0017 FARRELL COURT - BPA-16-1384 The Commonwealth of Massachusetts
Board of Building Regulations and Standards T L '�Ed
Massachusetts State Building Code,780 CMR Reviseb�lLd
1 _ Building Permit Application To Construct,Repair,Renovate Or Demolish�,b NOV 28 A
(n^X� One-or Two-Family Dwelling
" J This Section For Official Use Only
I Building Permit Number: Date Applied:
Building Official(Print Name) . Signature "Date,
SECTION 1: SITE INFORMATION
1.1 Ifferty Address: 1.2 Assessors Map&Parcel Numbers
FF�1Zcc� cloxc
1.1 a 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❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
-%1 ice, Atxttg(x,+J Sa xy- .I M P (A 9i-4t)
Name(Print) JCity,State,ZIP
01 Gurur+C4 �IV1Nq- LI`l32
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other pecify: (CID
Brief Description of Proposed Work : ::5h yjr -R rciD4K4"14*i n64--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 7>-� g� 1. Building Permit Fee.$ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ / }
4.Mechanical (HVAC) $ List: (.l
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: '
() 03 K ER I S VAl�,
Mlkll�p n(�a
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) )
n C;S o� (0iu�
_1A)01CIQ.CYI Y'ILA)CAA fLVCag11- License Number Expiration Date
Name of C L Holder
- _ q List CSL Type(see below)
� Tan
",UV-
No.and Street ([� Type Description
U 1,5�\ U Unrestricted2Family
(Buildings u el ing cu.ft.
City/Town,/Town,State,ZIP ,lJ R Restricted 1&2 Famil Dwelling
�' M Masonry
RC Roofing Covering
WS Window and Siding
W p i SF Solid Fuel Burning Appliances
Sb g 1012 31 y9 hr�W(a i�.c.L h I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement (HIC) I t I9�Mb + ?o (
1 l 4JV�k(1 I IA I f 1 I/(� HIC Registration Number Expiratlon Date
HIC Company Name or HIC Registrant Name
H IQ.hVtAAN
No.and Street Email address
(,�S�bSacN, n1A OiS30 'oX'01Z-314�
City/Town, State,ZIP 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 ..........ED
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.
Print Owner's Name(Electronic Signature) Date
SECTION 71b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Z V QL lam- 10, z 1 Ln
Print OwnlYs or Authorized ent's Name(Electronic Signature) Date'
NOTES:
j I. 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. og v/oca Information on the Construction Supervisor License can be found at mn1.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"may be substituted for"Total Project Cost"
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-076146
Construction Supervisor
"a
WOJCIECH J PIWOWARCZYK
4TANNERROAD
WEBSTER MA 01570
Commissioner Expiration:
0 110 212 018
r//re`frorirrimirurcn/!/r f c'/(lr;;lff�nJCIL'
_ Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
0. 9istration: 149606 Type:
piration: 1Q62018 Private Corporatior.
WPI CONSTRUCTION INC
WOJCIECH PIWOWARCZYK
4 TANNER ROAD
WEBSTER,MA 01570 -g
Undersecretary
4co CERTIFICATE OF LIABILITY INSURANCE OAT 10/2412/za/zO/o16
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(les)must be endorsed. If SUBROGATION IS WAIVED,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 endomement(s).
PRODUCER CONTACT
NAME: Donna Kenna
OXFORD INSURANCE AGENCY INC. PHONE S0e 987-0333
E p IIL . dkenne oxfordinsumnce.cem
300 MAIN ST. INSURERS AFFORDING COVERAGE NAIC0
OXFORD MA 01540 INWRERA: TRAVELERS INDEMNITY CO OF AMERICA 25666
INSURED
INSURER B:
W P I CONSTRUCTION INC INSURER C:
INSURER D:
4 TANNER ROAD INSURER E:
WEBSTER MA 01570 INSURER F:
COVERAGES CERTIFICATE NUMBER: 96454 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.
L"STRR TYPEOFBISURANCE �� UBR POLICYNUMBER M LICV EFF POLICY EXP LOARB
COMMERCIAL GENERAL LABILITY EACH OCCURRENCE $
CLAIMS-MADE ❑OCCUR E (R
PREMISESS Ea oaunen $
MED EXP(My one person) $
N/A PERSONAL S ADV INJURY $
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE It
POLICY 0 J'Mo- LOG PRODUCTS-COMP/OPAGG $
OTHER: $
AUTOMOBILELIAINUTY COMBINED SINGLE LIMIT $
' Ee acdtlent
ANY AUTO BODILY INJURY(Per parson) $
ALL OWNED SCHEDULED
AUTOS AUTOS N/A BODILY INJURY(Per acatlent) $
NON-OWNED' PROPERTY DAMAGE
HIREDAUTOS AUTOS Par accitlem $
UMBRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LJAa CLAIMS-MADE N/A AGGREGATE $
DED I I RETENTIONS $
WORKERS COMPENSATION X/ PER OTH-
ANDEMPLOYERS'LIABILITY YIN ^ ST TUTS ER
ANYPROPRIETORIPARTNEIVEXECUNE E.L.EACHACCIDENT $ 1,000,000
A OFFICERAIEMBEREXCLUDED? WA WA WA 6HUB99011-94216 01/01/2016 01/01/2017
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If we descdhe under
DESCRIPTION OF OPERATIONS hel. E.L.DISEASE-POLICY LIMIT $ 1,000,000
N/A
DESCRUrTTON OF OPERATIONS I LOCATIONS I VENICLES(ACORD 101,AddMonel Rern A9 Schedule,may W attached Nman1 space Is rpuhad)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/lwd/workers-compensationriinvestigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Salem Housing Authority ACCORDANCE WITH THE POLICY PROVISIONS.
