6 WHITE ST - BPA-10-446 INSTALL 6' SLIDER The Commonwealth of Massachusetts CITY
A Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR, 7ih edition ALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
Th' ection For Official Use Only
Building Permit Number: Date Applied:
Signature: '�!-
Building Commissioner/kspectoro uildings Date
SECTION 1:SITE INFORMATION
11 Property Address: 1.2 Assessors Map& Parcel Numbers
6
L la 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
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public O Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnert of Record:
rJ t^e SS G �.�1�2 Sflee V Nt�
Nam rint) Address for Service:
998- S '7&- r78Y4
gignatvje Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 171 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': Zr-- la 6 C No y-e e-ii M?
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:
El Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost' (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ rj^ 60
dt�- El Paid in Full ❑ Outstanding Balance Due:
C C)i d
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) e.5 7.I 9 1 3 �
QI,enrN S qeNA License Number Exp at n Date Name of CSL-Holder
�"u 1G1 e ! 5t List CSL Type(see below) 00
Addres Type Description
U Unrestricted(up to 35,000 Cu.Ft.) ,
R Restricted 1&2 Family Dwelling
nature M Mason Only
(�" o RC Residential Roofing Covering
Telephone - WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Imp ovement Contractor(HIC) 13
Gke nr N �ry ra�,N�
HIC Com any Nay r IC Registrant Name Registration Number
N r ez P�NJ\<3" , 60'.0131O
Addres f r1 a6 1D
, � q7 a-gb q"O3 52 xpira[ion Date
Signal 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 .......... No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, R YO tJ Mess 1 o.O,.V , as Owner of the subject property hereby
authorize--i)t_xc„ to act on my behalf, in all matters
relati e to work authorized by this building permit application.
I Oo
'SlEnatilre of Owner Date
c,,� SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, t/ua hNe Fu 1le,r ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Messe�a�.f
Print e
� (50 Y
Signature of Owner or Authorized Agent Oatq
(Signed under the pains and penalties of er u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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
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"
.,operrmenr of inaustnai Aeeivents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information A Please Print Legibly
Name(BusinessrOrganizatiowlndividual):�y " -, /J'
Address:__
City/State/Zip: ^f F-v.AaaLe.t p o Phone#:
Are you an employer? Check the appropriate boa: Type of project(required):
1.❑ I am a employer with 4. [j I am a general contractor and I 6
❑New construction
emplyees(full and/or part-time).' hate hued the sub-contractors
i 2.X1 am o a soleproprietnr orpartner- listed on the attached sheet t y ❑ Remodeling
ship and have no employees Tbese sub-contractors have 8. E] Demolition
working for mein any capacity. workers' comp.insurance. 9. Building addition
o workers'co insurance 5. ❑ We are a corporation.and its
romp, 10.0 Electrical repairs or additions
required.] officers have exercised their
3. I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself[No workers' comp. c.15% §1(4),andwehaveno 12.0 Roofrepairs
insurance required.]t employees. [No workers' I 13.❑
comp.insurance required.]
•Any applicant that chador box#1 must also 5n out The section below showing their wo,km'compensation policy infonnatian:
r Homeowners who sub as this affidavit indicating they are doing all work and then him outside conLadoramust submit anew affidavit ideating such.
%Contractors that chock ibia box most attached so additional sheet showing the name of the.sub•cantmcton and their workers'comp,policy information
I am an employer that is.providing workers'compensation insurance for my employees- Below is the policy andjob site
injormatron _
Insurance Company Name:
Policy#or S elf-ins.Lic.#: '✓ 10 `fO a Expiration Date:
Job Site Address: City/Stattzip: —
Attach a copy of the workers' c a e .
Faihtre to securcoy errege as required under Section 25A of MGL 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 statement may be forwaided to the Office of
Investigations of the DIA for insp a e-e coverage verification,
I do hereby cat 1 under ih sins and penalties f perjury thar the information provided above is true and correct
rSienahue: - 1" 7 Dater
61
Phone#: 9 — 03s'z
Official use only. Do not write In this area,to be completed by cityor town official.
