77 WEBB ST - BUILDING INSPECTION (3) i
Z, The C'onunonweahh ol•Massaehuse(i
1� Board of Building Regulations and Standards CI'I 1.OF
�)•'r;, Massachusetts State Building Cole, 790 C'tiIR S,\LG\I
Revised 16rr•_'ll//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
(Ale-or Two-Familt Dtrellin•g
This Section For Official Use Only
Building Permit Number: Date Applied:
Iluilding Oticial(Print N�unc) Signature Date
SECTION I: SITE INFORMATION
1.1 Property I ,Address: 1.2 Assessors Slap& Parcel Number
� s� _
1.1 a Is this an accepted street?yes no Map Number Purcd Number ,
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area IN 11) Frontage(11)
1.5 Building Setbacks(it)
Front Yard Side Yurls Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G,1.c.40.554) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Privme❑ Zone: _ Outside Flood Zone? 1 Municipal❑ On site disposal Check fif es❑ P system ❑
SECTION1: PROPERTY OWNERSHIP'
2.1 Ownerl of Record: e
7 (,c/�
N;une it ri city.State,ZIP I
Nu.and Street I'dephone F:mail Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specily: aQ IX-
Brief Description of Proposed Work:_ ,C��/ �
SECTION al ESTIMATED CONSTRUCTION COSTS
licm Estimated Costs:
(Laborand.Materials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard CityrTown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
7, Plumbing g 2. -
_. Other Fees: S
4, Mechmtieal illy.\('I S Lisle
' S. \tech;wical (Fire - ---- -------- --...----- . .
tiu„rcssiunl S Total .\II Fees: S --.__.._.. .
Check No. _('heck Amount: (•ash \mount
I,, 11Ha1 Project Cost: S ❑Paid in Full p Outstanding Balmice Due:
SECTIONS: C0NS1'RUC'TION SF.RVI('v -- - ts
5.1 Construction Supervisor License(C'SI.) �( / 7
/ .T ------ J
... � (03
yz --._�./ u, --.--_ License Nmnhcr T�pirntian 1)alc
None ol'C'Sl. l)older
'I'%pe Description
trM
(InrcsuictcJlBuilJin'sli 1o15.UIWcu. 11.)
� -- ��" it I(eAriaeJ LY;l P:unil Dwellin
C'igi"awn,State.Ll M Ahuon
RC Rlatin C'oserin
...—. W'S W'indowand.Sidin
SF Solid Fuel Ilurning Appliances
I Insulation
Fele hone Finail address D Demolition
5.2 RezWeered Iloyme Improvement Contractor(HIC) C
jJ//( l VC I nC Registrltiun Number lisp rat ul
I IIC C'oalpan) Name or I IIC liegistrant Norse
No. as +S'jtget C G t Email address
City/To n,State,ZIP 7 fcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c, 152.4 2SC(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 Issujince of the building permit.
Signed AfTtdavit Attached? Yes .......... No........... ❑
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nwne(F:lectrunic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the infor lion
contained-in this applicati is true and accurate to the best of my knowledge and understanding.
Print Owner's or:\u rind,\gwds Name Ililectronie 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
I not registered in the Hume Improvement Contractor(HIC) Programl,will no have access to the arbitration
program or guaranty fund under.M.G.L.c. 142A.Other impunant information on the HIC Program can be found at
WI k 11"t" �;"+ ,,,,I Information on the Construction Supervisor License can be found at++)IU.IILI. fl:O\ -III,
2. W'hen substantial work is planned,provide the information below;
total (lour area Csy. ft.) - I including garage, finished basement attics,decks or porch)
(buss living area I sq. I),I " _ Habitable room count
\unlberol'lircplaca___ _ Numberolbedn:vnns
�unlher of hothroonu \umber of half'haulm
I)Ile of heating s)stem . . _ -. " Number of decks, porches - ..
