Loading...
12 WILLIAMS ST - BUILDING INSPECTIONf V. s IThe Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR 7`s edition B OFd wry 'J1 Building Permit Application To Construct Repair, enovate Or Demolish a 1, 2008 One-or Tw amily Dwel ng This S i n For Offi 'al Use Only Building Permit Number: Da Applied: Signature: Building Commissioner/Inspe_ r of Buil ' gs - Date SECTIO 1:SITE INFORMATION 1.1 Prop&qy .S Address: 1 1.2 Assessors Map&Parcel Numbers ' 2 2 GJ,'L ci�9i'1�4 S l 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(ft) 1.5 Building Setbacks(R) 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: d3dr, &AEA A, �K Nam n Address for Service: x 97 r--,) S—S/j.S SignatureTelephone SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work : /LS d1�C. C z' tiT W tiQ$ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs:Labor and Materials Official Use Only, 1.Building $ I. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)xmultiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List G 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 13 V- V ❑Paid in Full ❑Outstanding Balance Due: c 9R �a �� ti Ey SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) /� _ /�f�'. ��'�./1lA(_)LT icense Number Expiration ate Name of C L-Hold ' Z� jZ�1 d r��� List CSL Type(see below) Ad ass W10/1�l Type Description U Unrestricted u to 35,000 Cu. R Restricted 1&2 Family Dwelling store /ti M Masonry Only V RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 egistered om IrnprovementCollctor ) �639oS 'hJ2's> ' i r ria�V Co yN eor C e [rant ame Regisnatio Number l Expiration Date Si (gnamre ate/" Telephone 7� b 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 ..........❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 8 o as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work Authorized by this b ilding 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 behalf. P " Nam x tgnature of Owner or Authorized Agent Date (Signed under the pains and penalties ofperjury) 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.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"maybe substituted for"Total Project Cost" MOYNIHAN LUMBER OF BEVERLY, INC. "QUALITY BACKED BYA DESIRE TO PLEASE" 82 River Street P.O. Box 509 FEIN:04-2261995 Beverly,MA 01915-0509 A A Contractor Reg No.: 978-927-0032 96 HH Exp. Date:_//— Salesperson(s): HOMEOWNER INFORMATION Name Daytime Ph /; lLGy�CClaAr�31 slime- Street Address(Not P.O.Box) Evening Phone Citylrown State Zip Code Mailing Address(idifferent from street Address) WORK TO BE PERFORMED AND MATERIALS TO BE USED Moynihan Lumber of Beverly, Inc.agrees to perform the work set forth in Exhibit A for Homeowner and to use such materials in connection therewith as set forth also in Exhibit A, attached hereto and made a part hereof. The following schedule shall be adhered to unle s Ci umstances arise beyond Moynihan Lumb f Beverly, Inc.'s control:Work so led to bey i / /_ Expected date of completion. a be based u n vol o/ 'al order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Moynihan Lumber of Beverly, Inc. agrees to nrm the work, and furnish the material and labor set forth in Exhibit A for the Total Contract Price of:$ G/• (which amount includes all finance charges). Payment hall ba-made by Homeowner according to the following payment schedule: $ O(5' Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of one-third(1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom Orders as set forth below). $� by—L-/ or upon completion of delivery of materials $ by_/_/or upon completion off t II $ !upon completion of the Contract In order to meet the completion edule set forth above, the following materials/equipmen ust be special ordered before the Contract rk begins,for a Total Cost of Special/Custom Orders of $ to be d for building permit $ to paid for $ o be paid for / DOO�NOT SI N THIS CONTRACT IF THERE ARE ANY BLANK SPACES Moynihan Lumber of Beverly.Inc. IV z�' U Homeowner's Signature Date Contractors Date ,(f ea /_01A1Vjt_,k- Homeowner's Name(Printed) BY: 16�L-r-11L Nam (Printed)and Title of Signatory You may cancel this Contract if it has been signed by a party thereto at a place other than an address of Contractor,which may be its main office or branch thereof,provided you notify Contractor in writing at its main office or branch by ordinary mail posted, by telegram sent or by delivery, no later than midnight of the third business day following the signing of this Contract. See attached notice of cancellation for an explanation of this right. 