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24 HAWTHORNE BLVD - BUILDING INSPECTION
c$ l 32 C-,r- 2_Q-7Sz t The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards RE .EI J6 LElvl Massachusetts State Building Code, 780 CMR IMPECTIC jRe�isid',f(tr1130Y$ tion To Construct, Repair, Renovate Or Demolish a Building Permit Application P One-or Two-Family Divel ing This Section For Official Use Onl" Building Permit Number. Date.A p ed 3 / -Building Official(Print Name) - Signaluro'; - Dale I ^, SE .� CTION 1. SITE INFORi&IATION' U , ddr 1.1 Pro er ' ' 1.2 Assessors blip alit Parcel Number I 2 IAO. Lid ( 1.1 a Is this an accepted street?yes no M1fap Nwnber Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq R) Frontage(R) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Requiled _ Provided Required- Provided.. . Rcqu,nd Provided 1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal system: ' Public O Private 0.- Zone: _ Outside Flood Zone? Municipal O On site disposal system 0 Check If esO . SECTION 2. PROPIRRT((Y-Ofg9VNER$HhP!q (� 2.1 O QcrrofRecord, AYIh,IL1R11M p I'J Print) ci. ZI rel ZI G zy-1 A-e,rr 51" P r7 s�' S6�S 6 rr t. hily>7 zl �M No.and Street - Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK4(cheek all that apply) New Constriction 0 Existing Building O Owner-Occupied 0 Repairs(s) 1� Alteration(s) Addition O Demolition f] AccessoryBldg.0 . Number of Unit_ Other 0 Specify: Brief Descr'ption o Proposed Work': StIESSTIMATED CONSTRUCTION COSTS E : Official Use Only Itcm Laals I Building SI. Building Permit Fee:$ Indicate how fee is determined: O Standard Cityfrown Application Fee2. Electrical $ 0 Total Project Cost'(item 6)x multiplier s3. Plumbing SP Qther Fees: $4.Mechanical (tIVAC) SList: / y -5.Mechanical (Fire Total All Fees:S Su ression) Check No. Check Amount: Cash Amount: G.Tura, Project Cust S ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5,1 Construction Supervisor License(CSL) _4A 1 7 O ► „J i t {,L; 55" 5j LicenseNumber / Expiratio at Name of C$ [folder List ki-b�--Jr-- A 4� �a� n 4 r �, List CSL'fype(see below) No.:and Sire•t �-�•(~ TY - ,. Description .. NNS A / fi✓ 00-0 � �- + Unrestricted(Buildingsup to 35,000 cu. Il. / f"l.�l 1 Restricted 1&2Famil Dwelling City/rown,StotE,ZIP M Masonry RC Rooting Covering WS Window and Sidina SF Solid Fuel Burning Appliances 1d 6�30 ss k�r4c�tlt 1Insulation Telephone &nail address D Demolition / 5.2 Re Ho�mpeImprolvement Contractor( IC) f 743 10 111C Registration Number E.piration Date IIIC C m anyNglortif R 'stran arae O 5 0. d . No.atd Street 128`( S 4 3 66 Email address � H fr...e) �— City/ToAn.State ZIP Telephone SECTION 6:WORKERS'COMPENSATION 1NSURADICE AFFIDAVIT(M.G.L:c.152.4 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 Isivan of the building permit Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TOBE.COMPLETED.WHEN' OWNER'S AGENT ORCONTMIL&OR PPbE3FOB BUILDING PERMIT' I,as Owner of the subject property,hereby authorize l i) HL &5_15Qq t9 act on my behalf,in all matters relative to work W*orizetPVhjs building permit applicatio Print Owner's Name(Electronic Signature) Date SECTION 71b: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 contained in this application is true and accuof my knowledge and understanding. 