The URL can be used to link to this page

27-29 RAYMOND ST - BUILDING INSPECTION GK132S The Commonwealth of Massachusetts q n 4 f r Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR j)�� pp SALEM Building Permit Application To Construct, Repair,Renovate Or ISemoTIs b �ev d r 2071 �— One- or Two-Family Dwelling Ln This Section For Official Use Only Q Building Permit Number: Date Applied: n b Building Official(Print Name) Signature Dat SECTION 1: SITE INFORMATION 1.1 Prope� Address: r� 1.2 Assessors Map&Parcel Numbers — �cJr�FJ`AI'l 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 Ownert of Records• (� ...�q o Name(Print) City,State,ZIP 12f pkv ?o No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Workz: Cw C, SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Offi Tal We Only Labor and Materials 1.Building $ - '"' 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ 1:1 Standard City/Town Ap lication Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (FIVAC) $ List: 5.Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: lC.rnrat�p'b `I ) 2-�' SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) I o r3 A t (rte O LicenseNumber Expiiaticih Date Name of CSL Holder enlr?/ List CSL Type(see below) No.and StreetV Type Description {�� G`� ' ^ R Unrestricted2 Family (Buildings u el ing cu.ft. rVIJ R Restricted 1&2 Famil Dwelling Cityaown,State, M Masonry RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) )� 3! � I(! /' l (' ! rA tJ � n HIC Registration Number pirEk ati6n/Date HIC Comp N e or_F[)� mac... o Regi arae n t-0 l lJ _ No,qnd SVeet Y Email address ra m r`^5� CJS 10 Ci /Town, Ue,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 Issuansp of 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 ( `/\0S cc— to act on my behalf,in all matters relative to work authorized by this building permit application. o coo �c4 �U J. 9 11 Print Owner's Name(Electronic Signature) ate SECTION 7b:OWNER'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 accurate to the best of my knowledge and understanding. �ycA l> L Print Owner's or Authorized Agent's Name(Electronic Signature) D to 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.gov/dps 2. When substantial work is planned,provide the information below: Total floor 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"maybe substituted for"Total Project Cost" (t Massachusetts Department ofPublic Safety - Board of Building Regulations and Standards ' License: CS-104381 j y Construction Supervisor ARTHUR R CARBONE l 4 SILVER LEAF WAY,-APT 32� PEABODY MA 01960' w r n , n .Expiration: Commissioner - ]2/7 112 017 z _ ••K � �,C�'/ie,�pa�run'�` Omwm+.�iedll�o�'C��al7b -�\ ceor ConsumerAXairs'&:Baseness Regulation % E-1 1N -- �i H11 OMEIMPROVEMT CONTRACTOR s Reegistrabon 159367 Type:, `Epiratio0QB�. DBA s i ACTION SIDEI,NG ARTHUR CARBONE� �, 4 4�$ILVER LEAF WA AFT. >/�' �. P,EABODY,MA01960 Undersecretary S i CITY OF SM.E.Nis A. LksSACHUSETTS • BuILDLNG DEPART%lE2NT • t 120 WASHINGTON STREET,Stn FLOOR ej TEL (978)745-9595 FAX(978) 740-9846 [O,,,iBFAr FY DRISCOLL THOMAS ST.P>ERRH ,LIAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONIMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben Applicant Information Please Print Leefbly Name(Busimss;Organization/lndividmi): - ��U Address: -- ` <<3I City/State/Zip: caac,V324A /v Phone #: (D Are you an employer?Cheek the appropriate box: Type of project(required): 1.C3 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 subcontractors 2_❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MCL I I.❑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' 13.0 Other comp. insurance required.) •Any applicant that checks box 61 most also fill out the section below showing their workers'eompamation policy information. t I Inmcowtrn who submit this affidavit indicating they ate doing all work and then hire outside conttvctota most submit a new affidavit indicting such. :Cmutacton that check this box most anxhed an mWitional sheet showing IM name of the sub controcbn and their woken'comp.policy infomation. I am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and job site information. (� Insurance Company Name: Policy#or Self-ins.Lic.#: aS 2) ya��G�(.��CJ ?_ Expiration Date Job Site Address: C� \CC�i)/ �C./��1 City/State/Zip: � V` G Attach a copy of the wonders'compensatio 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 S 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 5250.00 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 the puin nd en des of perjury that the information provided above is true and correct Signature: /tet r /tip Date: Phone#: (0 � � Oficial use only. Do not write in this area,to be completed by city or town afciat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of llealth 2.Building Department J.Cityffown Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other. Contact Person: Phone#: Invoice No. &77&gp 7 7 Action Sidinor INOI EE Misc Customer tt Date Name _� ��• Q A I Order No Address Rep City Ma FOB Phone Qty — Description Unit Price TOTAL E--§ubtc)tal PaymentSelect One .. TOT Comments AL Name GC# Expires Thank You L ---s MTE(wfflwYYM Acca CERTIFICATE OF LIABILITY INSURANCE o3M20 s `J LATE HOLDER.THIS OR ALTER THE COVERAGE AFFORDED BY TAU7NUtti�U THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTENDTHE ISSUING INSURER(% BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONS71•TUTE A CONTRACT BETWEEN REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER on�� ices not Comer rights to the IMPORTANT: If the certifiYate holder Ls an ADDITIONAL INSURED,the pOIIL'y(re5)must tie eldDrsed• If SUBROGATION t5 WAIVED.subject to the terms and conditions of the policy,certain policies may require an endorsement A statement certificate holder in lieu of such endorse s)• N_ atafie Leuzri PRODUCER PHDNE �/gt)714-0503 _-___J Ror ._. _. JOSEPH PINTO INSURANCE AGENCY (Mc NP,Ea)- _ Mw IES5: iceeph.plmo4@r¢on.net Na cs._ WSUR9451AFFORDWGCOVERAGE __ 25674 7 Lincoln Skeet Sted204 MA 01800 WSDRERA: TRAVELERS PROPERTY CAS CO OF AM . -. - .. WakefieldnxsuRER6: -- -- eLsuREo INyTIREN c: .. _.- ACTION SIDING AND REMODELING INC msuBERO_ _ USURERE: _ -.. ----------- - 14 SILVERLEAF WAY 453 MA 07960 INsuRER F: I PEABODY REVISION NUMBER: i COVERAGES CERTIFICATE NUMBER- 39366 FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W1T7(RESPECT 70 WHICH THIS THIS IST. CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,.THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN LS SUBJECT TO ALL THE TERMS. EXCLUSIONS ANOCONDMONS OF SUCH PO LGEl' LIMA PmICYWIawm DMEERBEEN REDUCED BY PAID POD— S wwi TYPEDFMSURANCE i l S l EACNOCCURRENGE 1 l��COSBIERCIAL GENERALLIABIIIfY l _ i l !CLWMSNADE �OCCUR -: � i I NFD EXP( AOV INIURY .S _ PER$OPNLa , 1 rorA %�ENERALncGREonTE is GENL AGGREGATE LIMIT APPLIES PER 1 -- I PROOUCTS_CprPATPAGG :S POLICY _l r 1, LOC 1 Cots NEDSINGUEUTAT :S OTHER: • IEa AUIOMOBILEUABIU Y j i BOOBY wJInN(PHP ) S At"AUTO - ' F"LY INJURY(Pet S amtlenll' ALL OWNED SCHEDULED i WA ' 1 1;iuF0PEa1Y DAMAGE •S AUTOS �I AUTOS Iperzl _. NJEO I .S HIREDAUTOS �—A AUTOS ! EACHOCCUR(8•ICE s umaREUAUAB OCCUR 'AGGREGATE •S ellcEssuAe twM.wA1JE• WA `— _ P R 10TH ! !OED 1 RETENTONS �WORBERSCOMPBUAMON 1 EANOEN1R-OYeWUABIUrY YIN CH 14000 is 100.000 �AANYPROPWETORIP EE M ECUIME EW WA Nlw Mw 7PJU82E07222618 1D3I102076 03110120171DjSE0.5E-EAEMPLOYE S 100,000 CiiiFiCERAMEMBeii�CAfWNHJ1 (EL 015FASE-POLICY 11MR I S 500,000 OFSCWPTIONOF OPERATIONSI¢ WA l I ! 1 DESOMMMOFOPMtAIM ILDGTIONSIVEMClbS IACORD tOt,gp�ty Rv®tb SrJaWla.wol EeamtAeAeRlotesWtg WC 201 Workers'Compensation benefits sunt be paid to Massachuse0s employees OW Pursuant to Endorsement(RQ:20 03 06 B,no auttteaachu is is to jJay claims for benefits to employees in states other than Massachusetts if the insured Wines.or has hired those employees outside of MassatltusBds- This certificate of insurance shows the policy in force on the date that this certificate was issued(untess the ekptrafion date on the above policy precedes ll1e issue dated this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/MdMmfkem-cDmpensaborrAmrestigationrJ. - CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCEwrTx THE POLICY PROVISIONS. Aem01ffiEDREPRESENTATNE Daniel M.Crowley,CPCU,Vice President-Residual Market-WCRIBMA ' ©1968-2014 ACORD CORPORATION. All rights reserved ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD