An&Woyer is defined as`an Individual,partnership,association,.corporation or other legal entity,or any two or more ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased eraployerr or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MOL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or UP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permitnicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitAicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that.has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.where a home owner or citizen is obtaining a license or permit:not related to any business or commercial venture (Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth,of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.# 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.mass.govfdia �attp� Q a > x •• lase TOWN OF WINTHROP BUILDING DEPARTMENT OFFICE OF THE BUILDING COMMISSIONERANSPECTOR LAMES SOFM COMMISSIONER 100 Kemedy Dr,Wmthrop,MA 02152 Tel(617)846-1341,Fax(617)539-1545,Email js0p=@town.wiadnopm u DEBRIS REMOVAL.FORM Section 111.5 780 CMR, State Building Code states: "Asa condition of issuing a permit for the demolition,renovation,rehabilitation,or other alteration of a building or structure,M.G.L. c.40, subsection 54,requires that the debris resulting there from shall be disposed of in a properly licensed solid waste disposal facility as defined by M.G.L.I11,subsection 150A." Job Location: 3 fJs�dl tc�1'1 Location of F ity or Dumpster Company's Name and Address Signature f AWica& Print N e Building Permit Number: Date: Revised July.8,2010 /ro c ON SF,.•., a eFoh� . oGr�coo 'atio'f'On?OIF y� �'1q,LT"9TFS.'L ST �LS.T .' g j �3jblciyT �� c @o< a assa h yROAq�F o00A O RGc °j24��S .c��vrR7 °os�Oeo °'`e GSP -`902 �Q: - 00-. Oe cTo e77 6%�cc t'G�Go CS'io'tsOP 'S2 ,� Type }O° ST.B,q 2 1,p pB 9,QP9a�� O,y�'Qy c y,TO GAP�gn? Goa P�f . f'o 0 v?8 T QpO� ao G6 ve P^ i F+ 7� at; A6+ a CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYYYJ llt� 1 11/29/2016 ((i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS I 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: 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 I certificate holder in lieu of such endomement(s). PRODUCER CONTA T Ann Schraffa NA y ME: John E. Biggio Insurance Agency PHONE (617)846-8600 FAX YUC,No:(617)e46-8929 399 Winthrop Street Ei^AIL ADDRESS: mb gg 2@bi >_oinsurance.com ' ( INSURIER(SI AFFORDING COVERAGE NAIC0 { Winthrop MA 02152 INSURERA:EeaeX Insurance Companyf INSURED INSURER B.-American Zurich _ I Stephen Stoddard p INSURER C DBA Lighthouse Construction INSURER p: ) 1140 Saratoga Street INSURERE: _ l East Boston MA 02128 INSURER F: 1 COVERAGES CERTIFICATE NUMBER:CL162101898 REVISION NUMBER: e 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 INSR ADDL SUER POLICY EFF LTR TYPE OF INSURANCE POLICY NUMBER ID PMOLICY EXP OLIC OMITS a( COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ $ 1,000,000 i A CLAIMS-MADE ❑X OCCUR DAMAGET f PREMISES(_Ea occurrence S 50,000 3ED7329 1/29/2016 1/29/2017 MED EXP(Any Meperson) S 1,000 PERSONAL$ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- OTHER �JECT � LOC PRODUCTS-COMPIOP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea acdtlent , ANY AUTO BODILY INJURY(Par person) S ALL OWNED SCHEDULED AUTOS BODILY INJURY(Per acaccident)accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS AUTOS JPwamide,d $ i $ UMBRELLA LIAS OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION YIN 6ZZUB-7H74213-4-16 10/22/2016 10/22/2017 STATU �R AND EMPLOYERS'LIABILITY ANY PROPRIETOWARTNERIEXECUTIVE E.L.EACH ACCIDENT S 500,000 OFFICERIMEMBER EXCLUDED? ❑ NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 500,000 I If yas,describe under DESCRIPTION OF OPERATIONS twemv E.L.DISEASE-POLICY LIMIT S 500,000 1 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may beaeeched ifmom apace is required) t• 1 i I CERTIFICATE HOLDER. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE j Joseph Kay THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 33 Warren Street ACCORDANCE WITH THE POLICY PROVISIONS. Salem, MA 01970 AUTHORIZED REPRESENTA E ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) , I