16 HAWTHORNE BLVD - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept f
Building Permit Application To Construct, Repair, Renovate Or Demolish a
On�yer- ro- n ifs Dtrrlling maim
This S ction F r Oficial Use Only
Building Permit Numbe : Date Applied:
Signature: /��6 \
Building o -ssioner/Ins r f i s Date
CTION 1:SITE INFORMATION
I.1 Property ddress• 1.2 Assessors Map& Parcel Number
x ; .
I.I a Is this an accepted streetl yes no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(sq it) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
ff
Provided Required Provided Required Provided
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 ❑Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
of Record:.A- .0,lLCi X t�2 Address for Service: S�Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Of I Repairs(s) ❑ TAltertitior(s) Addition ❑
Demolition ❑ 1 Accessory Bfdg.❑ Number of Units Other O Specify:
Brief Description of Proposed Work': U rn-yd
�f
VAA
1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building S y'00 0_ 1. Building Permit Fee.S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S — ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ I0() — 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppressionj
Check No. _Check Amount Cash Amount:_
6, Total Project Cost: s G�600— 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed ConstructionSupervisor(CSL) �• 8 c7� 1l�js,
r•sG ti U•/;,14 -1
Z7&4, License Number Expiration Date
Name of CSL H er Lut CSL Type(see below)___a__
Sa, cuv_?
AJJr• Type Description
U Unrestricted Jup to 35,000 Cu. Ft.)
/\ R Restricted 1&2 Family Dwelbn
Si nature
d � M Masonry Only
RCRcstdcnual Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R laterad Home Improv meo contractor(HIC)
s f.t�fa ro IT, /vr,Z,� 14aoo7
HIC�mpa�y Namepr Hj egisy�ant am�� 8 Registration Number
(I IC=Ywo �E/ J �/ 0 7.7
Add est
Expiration Date
Signature elephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.f 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.......... O No........... ❑
LSECTIONOWNER AUTHORIZATION TO BE COMPLETED WHEN
ENT OR COLLNTRACTOR APPLIES FOR BUILDING PERMIT
C.U� , as Owner of the subject property hereby
Sa to act on my behalf,in all matters
authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
tha he statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Pri t N e
Signature of Owner or Authorized Agent Date // 2
Si ned under the pains and penalties of perjury
NOTES:
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 g(have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. 'Total Project Square Footage" may he substituted for 'Total Project Cost•
CITY OF S.U.E.NI, .L%LAS&XCHi:SETTS
BUR DING DEPARTNMNT
\ ` 120 WAS14INGTON STREET, ago FLOOR
TEL (978) 745-9595
F.t:t(978) 740-9846
KINfB Rt FY DRISCOLL
'MAYOR T HONLO STTUERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%aSSIONER
Yorkers' Compensation Insurance Allidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Legibly
Nalne(Busimv Organizatiorvindtvtdual):
Address: A 64 IFiI. J q �/
City/State/Zip: �a� itf.,T 03 3 Phone #:—(q 70 /o21 " /7,7
Are you an employer?Check the appropriate b9a: Type of project(required):
I. 1 am a employer with 4. I am a general contractor and 1
employees(full and/or part-time).* have hired the subcontractor 6. El New construction
2.0 I am a sole proprietor or partner- listed an the attached sheet : 7. 0-Remtxleling
ship and have no employees These subcontractors have S. C1 Demolition
working for me in any capacity. workers' comp.insurance. 9, 0 Building addition
iNo workers'comp. insurance 5. ❑ We ate a corporation and its
required.] officers have exercised their I0.013lectrncal repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MCL I I.[.p]'Plumbing repairs or additions
myself.(No workers' comp, c. 152,§1(4),and we have no 12,0 Roof repairs
insurance required.]t employed. [No workers' 13.0 Other
comp. insurance rmequired.J
•Any applic:ua that checks box 01 noun aim fill out the sectio bclgw showing thea worksas'compensation policy information.
'I Lwncownen who submit this aRfdavil indicating they ata doing all work and then hire outside contrscton must submit a new alridavit indn6mc
catik
sto
=C,mtrasaon that cheek chis box most snachod an addhio vel shs showing the name of the sub cantracmr,and their vorism comp.polity iic.6 a 1
I um an employer that Is providing workers'compensadon lnsuraace jar my employee.& Below is rhe poUcy and job site
information.
Insurance Company Name:
Policy#or So1f--ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy 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 imprisonmcm as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
Invesusations ol'the DIA for insurance coverage verification.
I do hereby certify upod�and penoldes of perjury that the information provided above is true and correct.
�i•naitrc: ?}'/ Date: o9
/q_1/37
OJJfcial use anly. no nor write in this area, to be cumplered by city or town offtciol
i
City or Tuwn: _ Permit/License il
Issuing Authority (circle one):
--
L Board of Ilealth 2, Building Department 3.City/town Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#•
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
L': U 111%,..,c:>:< 1 r 1 SAI I U, \I t.,�, ,. i
II I '+'y.'4;.);-j; • I tC. ';'g V_ •+.i 7i.