0M , 40 s rate to the t 1 Print Owner's or Authorized Agent's Numc( Icctroni S i Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor knot registered in the Home Improvement Contractor(HIC)Program);will n have access to the arbitration program or guaranty fund under M.G.L.c. Id2A.Other lmportdnl mformaTion oolhe H1CYrogrem can be to`unat-- - wsvw.mass.gov.'oat Information on,the Construction Supervisor License can be found at www.mnss.gov,'Jns . 2. When substantial work is planned,provide the information below: Total floor area(sq. R.) ,(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 .1. "Total Project Square Footage'may be substituted 1'ur"'rutal Project Cost" The Comptronw¢alth ofMassachnsegs Department oflndusNalAccI&I O,/)'lce oflnvestigations 600 Washington Street Boston,MA 01111 www.mr}ss gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbera A Brant Information /� Please Print bl . Name(Bosfnps/pregattizadOWIndividual): �-2 t ' I Aj j C v t c� w Address: J Ci /stn L'\- � v Phone.#: 1T/-S�3 -�63 6 Are you an employe{!Chec the appropriate boa: 1. 1 am a employer with �. am a general contractor and I Type of project(required): �Pbl ees(full and/or part-time).• have hired the sub contractors 6- ❑New constriction 2.[] I am a sole proprietor or partner- listed on the attached shut. 7. Ship and have no employees Theae sub contractor#havo 0 Reiaedeling wonting forme in airy capacity. employees and have workers' g Demolition [No workers'comp.insurance comp.Insurance.: 9. Building addition r0Q°Irsd] 5• ❑ We ora a corporation and its 10.❑Electrical 3.(] I am a homeowner doing all work offitxrs have acercIsed their repairs or additions myself.Mo wow'comp. right of exaaptloa per MGL 11'�Plumbing repairs or addidona insurance ralud)t c. 152,¢i(4).and we have no 12.[]Roof repairs �Pla3'ees.[No workers' 13.❑Other co insurance uhvd.] entry appaant datc1 1- hon#1 must also fill out the sectloa below. T Homeowms who aubmit this Affidavit indicating they am doingalt horsing duo wodms'compensation policy iofomstton. "caur"'ar that doll 111wind!aid We-hire outside�etoa moat submit a new agidavit mdlatotg such, .employed. lfdasu b-conhaetun have attached 0 tdditrond sheet diowingthe-2104 cf the rub-cotmacmn and stele whether or nottil mtil a have 4mployees,thry muatProvide thefr wdkms'C010P•Poary number. A am Am aloyer that IsProviding workers'compeaun btsxrtmee jot a to ees. B .r t'fl mp Y Blow is the po0cy aadJob site Insurance Company Name: Policy#or self-ins.Lic.0: Expiration Date: Job She Address: Attach a copy of the�rorkerst compensation Policy d City/state/ztp. Fallure to seclne p cY ectaration page(sbowing the policy number and coverage as required under Section 25A of MGL o. 152 can lead to the imposition expiration date). fine up to$1,300.00 and/or one-year imprisonment,as well as civil penaitia is the form of a STOP WORK OItDEK and of a Of up to$250.00 a day against the violator. Be advised that a co of this Investigations of the DIA for insurance coverage verification COPY Statement may be forwarded to the Oi$ce of f do hereby cert jJr xxder the pools cxd pMAN a enalties ofpsrfxry that tde tajarMarlax provided above l4 xzts and correct OfJ7ctat we only. Do not write In.this areor to be edmp/rtedb y city ortown offktai City or Town: funingAeBrority(etrcle one): Peradt2[cense# L B>tard ofHealth 2 Building Department 3.!Ity/'pown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Gther Contact person: Phone#• ACCO CERTIFICATE OF LIABILITY INSURANCEDATE('"'°°'YYYY II 10 20 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THL CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE., BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), Ar rrHORIZEI REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policypes) must be endorsed. If SUBROGATION IS W.MVED suL,eet t the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to th certificate holder In lieu of such erldorsement(s). PRooucER NAOA"TACT I Christine Martin Benevento Insurance Agency Inc PHONE FA% -— 497 Humphrey Street anal 781 599-3411 I Na: (lei) 5e1-72D Swampscott, MA 01907 ADDRESS: INSURE 5 AFFORDING COVERAGE NAZCA INSURERA:Essex Insurance Co. INSURED INSURER B Leland M Hussey MaweERc: Hussey Contracting INSURER D 490 Washington St. INSURER E: Lynn, MA 01901-1216 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOI INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THR CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM: EXCLUSIONS AND CONDITIONS OF SUCH POUCIES,LMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. NSR ADOL SUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE POLICY NUMBER MROIY ANJDDIYYYYI LIARS A GENERALLIABLITY 3DT2108 3/2/14 3/2/15 EACH OCCURRENCE $ 1 QQQ QO X COMMERCIAL GENERAL LIASIUTY DAMAGE TO RENTED $ soloMISES IE. CLANLSWADE OCCUR MEDEOP(Arwompaoo) $ 110 PERSONALSADVINJURY $ 1 ,000,0 GENERAL AGGREGATE S 2,000,0 GEN'L AGGREGATE L MIT AF7jECTLPER PRODUCES-DO WIDP AGG $ 2,000,0 ri POLICY PR0. LOC $ ALTOMOBLELIAa{ITY OABM ❑SIN L LIMIT eaaid,ol $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per ecGtlenl) $ NON-OWNED FIR E11 DMM GE $ HIRED AUTOS AUTOS eracdderd $ UA6RELLALIAa OCCUR EACH OCCURRENCE $ EXCESSSLIAB CLAIMS-MADE AGGREGATE $ Dm RETENTION$ S WORKERS COMPENSATION WC STATU- OTH- OND EMPLOYERS'LIABILITYV f NLUC ANY PROPRETORrPARTNERIEXECUTNE EL.EACH ACO DEM OFFICERWMBER EXCLLOED7 NIA pAantlamry M NN1 E.L.DISEASE-EA BF LOV Ryea,dmaibe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMB DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Porch ACORD 101,AddiSenal Remark.schedule,Rmom apace Is regdred) CERTIFICATE HOLDER CANCELLATION - ---- -- - SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORigD REPRESENTATIVE AnthonyBenevento ©1988.2010 ACORD CORPORATION. All rights resery ISI ACORD 25(2010105) The AC ORD name and logo are registered marks of ACORD DLnnn Fav F_M.R. L...es........h.�..�.:....Os L.... ......, I ACI! GAIE,YiuDDYv1.., CERTIFICATE OF LIABILITY INSURANCE FHS CERTIFMATIE ISSltE0 A$A NATTER OF LwoRMATION ONLY AND CONFERS ND R16HTS UPON THE CERTIFICATE HOLDER 24/15 4/ 5 ;CER7IFlCATE DOES NO7 APFl(BAAT1VFyY UR NEGATNE3.Y AMEI47, EXTEND OR ALTER TF¢ COVERAGE AFFORM BY _w POLICTHS IES BEL.aN. 7745 CEi,'i�1CA7E OF INSURANCE DOES NDT CONSTRUTE A CQNTRACT BETWEEN THE ISSUING MURER(S), AUfFpR[Mn REPRESEMAIiVE OR PRODUCER,AND 1HE CERflflCATE HOLDER PORTANT: }le cerBfieafa holder®an ADDITION INSURED,the palcy(ics)must lfe enTlolsad. N SUBRQGAT W tlla Nnne and o0nd4otls a(!he Pahl rend h pDl(elee mgY regDlFe sn 8ndoreemenL A atabment on!N8CeFBBq(e does not copli cerNtkals holder In Re11 Of such andoreanen8' righE to the At9lZDNia Insurance Agency Inc. N E 66 Bow Street 6 625- 00 ffi . (6'.7) 666-0037 Somerville, MA 02143 s' e1s11rat AEEggQNQ OMpAop MAIC N NSIW® INguaetA:Western Worid Insurance Cp OAR TREE HOM IMPROVDZNT INC INVUREHte:GUARD INs[AtANCE COMP Saulo Saapaic, INtuaee e: a pamsla Road Savgus, NA 01906 RER E' OOVERAEg aha F: CERTIFICATE N UMBER: REVISION NUMBER: THIS 13 TO CERTIFY THAT 746 POLICES OF INLpAZAtK:F UST1 BELOW HAVE 8t1:T 139LED TO THE INSLRED NAMED ABOVE FOR THE t'OLICY Pf3i100 uQkCATEO. NOTVATFISTANONG ANY REOUREIdItM.TERM OR CONDITION OF ANY OCNPRACT OR OTHER DOCUMENT WRH RESPECT 70 WHCH TH-ES CERTFHCATE MAY BE H$$Um OR MAY PERTAN,THE IN&ARANM AFFORDED BY THE POLICES OEBCR7BED wlliEN G SUBJECT TO At THE TERMS, fikA.UMM ANDCONCIMONS OFSUCH POUCIF'a,LIMITS SHOWN IA AY HAVE E)Et I CI PA ESCRIS S. LJAM NPe OF IN9URANM PODGY A na+MALUAeItm NPIPS237992 (CA=LL 4/2/15 4/2/16 EACH DCC E s 1.000 000 CM60MCIALGe REMLLUMRITV TO 1E° c • 10 000 wNs4lnDE ®oocua rE0 E1P ons poem g PM$ONtL4ADV1KIURY g 1 0 000 GENERAL AGGREOATE g 2 0 000 GFj1'LAOOItECJTE 1a4TAPPUES PER POLICY LOC PRODUCTS-0014` PAGO 4 O O AUTDNOegELIABRH'tY 4 s+ a1rt aearmrf OWHI�ED nUiLED RODLwYNJURY(F, t S tyros HR:ED AUTOSNON.OVNED 6000.YINaJRY(pe,emifMtl) g _ AUTOS veotltler! 4 LNIREL&A LDe 0QCVR i ExGg 8 LIAe cLANaetweE EACH OCCURRENCE 4 AOGi'fE TF g D R NS B API ENPD L9MMr UMUNN OANC619517 4/23/15 4/23/16 WC STATU- Orw AwPROPR*1wwARTNENE)EoJTR% YIN l,FPICEFM MBEtMOLMM? N/A :. DOO DOO i�wy*qAm�a"i,NRt - 000 000 nESGRIPT�ION M OPEPAnnN below L.DFS BA+tAYE 4.C18EraE-PolicnaM :. 000 000 lE9p�igH OF aPaM1gN9!LDO 7ftS lVO4mE8(Atly,{,AMID 191,A411bAe RAnede 9&&dtb,U met RPM a,epl" HtT87CA HOLDER CIWC ELLATION SHOULD ANY OF THE A=VB DESCMED POLICES BE CANCELLED 9EFORE TAland M. T{yae THE EXPIRATION DATE THEREOF, NOTICE WILL 166 DEIAGR60 N eS( AOCORDANCD SWM THE Y PROVISIONS. Far:781-593-4944 - 490 Washington 9t. AE .yen, as 01901 Aonia.% uranCeAgengy CO O 251201 M" The AC ORD name end loge aivre d madae of A 10 AC PO RD CORRATIONhts, All rigIeaar+Aed. : E-Mail: Massachusetts Department of Public Safety -V' Board of Building Regulations and Standards License: CS-032197 Construction Supervisor '- LELAND HUSSEY _ t 490-600 WASHINGTON ST P LYNN MA 01901 - Expiration: Commissioner 10/16/2017 i C�._OtRce of Cuosumer Affairs 8i Business Regutapeu I it DME IMPROVEMENT CONTRACTOR ' egistration :_701743 Type: i Expiration 61291201.6: DBA .LELAND M.HUSSEY CflNTRACFIDR i Leland Hussey 490500 WASHINGTON ST=- +� LYNN,MA 01901 -..; 4 Uederseeretary 09161NA1,