B-19-1020 - 0035 BALCOMB STREET - Building Permit r
The Commonwealth of Massachusetts ,
Board of Building Regulations and Standards F. KL L I Vc la FOR
1 Massachusetts State Building Code,780 CMR � ���' L S �liJ1�T CIPALITY
SE
Building Permit Application To Construct,Repair,Renovanor nylir h a� �ev ssed Mar 2011
OOne-or Two-Family Dwelling
i I This Section For Official Use Only
l V Building Permit Number: Date Applied:
O
Sf�v� c�•�-�.yr c� 9-��-/s-
Building Official(Print Name) Signature Date
r SECTION 1:SITE INFORMATION
' V 1.�1 .5, 2rty A6-1resCs0 Y.-,6 S'4- 1.2 Assessors Map&Parcel Numbers
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 rYf Record:
e\4J C—Y) S 6-1
.N► A
Nam9Print) — City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other [3 Specify:
Brief Description of Proposed Work 2: Ym E 0 O
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
1.Building $ d O 0 0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ �
Suppression) Total All Fees:'$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ b () ❑Paid in Full ❑Outstanding Balance Due:
l I�- ItiL►�l ter) A�. Zo®jr.
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) I o s! �..�C .
'�C`r� Gr1� ✓ Z License Number Expiration Date
Name of CSL Holder
/ ijY � List CSL Type(see below)
No.and Streetf Type Description
Ll U G U Unrestricted(Buildings u to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered H me Improvement Contractor(HIC) 'T 5 3 I Y SA Z�Z 0
yr,off � J o 0 �
�,/ - � / � �t � HIC Registration Number Expiration Date
t 4(C LY or HI,C Regj�t�t Name
(o.and Street C�/ Email address
City/Town,State,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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize���(-,4-- wry ✓�Z
to act on my behalf,in all matters relative to work authorized by this building permit application.
CNV-) e--Y -/ ) (Cl v 2rn — — ?
Print Owner's Name(Electronic Signature) Date
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. )
Q-.c1 � ��1 q..! c- Z 9,1 Z-- / l
Print Owner's or Authorized 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 HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.g_ov/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"may be substituted for"Total Project Cost"
CITY OF SI�LE:�I, 1�I�xSS.�CHUSETTS
' BUUMING DEPART.%1LNT
120 W ASHINGTON STREET,r FLOOR
TEL. (978) 745-9595
KI�iBERLEY DRISCOLL FAX(978)740-9846
MAYOR _ THOMM ST.PIERRF
DIRECTOR OF PUBLIC PROPERTY/BUILDIING COMMSSIONER
Workers' Compensation Insurance'Afi3davit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busin'ssrOrganizatiorvindividual): 1 ' �(1�, � e-' Y v LE i
J
Address: ! 6 6
City/State/Zip: /--/Yvr AA 14 0 9 U Z- Phone 1/: �1 0
Are ypu an employer?Check the appropriate box:
Type of project(required):
I. 1 am a employer with__f, __� 4. ❑ 1 am a general contractor and 1
employees full and/or )+ 6. ❑New construction
( part-time . have hived the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp,insurance.
[No workers'comp. insurance 5. ❑ We are a corporation and its 9 ❑Building addition
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. e. 152,91(4),and we have no 12.02(Roof repairs
insurance required.)f employees. [No workers' - "
comp.insurance required.) 13.❑Other
Any applitnt that chmxica box m11 must also fill uut The section below showing their workers'compensation policy information:
1IM-owns s who submit this affidavit indicating they are doing all work and then hire outside eontracrors must submit a new,affidavit indicating smuh
=Cuntnk tore rhot cheek this box must attached an additional sheet showing the tmartte of @me sub-contractors and their workers'comp,policy information.
!am an employer that Is providing workers,compensation insurance for my employees`, Below is tht popsy and job site
information.
Insurance Company Name: CCIC17 6 Y) I-Vyt -y/Y&r, e C
Policy#or Self-ins.Lie.f/:_ J 6 z 13 V AIUy6 7-5-0 piration Date: 9"q"E o
Job Site Address: City/State/Zip:_ S 42 L M A
Atticb 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 f
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 of
a fiane
of up to S250.00 a day against the violator. Be adviwd that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify under the pains and penalties of perjury that the injornration provided above is true and corrrcC
ins t�
/ Date:
• Phone#: 7 � �6�) Z
Official use only. Do not write in this Brea,to be cuurpleted by city or town off
City or Town• Permit/I.Icense#
Issuing Authority(circle one):I. Board of 1lealth 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person: ___ "__ Phone#:
i
✓ s QTY OF SALE
A MASSAQRSE'I?'S
` BUILDING DEPARTMENT
120 WASHINGTONSTREET,3RDFLOOR
AL.(978)745-9595
KR4BERLEYDRIS0DLL FAX(978)740-9846
i MAYOR THOMM ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING OOM OSSIOMR
Construction Debris Disposal A idavit
(required for all demolition & renovation work
'In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris
and the provisions of MGL c40,S54;Building Permit fl '
is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S150A.
