144 WASHINGTON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
f Massachusetts State Building Code,780 CMR,7`s edition OF SALEM
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 1008
One-or Two-Family Dwelling
This Section For Offici Only
Building Permit Number: 1 Date pp1 f
Signature: A11 3
Building Commissioner/Inspec r of Buildings 1pate
SECTION 1: SITE INFORMATION
1.1 Pr erty Address: �a.1 1.2 Assessors Map&Parcel Numbers
1 5tv
u/astil -eed'
1.1 a Is this an an accepted reet?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own 'of RecortL
Name(Print) Address for Service:
178 4aa - 0 YOO
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)A
Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Propo ed Work': t
S U caPM �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost"(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ W List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
- C��� 1.✓�dh OttS`L!��
�0 �
l/ Awn
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constructio Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below)
Address T Description
U Unrestricted(up to 35,000 Cu.Ft.
Signature \\ R Restricted 1&2 Famil Dwellin
M Mason Onl
Telephone RC Residential Roofing Covering
WS Residential Window an'Siding
�\ SF Residential Solid Fuel Burning A212liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) t I � �
s v22S �rvc. �-�Ger+52 �Va 5hep+ yne u��nesS
HIC Company Name or HIC Re [rant Name Registration Number
Addresl "S9 0lQ S�'e+
V n 01 a3 4'7aQ 7� Expiration Date
Signature Tele one
SECTION 6:WORKE ' OMPENSATION 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 to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SE TION : WNER' OR AUTHORIZED AGENT DECLARATION
1' as Owner or Authorized Agent It declaze
that the statements and in mration on the f going application are true and accurate,to the best of my knowledge and
behalf. Leo k ho
Print Name
Signature of Owner o Aut orized Agent Date
(Signed under the pains and nalties of . ry)
NOTES:
Fru
wner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
gistered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
m or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
ction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
substantial work is planned,provide the information below:
s area(Sq.Ft.) (including garage,finished basement/attics,decks or porch)
g 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"
AC-ORD. CERTIFICATE OF LIABILITY INSURANCE OP ID &1
TECHA-1 01 26 li
PRODUCER - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Thomhs Gregory Associates Inc. - HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
601 Edgewater Drive 0235 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Wakefield MA 01880 -
Phone:781-914-1000 Fax:781-246-2601 INSURERS.AFFORDING COVERAGE NAICt
INSURED INSURER& Atlantic Chanter Insurance Co.
INSURER B: Peerless Insurance Co. 2419E
Tech-Air Systmn, Inc. INSURER C:
156 Maple .Street INSURERD:
Danvers MA 01923
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NS TYPE OF INSURANCE POLICY NUMBER DATE MMIOD DATE(MMU LIMITS
GENERAL LIAB&.ITY EACH OCCURRENCE £ 1,000,0 0 0
B X CCMMERCIALOENERA_LVBILRY CBP3003061 - 04/29/10 04/29/11 PR EMISEs(Ee ocarence) $ 300,000
CLAIMS MADE O OCCUR MED EXP(My one person) $ 15,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $2,000,000
GENL AGGREGATE LIMIT APPLES PER: PRODUCTS-COMPIOP AGG E2,000,000
POLICY JECT
P LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
MY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per Perspn) $
HIREDAFTOS
BODILY INJURY $
IXJDIOVJFED AIROS (Per eccidert) '
PROPERTY DAMAGE $
(Per eccidert)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
MY AUTO OTHER THAN EA ACC $
AUTO ONLY: ASS $
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE E
OCCUR F—ICLAJMS MADE AGGREGATE $
E
DEDUCTIBLE $
RETENTION E IS
WORKERS COMPENSATION AND X I TORYLIMITS ER
EMPLOYERS'LIABILITY
A MY PROPRIETORI'r ARTNER/EXECUTIVE WCP_0.0256209 06/03/10 06/03/11 E.L EACH ACCIDENT $ 100,000
OFFICERMPMBER EXCLUDED? E. DISEASE-EA EMPLOYEES 100,000
If ya,describe order
SPECIAL PROVISICNSb - - E.L.DISEASE-PO LIMIT $560,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITYAN ) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING HS{IITER VML ENDEAVOR TO MAIL 10 DAYS VIRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LMBILRY OF ANY KIND WON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIiED SENT&
&CORD 25(2001/08) 0 ACORD CORPORATION 1988
CITY OF S.u.F.N4 ti'L-1SSACHL'SETTS
BI:ILDLNG DEPART.%rENT
• 130 WASHINGTON STREET, 3aa FLOOR
TM (978) 745-9595
FAX(9711)740-9846
KI-tBFRLElf DRISCOLL
MAYOR THOMAs ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CON12,11SSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� C TPlease Print Leeibiv
Name (Busimx Organizatiorvindividual): Te () P J fIr V r>it yn S
III /
Address: l 5 6 YY10��e St re e N
City/State/Zip: 0any45, mA t 0 1.1-13 Phone#: 17 $ 777 — 719
9
Are you an employer?Cheek the appropriate box: Type of project(required): `
I X I am a employer with t 1 4. 1 am a general contractor and 1
_ — ❑+ have hired the sub-contractors 6. ❑New construction
employees(full and/or pan-bate).
2.0 1 am a sole proprietor or partner- listed on the attached sheet 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. q, El Building addition
[No workers'comp. insurance 5. El We are a corporation and its
required.] - officers have exercised their 10.0 Electrical repairs or additions
right of exemption r MGL I I.❑ Plumbing re
3.El i am a homeowner doing all work £� p per g airs or additions P
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs /t�I ,y
insurance required.]t employees.[No workers' 13.XOther �V�L I�P.0)A.L e.1 .1
comp.insurance required.]
j Any applicant that checks box#1 must also rill out the section below showing their workers compensation policy information.
'i hna:owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new,attidavit indicating such.
=Contractors that check this box most attached an additional sheet showing the name of the sub•contracwm and their workers'comp.policy infomution.
I am an employer that is providing workers'compensation insurance jar my employees. Below IT the policy and job she
information. /n
Insurance Company Name: A* a- +( C I YISW 111ce
Policy k or Self-ins. Liic.M WC A ®O a S (t ae Expiration Date: '
Job Site Address: 14 I W( fixky, 1l-],.Ut'i Ctt+- City/State/Zip: sdtle, 64,O)9 7C)
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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigutioru or the DIA for insurance coverage verification.
Ida hereby certify nder the Ins penalties perjury that the iuformadon provided above is true and correcA
SiLnature: 1 Date:
P o
Ouch d use only. Do not write in this area,to be completed by city or town afficiaL
City or Town: Permit/License/t
Issuing Authority(circle one):
1. Board of Health 2.Building Department 7.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
V M
�Bo&rb of Regiztratton of *beet �Retat uhrke .5
T9abing gatigfieb the requirements of �Ra5.qarbu5ett.5 general dab,
Ebapter 1122 section 237 tbrougb 251
i$ berebp granteb tbi$ certificate no. 82 a.' ebibence to practice a$ a
beet fRetat 39u5t" u,e.55
on tbiq 140 bap of ®rtober 2010
In Tegtimonp 3Dbereof, i$ bereuuto affiXeb the name of the CExerutibe Mirertor of the jBoarb
d (October 21, 2010
QExe[utiUe ire[tor � ,� �IDate
j
y MMMONWEALTH OF MASSAOHl7SETTS
. _
SHEET METAL WORKERS
���15�1INASTER-UNRESTRICTfb ,
SSUES ii ABOVE CENSE TO
tv
1K HA
2�ib HIGHLAND ST
��' S HAMILTDN MA`�01982=i306 `'
➢ .' 2462 11/28/11 88B041_
LICENSE No. EXPIRATION DATE SIERIALNO.
F DEPARTMENT OF PUBLIC SAFETY
Refrigeration Technician License
1` as
- } Number RT� 021170
Expires 411/30/2012 Tr.no: 759.0
RestH—'d 00 t}
i
3 LEO D KULHAVY
f 246 HIGHLAND ST` �,,, !`� �-- ,
S HAMILTON, MA
Commissioner
DEPARTMENT OF PUBLIC SAFETY i
Oil Burner Technician Certificate
Numb
e 1BU, 120251
s
,Expire31 s 1t30f20;11 Tr.no: 1863.0
Restricted, DO—' 1,j
246 HIGHLAND
SO HAMILTON, MA 01982
Commissioner �