1 ISLAND AVE - BUILDING INSPECTION / The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
V This Section For Official Use Only
Building Permit Num ear.,j/�"}�"",� Date Applied:
Building Official(Print Name) Signature
SECTION 1: SITE INFORMATION
1.1 Property Ad ss: 1.2 Assessors Map&Parcel Numbers
1.1a 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Ab�C�cxir,✓ 5�/—0 �4L�Jh ✓-7A 01970
Name(Print) City,State,ZIP
I 15LAA. t ) Aub. (�/2-3/,2-3ysy
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 Other ❑ Specify:
Brief Description of Proposed WorV:Cj24 C� _v Corti Avil &kry*Vr-G f-/rvtrfC.
2F�E QC �fF�Ei�r alt- t1 to Cot ir- RS
<.1,t�Iy.v -lnJ LLcyi2. ��C—'�i1JS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ � 1. Building Permit Fee:$ Indicate how fee is determined:
4 000,06 ❑Standard City/Town Application Fee
2.Electrical $ 1 a 00 0-00 ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ )oZ 000, co2. Other Fees: $
4.Mechanical (HVAC) $ /(a fjtq® OD List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ / 0 Vr7 0 Paid in Full ❑Outstanding Balance Due:
P0h
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
' S13956
�,_p. License Number Expiration Date
Name of CSLFolder
List CSL Type(see below)
��pctaGlcciu f as 1�/t_.
No.and Sheet Type Description
' (� ���'/ eti K► t� f 9lo OE Unrestricted(Buildings u to 35,000 cu.ft.R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
979-,v;-& - 9393 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/'� )Gln ti 7tA /6
.i1ion
C 11l"r/•-+Sa/!_SS �UNSY7LtJ�rirCs9� HIC Regts--' traton Number Exp'vation Date
HIC Company Name or HIC Registrant Name
a I l�t9c.4Hcwfw►r iN�t.
No.and Street Email address
ps�,a f 97a-.2&T-9 RI
t /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 ..........X 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 C C2, 7, r�,< 1'e9„r JtL tj c*F .J
to act on my behalf,in all matters relative to work authorized by this building permit application.
AUt,VSfry 5E2.wo
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
contained in this avolication is true and accurate to the best of my knowledge and understanding.
_ 5- 5--1/
rPrmt�er'S ufhorized 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 MC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) /7 aS (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) }? )$ Habitable room count Co
Number of fireplaces p Number of bedrooms
Number of bathroomsNumber of half/baths
Type of heating system KL Number of decks/porches
Type of cooling system /yuAG Enclosed Open_)K-
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
m
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investfgatfons
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leldbiv
Name(Business/Organiration/Individual):�I FN S L .L�a./�fi/Z ur—Y-4roV
Address: o1/ I�,JC,*Ne.-Zy+g5 1,2.
City/State/Zip: ���jii3od}r /+act . Oi 96to Phone#: Q 7 r',Z(o'.'r R V9
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet I 7. El Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for min my capaci ry. workers'comp.insurance.
9. ❑Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I l.❑Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
• `-
Any applicant that Checks box W must elect fill out the section below slowing their workers compensmoupolicy information.
t Homeowners who submit this atadovit irdicaong they ma doing all wmk and thrn hire outside eo mactms must submit a new affidavit indicating such
tContracims that check this box must attached an additional sheet showing the rremc tribe sut-ontmcans aid their worker'comp.policy informatioa.
[am an employer that is providing workers'eompensadon iraurance for my employees. Below is the policy and job site
Information,
Insurance Company Name: rO(-)tqn `� . LOUS U QdJ C!g q
Policy#or Self-ins.Lic.#: 54 G23 13 y lo 7 Expiration Date: O— y — 1
Job Site Address: I, _IC( AaS, AtSr City/State/Zip:5�qczia A",q cS/.070
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to seem 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 fate
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby terrify ander the pains and Penaldey ofperjury that the information provided above is true and correm
Simaturen n' Date:
Phone#: Y7$_otG>'�" 7-,i
Official use only. Do not write in this area,to be completed by city or town o ficiat
City or Town: Permit/License#
Issuing Authority(circle ora):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
ACORD� CERTIFICATE OF LIABILITY INSURANCE 04/11/2011
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A.MERCHANTS INSURANCE GROUP _
Cummings Construction INSURERS:Guard Insurance -
21 Pocahontas Drive INSURER C:
INSURER D:
Peabody MA 01960- 1 INSURER E:
COVERAGES
THE POUCIES 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 CERMFICATE 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.
INSR DO'L , POLICY EFFECTIVE POLICY EXPIRATION
LTR INSIRD I TYPE OF INSURANCE POUCYNUMBER DATE(MMIDOIYY) DATEIMMNONYI LIMITS
A GENERAL LIABILITY BOP9099351 11/08/2010 11/08/2011 EACH OCCURRENCE S 500,000
DAMAGE TO RENTED 50,000
R COMMERCIALGENERALLABILITY PREMISES Ea Ucclmence $
' CLAIMS MADE 0 OCCUR / / / / MED EXP Any one Ison) $ 5,000
PERSONAL S ADV INJURY S 500.000
GENERAL AGGREGATE S 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 500,000
7 POLICY Ll JTC2 LI LOC
AUTOMOBILE LNBILRY / / / /
COMBINED SINGLE LIMB $
ANYAUTO (Ea accident)
ALL OWNED AUTOS / / / / BODILYINJURY S
SCHEDULEDAUTOS (Per person)
HIREDAUTOS / / / / BODILY INJURY
` NONOVMFD AUTOS (Peraccident) S
PROPERTY DAMAGE
r (Per accident) S
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S
ANYAUTD / / / / OTHER THAN EAACC $
AUTOONLV. AGG 8
EXCESSAIMBRELLA UABILRY / / / / EACH OCCURRENCES _
OCCUR CLAIMS MADE AGGREGATE S
E
DEDUCTIBLE '/ / / / $
li} RETENTION $ I S
H WORKERS COMPENSAMN AND STWC134307 08/04/2010 08/04/2011 RTORysTL T9 ER
EMPLOYERS'UAINUTY
I ANY PROPRIETOR/PARRIER/EXECNTIVE EL EACH ACCIDEM S 100,000
I OFFICEPoMEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYE $ 1100,000
ayes,dsm amer 500,000
SPECIAL PROVISIONS Eebw EL PO
DISEASE- UCY LIMIT S
OTHER
DESCRIPTION OF OPERATMHSILOCATIONSIVEHICLESIE.XCLUSIONS ADDED BY EIDORSEMENTISPECNL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION OATS THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
L 030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
FOR INSUREDf3 RECORDS FAILURE TO OO SO SHALL IMPOSE NO OBLIGATION OR.LIABILITY OF ANY KIND UPON THE
INSURER RS AGENTS OR REPRE TNES.
I — AU ORQEO0.EPREBENTATNE
1
r
19i CITY OF S.U.EN1, iNL-kSSACHUSETrS
• BULDLNG DEPARTM&NT
P 130 WASHLNGTON STREET, 3'D FLOOR`. aN TSL (978) 745-9595
Fax(978) 710-9846
KIN
IBERI EY DRISCOL L
MAYOR T m&us ST.PIERR&
DIRECTOR OF PUBLIC PROPERTY/Buumi NG coNMUSSIO,iER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
l Lv fits �e� c,�[fl
(name of hauler)
The debris will be disposed of in
13 Fl _
(name of facility)
/ �t3v2ti Sy-. i�EQf3cr1)y rra
(address of facility)
nature of permit ap 'c t
date
d0risalUm
46
. „r Pnhlic Safer
_ F Massachusetts- Department of Public Safer
_: Board of Building Ret:u4Rimis and Stand:ulds
LLL���11 Construction Supervisor License
License: CS 83956
STEPHEN D CUMMINGS
21 POCAHONTASiDR
PEABODY, MA 01960
0
Expiration: 10/1/1012 5
('onuaicsiuncv'' Tr#: 5304
�ianvnioouaealf/a �,/�amar/�uaelA
Office of Consumer Aftair's& asiaess Regulation -
9 HOME IMPROVEMENT CONTRACTOR
Registration: 140576 -
Expiration: 1012712011 Tr# 289061
Type_ . DBA -
CUMMINGS CONSTRUCTION,
STEPHEN CUMMINGS - '
21 Pocahontas Drivei.
Peabody,MA 01960 Undersecretary -
�s
b
BlninB Room Area
Cloaet
Lavin Room Area
as a°
e
Dec
L
Slider
® O
1aa1n"(L
� O
Bedroom#1 BeMroom� Oh'
O o a KIM-hen Area
b
te'e"
° 1r tae"
Closet �
0 oQ OO
39'P
Cummings Construction,Inc.
1 Island Ave-let Floor Plan
Sheet 7 of 7
0 � oo a
12'0"
Master Bathroom
S Closet 2•7tn•
Laundry
aI'n
Bedroom N2 I -
Master Bedroom
Closet Closet O
Bathroom
O F
0
Master Closet
Bedroom#1
6•w 1515 in-
36-T
n"11 H 11
11
38'3•
Cummings Construction,Inc.
7 Island Ave-1st Floor Plan
Sheet t of 1
I q I
1
3'11-
xz'
� l ) N
Dining Room Arse
Closet
dn
l
Living Room AreaDock
nr I j I
II i ! IIII I i ( r
III '
I I N I III l i l
i� Glider
�
mztrz•
y�Bedroom W �Bemmom: i � � '\�) � � I� � ! � !
! a , 0 N a KMehen Ami
b V
i1e p I
f 1T 1C
Closat
�I
0I o o
MY
Cummings Construction,Inc.
1 Island Ave-let Floor Plan
Sheet 1 of 1
O ]�1
f Master Bathroom
{ I
C Closet ta']trz-
�,
U Laund LJry
Bedroom 12 I
I
I ri j
Master Bedroom -
Closet Closet
IJ Bathroom
I b
F
Mester Closet
Bedroom 07 L n
39'3-
Cummings Construction,Inc.
i
1 Island Ave-1st Floor Plan
Shoed of I
a