The debris will be transported by:
(name of hauler) t
The debris will be disposed of in:
73 a5-1 \jj e-S4 Q-
(name of facility)
go e—V ex
(address of facility)
Signature of pa pica) nt
(today's date)
Commonwealth of.Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constructg6AWr Specialty
j.
CSSL-105964 > + ' 4pires: 03/13/2020
IVAN HENRIGUEZ, s .«
166 TRACY A NUE � s
LYWMA 0196&� ,,'
01.
l j, a
Commissioner
fie °min%o�zcaea,�,J�a�cJ%I�"aaacu,�,.i.�aaf� is`
'�` .Office otConsumerAffairs�Business Regulation
.; HOME IMPROVEMENT CONTRACTOR
TYPE"5-cwlementCard- l ?'
1 05%25/2020`
MAJESTY ROOfAJ;r- P
D/B/A MAJESTY ANY
IVAN HENRIQUEZ "
166 TRACY AVE.
a —^
LYNN,MA 01-..02
Und@rsecfetary ,
� ,} �! r•�k pr. := v.: rra, T k � q, '19rr i�irO�t racr <'S :eet 3. �.
i stftlKVI
Ma' ra �tS tJa pt a ti k vyph �u
.-fry \ 1.( "t f' ..� 3 �. .�- y,•4t 4r. 11�E. i f
des Woof ing Company
Doing our job'with excellence
166 Tracy Avenue
Lynn,MA.01902 4 Date of
yr.. contract:
617 460 2823 Fax: 781 595 1462 4,
w
info@majestyroofingco.com
www.majestyrQofingco.com
Customer Information
Name ,
a
Address 1 4/0 C 1) rw'
;. 0,' _
Phone.# e
Description
/ Line Total
a •
a ,¢ ,� 1' i D.:._ C �• C� ems.� 4
lr:
� 5�
514
6
n. Payment Schedule:1/2 when the contract is signed,final'/z when the job is completed
` Contractor: ate: Total
to To accept this contract,sign here: i'f —Date-
By signing you are legally bonded to this contract.
X ''
CERTIFICATE OF LIABILITY /YYYY)
�.- ABILITY INSURANCE DATE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER9 THIS 9]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 have ADDITIONAL INSURED provisions or 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:
Sanviti Insurance Agency,Inc PHONE
699 Broadway A/C o Ext: 617-389-2020 A/ No: 617-389-2418
Everett,MA 02149
a��ReSS info@sanvitiagency.com
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Northland Insurance Company
INSURER B: Safety Indemnity
Majesty Roofing Company INSURER C: ACE American Insurnace Company
Ivan Henriquez
166 Tracy Avenue INSURER D:
Lynn,MA 01902 INSURER E:
i
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 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.
IN R
UBRI
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLI EFF P LI EXP
MM/DD/YYYY MM/DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY i I
I EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE OCCUR I DAMAGE TO RERTET— —
PREMISES Ea occurrence $ 100,000
A MED EXP(Any one rson $ 5,000
WS389970 05/05/19 05/05/20 PERSONAL&ADV INJURY $ 1,000,000
GE AGGREGATE LIMIT P.PPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY L =RO LOC
PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY
i ! COMBINED SINGLE LIMIT ANY AUTO ! Ea accident $
OWNED BODILY INJURY(Per person) $ 100,000
B AUTOS ONLY �Q SCHEDULED
AUTO 6204239 08/29/19 08/29/20 BODILY INJURY(Per accident) $ 300,000
HIRED I NO
N ONLY
PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident $ 100,000
$
UMBRELLA LIAB OCCUR j
EXCESS LIAB EACH OCCURRENCE $
CLAIMS-MADE I AGGREGATE $
DIED RETENTION$
WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY Y/N STATUTE ERH
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑IN/A; 6S62UB4N44675819 09/04/19 09/04/20 E.L.EACH ACCIDENT $ 100,000
(Mandatory in NH)
If yes,describe under i ; E.L.DISEASE-EA EMPLOYEE $ 100,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
I
i
i
i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Roofing
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Gem AUTHORIZEf1 ESENTATIVE
r!�
@ 19 8-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) T i'sa ACORD name and logo are registered marks of ACORD