City or Town: Permtt/Lleense#
Issuing Authority(circle one):
1.Board of Health Z.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: ' Phone#:
SULLIVAN INS PAGE B1%81
CERTIFICATE_OFIi LIB OLITY INSURANCE 6/29/�/200
P'noouckH I THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION
Tewksbury Ineuranoe I; ONLY AND CONFERS NO RIGHTS WPON THE CERTIFICATE
$$5 Main Street HOLDER. THIS CERTIFICATE DOES �07 AMEND, EXTEND OR
.1 ALTER THE COVERAGE AFFORDED Y THE POLICIES BELOW.
Tewkabury, MA 01876 I'
978-851-9600 i! _ INSURERS AFFORDING COVERAGE I NAICR
PLsuRED SargatZ�KimCdekl ing I, suaexwVermont Mu ua Gm}ap
Glen Sargent f ,"W;IS s: ymouth Rock Ammuaanee -
18 Chandler Circle INspg�R��urle Znaurance any J
1 Andover, I.M 01810-2805 rmsuRERc i�-�
IL_�— 1 WSIjRE0.e
COVERAGES '
THE POLICIES OF INSURANCE LSTEO BELOW HAVE BEEN 153UEt "O THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING
ANY REQUIREMENT TERM OR CONDITION OF ANY CON CT f OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
I i
MAY PERTNN,THE INSURANCE AFFORDED SY THE POOL. DE: I:RIBEb HEREIN IS SUBJECTTO ALL THE TERMS.EXCLUSIO AND GONOMIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MA V RAVEBEENRE DUGEC iY PAID CALMS,
'1�R Ini TYPE DF IN557B POD �+NI1MB II_ ICY Plbm LINKS
GENFRM uABR.m EACH occuryceNcc 3 500,000
R COMMMO.W EVER UPSILRY PREi.B9E6 EEq.m�aw�rccL c 50,000
I CLASMSMwe �I DGcuR MBD EXP Mn yplla Pare�R1 S 5,000
A SP-1100 I15 0S/01/09 05/01/10 PERSON46 VWURY S 500,000
GENERAL A REGATE S 1 000,000
GENT AGGREGATE LIMB APPLIES PER: PIODUCTB-SOMPIDPAGG S 1,000,000
j rl
POUCY P
E, - r�LOC
AUTOMOBILELIABILRY _ C SINGLE LIMIT
SIN LIMB 3
(Ee 3crida:T) !
I I NiYAUTO I
ALL OWNED AUTOS I I DOOILYINJUIY , 50,000
I A WHEOULED AUTOS
B HIRED AUTOS PRA1000. 99' 048 I07/14/08 07/14/09 BopavWnn(Y s 100,000 j
NON-OWNEOAUTOS (PvPtt.Mad)
i PROPERTY OHMAGE. = 100 000
. I Ovremen3l
GARAGE UY TUTY AULD ONLY-11AC01DE14T 3 I
AHYAUTO OTHER THAMI EAAGC S
AUTO ONLY:
I�¢nI����'�"" ACG s
ECESBVMSRELIA LABILITY EACH OCCw}/ tE '3
OCCUR CI CIAtMSMAOE AGGREGATE! S
� 3
DEDUCIBLE
REfENT10N g I OIDEWNT
6ZZUB- 6052 L4-4- 06/09/0-9 06/09/10 EL EACHA s 100,000
NY�PPOWUEIOMAATIFA?�'RVfNE
C 09 S.L.DISEASE!-ea ErIPLO s 100 1000
,
'I BCALPROMS10 61,D:SEASt-POLICY LWIT s 500 000
s�EcwLPRLrASIONs�D.,
OTHER
OE9CRIPTION Of UPERATONBI LOCATONS/VEHIClE31 E%CLU310N AODEC I:�ENpORSEMENT/SPECwLPRON510N5 ! I
Glen Sargent is not covered urier !lain .Worker's Comp Policy.