1057-BEV 4/09 White-Office Yellow-Sales/Service Pink-Customer Page 1 of 5 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/Individual):Eric Arserault Address: 24 Graham Street City/State/Zip: Leominster, Ma. 01453 Phone# 978-660-4860 Are you an employer? Check the appropriate box: Type of project(required): 1. - I am an employer with 4. - I am a general contractor and 1 6. - New Construction Employees(full and/or part-time)* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. = 7• - Remodeling Ship and have no employees These subcontractors 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 10. - Electrical repairs or additions required.] officers have exercised their 3. - I 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 insurancerequired]H employees. [No workers' 13. - Other comp.insurance required.) Any applicant that checks box Sl must also 611 out the section below showing their workers'compensation policy information. a Hotomween who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. I Contractors drat check this box must attach an additional sheet showing the name of the sub-contractors and their workers' Ian;an errtployer that is providing workers'compensation insurance for my employees'. Below is the polity and job site information Insurance Company Name: Tht, TravplPrg Policy#or Self-ins.Lic.#: I6 8 055 8 3MS 4 6 F�piration Dare:��/j/%j Job Site Address: For all FCCIP towns 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 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 the pains �annd penalties of�peei jury that the information provided above u true and correct / Signature: �� r� - l f Date: Phone#; 51t(,�® I-& (aD Oj,ficial use only. Do not write in this area,to be completed by city of town official. City or Town: PermWUcense#: 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#,. i �lasachusetts- Department of Puhlic Safch 9 " Board of Bpildfin_ R<_tdations unt6Standarth i Construction Supervisor License License: CS 100210 Restricted to: 00 ERIC ARSENAULT 24 GRAHAM ST LEOMINSTER, MA 01453 s Expiration: 11/26/2011 .. ('.nnmi•�i mcx. Tr: 100210 Office of Gossamer ARairs&Sesiaess Regula X06 HOME IMPROVEMENT CONTRACTOR . Registration: .163985 Expiration:. 8/10/2011 Tr# 287680 Type: Partnership ARSENAULT BROS CONSTRUCTION ERIC ARSENAULT 24 GRAHAM ST. LEOMINSTER,MA 01453 Undersecretary I ICORU. CERTIFICATE OF LIABILITY INSURANCE IMS NB DATE8/23 Y10 ARSEN-2 OB 23 30 ,UCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Terson, Bagley 6 Mayo ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE .:urance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Main Street, P. 0. Box 360 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. _ainster MA 01453 .-one: 978-534-5133 Fax:978-534-9385 INSURERS AFFORDING COVERAGE NAIC# ',xED INSURER A: The Travelers Shawn Arsenault & INSURER B: Eric Arseaault - INSURER C: Arsenault Bros. Construction 24 Graham Street INSURER D: Leominster MA 01453 INSURER E: 'ERAGES :.:POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING 'REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR .!PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH ._ICIES.AGGREGATE UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. RATIUN .__,SR .__..__,:TYPE OF c:S!IRPWCE _._.. .. _ POLICY NUMBER_,___ _OPEE rMYJDOFM.__OPrEIMMNIOOM'1- ...�_____._--LRBTTS___ GENERAL LIABILITY EACH OCCURRENCE $1000000 7WWGET(ME311 E. X COMMERCIALGENERALLIABILTIY I6805583M546 08/01/10 08/01/11 PREMISES(Ea aawarlce) $300000 CLAIMS MADE OCCUR MED EXP(Any ane Parson) $5000 PERSONAL&ADV INJURY $1000000 GENERAL AGGREGATE $2000000 GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG 52000000 POLICY PFR LOC CT F AUTOMOBILE LIAP.i:iTY COMBINED SINGLE LIMIT ANY AUTO - (Ea accident) 3 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS I I (Pat person) $ HIRED AUTOS I I BODILY INJURY $. NON-OWNED AUTOS ( I (Par accident) PROPERTY DAMAGE S (Pat accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION S _ $ _ WORKERS COMPENSATOR AND _ TWC STATUS T EMPLOYER$'TOR)PAY - - - E.LEACHACCIDENT r § ANY PROPRIETOR EXCLUDED? OFFICERIMEMBER IXCLUOED? E.L.DISEASE-EA EMPLOYE $ if yes,describe under SPECIAL PROVISIONS balco I EL.DISEASE-POLICY LIMIT $ OTHER "nPTION OF OPERAnoRs t LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS .71FICATE HOLDER CANCELLATION SHOULD ANY OF TRE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION -DATE THEREOF.THE ISSUING INSURER WILL ENDEAVORTO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Moynihan Lumber IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR 82 River Street REPRESENTATIVES. Beverly MA 01915 AUTHORIZED REPRESENTATIVE Richard M. Ba le :0 25(2001/08) - ©ACORD CORPORATION 1988