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6 MESSERVY ST - BUILDING INSPECTION „ / QV Dk) SPI -e— C «c (� The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR f Massachusetts State Building Code,780 CMR, 7h edition MUNICIPALITY Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January One-or Tw mily Dwelling 1,2008 ection Jor Official Use Only Building.Permit �/ber: Date Applied: Signature: -f Ay&a A a (?.:. Building Commis i ner/:Ins ector o t gs Date ON 1:SITE INFORMATION` z 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers /e Megre^” 5r 33-66a3-0 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: Zone: _ Outside Flood Zone? Public Private❑ Check if yes6/' Municipal On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIPr 2.1 Ownerr of Record: t Ta tti� : � Name(P Address for Service: 4700. 941 - 3iaa signatu Telephone SECTION 3:DESCRIPT NPROPOSED WORK2(check all that apply) New Construction❑T Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) al<Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief�tlD(�escr�ivption of Pronnnnosed Work2: T II3LYY� P�Q.u.li L,A/� SiAinG J SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials - - 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ ----'+ 2. Other Fees: $. 3 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suppression) $ Total All Fees: $ q�� Check No. Check Amount: Cash Amount: ` i v 6.Total Project Cost: $ r,L/,r Cl Paid in Full 0 Outstanding Balance Due: SLI t4/ s_• C) -0 t SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) C5 53 65 3 j)GQ„/ A )M(U!J F`1y 1L License Number Expiration Date NameCSLJ-Iolder 6XI CI(A�`t List CSL Type(see below) aG Ave dress Is; Type Description aI57 p U Unrestricted(up to 35,000 Cu.Ft. o R Restricted 1&2 Family Dwelling Signature � ( M Mason Only �1 RC Residential RoofingCovering Telephone / WS Residential Window and Siding l.1'7 J�7uS-30 51O SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) C Company Name or HIC Regjstrait# Nam Registration Number AT a t-0 Add#s13 13 7 q`i b� 14 Expiration Date sl�gnULUM 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 .........—IM No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGEN.Tf OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, V /V a "i 1 Jf7 I l/ps as Owner of the subject property hereby authorize ql,Y to act on my behalf,in all matters relative to work authorized by this building permit application. S aoo Si na o er_ Date ON 7b: O/ R AUTHORIZED AGENT DECLARATION 1, 1 h as Owner or Authorized Agent hereby declare that the statements a d nformation on the foregoing ap lication are true and accurate,to the best of my knowledge and behalf. -�- p �J14M Print Name Signature of O ner o Authorized Agent Date Si ed under t ins and penalties of a 'u 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 110.85,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' The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston,MA 02111 U1V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual))n: ` I)V H1. le"7 WLx-4'•"�-tr Address: o Colonic _ r Cit /State/Zi 11� Phone#: (_c,72 0)745 Y �SL10r^ JV+Ay Are you an employer? Check the appropriate box: Type of project(required): VCM I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or t-time).* have hired the sub-contractors 2.ElI am a sole proprietor or partner- listed on the attached sheet. t 7. E] Remodeling , ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.7 Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ 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' 1 g ❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit[Iris affidavit indicating 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 additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A ` 1 . Policy#or Self-ins.//Liic.#: l�C b� 714,X4 1 I14 '7 1 -1 Expiration Date:. /1 b Job Site Address: '�3�' IrneSCeNy4 City/State/Zip: . 3,, t T. Ilbi 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 a 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 certify under rthe pains and penalties of perjury that the information provided above is true and correct. Signature: Date: L"��±[ Date: Phone# /c17E3/� 7175 3® �'C� Ojjicial use only. Do not write in this area,to be completed by city or town official 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.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to 511 out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each _ year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. - The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111. Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-OS www.mass.gov/dia RF RR BL7M CERTIFICATE OF LIABILITY INSURANCE 04/13/DD 04/13/2000909 IRO Du 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 INSURERB: National Union Fire Ins Co PA. Suite 4 INSURER C: Salem, MA 01970 INSURER D: INSURER E: :OVERAGES THE POLICIES.OF-INSURA.CE.LISTED-aELOW HAVE-BEEN-ISSUED-TO THEINSURE&NAMED-ABOVEi(3R-THE-P©LIOY-PEikt(50INDICATED.-NOTP/ITHSTAN "--" -- 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. ISR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONTR INSR DATE wmtpn�i LIMITS GENERAL LIABILITY S 1542342 04/15/2009 04/15/2010 EACHOCCURRENCE s 1,000 000 _ FX-]COMMERCIAL GENERAL LIABILITY DAMAGE TORE ED ,$ 00,000 CLAIMS MADE f X]OCCUR MED EXP(Any one person) $ 10,00 A PERSONAL It ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000.000 FGENLOALCGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 3,000:QQQ ICY M PRO- JECT LOC AUTOMOBILE LIABILITY A 9091419 04/15/2009 04/15/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ A X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ X $500. DEDUCTIBLE PROPERTY DAMAGE COMP./COLE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO _ ._- - __.. OTHER THAN --EAACC '$ ... AUTO ONLY: AG G $ EXCESS/UMBRELLA LIABILITY S 1842342 04/15/2009 04/15/2010 EACH OCCURRENCE $ 2,000,006 X OCCUR O CLAIMS WOE AGGREGATE $ 2,000,000 A $ DEDUCTIBLE $ hX RETENTION $ $ WORKERS COMPENSATION AND WC6974417 07/01/2008 07/01/2009 X WC STATU- OTH- EMPLOYERS'LIABILITY IQBYLIMITS til B ANY PROPRIETOR/PARTNER/ ECUTNE E.LEACHACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYE $ 100,000 Byes,AL PR eUnder - E.L.DISEASE-POLICY LIMIT $ SQQ 000 SPECIAL PROVISIONS aglow OTHER )ESCRIP_Y)ON OF OPERATIONS I LOCATIONS-I_VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS O; ......... 'ERTIF ATE: OLDE -CANCELLATION, 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 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Rosemary Fulham/PMA LCORD 25 (2001108) ©ACORD CORPORATION 1988 4 Y d •�n • 1 t � '. r rti. C' - 1. f �>ie TOa4ivnwoearva� o�./flaaaac%ueef� Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrat o:,~145375 L Expiration 1/.13/2011 Tr# 282954 i(r 4je Corporation ROGER A.TRE M$L_1CQ ORS, INC. I. ROGER TREMBLEYF R"jl 7� l 10 COLONIAL RD Sl1 �A SALEM,MA 01970 Administrator