I
I1 pe of e+4+11n_l' '%sio 1 IJ1e o,cd Idle))
{. "I"olul Project Square Foolagc"nrq he suhstitutcd 11rt"I1nal Project Cast.
it
y
CITY OF S:1i Nfv Akss:kCF- usETTS
SUMDOW OEP.1ATtLNr
120 WAS.4LVGTON STAEST, 11O FtOOA
I'M (978) 747-9595
Kll®ERLAY DAMOLL FAX(974) 740.98.id
MAYOR THO.K�s ST.PZE1tAs
DIRECTOR OP PLBUC PROPEATY/9CROLNG Co-%Oi1SS1ONEA
Construction Debris Disposal Aftldavit
(required for all demolition and rcnovation work)
In, and
with the sixth edition of the State Building Code, 7SO CMR section l l I.5
Debris, and the provisions of MGL c 40, S 54;
Building Pe the
M is issued with the condition that the debris resulting from
1 11, S I SOA.
1 work shall be disposed of in a properly licensed waste disposal facility as defincd by NIGL c
I
The debris will be transported by:
The debris will be disposed of in :
(nama o—fudl�Y1 ..�_
(iddreea oYF�cihty)
yn�N�e o(permrt IPphcint _
CITY OF SMu ENlp lAksSACHUSETTS
r BUILDING DEPARTMENT
120 WASI-IINGTON STREET, 3'a FLOOR
T'EL (978) 745-9595
F.*L.r(978) 740-9846
KniBERLEY DRISCOLL
AYOR THD\tAs ST.PiERRs
DIRECTOR OF PUBLIC PROPERTY/aunD1NG CO\LNIISS10NEIt
Workers' Compensation Insurance Affidavit: t)uilders/Contrac tors/Electricians/Plumbers
ALplicant.information 1 /� Plcace Print Legibly
V;In1C(Rusiixss.Organi7atium Individual): %l`1[4LA) ( C/1t
Address: /9W A w,7 a0 S� #—X �T•
City/State/Zip: .�7t l /_i� M4= Phone
A e no an employer?Check the proprette box: 'type of project(required):
I.[yI am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 lain a sole proprietor or partner- lived on the attached sheet t ?• ❑Remodeling
ship and have no employees These subcontractors have V. (] Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ puilditig addition
[No workeri comp.insurance 5. El We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
J.❑ 1 oln a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'cutup. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' I3 (�Other
cutup,insurance required.)
�Anv applicant der chucks bos oI must also fill out the xctiou below showing their wurken'compensarion policy inlbtmelion.
'I Lvncowrwvs-ha lu unit thin affidavit indicting ihry am doing all work and then him outride contractors must submit a new 311.div;l indicting such.
tlm M- lors that chuck this box must anwhod an addow ud short showing the mmato of iha tub•canoactom and their workers'wrap.policy infemution.
fain un eaployer that is providing Ivorkers'cuntpensaflan insurance jar my employees. Below/x r1le policy and job site
hrjornradan, .
Insurance Cuntpany Nmne: � Lryys
Policy 4 or Self-ins. Lic. 0: i eSA(m X(f�AWC IJ Expiration Date:
Job Site Address: �7 Cily/Statelzip:
Attach a copy of the won ers'compensatlon policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 2JA ot'bICIL c. 152 can lead to the imposition of criminal penalties of a.
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the forth of a STOP WORK ORDER and aline
Of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be furwardcd to the OI)ice of
In vest i gat ivas ul'lhc OIA for insurance coverage vcriticatiun.
l du hereby c•errijy raider the pants and peaulties ojperjury that the injornrutlo-ar provided ubuv iY ua and correct
P u ,1• /� /T
i
if211iciul use only, no not wrile in this area,to be completed by city ur town ojjlria2
�
City or town: —.—. Pcrmitfl.lccnse.9
Iuuing Aulhurily (circle uric):
1. IJoard of liealth 2. Iluildint;Depurnnent .l.Cilyi fnen Clerk 4. Electrical hlgtcctor 5. Plunlhinq Inspector
b.Other
Contact Person:
I
e �
1
Information and Ins$ructIl®us
alassacltuseus 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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,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."
,MG].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 or compliance with the Insurance coverage required."
