21 WILLSON ST - BUILDING INSPECTION r
rThe Commonwealth of Massachusetts
^ Board of Building Regulations and Standards CITY OF
\�J1 Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate O Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A lied:
Building Official(Print Name) Signatur� W. L/',/vl//D/'a/t1e/',
SECTION 1: SITE INFORMATION
1.1 PmVddres • 1.2 Assessors Map&Parcel Numbers
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) a
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, Owner'of Record:
Ga-�f Pci 11"m la r, WN'
Name(Print)- Xl City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Descrip on of tProposed Work :
K Q 6a,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ JC 1. Building Permit Fee.Ar indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee;
❑Total Project Cosl3(Item 6)x multipli11
er x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (ffVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ���W 0 Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) lj 530-3 t't.
License Number Expuat on Date
Name fCSLHolder
List CSL Type(see below)
To.and Street !— J Type Description
�1 S 1 /` U Unrestricted(Buildings u to 35,000 cu.ft.)
I�� ��a R Restricted 1&2 Family Dwelling
City/Town,StW,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
r 5b I I Insulation
Telephone Email address D Demolition
5. Registered Home improvement Contractor(HIC) 9 5,37 5
�t.Pd Q ) !1-P vv��l C.0�1'�,jF- r l>5�'�1 aA HIC Registration Number Expiration Date
HIC mpany Name or C Registrant are
110 cm1 _ � SL. _f
No.and Street Email address
S . f 9 yj � a19� k�ti�7y� 30�
City/Town,State,ZiP Telephone
r
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,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.
Pnnt 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 pedury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print O er's or Authorized Ag nt's Name(Electronic Signature) 1 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.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 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"maybe substituted for"Total Project Cost" °
1
Massachusetts - Dep u-tntent of t'ublic Safetv.
Board of Building Rt ulations and Standards
Construction Supervisor License
' License: CS 53693
I "ROGER A �TREMBLAY A
29 HATHAWAY AVE,
BEVERLY MA;01916
Expiration 5SM13 v� ,
(ummnaniner Tr#: 15182
lie Consumer
C/c Business
Regulation a
Office of Consumer Affairs&B siness Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 145375 Type: Office of Consumer Affairs and Business Regulation
- .z Expiration: 1/13/2013 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
20 ERA TREMBIEY CONTRACTORS, INC.
4
t
100ER TREMBCOLONIAL
E_1 r
10 COLONIAL RD SUITE-4
>ALEM, MA 01970 UndersecretaryI�U�2
At valid without signature
AC40R CERTIFICATE OF LIABILITY INSURANCE /12/011
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 the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED, 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
certificate holder in lieu of such endorsement(s).
PRODUCER NO TACT Construction
Eastern Insurance GI'OUP LLC PHONE (SOH)6S 1-7700 FAX No:I50e165s-e853
233 West Central Street D RE
PRODUCER p0033507
Natick NA 01760 INSURE S AFFORDING COVERAGE NAICIt
INSURED INSURERA:Selective Insurance Co of SC 19259
INSURERsArbella Protection Ins. Co. 1360
'ROGER A TREMBLAY CONTRACTORS INC INSURENICHartford Und.-WC Pool
10 COLONIAL RD
INSURER D:
SUITE 4
INSURER E
SALEM XA 01970-2943 INSURER F:
COVERAGES CERTIFICATE NUMBER34ASTER 2011.5 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.TD ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE DL POLICY EFF POLICY EXP
LTR POLICY NUMBER MMIDD MMIDD LIMITS
FCIAIMS-MADE
EACH OCCURRENCE $ 11000,000
MERCIAL GENERAL LIABILITY PREMSES E �o $ 100,000
A X OCCUR 1842342 /15/2011 /15/2012 MED EXP An we person E 10,000
PERSONALS ADVINJURY $ 1,000,000
GENERAL AGGREGATE $ 3,000,000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 3,000,000
JECT
POLICY R PRO- LOC $
AUTOMOBILE LIABILNY COMBINED SINGLE LIMIT $ 11000,000
ANY AUTO (Ea accident)
B ALL OWNED AUTOS 59013400004 /15/2011 /15/2012 BODILY INJURY(Per person) $
X SCHEDULED AUTOS BODILY INJURY(Par ac*Iwt) $
X PROPERTY DAMAGE
HIRED AUTOS (Per acddenU $
X NON-OWNED AUTOS Medical payments $
PIP-Bask $
$ UMBRELLA LIAB [XN OCCUR EACH OCCURRENCE $ 2,000,000
EXCESS DAB CLAIMSIUADE AGGREGATE $ 2,000,000
DEDUCTIBLE
A X RETENTION $ 0 1842342 /15/2011 /15/2012 Is
L+ WORXERS COMPENSATION X I WC STA71% OTH-
AND EMPLOYERS'LIFBILITY YIN LIM
ANY PROPRIETOMPARTNERIEXECUTVE E.L.EACH ACCIDENT $
OF I(MaICCEa�EBMBER)EXCLUDED? NIA A33507 /1/2011 /1/2012 500 000
E.L.DISEASE-EA EMPLOYE $ 500,000
Hyyeeaa desaitMunder
DESG�RIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT i$ 500.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addlepnal Remarks Schedule,Nmove Span Ia required)
TOWN OF FRAMINGHAM IS RAINED AS ADDITIONAL INSURED.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PMA
ACORD 25(2009/09) 01955.2009 ACORD CORPORATION. All rights reserved.
INS025(28oso9) The ACORD name and logo are registered marks of ACORD
CITY OF Siu.&N4 INL1SSACHUSETTS
Bun=NG DEP.mMIENT
• 120 WASHLNGTON STREET, 3"a FLOOR
e� TEL (978)745-9595
FAX(978) 740-9846
KINIBERMY DRISCOL
T
i�AYOR 3iOMAS ST.1?IERRIi
DIRECCOR OF PUBLIC PROPERTY/BUILDING COMBSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
dame(Busimm organization/Individual):_I'1&29P, WA)Ir-4
Address: e 0 C.plo>n) Q 4°J L 4, L/
City/State/Zip: JCl�D m YY^ U I� Phone hlb?P���� 5 C�
.re ou an employer?Check the appropriate box: Type of project(required):
am a employer with?A� 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers ME]Other
comp. insurance required.]
•Any applicant that checks box#1 most also fill out the section below stowing their workps'compunution policy infumradon.
'I Iomeownnc who submit this atndavit indicating thcy are doing all work and than hire outside contractors must submit a new affidavit indicating such
:Contractors that chock this boa must anached an additional sheet showing the name of the sub comracton and their workers'comp.policy infotmatirm,
l am an employer that is providing workers'compensation hisurance jar my employees. Below Is the parley and fah site
information. } /
Insurance Company Name,
_T4✓1
Policy#or Self-ins.
�Liie.#:_ l LA 3 S 5"i?�:) Expiration Date: `7
lob Sire Address• City/State/Zip:
Attach a copy of the workers'compensation Polley 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 S1,500.00 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
Investigations of the DIA for insurance coverage verification.
I do Irereby certify under the pains and penalties ofperfury that the information provided above is true and correct.
1 ore: K, Ao�-� V2q Date: l) 2
Phone
Offeciad use only. Do not write in this area,to be completed by city or town offtcialL
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#: