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27 LEMON ST - BUILDING INSPECTION t c/ its The Commonwealth of Massachusetts tiU Board of Building Regulations and Standards ,s Massachusetts State Building Code,780 CMR, 7`h edition Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised r I / One- or Two-Family Dwelling Aril 15, 2009 ' 4 This Section For Official Use Only Building Permit Numb : Date Applied: / Signature: 41.0 t 41d Win Building Commissioner/Insrector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Propertyne§s:-,,. 1.2 Assessors Map&Parcel Numbers L 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: (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 Ownet f R cord: �� a7l�,pn�tK� o Name(Print) 17 �� Address for Service: -7 39tiWin Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work': , Ali/ 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: r ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 7 6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due: AA"l r<n,f 40 CONSTRUCTION SERVICES r ' 5.1 Licensed Construction Supervisor(CSL)i I013w�j 1� ��11�►,��t 's Lic rise ber E: v non ate 47 Name of--a f CSL-Hold I-7 P_W4�41 X/5' List CSL Type(see below) lie zow f } type Description A res, U Unrestricted(up to 35,000 Cu.Ft.) d - R Restricted 1&2 Family Dwelling Sign rn ' �n� r M Mason Only �(� /X(dJJ RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registere Iroe a tract r(HIC) 00 H ame or IC Re i e Registration um er Ad ess Expirati n ate Si a re 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 9f the building permit. Signed Affidavit Attached? Yes .......... 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 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION I, ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and be hal P rut Nam St tu of wrier r Authorized Agent Date (Signed krider the pains and penalties of perju ) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 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 half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ass-a-1'7 _ Nacral-VASTTan 3132' C-' 135 .73 ave Vii-io Rd Nry-M)3s No L]n Ln]'Id CLIC, I 9!n ® No Cold] t SLA caj LLL]a - ENERGY PERFORMANCE RATINGS . . e0jl}A=t4 DE REM IMFEWO vaPaEnco Id-Factor Solar Heat Gain cc ent . F&=n U CnaA Gwada d4. rgis scur /01. 32 1 . 8 a ADDITIONAL PERFOR CEAATINGS ACON SUPLpAE?R De REN Vlsible Transmittance . Trarumlilan de U¢vurole . . .. . . . 0 . 52 fN,dttrY>mpl�,ft use n"a+dam m mae�+ f r ditm anon Podrt oahrnvrcx WK ndao»dase,N,d Ar a Aod of C9.nnisa—sw ad a �. ; �� .. - . ed dom not wvrvd c.eWdNRy cf ry maid Thr my ua or.at ' am woe.aaeden pou®rao�s eaoEka Id'RL pn detarmlm r mando P 10%hl - _ p,&M Las vskm An"pa(3PC son PQ'n orJu b Ap d, rtwnl lr f u Ho t d PT*JM -ripadaa!ERC ro romNsnda*or Y ro ptrn7Ca las r pwDdUJ0'r 90 un ac upwilka Cxw'w mn r _ . . nava,dr prs r uae apoobw m qti Un1[ q..aLlLiu Tor ERCY STIR cagLon(+) : l+octencn Noctn Can[.a1, .9o..ln Ca't,'j, 9o.Cn awn- ' <Nf A6r TTM - L] un LC]A eaLLfica.pn. Ia U7 cty LOnluJ ENOnGY. 9TIll: Noctt, Nota Cantc]1, Suc Cantc]l, 9.c .. IND: R21n DO/CLlaa l/3S'!H-Ra] _ . - . taitkd 9Laa: ' IND: (lafuaoco 00/Vldclo 1.38 avalH Rtl DP- x-45/ -45 21m]da .obado: 91.4 cn x I6D ca- - �7771 . ' . IRS Hof fu]n - 297112➢. - JE f 0- taspdmwforpasyblsEAR9Sur rlbftToleanwlvw A11 1mr.. ` Giolde am orkut U Dma 9�nam5o6m QIEA6Y SUl>•two m(ro(er mm aoim dt aslo,ship wxentRr+tot2n h � 7/re �ianvnzmu�v¢�z a�./l�.anoor/cr�ar.CF „ - Board of Building Regulations and Standards - "� HOME IMPROVEMENT CONTRACTOR Registration:. 126693 Expiration: 8/3/2010 -- .,Type:,Supplement Card . The Home Depot At Home Service RICHARD FALLONE 2690 CUMBERLAND PARKWAY S GA 30339 Administrator , - Ionn rnoo r_ei i Gi7iA�DKN/Y.SMlO i� �. The Commonwealth of;llassachusetis Department oflndustrial Accidents Office of lit vestigations 600 Washington Street Boston, ,11A 02111 www.mass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organizational ndividual):_ Ile Address: City/State/Zip:_ Phone F mployer?Check the appropriate box: . m to er with 4. rpe;f project (required):P Y ❑ 1 am a general contractor and 1 �New constructionees(full and/or part-time).* have hired the sub-contractorsole proprietor or partner- listed on the attached sheet. : `" ❑ Remodeling t have no employees ' These sub-contractors have F] Demolition for me in any capacity. workers' comp, insurance.kers' comp. insurance S. ❑ We are a corporation and its Building addition required.] officers have exercised-their I0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LE�] �Plluumbing repairs or additions myself. [No workers*comp. c. 152, §1(4),and we have no 12.044 oof repairs insurance required.] employees. (No workers' comp. insurance required.] 