19 GOODELL STREET - BPA B-17-80 t 3 5
The Commonwealth of Massachusetts RECEI
VEM
;. Board of Building Regulations and Standarr]Oa PECTIONAL ERVIL6k�,OF
Massachusetts State Building Code,780 CMR���qq��55 nnFF(r 9 R SALE 2011
4 (AAMA
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Building Permit Application To Construct,Repair,Renovate e t
One-or Two-Family Dwelling
O This Section For Official Use Only
�- Building Permit Number: Date plied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
I 1.1 Property Address: 1.2 Assessors Map &Parcel Numbers
101 600 o C
1.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: (NLG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public 1:1 Private El — Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
R Jw� C ��m ��
ahl.�l-lt1- fb
Name(Print) City,State,ZIP
iq wo'nc-c 479 - " ) - lltd
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify: V 08 C-
Brief Description of Proposed Work 2:
CHIP C 5 Lblvv6 AI OP Ob P lr> LG 1- CAJ
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ r 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su ssion $ Total All Fees:$
re
Check No. Check Amount Cash Amount:
6. Total Project Cost: $ ( ❑Paid in Full ❑Outstanding Balance Due:
Nltat Tt-' . N .o .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1 l9Co�06�(
0( v'p r"A 0 �✓ O l—t(_.(..6 License Number Expiration Date
Name of CSL Holder r ,
<6 LA(-,S6 k) C/ List CSL Type(see below) U
No.and Street Type Description
eA (,�A I /4}— U Unrestricted(Buildings u to 35,000 cu.ft.
U a t�c.KJ ���/ `� R Restricted 1&2 Family Dwelling
City frown,State,ZIP M Masonry
RC Roof Cove
WS Window and Siding
7�( 7 O SF Solid Fuel Burning Appliances
7 7 V I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
1-11�ompanV �r HIC ReRlskent Name
—164 StreetC1A b^ w ^� Email address
Ci /Town, State,ZIP v✓ l 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 ..........0 No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRAC'T�OnR,APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property, hereby authorize tboq,'-S M(S(X.,
to act on my behalf,in all matters relative to work authorized by this building permit application.
"UM-) tZ —7( — ( 5
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERr OR AUTHORIZED AGENT DECLARATION
By enteringmy name below,I hereby attest under the pains and penalties of ury that all of the information
Y P Pe Pert
contained in this application is true and accura o e best o edge and understanding.
wL0 (--2 - z(
Print Owner's or Authorized Agent's Name(Elec o 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
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/d s
2. When substantial work is planned,provide the information below:
Total floor arra(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"
Brown
Serving Greater Boston for Over 20 Years!
an
_t L LMA Dave Tomolillo
HA
Email: davetomolillo@gmail.com
HOME BUILDING &. REMODELING
CSL#: 064063 HIC#: 158936
Standards & Quality are our Priority!
Jonathan Brown
19 Goodell Street
Salem, Ma
978-587-1115
brownvll4@yahoo.com
Roofing Specification:
• Strip the entire roof down to the sheathing (2 layers)
• Remove all nails and replace up to 50'of spruce ledger
• Apply 6 feet of Water Shield along all eaves
• Apply Water Shield around all the chimneys
• Install new vent pipe water diverters
• Re-lead perimeter of chimney with new lead
• Install new secondary chimney step flashing
• Apply 15 lb.felt underlayment as protective base
• Install 8"aluminum drip edge along entire roofline perimeter
• Removal of roofing debris by dump truck
• Total number of roof squares [ 13 J
• GAF Timberline 30 year architectural shingle
• Providing all Insurances,Licenses and Permits
• Total cost of materials and labor: $4655.00
Hijonathan
This was quoted in 2012,in 2015 it is$5525
Because you are Mike's friend 1 can do it for S 00.0
David Tomolillo
Hallmark Homes Associates,Inc.
Hallmark Home Building&Remodeling, Inc.
PH: 781-838-0789
E-MAIL: davetomolillo@gmail.com ,[
WEB: www.halimarkhomebuilding.com
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbem
TO BE FU.F.D WTTH THE PERMITTING AUTHORITY. .
Aoolicant Information Please Print Leer
Name(sasaessrorgmi abaanndi,i0 l):Hallmark Homes Associates, Inc.
Address: 56 Wilson Street
City/state/zip: Medford, MA 02155 Phone#: (781) 838-0789
Are you an employer?Check the appropriate box: of project(required):
Type P 1 (meq ):
1.®I am a employer with 2 employees(full and/or part-time).• 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling
any capacity.[No workers'comp.insurance -rafted.] .