j I
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I
CERTIFICATE HOLDER CANCELLATION
Monahan Lumber SHOULD ANY OF THE ABOVE DESCWBEO POLICIES gE CANCELLED BEFORE THE E VIRATION
Mon hanChe Lumber
Street DATE TNEREOF,THE ISSUING WSURER WILL ENDEAVOR TO Ma-Q DAYS WRITTEN
North Reading, ee O1 B 6 NOTICE TO THE CERTIFIGITE HOLDER NAMED TO�HE LEFT BUT FAILURE TO OO SO SHALL
NPD6E NO OBLIGATION OR LLABPJTY OF ANY I<,4D UPON THE INSURED..ITS AGENTS OR
j REPRESENTATIVES. 1
AVMORILE REPRESENTATYE —�
I 978-664-9078
A R 25(2001/0R) � ®ACORD CORPORATION I9B8
I
I I 1
I
MOYNIHAN LUMBER CO.
Moynihan Lumber of Beverly, Inc. Moynihan North Reading Lumber, Inc. Moynihan Lumber of Plaistow LLC.
82 River Street 154 Chestnut Street 12 Old Road
P.O.Box 509 P.O.Box 128 P.O.Box 116o
. Beverly,MA 01915-0509 North Reading,MA 01 8 6 4-01 28 Piaistav, NH 03865-1J60
(978)927-0032 FAX:(978)927-8658 (976)664-3310 (781)944-8500 (603)382-1535 FAX:(603)382-1935
FAX:(97j88))664- 72
❑. LJc ❑
Subcontractor Workers' Compensation Waiver
I (� I&l So v 1- 'T hereby acknowledge that I, as an independent
contractor, have been asked by Moynihan Lumber Co. to provide it with a Certificate
of Workers' Compensation Insurance coverage for myself. Based on the exemption
provided by the Workers' Compensation Insurance coverage for myself because 1 am
a sole proprietor without employees. Therefore, I hold Moynihan Lumber Co. and it's
related organizations and the Arcadia Insurance and or Self Insured Lumber Business
Association, Inc..totally-harmless for any injuries or cost of injuries incurred by myself
because I have voluntarily chosen to exclude myself from coverage by engaging
the exemption provided under the Workers' Compensation Laws.
I have taken this option of my own free will.
I
I, WITNESS SIGNATURE
— — DATE: 6- 9-o 6-
whim. Moynihan Yellow:Installed Sales Pink:convact ..
Forma 1203
i
k[nssachuscitr- Dcpnrtment of Public Sul-et,
Board uf.BriildinG Rclndatinnx;wd S4lmlards \
Construction Supervisor License t
License: CS 70913
Restricted to: 00
GLEN SARGENT
18 CHANDLER CIRCLE
ANDOVER, MA D1810
Q--
Expiration: 5/4/20{t
f'nniutlsd°nrr Trp: 14814
o \
❑edtE6n ,,� .�i .
1 � 1i �Yrcu�tM(i�1(N License ar registration valid for' dividul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. fau d return to:
Registration: 131640 Board of Building Reghla lionIf s an Standards
Expiration: 8/17/2010 Tr# 274244 One Ashburton Place Ron1301
Type: DBA Boston,Mn.02108_
GLEN SARGENT
GLEN L 'f
18 CHANDLER CIR. -� --
C l bwQs
ANDOVER.MA 01810 Admiuisiratar Not valid lvalloul signal re
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Sax
ui ng egu aons aai an
One Ashburton Place - Room 301
i Boston. Massacliusetts 021
Home Improvement Contractor Re stration
Aistration: 13686D
Type: Private Corporation
MOYNIHAN NORTH READING LUMBEt'r; IN " F$xpiracon: 9/6/2010 Tr# 274710
JOHN MILLER JR,
PO BOX 128
N. READING, MA 01664
.. PAdd Ad ._ ..
Update Ad I . ... .... .___.. ._..
@ss and return card,Mark reason Por change.
orscwr o sow.o>roi.res+aa - '
I-, ❑ $enewal [1 Employment U-II Lost Cerd
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