13. er d *Any applicant that checks box ql must also fill out the section below Showing their workers'compensation policy information. *Homeowncrs who submit this affidavitindicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. •Contractors that check this box must attached an additionalsheet showing the name of the sub-contractors and their workers'comp.policy information I am an employer that is providertg workers compensation Insurance for my employees. Below is the o! information. policy and job site Insurance Company Name: __df� Policy#or Self-ins. Lic. #: � Expiration Date: Job Site Address: a7 ( Q Hyl 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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine 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 cerfij1, i r th pal and penahies ofperjun-that the information provided above i tr�nd correct. Si nature: Date: Phone#: r' Official use 0,711'. Do not write in this area,to be completed by cite or town offcial. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. 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MA 02143 z.. Etpneu0at WMA12 ••nnni•.7•.»• rr--: 101433 ti ^w gN t I Vf t�. tJut.�tt Dcp:iitmcn of Puhlic N;d'�n 3 7 13utt11 (it 6mldlo Kc uhuon. andS7inJ:nrl _nst....CijJR ..L?-r r ..Glelly ICnGcO license'. CS SL 99699 Restricted to: WS ROBERT POCZOBUT �,..,, 17 BEACH ROAD APT. 45 LYNN, MA 01902 5 Expiration: 218i2012 { •rnrn i-..i„ncr Tr7:'99699 - ' TM w CERTIFIED E VINYL SIDING E JN MMR _ t . C Spoaaared by tlu Ymy1 5dmg lM'bWle ^. #800004816 t Poczobul,Robert -Expires: 07101111' . 1'3eacn Hcaa-Apt.45 � AtlministereE B1r L' . lynn;MassacbasetE'C19C2 "�..4rcbkectura Tes£ng;Inc i P6b �4CORQ. CERTIFICATE ®F LIABILITY INSURANCE 022/20/20/0099-- DY, PRODUCER 1-409-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION w:u-sh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOI ANIE.ND, EXTEND OR ,usiedepot.cer treques CC=`raa rsh.corn ALTER THE COVERAGE AFFORDEDBY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, CA 30305 F. (212) 940-0902 INSURERS AFFORDING COVERAGE NAIC# D At-Home Services, Inc. INSURERA;SUeadf Steadfast In. Co 26387 Tfl wsurzma:Zurich American Ins Cc 16535 2690 Cumberland Parkway wSURERC:NATIONAL UNION FIRE INS CO OF PITTS 19445 Suite 300 Atlanta , GA 30339 INSURERO:New ,Hampshirs Ins Cc 123841 INSURERE'Illinois Natl IRS Co 23817 COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADOI POUCYEFFECTIVE POUCYEXPIRATIOH LTR N R POLICYNUMBE0. DATE JMIRDDATEM D LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/09 03/01/10 EACHOCOURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS DAMAGE TOR N PREMISES Ea occurence $1,000,000 CLAIMS MADE aOCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Any one person) $EXCLUDED PERSONAL 6ADVINJURV $4.000,000 GENERAL AGGREGATE $4,000,000 - GEH'LAGGREGATELIMITAPPLIESPER: - - PRODUCTS.COMPIOPAGG $4,000,000 - X POLICY PRO- LOC B AUTOM081LELIABILIW BAP 2938863-06 - 03/01/09 03/01/10 COMBINED SINGLE LIMIT X ANYAUTO (Ea accident) $1,000,000 ALLOWNEDAUTOS - BODILY INJURY S SCHEDULED AUTOS ', (Per Verson) HIREOAUTOS BODILY INJURY $ NON-OWNED AUTOS (Pei accftlenl) ..... X SELF INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE (PeracaEent) GARAGE LIABILITY AUTO ONLY.:EAACCIDENT $ ANY AUTO 07HER THAN "EA ACC $ AUTO ONLY: AGO E A E%CESSIUMBRELLA LIAR ILITY IPA 3757 608-02 03/01/09 03/01/10 EACH OCCURRENCE $ 5,000,000 X OCCUR CLAIMS MADE AGGREGATE 3 5,000,000 $ DEDUCTIBLE S RETENTION $ $ C WORKERS COMPENSATION AND 3566916 (CA) 03/01/09 03/01/10 % WC J.1 CTW ER D EMPLOYERS'LIABILITY 3566915(AOS) RY MIT ANY PROPRIETORIPARTNERIE%ECUTIVE 03/01/09 03/01/10 EL EACH ACCIDENT $1;000,000 E OFFICERIMEMBER EXCLUDED' 3566917 (FL) 03/01/09 03/01/10 E.L.DISEASE-EA EMPLOYEE $1,000,000 Ilyes describe under .. SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER D Workers Compensation 3566918 (KY, MO, NY, WI, ) 03/01/09 03/01/10 F TX Employers Excess _ TNSC45694422 (TX) 03/01/09 03/01/10- ccurrence/SIA 25M/2M C workers Compensation 4801323(QSI) 03/01/09 03/01/10 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: EVIDENCE OF INSURANCE - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THD AT-HOME SERVICES, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL 2690 CUMBERLAND PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR SUITE- 300 REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)ckomraus hd ©ACORD CORPORATION 1988 11172180