3. 1 am a homeowner do' as work . - 9. ❑Demolition
❑ mg myself.[No workers'comp.insurance required]r
4.r-1 I am a homeowner s in will be hiring contractorconduct as work on my property. twill
10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the subconuactms listed on the attached skeet. 13. Roof
These subcontractors m
have employees and have workers'comp.insuace.: - ® repairs
6.❑We are a corporation and its officers have.exercised their right of exemption per MGL c. 14.❑Other
152.§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box Irl must also SII out the section below showing thein workers'compensation policy information
t Homeowners who submit this affrdavh indicating they are doing an work and then him outside contractors must submit a new affidavit indicating such
LCommctors that check this box must attached an additional sheet showing the name of the subcontractors and state whether a trot those entities have
employees. Ifthe subcontractors hese employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurancefor my employees Below Is the policy andjob site
tnformadom
Insurance Company Name: The Travelers
Polley#or Self-ins.Lie.#: 6KU B-5B29684-3-14 Expiration Date: 03/17/201,61,,,p
Job Site Address: 1900A9,U . 5Ir City/Statelzip: S Gt✓LI 't /t^J
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to.secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verificati
I do hereby cep unfT the and ofperjury that the htformadon provided above is true and correct
Signature Date 11/25/2015
0
Phone#: (781) 838-0789
Official use only. Do not write in this area,to be completed by city or town oo7dal ^
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Hallmark Homes Associates, Inc. — DavidpTmopmmollipllop
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TOMOLILLO
Dawn f
I 56 Wilson Street t aN a,wnnsss.P,aa wr. ENr x. r
/ Medford,MA 02155 1
Massachusetts-Department of Public Safety 'Unrestricted-Buildings of any use group which
Board of Building Regulations and Standards contain less than 35,000 cubic feet(991rna)of
Construction Supen icor enclosed space.
License:
C CS-064063
DAVID F TOMOLILLOr' '
56 WILSON ST f �^ Y
MEDFORD MA 02155 #
Failure to possess a current edition of the Massachusetts
Expiration 1 y State Building Code is cause for revocation of this license.
Commissioner 0311512016 I t For DPS Licensing information visit: www.Mass.Gov/DPS
J L .
r_)711`trrntn.r rrn+rrlrf�r �r.wrcrfryat.Ii'£
Y� License or registration valid for mdmdul use only
IOftfee of Consumer Affairs&Business Regulation before the expiration date. If found return to:
;HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
{tegistmtion: 156936 Type: 10 Park Plaza-Suite 5170
Expiratlon: 3/18/2016 Private Corporat( Boston,MA 02116
HALLMARK HOMES ASSOCIATES INC.
DAVID EHILLTOMDR. I
1 STONEHILL DR. 1F
STONEHAM,MA 02180 �'— -----
Underserretary Not valid wi out signature
,a►coRL7' CERTIFICATE OF LIABILITY INSURANCE 06!2 12 r015
0911 5
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 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 endorsement(s).
PRODUCER CONTACT
-NAME: Peter A. Rossetti Ins. Agcy.
Peter A. Rossetti Ins.Agcy. PHONE FAX
436 Lincoln AvenueIWC.Na Ea:781-233-1855 ac No: 781-231-3752
Saugus,MA 01906 E-MAILs:pnickerson@rosseftiinsurance.com
Peter A.Rossetti Ins.Agcy.
INSURERS AFFORDING COVERAGE NAIC If
INSURER A:Western World
INSURED Hallmark Homes Associates Inc INSURER B:Pilgrim Insurance
PO BOX 685 INSURERC:TraVelers
Medford, MA 02155
INSURER D:
INSER E
NSURERURF:
COVERAGES CERTIFICATE NUMBER: 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.
INSR TYPE OF INSURANCE POLICY EFF P LILY EXP
LTR p 0 POLICY NUMBER MMIDDIYYYY MMIODNYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE FX]OCCUR NPP1349917 06/11/2015 0611112016 PREMISESE-�a cTenwl S 50,000
MED EXP(Any one person) S 1,00
PERSONAL B ADV INJURY S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S 2,000,00
POLICY❑PRO- ❑LOC PRODUCTS-COMP/OP AGO 3 2,000,00
JECT
OTHER. Emp Ben.. S N
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00
Ea accident
BI AUTO PRC00001001303 0412312015 04/23/2016 BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED BODILY INJURY(Per accident) 5
AUTOS NON-OWNED PROPERTYDAMAGE
AUTOS
X HIRED AUTOS X AUTOS Peraccidenl $
5
UMBRELLA LIAS OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY STATUTE X ER H
C ANY PROPRIETOR PARTNER EXECUTIVE Y/N 6KUB-SB29684-3-14 03/17/2015 03/17/2016 E.L.EACH ACCIDENT S 1,000,00
OFFICERIMEMBER EXCLUDED? NIA
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,AddlUonal Remarks Schedule.may be axached It more space Is required)
Carpentry Operations.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Inspectional Services ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
r ( � �