27 Charter Street
AUTHORIZED REPRESENTATIVE
Salem MA 01970
Daniel M.C y,CPCU,Vice President—Residual Market—WCRIBMA
01988.2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
CITY OF S.0 EN1, 1AXSSACHUSETTS
• BUILDLNIG DEPARTJ(ENT
120 WASHINGTON STREET,3'a FLOOR
TEL (978)735-9595
FAX(978) 740-9846
KimBERLEY DRISCOLL
MAYOR T41O&w ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BCILDIING CON06IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `-�"r w�M�l�J yY, Please Print Legibly
Name(BusinessiOrganization/Individual):_ (t) C_h(�-
Address: LI Ta/n)r\Qy "
City/State/Zip:IA—) S4f-,V/ ME UIS-?UPhonef;e: C��"�0/Z'�1 ���_
Are you an employer?Check the a propriate box: Type of project(required):
1.�D am a employer with 4. 0 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 shceL t 7• 0 Remodeling
ship and have no employees These subcontractors have S. 0 Demolition
working for me in any capacity, workers'comp.insurance. 9. 0 Building addition
(No workers'comp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 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, oof repairs
insurance required.)t employees.[No workers'
comp.insurance required.) 13. Otber
•Any applicant that checks box HI must also all out the section below showing their workers'compensation policy inlemtalion.
1 I1mxowners who submit this affidavit indicating they are doing all work and thm hire outside commsai s must submit a new affidavit indicating suds
=Comm non that check this box must attached an additional spec1 showing the name of the sub-comwclwa and their workem'comit policy infotmmion.
l am an employer that is providing workers'compensation Insurance for my employees. Below is the pollry and fob site
information.
Insurance Company Name: l ��y� ' �[ ( ( Vn/t/V Q
Policy#or Self-ins.Lie.q: ( f�td�`��0� L�q Z[ (O Expiration Date: j � l /ZC)
Job Sire Address: (91 � City/State/Zip:llm 4 A-
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 S 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 forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify under the pains and penalties of pert ary that the information provided above is true and correct,
Sienattim Dnte
Phone#:
Official use only. Do not write in this area,to be completed by city or town Official
City or Town: Permidlicense#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
�-III �
ACC>Ro• CERTIFICATE OF LIABILITY INSURANCE �"� (MMmomr
10@412016
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 policylies) must be endorsed. If SUBROGATION IS WAIVED, 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 endomemengs).
PRODUCER Phone:(5M)987-0333 Faz 508-987-0063 '=ACT Ross
OXFORD INSURANCE AGENCY INC P O BOX 370 a°H EdL(508)987-0333 "'rLAC,NP 508-067-0063
EMAIL
OXFORD MA 01540 E,MAILADDRIES,
rlavoie@oxfordinsurance.com
INSUREDS)AFFORMNG COVERAGE NAICa
INSURERA :Penn-America Insurance CO.
INSURED
W P I CONSTRUCTION INC. INSUREBB Commerce Insurance Co.
4 TANNER ROAD wsuRERC
WEBSTER MA 01570
INSURER O:
NSURERS
INSURER F
COVERAGES CERTIFICATE NUMBER: 93382 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,
XCLUSIONS AND CONDITIONS OF SUCH LICIES.LIMITS SHOWN MAY HAVE BEENREDUCED BY PADCLAIMS
INSR TYPE OF INSURANCE ADDL SUBR POMCY EFF POUCY UP
Lm INSR WYD POLICY NUMBER Mx MMIBDIYYYYI LIMITS
A X COMMERCIAL GENERAL LIABILITY PAV0092210 05126116 05/26117 EACH OCCURRENCE $ 1,000,000
CLAIMSIdADEOCCUR DAMAGE TO REmED
-PROMISES Ee--) $ 50,000
X BLANKETADDmONAL INSUREDS
MED.E%P(Any we person) $ $,000
T
PERSONAL B ADV INJURY $ 1,000,000
GEN-L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000
PRO-
POLICY[:]JECT LOC PRODUCTS-COMP/OP AGO $ 1,000,000
OTHER: $
B AUTOMOBILE LAMUFY BCCZ42 12122115 12122/16 COMBINED SINGLE LIMB
SO,xdmm) $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS X AUTOS BODILY INJURY(PeraoCxmnt) $
Ix
HIRED AUTOS J( NON-0WNEO PROPERTYDA GE $
AUTOS Iper.«aen0
UMBRELLA LAB OCCUR EACH OCCURRENCE $
E%cESS LAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER OTIL
AND EMPLOYERV LAILn BY BTATUFE ER
ANY PROPRIETOMPARTNERADURUTIYE YIN ELEACHACCIDENT $
OFFICERIMEMBER E%CLUDEDi es,d MIA E.L.DISEASE-EA EMPLOYEE $I ay In NMI If yes, ON N er
DESCRIPTION OF OPERATONB belvx E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached It more space Is requlmd)
Workers'Compensation Certificate of Insurance to be issued directly by the insurance carrier under a separate cover.
CERTIFICATE HOLDER CANCELLATION
Salem Housing Authority SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
27 Charter St THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Salem,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPREBENrATIVE R
Attention: 4^Y�',�'{'�,', L lwme.11k
Brian M. Ravenelle
ACORD 25(2014101) 01988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD