0017 MARLBOROUGH ROAD BPA -13-405 INSUL. The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code,780 CMR USE
Building Permit Application To Construct, Repair, Renovate Or D olish a Re ' ed Mar 2011
One-or Two-Family Dwelling
This Section For Offici Use
Building Permit Number: I DateApplied:
Building Official(Print Name) signs. Date
SECTION 1:SITE INFO N
1.1 Property Address: 1.2 Assessors M 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 fi) 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private ❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Ownerr4Record:
y I _,�
am;(Print City,State,ZIPNo. Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units - Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION C 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 p
3.Plumbing $ 2. Other Fees: $ f�
4.Mechanical (HVAC) $ List:
5,Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) — '�License Number Ex irati Date
N .Ce �f+/C�SL�Holder Q List CSL Type (see below)
Type Description
No.and Street
//,, q U Unrestricted Buildin s u to 35,000 cu.ft./ VZ 99 t R -Restricted 1&2 Family Dwelling
ity/Town,State,ZIP. M N4awnry
RC Roofing Covering
WS Window and Siding
SF - Solid Fuel Burning Appliances
Tn-sulat
TelI Demolition
Tele hone Email address � D Demolition
5.2 Registered Home Improvement Contractor(HIC) /jA `� 1
HIC Registration Numbec E irati n Date
HIC Company Name or HIC R69istrantNamc
an eet Email address
z D CR�Reo-��
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFEIDAVIT(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
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 Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con e m this application i's(true and accurate to the best of my knowledge and understanding.
PrintO.P t�L 1 ��� 40&41—
or Authorized Agent's Name(Electronic Signature) 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
Any.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dus
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"may be substituted for"Total Project Cost"
w.n
next step living
tmrrie emdexy,nwEe eery -
. - _._ CONiftIICTOR .
This agreement is made by and among
Market Shield
17 Madboroogh Rd Next Sep Living,Inc(•NSL
21 Salem,MA 01970-1813 _ � 2-floor
Bos
02210 -
CustomerID:C0061)(1111ISM Contract ID:20120789-1 WORK _
. Site ID:S00002070651
1. DESCRIPTION OF WORK TO BE PERFORMED - -
NSL wg perform orcause ta be performed the following work on the tstomees address above,In a professional mannerand in aocadanoe weh the tams of
this Contact Irwduding the atached netommendations1work order desalbirg the work in detail(the'Work')which are incorporated herein by reference:
. Dwcdotl= amorally Location
Insulate MuI1FLaw Sidtg Wag With r Dose Palk Cetulose _ 883 Living Space,
knutats Wood Shinuls Sided Wall With 4-Derhee Pack Cellutme 83 Living Space $199.
Sub Total: - $2,270A0 _
Energy Ef0dancy Incenthm $1,702.80
Net Sales Taa After Incentive $0.00.
. . Tots! '$W7.80
. - - Printed:7112FM2 Pagi of 2
2. PAYMENT:CUSTOMER agrees to pay NSL forthe work as follows:
PaymaMRt$
CmdB Card or Ectteck deposit's due at the tare tha Work is schaduled.Regulmd payment information wit be owlecledmmr the phone by a customer service -
representatveatthetmeofschedulih!). Deposhls notto wx;aW 113d to total retail cross. This contract is not in effect until this deposit is paid by the
Customer.(Nos:Mastercard,Vsa,ant Dsoo w accepted) _
Additional Payments ant Final Invoice:$ y671
ko
-Additional payments for the Work shell be due upon oomplaton of the Wort _
Oct 11, 2012
Customer SgWarre - Date
NSLSignature --- D Name of NSL Representative
The Terms of this Agreement'are contained on both sides of this page
Next Slop 1"21 Drydock Avenue=2m floor•Boston.MA 02210•(888)867A729^inqulry@nextstaplMnglnccom•wv w.nenstewnfilre eom
(
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e1�Il IC��1/OTC/UT/�@//i�i?�����Af aii artd usinjess ]regulation
office of Consumer
101'ark Plaza- Suite 5170
Boston,Mil§gachusetts 02116
Home jnprove j3Qontrract®r Registration
Registration: 162111 _
•' �' "'''".- -°' TVpe: Supplement Card
:`::1 - = '• i. Expiration: 1114/2013
NEXT-STEP LIVING INC. • ;' ''';W
BRIAN HESSION =t_ s..- F`, •
25 DRYDOCK AVE. 5TH FL
BOSTON,.MA 02210
-- - Update Address and retum card.Mark.reason for change.
-' - Address fltenew'alr D Bmplayment 0 Lost Card
]OIYV`G1012\6 ' -
. �/ee'Poavxmcorunealf6i o�\ -
lue of Consumer Affairs&.ausimsRegula6on License or reglstratlon Valid for iRalVldnl use Only
- before the expiration date..If found return to:
n1flE IMPROVEIyIENT CONTRACTOR .
r..., Office of Consumer Affairs and Business Itegplation
egistratlonr :I62111 Type- . lOParkPlasa-Suite 5179r
Eupira n's'''; (gY,13, SupplemenlCard Boston,MA02116
_
OK P.VE.?5T(Ilf0'".'.:� q_•. ._ � 'ur•y� .
JIA _ Undersecretary Pigtvalid withoutxi ature
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Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Cunstructi(m Super% isor Spccialtx I
License: CSSL-102811 l
ROGER A OVELLETTE .r,_,-
55 STANMORE ROAD
Warwick RI '028$9 � 4 .a
Expiration E
uommissionei 09M/2014
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Restricted To: CSSL-IC -Insulation Contractor
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Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS Licensing information visit: www.Mass.Gov/DPS
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ACORD- CERTIFICATE OF LIABILITY INSURANCE 9/06/2012
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
William Gallagher Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Insurance Brokers,Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
470 Atlantic Avenue
Boston, MA 02210 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: One Beacon Insurance Company. 21970
Next Step Living, Inc. INSURER B: A.I.M. Mutual Insurance Co. 33758
21 Dryd Ook Avenue INSURERC
2nd Floor
INSURER D:
Boston, MA 02210-2600 - INSURER E:
i
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 CONTRAOT 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.
POLICY EFFECTIVE POLICY EXPIRATION LIMITS NSR TYPE OF INSURANCE POLICY NUMBER DATE /Do YYYY DATE MM DD
A GENERAL LIABILITY 792000560 11/11/2011 11/11/2012. EACH OCCURRENCE .$1000000
X COMMERCIAL GENERAL LIABILITY PREM SES RENTED n $1 000 000
CLAIMS MADE Q OCCUR - MED ENT,(Any one person) $1 O 000
PERSONAL&ADV INJURY $1 00O 000
GENERAL AGGREGATE s2.000.000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $1 OOOOOO
POLICY PROJECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIREDAUTOS - BODILY INJURY
$
(Per accident)
NON-OWNED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG $
A EXCESS/UMBRELLA LIABILITY 792000561 11/11/2011 11/11/2012 EACH OCCURRENCE $1 000 O00
X OCCUR CLAIMS MADE AGGREGATE $1 OOO 000
$ t!E
DEDUCTIBLE $ Fk
RETENTION $ $ 1
B WORKERS COMPENSATION AND AWC7025153012011 11/11/2011 11/11/2012 X WORYC STATU� GTH- .
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 OOO
OFanFICd ER/MEMBER EXCLUDED?
(M atdry In NH) N E.L.DISEASE-EA EMPLOYEE $500 000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Certificate holder is included as additional insured as regards General Liability where required by written
contract. Coverage is subject to the policy terms and conditions.
:ERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL An DAYS WRITTEN
NOTICE TO THE CERTFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIYE
WORD 25(2009/01)1 of 2 #S290682/M242379 0 1 8 -200 CORD CORPORATION. All rights reserved.
Tha Ar7nRn name and loan are registered marks of ACORD MCL
The Commonwealth of Massachusetts Print Form
--=- Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100 )
Boston, MA 02114-2017 ,www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/]Electricians/Plumbers
Applicant Information Please)Print Le i� bly
Name (Business/Organization/Individual): Next Step Living Inc I
Address: 21 Drydock Ave
City/State/Zip: Boston, MA 02210 Phone #: (617) 850-9101
Are you an employer? Check the appropriate box: Type of project(required):
1. ✓0 I am a employer with 400 4. ❑ 1 am a general contractor and 1 6 ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ 1 ship
a sole proprietor o partner- These sub-contractors have
ship and have no employees 8. ❑ Demolition
employees and have workers'
working for me in any capacity. ,. 9. ❑ Building addition
comp. insurance.*
[No workers comp. insurance 10.❑ Electrical repairs or additions
required.] 5. ❑ We are a corporation and its �
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers comp.
right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no Insulation
employees. [No workers' 13.� Other
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
iContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
{
I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: A.I.M Mutual Insurance Company
Policy#or Self-ins. Lic.#: AWC7025153012011 Expiration Date: 11,111/2012
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and ekpiration 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine i
of up to$250.00 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 hereby certi under the ain an4 en ies o er'ur that the information provided above is true and correct.
Signature: - - Bate: t-)- L E
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
I
6. Other
Contact Person: Phone#: