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29R UPHAM ST - BUILDING INSPECTION $ X36/ Cr, 20 1 -z- The Commonwealth of Massachusetts a Board of Building Regulations and Standards RECDvED CITY OF Massachusetts State Building Code, 780 C „ ECTIONVAL SEp,, lCE5ALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish : 53 One-or Two-Family Dwelling IaIS DEC -3 This Section For Official Use Only Building Permit Number: Date Ap d: Building Official(Print Name)- Signature Date 1 SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers fl 291P tJP�iH w S;. Sir , �l� 27 oZ co I L l a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Rti- Ac6i6rV-r1 ?— /. l�Sb Zoning District. Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards RearYard 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 Id1Private 13Check if yes❑ Zone: _ Outside Flood Zone? Municipal 15On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 21 Owner'of Record: m b .Cot�.E'77V�y Name(Print) f City,State,ZIP 29R 790 Y7(01 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Rri Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work : /NSTIict. Ngo z^o✓4477c.y zv,qz, � OAR1Z..�V�O�Nlow SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ OZ j. 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ A ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ N9 2. Other Fees: $ 4.Mechanical (HVAC) $ A19 List: 5.Mechanical (Fire 76Total ession $ W/9 Total All Fees: $ Check No. Check Amount: Cash Amount: Project Cost: $90 ❑Paid in Full ❑Outstanding Balance Due: mAlt �D I-z- 1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder /� List CSL Type(see below) C/ / 75 OS No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances d-Aos y3y 7600 CA,-a o(Erex-c✓ Xulleoi15 COrc/ I Insulation Telephone Email address D Demolition 5.2_Registered Ho Improvement Contractor(HIC) /;E?co.J �cbV37X'c'CT�M/ -mac'✓/GES 7 cs GVE.0 HIC Registration Number Expiration Date BI7C Co any Name or HIC Regisffan[Name / "7 f_.Ornme.ec.:9-r. C.V /7OS. CM/ No.and Street �' Email address G,nw-ocvvof�" N// '93053 y3y 7600 Ci /Town,State,ZX 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 ..........4K No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT-222 I,as Owner of the subject property,hereby authorize C�//11�/5 7biOzlf t= /- s J ' JS'9x�✓ 1/f/� /E J/ to act on my behalf,in all matters relative to work authorized by this building permit application. 5pL✓T?-U / S Print Owner's Na&e(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information 7co ed in this ap lication is true and accurate to the best of my knowledge and understanding. Q.474a k- //•3D /S Owner's or Nuthoriz6d Agent's Name(Electronic Signature) Date 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 RIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at u .mass.eov/ds 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths 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 14 1 Congress Street, Suite 100 Boston, MA 02114-2017 www massgov/dia \Vorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information /J /l ! c- Please Print Leeibly Name (Busine7ss/Organization/Individual)' tCFfCoN C_Bt/STXyG�on/ J�VlC5 /-Le Address: J �OMME.QGiyL /_,t , �t C City/State/Zip:zcv�oo.vctce)� 1V41 Phone #: Are you an employer"Check the appropriate box: Type of project(required): I. 1 am a employer with kaemployees(full and/or part-time),- 7. [] New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in $, remodeling any capacity.[No workers'comp. insurance required.) 3.01 am a homeowner doing all work myself. [No workers'comp.insurance required]t 9. ❑Demolition 4.Fit am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.[] Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.El 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ROof repairs These sub-contractors have employees and have workers'comp.insurance) 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[]Other 152,§1(4),and we have no employees.