3 WOODSIDE ST - BUILDING INSPECTION rt �� The ('ununumcealth of ;A1ussachuseus
---
0 t Huard of Buddllig Regulations .and Slandaids I t ll<
l i `lassachusetts State Building Code. 780 (',NIR. 7"' rditiun \II �1( lP \III 1
' p Building Permit Application Tn 'I,nstrurL Repair. Rrno\.atr Or I)rmuli.h a
�\ (hle or Tu -/-%,unit, Dtrt lint ro,v
t
['his See (in For Official Use Onl_V _ ---
Building Permit Number: Date ApplirJ -----j
-- ------
Signature: II I Cumy�fill.aunr Is iv Y , Rwldules
IX
L _ '1'ION 1: 51"1'E INF'UR,,L-,'PION
— — -- —
Ll Proper" Address: 1.2 Assessors Alap &, Parcel Numbers
I.la Is This an :trcrplyd slrrei_'.s_es_✓tu_ :\lap Nwahr:
1.3 'Zoning Information: I 1.4 Property Dimensions:
7_n;: - Du;rict - P.mwscJ L'.xo- !_.o: 4n•a ..y Gl F.;,: �::, i
LS Building Setbacks (f ) — -- — —
I Front Yard Side Yards Rear Y:ud ._
R!1e
Pro,
Rc uurd P 4 n>viJrd Reyu urJ PnniJrJ
1.6 upplly: (M.G L r �0, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:PublicPrivate ❑ Zone: — Outside Flood Zone:'
Check il'yes❑ Municipal ❑ On site Jislwsal system ❑—
_ SECTION 2: PROPERTY OWNERSHIPI fI
1 wnerlof Reco i¢U e Vti(
.\'.m:,� IPriorl Address for Sere ice:
Telephone
SECTION 3: DFSCRiPTION OF Pg.OPCSED WORK (checl; all that appl:)
NewCunstru:aion ❑ Existing Building Owner-()crupied ❑ Repalrstsl ❑ A!t.r;;um;sl ) i_\Junior ❑
Demolition ❑ Arceswr Bldg. ❑ Number of Units T _ —_ _-
5 K I Other ❑ Spcnly:.___
I Brief Description of Proposed Work': ----- -- -- ----------
S —
_ SECT'!ON d: ESTIMATED CONSTRUCTION COSTS —�
Item Isumated Costs: -- --- -7
t Labor,Ind Materials i Official Use Only
0=1
I. Building Permit Fre: $ Indicate hw Ire a Jetrrnuncdl ❑ Slandard Cityll-awn :\petitauun Fee
❑Tidal Project Coat' fItem fit .x multiplier xg 5 �, ether Fees: 5
cal IHVAC1 .5 i_istal tFire) y I Total Fees: S__—
('heck Nu. __Check :\mount: ('.I>h :\ntoune t I o Total Project Cost 5 --- —. .
_-- I / 6oG I ❑ Paid ut Full ❑ Out tandm ' BaJv- . - Du _
i
I
SECTION 5: CONSTRUCTION SERVICES --�4
5.1 Licensed Construction Supervisor (CSI,)
Lieeroe Number Fvpn;trion D.uc
Nainr of(SL" Holder L ! 1.1,1 CSL ripe i cc helm%)
�� ✓ f�, e Deuntrion
u r at
Wdr C lore>u�clyd
R ResuiAcJ I.@_' Fanuls -
- \ NI Ntasonrs Only
QJ7� / RC I2raJrnual ku,1linc l'mnine ._
frlrphune
SF Re.iJ:uua Sorid Fuel liw once \ li.n.. lu.i.l Lii iu
U Readruhul Urnpd won -
5.2 Registered Ilorne Improvement Contractor IIIIC)
"-
HIC Company Nam' or It R• Lstranl Name / 1
Address (/
Telephone
Signulurc
SECTION 6: WORKE S' COMPENSATION INSURANCE AFFIDAVIT (M11.C.L. C. 152. § 25C16)1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to proside
this affidavit will result in the denial of the issuance o p he building permit.
Signed Affidavit Attached? No ..Yes _........ .-.
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
to act on my behalf, in all m:uters
authorize
i
relative to w.>,k authorized by :his uilding permit application
--- --- 2 -�
-- Dale
Signature o1 Owner
SECTION 7b: NEW OR AUTHORIZED AGENT DECLARATION
(.
as Owner or Authorized Agent hereby decl:ue
that the statements and information on the foregoing applica on are true and accurate. to the best of my knowledge and
behalf.
Pont Name lJ
Date
Signature of Owner or Aulhoraed:\g nt
I Si gned under the I inns and penalties of r it NOTES:
1. An Owner who obtains a building permit to do his/her own work.or an owner who hires an unregistered runt ra,lol
(not registered in the Home Improvement Contractor (HIC) Program), will mR have access to the mhitr:uion
program or guaranty fund under M.G.L. c. 11'_'A. Other Important information on the HIC Program and
Construction Supervisor Licensing WSLI can be tound in 780 CNIR Regulations 110.RG and I itl.R5, respecmrle
When substantial work is planned. provWe the information below
Total floors area lSy. Ft.l (including garage. finished basen)enUatucs, decks or purrhi
H:Ibitable room count
I Gross living area (Sy. Ft.) Number of hrdnu tins —___---------._
Number of tuepla1es Number of halt/haihs ___ __------- --
I Number of baftoon)s Number tit Jerks/ --------
Tvpe of hearing system —
Type of"w1ing Nystern --
i. "Total Project Square Footage" rn:ly be substituted for 'fetal Project C o,t
From: Saundra Wtightington At MF&T Insurance FaxID:781-261-1 1 11 To:Michael Shea Date: 5/6/2008 09:16 AM Page:2 of 2'-
DATE(MM/ODrYYYY)
AL'or CERTIFICATE OF LIABILITY INS URANCE UNITEDR O5/06/08
PRODUCER 7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
MF&T Ins. Construction Div. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Construction Division HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
77 Accord Park Drive Unit B-1 -. TER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Norwell MA 02061 -
INSURERS AFFORDING COVERAGE I NAIL d
Phone: 781-261-2000 - --- - - ----
-'—' --
IN L rRn'
wsUREO - - . Northland Insurance
---------- _
f INSURER B: American International
United Roofing Contractors,LLC NSURER C------------ --
5 Brentwood Avenue INSURERD' _----------i-
Salem MA 01970 :NSOPPRE
COVERAGES
THE POLICIES OF IN9UFAIJCE LISTED BELCNr HA`✓E BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING
ANY REOUM12Eh1EN?,TERPA OR COIJDI."r`�'OF Ai lY CONTRA: OR Q71HEE.DOCUMENT� ITH R FE'�T TO WIi.CH THIS CERTIFICATE PLAY BE ISSUED OR
MAY PERTAIN.THE INFURANCE AFF DFLPEM B. THE PO IC. -DF.SC IBED HEREIN S SJB IE T T0.4L THE TERMS.EXCLUSIONS AND CONC:ITIONS OF SUCH.
POLICIES AG GPEGA E LIMITS SH,4 d MAY HAVE BEEN RED ICED?Y PAID CLAIMS - --
EFFECTrV
LTR NSR TYPE OF INSURANCE I__,_�
CtlNUMBER p�qM M;DDrW) DATE(MM/DD/iN)IN PC
LIMITS `
. EAR H�c '1P N�_e--Tg 1000000 GENERAL LIABILITY
i $ 100QQQ
A X eGnnMeRCIA'�C-ENERA�_uAci�iT� CPS54790 '0'S/O8/08 05/08/09 cREMI ;Eeneurr_-)
' R MED EXP(Pny one person) $ 5000
I CLAIMS MA C(
DE X 0.-,%I
1 �aE AL. AD( 1UIJP: $ 1000000 -
_ GENE ALA e 3L E $ 2000000
--� PRODUCT OMPAPAGG $ 2000000
SEW FcfA EL:MIT APPLIES PER
X PRCi —)IOC
X .POL I IErT __.
1 Otat r . 'YGLE.IMiT I7,
AUTOMOBILE LIABILITY
ANY.AIrO --- �—
ALL OvMNED,AUTOS BODILY IP:,IUHY
1 t I(Perpe N,'
SCriEDL�ED AIj 1 lS
I I BrnII m :TnY $
I 1 HIRED AUT0.S
1 1 IPVr a clrl t/
- NON OWNED 4C705 -
PROPEPTI DpP,AGE
- (Par aQndenl)
I
GARAGE OTFfcn THMI
LIABILITY AIJT.^..GiJCi-EA ACC!DEHT L _—
EA ACCY —
ANY AUTO I AUTO OIL'- ASS `s
r-1
-- EACH OC.CURPENCE
EX_�CESS/UMBRELLA LIABILITY
Of CLIP, I� CLAIMSM<S —�
DEDUCT;BLE '— �{-----
I RETENTION. $ QL'�T"TJ- V I
X DP; IMITB FR _—__—
WORKERS COMPENSATION AND
B ! 1-
DDDDD
Q5/Q$/Q$ D5/D8/D9 EACH DENC;
EMPLOYERS'LIABILITY
NYPROPRIE -)E/PARTNER/EXECUT!\'E WC 697-01-90 $ SOOOOOLE EA EMPLC'Ew I
OFFICER/MEMBE9ENIX.VD'D7 —
It yes,desmb«under I EL DISE1,E-POLK''l!MI- 1 $ 5DDOQD
SPECIAL PROVISIONS belovr
OTHER I 1
I
I 1
DESCRIPTION OF OPERATI0IJS f LOCATIONS I VEHICLES/EXCLUSIONS ADDED B'e ENDORSEMEPJT I SPECIAL PROVISIONS
Operations usual to insured;
CERTIFICATE HOLDER CANCELLATION
EVIDENC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIOI•
DATE THEREOF,THE ISSU114G INSURER WILL ENDER'✓OR TO MAIL 3O- _ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Ira AGENTS OR