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102 JACKSON ST - BUILDING INSPECTION Ja�, � r }The Commonwealth`of_Massachusetts't , ' b Board of Bwldmg Reguluuons wtd St tndnrds . hOR ` 1 Massrchusetts Stnte`Buildmg Cade -78U CMR 7"ed,non , MUy E t fl 1 Butldmg PermiCApp►tcauonT Repair Renovate Or Demolish a Rc7rxul Jnnuw, e s -.f71tLrY6r7i-o-Fnnuly' ettui + r i, r ' i I '4XkYof r.< is Section,. .J.' nal. seOn1Y Avy RAP. Bomldmg;PecmtNumbeP.• e= plied ` i Sigtunure 3 BuildwgCnmmissi er nspectorofBul p ' Dwe -� f y -: ' `>r ' you Dor EC: S1T6`INFORMATION q c r r 1 1 PropertyAddress 12 Assessors Mq &Percel'Numbers �` e` ILL Qxfyx� P x NFC�`t"C3ir[ �� -' --<Y_ -:.'r Y,-• Lx a .,. } t gy" WOO : ltu H th#s gniu�epted;sireet!ya '_`= .Im_'-;, M�+P:.Num6er i `r K Purccf Number` ' 1.3 Zoainglaformatloa L4.-Propet1y Dlmeaslons � � s , ' - t :Zoning District.K' l'#nposedUse ` :- ., fCat.Nen(sq RI,> „ i Fmntage,(RI Lam. 15 Bulldhrg Setbacks(ft) „ r r"- -:Required Proyrded G Required "� Provided Ragweed 3-- Pruv_tdcd"" t 16 Water Supply (M QL c 40,§54) L7 F1-- Zone Informatlou v I S Sewage DLsposal System ` ,t: - _ + - Tone -:- ."'tAlt.9[tlG'Flnad 7.(76!7. L + - ` ' iyy-:: i k �• ' Public Pdvate❑ ':,rte , ; ' .`,;_Qtedi if esO Municipal O�On site'disposW,sps#eln D w_ s ' y. r ..... 3ECTIONa t1ROPE1twazbw ERSNIP *. Y 21-Owner(o Rerq ) l -N h F Nome(Foot# � -;-. AJd#ws for$ervicb. ? - f r v n t $f OtUtCF 7 r TGlepbtlM J"r » + v-•r :` res, J .> WOW < ^s m i.r L y , "Tr. ;_, SECTION 3 DESCRIPTION OrPROPOSED`W,ORK;{chuck+uU(tial uP.pIY)J°'f r New Conslructign O 'Eusnng Bwldmg'Oz O�yner Ocxup�ed O §}ugs(s)yO A uauan(;)SO; Addina.,O , s Demolition `:"` O._ Accessory Bldg Nnmber af,UnLs''S Oihefx O Specify -` Bnef Descduon of Proposed Wmk� " r, to auk S' r sown A tr - 1 x r.,;� � ,�� ,SECTION4 ESTIhIATED�CONSTRUCTION COSTS rA 4r" ' ' _ ` 7 .� s r Estimated COstSAs _ r tl' r• ' OIQejBI Use�I 'R + . ows y x %(Caliar`,and'Matratglsl. g ` ' I Bwldmg:PerNN" WWI mnFee`$ t Intllcatehow fee lsdetermirled 1 Bdllding r t rY 2 Electncal $ res r z �Standa�d`C7ry/fown'APPUcabonEee r s O Total Project Costs(Item6)xmWuplier x 3 3.Plumbm8 ,, t' F :$ ,, iherF� $ � �, �, t y 7 •1 l Y ( h} ! Y 4 Mechagrcal (HVAC){ ,S F ANMI 6 Tota{Project Cost :S S,Y ❑Prud mn Full s D Outs[and n �, a 1 g Balanie Due cam, y t ° 5- , s s. (• .a u. .i n,+ y 3 f-r r'v`n �, t '1 t > r rl�:r l�F"`k�a�'✓'�5•��ir $`6'�Yi'llft>:`SP`3'ii�°,.:.:a'ne�J^Y F{i3�s°t a, c :....�' :--.,, x, .- T_' e l r`.. sr rrftys' ' Z4W W SrarS , SECTIONS CONSTRUGTIOAISERVICES ' � ;T S YT2Licetued Coustrucdob Super'(CSW�uv��f t ' 3" ,'•,�y+ ��e ' S �� '��,t ",.Mw y �t nX, dL'^�'tw. r '�' �'' c S.G � st c C' '�'�•P�S (� 1 " ' � 1._' � k e w � _^ ',� � -,�xM , �.�'' i` &i a-/'a ?,•"'�" �'at LtCQt$C Number t 4 E7IpItWIa11 t}JlC i" '�ro'��(�2 n �..- t ti I V �S V w t ( ).yva f iv yt .--,.- �'yF v �' - k + �.fka'mac�'Y� .E,�/ k ♦ £ -- �yryra1.151 CSLTypelSee below) -+ } r .� T s t ,�. R F , " !tom. '` s 'r -\u s Q 7 f� Desai en t}Et 9 +�•rim a s v _ `` 'U - .Unrestnelnl'lu [a3.5'006Co.pt,i' '" vx 2�t 'y, r r.. s gn�Ci Wd f+ ! a y -. r t"-s, a ? moky xMdk Dltl.h am v c•-,� Sid, v'cv1:. ,t�ttF.S-"" t r ,e*r RG �, 'ResidthttiiU Routs a Covcrin +' �``� '� K `h ti, STrlephotu --a , J < n '` - 'tN' p"1Y5 F 'RCndlndal Wlnduaund Siihn XF y Sp'a- `.R �fiVdkSu1W Po 'B m A liw nstatlattiin'' �w `:, , ' r S-' - _ ' . �• r .--. - , ' i--�. �D'`1 ''RGSIdCRllal DCmuhllun�`.:, ' .,< - � '�. +:; 'Regtsleied Hamefmprov Co ra (HIC) k< HIC - ' a<sx ism .A'C� YV�. 'Px`L1 r:• Qom- a ��f!�`1�� pnauon Date ;- 1 f } , s -Stgnoturc i ` SECTION 61WORKERKMOMPENSATION INSURANCE AFFIDAVIT(M G.L:c 1SZ W25Q6 , +4ki-._F G- -c "ha^ k -.4 v� t-r.'•?�e r as - i a r =;z x r r .r n a ri -r� s aVorkers{:ompeasatuominsu�rtceafTdaVrt muRUN- ti t be caark submitted welt this appltcuden ,Fadure d�pn>vtde Ihts uffiduvrt wdl restilt to the denial ofthe,I�Q!s b'f�ihe bmMmg permtG „' :;r ma— w f .3.. - s twool 2 x SECTIONla ,OWNFRAUTIiORIZhTION TO BE COMPLETED WHEN y _ r e'OWNER'SrAGENT-'OR CONTRACT.ORAPPLrIESiF_OR.BUILDAVG. iitjOIT . ,. .,` :, i ` ..t - ...i ' - '; = I, " + as Owner of the subject property hereby �uthonze toIn aet an my behalf in ell metiers_ relndveto-work authonz' by this:btuldmg pennrt oppHcadon j + .—.....a..a• -Sl _ Si atdreafthvner„ - � ,., a: _ .:Dote -c y f,„SBCTION7ti:-UWNERtORAUTHORIZED;AGENTD_ECLARAYYUN , f that thestat nts and m£armntion an he foregoing applicaUon aretrue and accurate to't a bes y know_ ledge and l .s`T t SAW Way T. Stg f Owner or:MOW Authorized Ag u u v r t - (Si undvdte ismld ties of- )•c^t a z ._..'t a , _ - J t . + x- n•2_..,. �.r. -.,. 1 �An Owt who oflown binins a building permtf to db hts/kerown5work,of an owner,who luras ununregister�contras (stat regtateied'tiu cthe Hama Improvement Contractor(FAC)Frogtnm),iwl l eat hove-access to the arbitration ' - k'Sy:.. 4 O r* 't +4-•L c Kh C program or gttarardy fund under IN G L c 142A Othec3impottant information on-t Fmgrnm olid , Cbnsri coon Supervisor licensing CCSL} ha found in`780 CMR Regulations 110 Rb and i LO R5,mapec�ively? -Z71•When`subsmntral Work is planned Iprovide the information below y , s Toml floors area{Sq ) (mc1ddmg garage 6 "fa:bmcment/nttrcs deals iii punht t;e *- Grass livmg�aiea(Sq,FL} x 4 `a .�`Ilabttable roomcoumr ^==r ' r I ' f ' NumberaF4firipinces ` ` ` ` ,, Number oFbedrounts < �-� � 1Yumbeydf'bathrooms Number bfhalflbaths ,, Type of heaung'syste"m` E-Number of de�krJ poahes tr ,iT,`ype of'cdoling sysFem '+ f ' �. ERIIbSed --'' - 'i -OpCn rz.c— .a - t - u G 3 "Totnl'Project Square Froolage :may be substituted for"Total Protect Cost ; , , + ' a yEAWt14v �. .. n i.. 9 �\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Regiatrat rt 145375 ExQiratron 9M3/2011 Tr# 282954 �FZ:QX e P y1e Corporation I ROGER A.TREMBt�G�g6TORS, INC. �I ROGER TREMBLEyyEJL2 � \rl 10 COLONIAL RD SU17�=4:^`- ` C. SALEM,MA 01970 Administrator CITY OF &U.&NI, NLkSSACHUSETTS • BUILDING DEPARIN ENT • d 130 WASHINGTON STREET,Sao FLOOR TEL. (978)745-9595 FAX(978)740-9846 Kl%,(B Ri FY DRISCOLL ST.PIE T MAYOR DIRECTOR RRE DIRECTOR OF PUBLIC PROPERTY/BUEMLNG CONMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 7 1 Please Print Legibly dame(BusinessiOrganizatiotvindividuap: R(7 G?✓ //l�IG4 Cpy, `rxcba Address: k) CO__ PYA)c.Q R J City/State/Zip: �LC M VYA 1) 0 -ro Phone 1/: re you an employer?Check the appropriate box: Type of project(requh-ed): 1 am a employer with 4. 0 1 am a general contractor and 1 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 1 am a sok proprietor or partner- listed on the attached sheet Remodeling ship and have no employees These sub-contractors have V. 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 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp. insurance required.] 'Any oppficam that cheeks box#1 must also rill out the section below showing their workm'cmrtimmilmn policy information. t I lomeowners who submit this affidavit indicating they are doing all work and them hire outside contractors must submit a new affidavit indicating such. :Conuouems that check this bra[must matched an additional sheet showing the name of the sutrcordrsctors and their workers'comp.policy infonnotioo. I am an employer that is providing workers'compensation insurance for my employees. Below Is the polley and Jab site information. Insurance Company Name: Policy#or Self-ins. Lic.#:_ b 1�uy I 1 Expiration Date:__I_! r O Job Site Address: City/slate/zin—S�/PCi,-, mA C7 fit{ ") 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 51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations urthc DIA for insurance coverage verification. I do hereby cerro under thhe/pains and penahles of perjury that the infarmarlon provided above is true and correcC Sisoatttre7 `-'j4,t...o [)are: L - 2- 9 Phonr#: Oficial use only. Do not write in this area,to he completed by city or town otrial City or Town: Permit/License# Issuing Authority(circle one): 1. Board of llelllh 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: A CORD�� 04/13 CERTIFICATE OF LIABILITY INSURANCE DATE(3/DD/Y/200099 'RODS 00)333-7234 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION EASTERN INSURANCE GROUP LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 WEST CENTRAL STREET HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NATICK, MA 01760 INSURERS AFFORDING COVERAGE NAIC# NSURED Roger A. Tremblay Contractors, Inc. - INSURERA: Selective Insurance Co of SC 19259 10 Colonial Road INSURERS: National Union Fire Ins Co PA Suite 4 INSURER C: Salem, MA 01970 INSS ERD: INSURER E: :OVERAGES THE POLICIES OF INSURANCE.LISTED-aELOW HAVE BEENJSSUED-TO THEINSUREB-NAMEPABOVE-FORTHE POLIeY-PERIOD-tNDICATEO-NOTWITHSTA '-"- - 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. JSR DDTR R' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY S 1842342 04/15/2009 04/15/2010 EACHOCCURRENCE Is 1,000,000 X COMMERCIAL GENERAL LIABILITY _DAMAGE I O RENTED CLAIMS MADE FX OCCUR MED EXP(Any one person) 1$ 10,000 A PERSONAL It ADV INJURY $ 1,000,00C GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 POLICY X PRO LOC - BECT AUTOMOBILE LIABILITY A 9091419 04/15/2009 04/15/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY A X SCHEDULED AUTOS person) $ HIRED AUTOS BODILY NON-OWNED AUTOS (Par accident) $$500. DEDUCTIBLE PROPERTY DAMAGE COMP./COLL. (Per accident) $ GAR AGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - _. -. __ OTHER THAN -EA AOC E AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY S 1842342 04/15/2009 04/I5/2010 :AG4GREGATE NCE $ 2,000,000 X OCCUR OCLAIMS MADE $ 2,000,000 A $ DEDUCTIBLE a X RETENTION $ $WORKERS COMPENSATION AND WC6974417 07/01/2008 07/01/2009 OTH- EMPLOYERS'LIABILITY TORY LIMITS rpB ANY PROPRIETOR/PARTNERIEXECUTIVE E.LNT $ 100,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE -EAEMPLOYE $ 100,000 Byes,describe under E.L.DISEASE.POLIQY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER )Esr.RIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 0. ;E TIF CA TE- OLDER - ANCELLATION- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY T, OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. J AUTHORIZED REPRESENTATIVE Rosemary Fulham/PMA 'rdlJ iCORD 25 (2001108) ©ACORD CORPORATION 1988 CITY OF SM.EM, NA-SSACHUSETTS ' Bua.DLNG DEPART.%E&NT 120 WASHNGTON STREET,3'0 FY.00R TEL (978)745-9595 FAX(978) 740-9846 KI3ffiERIEY DRISCOLL L$AYOR THomAs ST.PIHRRH DIRECTOR OF PLBUC PROPERTY/BI;II.DL\G CONL\IISSIONER 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: Case J1� , (name o haul The debris will be disposed of in : Cis All, (name of fhL lity) t I S �ny� � . �c�c►�� YW� .. (address of facility) signature of permitapplies cant date •lcbrivlTJx: Z J