(No workers'comp.insurance required.] Any applicant that checks box H I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this 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 nameof the sub-contmetors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name:Pt£55 //✓�`U�4�t/G� LO . Policy#or Self-ins. Lie. #: VUG S3r7`I X 2{(0 Expiration Date: Job Site Address:z9w 41A,9-,N 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 MGL c. 152,§25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby un er the pains and penalfies ofperjury that the informurrion provided above is true and correct Sign . Date: Z ' Z ' Phone#: ee&13- Q Official 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#: page 3 of 4 , 10 o CERTIFICATE OF LIABILITY INSURANCE GATE(MWDD015 `.� to/2o/zols r 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(les) 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 Julie Levesque, CPCU, CIC X242 Infantine Insurance PHONE . (603)669-0704 FAX .603 669-6831 P. 0. Box 5125 pplL :jlevesque@infantine.Com INSURE S AFFORDING COVERAGE NAICa Manchester NH 03108 INSURERAS7etherlands Ina 24171 INSURED INSURER e Peerless Ins Co 24198 INSURER C: Rescon Construction Services LLC INSURER D: 3 Commercial Lane, Unit C INSURER E: Londonderry NH 03053 INSURER F: COVERAGES CERTIFICATE NUMBER:15/16 Master 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 THE 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 AWL SUM POLICY NUMBER MMIUCT EFF MMWODY EXP LIMITS LTRIm JIM GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISE Ea occurrence) $ 100,000 A CLAIMS-MADE FxIOCCUR CBP8375427 /1/2015 /1/2016 MED EXP(Any one Person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPADP AGG $ 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY Ea,.d ..,SINGLE LIMIT 11000,000 A IX ANY AUTO BODILY INJURY(Par Person) $ ALL OWNED SCHEDULED 927917 /1/2015 /1/2016 BODILY INJURY(Per accident) $ AUTOSAUTOS HIRED AUTOS X NON-OWNEO PROPERTY DAMAGE $ AUTOS PeracadeM $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ B WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I NTS ANY PROPRIETORMARTNEMXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory In NH) C8379426 /1/2015 /1/2016 E.L.DISEASE-EA EMPLOYEII$ 500,000 If yes,describe under states: HB 6 !41 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Aaach ACORD 101,Additional Remarks Schedule,U mon space Is required) RE: 2400 Computer Dr. Westborough MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Forty Washington LLC ACCORDANCE WITH THE POLICY PROVISIONS. 116 Flanders Rd, Suite 2000 Westborough, MA 01561 AUTHORIZED REPRESENTATIVE �J— Charles Eamlin/JLL G f�4--� /71 ACORD 25(2010/05) ©1988.2010 ACORD CORPORATION. All rights reserved. INS025 nnlnnn)m Tho annpn nam¢.nd Inns aro ron:¢f¢rod ron.dr¢of ar.np T Office of Consumer Affairs and Business Regulation ' 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164895 _ - - Type: LLC Expiration: 11/30/2015 Tr# 245462 RESCON CONSTRUCTION SERVICES LLC CHRISTOPHER BROWN 4, 3 COMMERCIAL LANE SUITE C — ----- — LONDONDERRY, NH 03053 --- Update Address and return card.Mark reason for change.- -' SCAT 6 20M-0Sni Address �-- f 1I—', Renewal Employment i-, Lost Card — — r%1e�nnrrrrruracn�/�n/C-��r::ne%m-c/l.' #KgIstraflon: re of Consumer Affairs&Business Regulafion License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 164695 Type: Office of Consumer Affairs and Business Regulation piration: 11136!2015 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 RESCON CONSTRUCTION SERVICES LLC RECON BASEMENT SOLUTIONS- CHRISTOPHER BROWN. - 3 COMMERCIAL LANE SUITE C LONDONDERRY,NH 03053 - Underseeretaq' Not valid without signal re Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-105688 Construction Supervisor P CHRISTOPHER BROWNZ.,,, rrr. N 95 ROOAQ BEDFS - SrRO NH 03110 { I rlr \ 1-JZ7 CA_ Expiration: Commissioner 10126/2017 11/30/2015 15:53 6179234644 PULSE MEDIA PAGE 01/01 • November, 30, 2015 To whom it may concern: The Blacksmith Condo Trust has contracted with Peter Ryan and Son Roofing, Inc. to replace the roof at 183 Federal St., Unit 2, Salem MA 01970. The owners of Unit 1 -April Swieconek and Phillip Prodger and Unit 2 -Jeff and Alison Schmidt are both aware of the work to be done and have approved it Regards �� Jeff Schmidt Blacksmith Condo Trust