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102 SCHOOL ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7h edition K O ed mEiM ! I uary Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 1�) One-or Two-FamiV Dwelling A This Section!J Official Use Only ddd Building Permit Numb r: Date Applied: t 1 ! Signature: 2 sq , L Building missioner/Ins for of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Addre�s• t 1.2 Assessors Map&Parcel Numbers /0 2 SUi 00 / S� 1.1 a 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: 10 Z, f�p0 ff SA�Gr.1 �gA VA-rGAf Name int) Address for Service: JAma- 9d 97f- Z3J -12z.-7 Signa Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied'❑ Repairs(s) 01Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': Q 2 J — J SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only -(Labor and Materials 1.Building $ b D 0 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ 6.Total Project Cost: $ 41 p y Check No. Check Amount: Cash Amount: ` L/ 0 Paid in Full 0 Outstanding Balance Due:: // , 1 r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) �a2o7-�Y r�-7,Ly �7rG S i7 License Number Expiration Date Name of CSL'Holder /,,/�� List CSL Type(see below) 16 J dne7t;/ cc ' — �LZ�e _ Address T Description U Unrestricted(up to 35,000 Cu.Ft.) R Restricted 1&2 Family Dwelling 3� M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) / /f �tcc, 1-o//[es n 16 �- HIC Company Name or HIC Registrant Name Registration Number Address /e,/,/// F y y tf-r/rT Expiration Date Sign Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 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 .......... IR"� No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 114A !/f1✓/dA 1 as Owner of the subject property hereby authorize A 6 � 11 ft.0 to act on my behalf,in all matters relative to work authorized by this building permit application. K r� rV7qQ,6 Si afore of Owner Date G SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I, �c �Y-1 rLJ,, 0,;7 6 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 behalf. ( �r9✓N 1��(�1 Print Name (/ Signature of Owner or Authorized Agent Date (Signed under the Pains and penalties of 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 1 IO.R6 and I l O.RS,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"maybe substituted for"Total Project Cost" - 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington'Street Boston,MA 02111 www.massgov/dia Workers?Compensation Insurance Affidavit: Builders/Conti'_actors/Electricians/Plumhers AunlicanfInformation y Please Print Legibly Narne(Business/Organ ation/Individual):�£_IC ..(—ily/f}"A-0'I' t//r Address: y6 ✓n.n e f�— City/State/Zip: 1/f AA 0 1 Yd L Phone#; 771 Are y employer?Checkthe-appropriate box: Type of pin]ect(required): I. am a employer with 3 _ 4. ❑ Iam a general contractor and I - 6. ❑Newconstruction employees(full and/or part-time).* have hired the sub-contractors i 2.❑,I am a sole proprietor orpainter- listed on the.anached sheet.t 7. 5alemodeling "ship'.and have no employees These subcontractors Have 8. ❑Demolition working for mein,any capacity. workers'comp.,insurance. 9 ❑_Building addition. [No workers'comp.insurance 5. ❑We are a corporation and its: required,] officers have exercised their ]0:❑-Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption perlvlGl l I-.❑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,.❑Other% -comp.insurance required.] .Any applicant that checks boa pl most also snout the section below showing their workers'c rr pamtion polity information: r�Homeowners who sabm'irthrs affidavit iMirating they are doing all work and then hireaunid<cootixtms most submit a new alfidavit in licaung such. tConaacturs that iheck_t[tisUx mustaftachcd so addmou d sheet showing the name oche sub<omiucmrs and their workers'comp.policy intoimatioa. I am an employer that is providing workers'compensation Insurance for my employees. Refow is'the policy andjbti site information. Insurance Company Name; 6 X-e/"ly A1611_I/Qi/ Policy#or Self-ins.Lic.#: We2_-315'- 37S_9T7'-6/0 ExpiratiohDate: Job Site Address: City/StatdZip; Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Sectioa25A of MGL c. 152 can lead to theimpf c 9sition oriminal penaltiesbf a fine up to$1,500:00 and(ocone-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 thisstatementmaybe forwarded to the Office of Investigations of the DIA-for:insurance coverage verification. I do hereby certify under the pains �and penalties,of perjury that rhe'infa ma ion provided above is true and correct Signature: /71i24A_ Date:• /2 -/f L O Phone#: 777 ' 23-7 — i/y00 78/-3e'7 —f6yZ Officidt me only. Do nut-write in this ary4ro'be completed by"city or-town official City or Town: Permit/License N- Issuing Anthoft(circle one): 1.Board-of Health 2.Building Department-3:Cityfrown Clerk 4,.Electrical.lnspector,5.Plumbing Inspector 6:Other .Contact Person: Phone#: VAAC OQtUR erty ISSUING OFFICE 181 Wowkee Compen4ation and INFORMATION PAGE Employee Liabi�ity Policy ACCOUNT NO. SUB ACCT NO. L betty Mutual Insurance Group/Boston 1-375958 1 0000 LIBEI TY.MUTUAL INSU RANCE CO 15628 POLICY NO. JTD1CDJ SALES OFFI E CODE SALES CODE /R IS9' WC1-315375958.010 I XXX I WESTON 102 REPRESENTATIVE 3000 1 YEAR ASSIGNED 2010 Item 1.Name of A &F INSULATION CO LLC Insured FEIN 27-1525466 Address PO BOX 651 RISK ID 85023T, MALDEN,MA 02148 Status 46- LIMITED LIABILITY CO Otter workplaces not shown above: SEE IT EM 4 - Mo.Day Year Mo.Day Year Item 2. Policy Period: From 01-21-2010 to 01-21-2011 12:01 AM standard tin a at the address of the insured as staled herein. Item 3.Coverage A. Workers Compensation Insurance: Part Of ic of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two f the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident 500,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 500,000 each employee C. Other States Insurance: Part Three of the folicy applies to the states, if any,listed here: SEE END WC 20 03 06A I). This policy includes these endorsements ani schedules: SEE EXTENSION OF INFORMATION PAGE Item 4. Premium- The premium for this policy will be determined by our Manuals of Rules Classifications Ratel and Rating Plans. All information required below is subject to verificatic It and change by audit. Premium Basis Rates LIN 110 Per$I00 EMIn med Code Estimated of RE- Annual Classifications No. Total Annual Premiums munerstion Premiums SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 500 ( MA ) Total Estimated Annual Premium s 8,160 Interim adjustment of premium shall be made: ANNUAL This policy,including all endorsements issued eherewi h,is hereby countersigned by Authorized Re e.unletive Ute 01-29-10 Loc.Code Term. Oper. Audit Basis Periodic Payme Rating Basis POI.H.G. Home Slate Dividend 01.29.10 NR MA NEW i i i i GPO 4030 RI Copyright 1987 NatioI Council on Compensafion Insurance WC pt uo 111 A liBroker Copy MMIDDYYYY)CERTIFICATE OF LIABILITY INSURANCE DATE( 5/6/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Paul T Murphy Insurance Agency PHONE FAX (AIC No ExU (Ar No), 16 Lebanon St EWAIL ADDRESS: Malden, MA 02148 PROD'STUCER 7820 INSURER(S) AFFORDING COVERAGE NAIC4 INSURED INSURER A:Scottsdale Insurance Co A S E Insulation Co. LLC INSURER B:Travelers PQ BOX 651 INSURERC: Malden, Ma 02148 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 TFE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE AML SUBR POUCYEFF POUCYEXP. LTR POUCY NUMBER MIDDN MmmorYYYYl UMTS GENERAL UAINUTY EACHOCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY CPS1102497 1/14/10 1/1/11 DAMAGE TO RENTED $ 50,000 A CI-AIMS-MADE FilOCCUR MED EXP(Aryonepersm) $ 5,000 PERSON41-8 ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-WMP/OP AGG $ 2,000,000 POLICY PRO T17 LOC $ AUTOMOBILE LIABIUTY CONE INED SINGLE LIMIT ANvnuro BA-5225PI81 1/5/10 1/5/11 (Eaeccidert) $ 1,000,000 BODILY INJURY(Per parson) $ B X ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULEDALITOS PROPERTY DAMAGE $ X HIREDAUTOS (Per accident) NONO W NED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN M.T. ANY PROPRIETORtPARTNERIEXEGITNE OFFICE RMIEMBER EXCLUDED? NIA E.L.EACH ACGOEM $ (Mandalmy in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPE RATIONS below E.L.DIS EASE-POLICY LIMIT S DE SCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (Attach ACORD 101,Additional Rermr Schedule,H more space Is mqd red) Insulation and Carpentry National Grid Corporate Services LLC d/b/a National Grid,d/b/a Boston Gas Company,d/b/a Essex Gas Company, and Action Inc. are listed as additional insured, form CG2033 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tri City COummunity Action ACCORDANCE WITH THE POLICY PROVISIONS. Programs Inc. AUTHORIZED REPRESENTATIVE Cu Y)-� � feA © 1988-200 AdORD CORPOFfATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD « r Nlassachusctts- Dcpartmcnt of Public Safctc Board of Buildin- Rc_u •d lations and Stand:us Construction Supervisor License License: CS 8226 Restricted to: 00 GARY) LOPRESTIA s a 18 PENNY'HILL RD^ A, MELROSE, MA 02178 Expiration: 4I2I2012 ( ouunissiunrr. Trfi: 26349 0ce �omvma�ualdc o� Glaooa`/ei7 q� omee ofConsuiner Affuln 4 atio HOME IMPROVE64397 NTRACT04t RegisVaBn 164397o Expiiatwn w10/Y2011 T` �E44Z6� :No TYP,e�„�'t IndNidUali�d' ar_' `., GAt2Y LOP.RE4 16 PENNEY HIL` .YELROSEjMA,0217E' - Undeneel+t