Construction Debris Disposal Affidavit
(ICCluired li)r all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 780 CMR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
J"/ 4&A
(nann&of hauler)
I he debris will be disposed of in
(name of Iacihly)
(addres. of lacililvl
♦ILlialnl l' ,)f pe)unt .ytphcanl
,ane
A
OFFICIAL CHECK
Citizens Bank 1020 055021204-7
lJune 10, 2009
wxx$100 _ OOW= DOLLARS o
U
WCt7HHCWWEALTH QFHASSACHUSETTS3w
MEMO:
/' 1 r NON-NEGOTIABLE a
GUG�9Ar4 tvr,� U
PAYMENT 4e
IUVIssued by Integrated Payment Systems Inc.,Englewootl,Colorado
JPMorgan Chase Bank,NA.,
Denver,Coioretlo SAVE THIS RECORD
WE CANNOT GIVE INFORMATION OR SEARCH RECORDS UNLESS TEIS COPY IS PRESENTED
THE COMMONWEALTH OF MASSACHUSETTS pmt Registration No:
Board of Building Regulations and Standards
Home Improvement Contractor Registration Program
One Ashburton Place,Room 1301 Effective Date'
Boston,MA 02108
Expiration Date:
Application for Renewal of Registration as a Home Improvement
Contractor or Subcontractor-MGI.Chapter 142A,780 CMR R6 Date Entered,
(PLEASE READ BOTH SLtIDES CAREFULLY)
1. BUSINESS NAME: 93: 1, It��lcir C.DILLMcb�m lkeP alhj
nPrint the name in which We applicant is conducting �sinecs
SF_F.RACK OF FORM)
RA6
2. Mailing Address: Ig LfA IV (27,r) 1a2- J-73y
3. City: _So State: JJ9Zip:
03$73 Area Code Telephone Number
4. Street Address(if different):
(Print street and Number,a P.O.Box is not acceptable for address)City State Zip
5. Applicant type: _Individual I/DBA _Partnership _Trust Private Corporation Public Corporation
Limited Liability Partnership Limited Liability Corporation
Please Check One (See astructions on back regartlhg enclosing a city roman registration r I DBA ur T icolima rmne'law.MGL c tt0.5 S a 6)
6. Social Security m Federal ID Number. 0 oL0-kT`�fl�ii (see back) 7. Number of Fmployees n
(See back of Form)
8. Have you registered previously under law? p , / �/
If so,under what? S.j/4.Lt1f i y-Vd 'gty�j �pc pOMr� ltegisuation No: �70DO7 p�trs
9. Individual responsible for Home Improvement Contracts: / 11` Wo sa jnAz 'T
(See back of farm) last Nu Social Security No.
10. Tide of individual responsible for Home Improvement Contracts: &r;44T First
11. Does the applicant or responsible individual hold any other constnucfion related state,city,town licenses or registrations? Yes No
Type of License or 'on IssuedR I lige or registration 9 Date I Marne of License holder
Caaslntb« lmsr, ON JuiLm 0i inorr 111 j S
71
12. List all partners,trustees,officers,directors and majorowes(101/oor greater of ownership)of an applicant partnership orcorporation below. Use
additional paper if n See instructions below Check here if you wish to receive an application for additional ID cards fm key persons.
Last First MI Title in Applicant Business %Owner Address
S .r r Qct q 0
13. is the applicant claiming exemption from the registration fee?(See the instructions can the back) —eler No
14. Registration fee enclosed:$_ (see note#1,on back) Guaranty Fund fee enclosed:S /00 (see note#2,ou back)
If necessary,include two separate certified checks or money orders-one marked"Registration Fed",one marked"Guaranty Fund". See instructions
on back for amount of fees.Make all certified checks or money orders payable to"Commonwealth of Massachusetts!'. NO PERSONAL OR
BUSINESS CHECKS WHLL BE ACCEPTED UNLESS THEY ARE CERTIFIED.
Pursuant to Massachusetts General Laws Chapter 62C§49A,1 certify under the penalties of perjury that I,to my best knowledge and belief
have filed all state tax returns and paid all state taxes required ander law.
SigoaWre of applicant orapplicant's representative Title held with applicant Date
A false answer to any question in this application constitutes grounds for suspensionor-revocation of the applicant's registration.
Rev.4-08
Policy Number DECLARATIONS PAGE
94-BV-3993-0 a
STATE FARM FIRE AND CASUALTY COMPANY ..,m.$
ONE STATE FARM DR., CONCORDVILLE PA 19339-0001
A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON,ILLINOIS
Named Insured and Mailing Address
28-2007-FB76 T 2
MILITELLO,SALVATORE
DBA SJM CONSTRUCTION
24 ROWELL RD
SANDOWN NH 03873-2315
Cov A- Inflation Coverage Index: N/A
CONTRACTORS POLICY -SPECIAL FORM 3 Cov B-Consumer Price Index: 218.8
AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this policy will be renewed automaticallu
subject to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will
give you and the Mortgagee/Lienholder written notice in compliance with the policy provisions or as required by law.