Additionally. MGL chapter 152, §25C(7)states"Neither the commonwealth not 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-contractors)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 LLP 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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob 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
(i.e.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
Ofiice of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727.4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Rev:,cd 5-26-05 www.mass.gov/dia
CERTIFICATE OF LIABILITY INSURANCE 9/2 i 011
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: If is certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,subject to
the term 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 endoraema s.
PRODUCER NArriE Boynton Insurance
Boynton Insurance Agency PxoNE Far (781)449-6786 Ma.(Te1)449-4269
72 River Park Street ��:
PRODUCER CVSTGNEQ,00004109
I
Needham NA 02494 INSU s)AFFORDING COVERAGE NAM
INSURED INSURERAM" S ecialty
Kyron Inc. msuRERB:Hartford Insurance
I DBA Preserve Services INSURERC:
203 Washington Street,#256 INSURER D:
Salem,MA 01970
INSURER E:
I pERF:
COVERAGES CERTIFICATE NUMBER:14-18 Onion St. Condo 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.
RLISR TYPE OF INSURANCE Po11CY NUMBER POLN:YEFF NRPOUCYEXP Laws
OEMERAL LaIBIun EACH OCCURRENCE_ S 11000,000
x COWAERCML GENERAL LUIELRY PREMISES OEa amunenm S 50,000
A CLAMS-wm ❑a GCWR W=13100002122 /23/2011 /23/2012 NED EXP Vvy ono ) Is 5,000
PEtSONALSADVINJURY 1$ 1,000,000
GENERAL AGGREGATE s 2,000,000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG S 2,000,000
a Poucw O-PR Loc s
AUTOMOBILE UABRM COMBINED SINGLE UNIT
ANY AUTO (Ea arda,A) S
BODILY INJURY(Per peson) s
ALL OWNED AUTOS
BODILY INJURY(P.Wotd N) S
SCHEDULED AUTOS
PROPERTY DAMAGE $
HIRED AUTOS (Per accEMt)
NOWWMED AUTOS S
S
UtleRELLA UA9 OCCUR EACH OCCURRENCE $
EXCESS UA6 CLAMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ Is
B WORKERSCOMPENsAnoN RS MSTATU- oTH-
ANDEMPLOYELuourY YIN Z IN R
ANY PROPRIETORIPARTNER,EXECUTNE EL EACH ACCIDENT S 100 000
OFMCEPIMEMBER EXCLUDED? ❑ NIA
(Mandatory In NMI 86OUB0523HOO910 /20/2011 /20/2012 E.L DISEASE-EA EMPLOYEP.S 100,000
Nyyaaee,,clsarnLs m
DESCRIPnON OF OPERATIONS bebw IE.L DISEASE-POLICY LNIT I$ 500,000
DESCMPIION OF DPERATUMI LOCATIONS I VEHICLES(AtMch ACORD ICI,Adeeonsl Remuks ScM .1r a apecc M m"o M
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Prescott Village ACCORDANCE WITH THE POLICY PROVISIONS.
Lacy Road
North Andover, MIA AUTHORIZED REPRESENTATRIE '-
Michael Merrill/NRt -.--t2Z
ACORD 25(2009109) 01988.2009 ACORD CORPORATION. All rights reserved.
INS025(2aosos) The ACORD name and logo are registered marks of ACORD
n I
. trtmcnt of Pubtrc jafit;'.
( elt: 5t tnu:lt it
�; arhu>cit.- iuiatinn, urd�
a.. gtt a rl nt Smtrirn_K�
:�arsY.uc:tan=;;a=iyts�t l-
icF CS 93403.
°'$e; - ..
Res9nctmt .o:.
OCCNNOR
SEAN
z6 CHESTNUT ST
M,MA0070
SALE
- - ExPtratwn: '1213ia t .
- - Tr: 10208
.ioncr
F
I
ess ego a oo
sio
Office of oSnsan�mer CONTRACTOR
HOME IMPROVEMENT Type,
Reg DBA
�tltl istration 123553
V Expiration. 3162013
r�
Preserve Pamtm9-' `\\
Sean O'Connor #256 :-
=' g�
203 WASHINGTON'ST . 17ndersetmtary
SALEM,MA 01970 _- -
s