Policy Period: 1 Year The policy period begins and ends at Noon standard time at the
Effective Date: JUN 20 2008 premises location.
Expiration Date: JUN 20 2009
Named Insured: Individual
Location of Covered Premises:
24 ROWELL RD
SANDOWN NH 03873-2315
Coverages & Property Limits of Insurance
Section I
A Buildings Excluded
B Business Personal Property $ 1,000
Section II Deductibles-Section I
L Business Liability $ 300,000
M Medical Payments $ 5,000
Products-Completed Operations $ 500 Basic
(PCO)Aggregate $ 600,000 Deductible-Section 11
General Agg regate (Other Property Damage Liab.
Than PCO1 $ 600,000 $ 250 Per Claim
The Section I deductible will be applied to each occurrence
and will be deducted from the amount of loss. Other
deductibles may apply- refer to your policy.
Total Estimated
Forms, Options, and Endorsements Premium $ 929.00
Special Form 3 FP-6100 Audit Period: Annual
Amendatory Endorsement FE-6229.1
Inland Marine Conditions FE-8751
Fungus (Including Mold) Excl FE-6642
Dist Mat Violat Statues Excl FE-6655
Policy Endorsement FE-6656
Civil Union Endorsement FE-6854
Continued on Reverse Side of Page
OTHER LIMITS AND EXCLUSIONS MAY APPLY-REFERTO YOUR POLICY
Prepared _ O
AUG 12 2008 Counter ' ned
FP-8051 A C SEQO By L ___Agent
)8/1993 DEX HYLAND
four policy consists of this page,any endorsements (653)3235666
and the policy form.PLEASE KEEP THESE TOGETHER. I l010841
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ACORD_ CERTIFICATE OF LIABILITY INSURANCE OP ID LR DA7EjYWDO"�"�"
MATASTi 06/15/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Soderberg Insurance Services HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
200 Broadway ALTER THE COVERAGE AFFORDED HY THE POLICIES BELOW.
Lynnfield 291 01940
Phone:781-593-9393 Fax:781-599-7338 INSURERS AFFORDING COVERAGE NAIC8
INSURED - - -- - ;INSURM& Merchants Insurance Cc
I INSURER B. AxM,Lta HYcwa Tn6a[anq W
Steven Matarazzo ..INSURER C'
Mae Matarazzo .
43R No to gt IINSURER O.
salem 291197b . . .
INSURER E. I
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION MAW CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POUCHES AGGREGATE LBUTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTi
TYPE OF INSURANCE POLICY NUMBER TATE DATE tl uMTB
GENERAL LUUX IT EACHOCCURRENCE _ S„-_.. ._.
A R COMMERCIAL GENERALLMILITY CCP1037419 09/11/08 09/11/09 PR�EMESTO(EaEB�r )
lCLANS MADE [:] OCCUR' MEDEXP(A,.Pa )—3---
A
_
A CCP1037419 09/11/08 09/11/09 PERSONAL S ADV INJURY S
GENERALAGGREGATE S
GERL AGGREGATE LIMIT APPLIES PFR i MODUCTS.COMPIOP AGG S
POLICY PRO- j LOG
JECT
AUTOMOBILE I U aJ1Y j COMBINED SINGLE LIMIT S
8 ANY AUTO IHC 127791 04/07/09 04/07/10
X ALL OWNED AUTOS i BODILY INJURY s20000
SCHEDULEDAUTOS
HIRED AUTOS I IRODRY I
NON-OWNED AUTOS (P.= !S 40000
PROPERTY DAMAGE j$100000
IPn ecciBem)
fiARAGE LUIBIIJTY I AUTO ONLY-EA ACCIDENT S
ANY AUTO ! .OTHER THIW EA ACC S
j .AUTO GNLV. AGO S
EXCEBBNMBRELLA LIARLTTY EACH OCCURRENCE S
OCCUR LJ CLAIMS MADE 'AGGREGATE S
3 _
DEDUCTIBLE
RETENTION 5 S
WORKERS COMPENSATION AND
EMPLOYERS'LM&LOY RABIAIE.L.EACH ACCIDENT S
ANY PROPRUJOWPARTHERIEXECUTIVE I ._
OFFICEEA EXCLUDED? E.L.DISEASE-FA EMPLOYE S
MkWsP tleTaiEe Mltler - ..- _._
SPECIAL PROVISIONS beIw E.L.DISEASE-POLICY LIMIT S
OTHER
i PROPERTY 2500
i
DESCRIPTION OF OPENATRW5I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E104RA
DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAR 30 DAYS WIBTIEN
Sam Militello NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
603 879 0626 IMPOSE NO GBIIGATTON OR LUB1LRYOFANV DS AGENTS OR
REPRESENTATIVEB.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001108) 0 ACORD CORPORATION 1988