B-19-905 - 0015 BENGAL LANE - Building Permit 2 0
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALRevised EMar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
O One-or Two-Family Dwelling
This Section For Official Use Only
ldin' ermit Number: Date Applied:
V 64, Q4,re)N ri,
Building Official(Print Name) Signature Date
CNJ SECTION 1:SITE INFORMATION
: a Pr` }e-ty Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Ilhis 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:
Name(Print) City,State,ZIP
15 . .rvu►�1 Lit qyi- 744-1_�V
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) V1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
r
IF 0 k. F;
SECTION 4:ESTIMATED CONSTRUCTION COSTS x'
Estimated Costs: xt
Item Official Use Only
Labor and Materials
1.Building $ o 1. Building Permit Fee:$ Indicate how fee is de"te?rmiriedr '.
00 H
❑Standard City/Town Application FeeaY _"
2.Electrical $ ,i 3
❑Total Project Cost (Item 6)x multiplier x ti
3.Plumbing $ r 2. Other Fees: $
4.Mechanical (HVAC) $ List:_ ;.
5.Mechanical (Fire •
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ '?A ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 onstruction Supervisor License(CSL) 8 a l g 3 to ,� Ott
Maui( t License Number Expiration Date
Name of CSL Holder
r .gum Ie �t f �/_ List CSL Type(see below)
No.and Street* Type Description
SQ low ryV A OLTI b U Unrestricted(Buildings tip to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/T State,ZIP M Masonry
RC Roofing Covering
T WS Window and Siding
SF Solid Fuel Burning Appliances
doorddl,35 r"J Q mai t -(Deb, I Insulation
Telephone Email addre s D Demolition
5.2 Registered Home Improvement Contractor(HIC) 149688
Io MAI werine G¢ 1-ka HIC Registration Number Expiration Date
HIC Company Name or HIC Rxe�gistrant Name
1006 l.ows� *91 r(c ham)•C.Ina ton ®IOU,-Bi .ce.,
No.and Street Email address
��ti,n(le. ML ZT tt7 �711-�35_S
City/Town, State,AP 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 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 /'��`G('lard C kklo-w
to act on my behalf,in all matters relative to work authorized by this building permit application.
/YI f /u kJ1 G" O pp
14 -;Lot
Prmt Owner's Nar#Mlectronic 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.
a,J o ?- /6-Ao!¢
Print Nmer'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.a 142A.Other important information on the HIC Program can be found at
www.m-ass.gov/oca Information on the Construction Supervisor License can be found atwww.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"may be substituted for"Total Project Cost"
M
_ The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 021.14-2017
www.mass.govJdia
Wet•kers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/organization/Individual):Lowe's Home Centers
Address: 1000 Lowe's Blvd.
City/State/Zip:Mooresville, NC 28117 Phone#:704-758-1000
Are you an employer?Check the appropriate box: Type Of project(required):
1.E]i am a employer with employees(full and/or part- 7. ❑ New construction
2.Q 1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.(No workers'comp.insurance required.]
a 9. El Demolition
3.
I am a homeowner doing all work myself.[No workers'comp.insurance required.)'
4. 10 El Building addition
❑I am a homeowner and will be hiring contractors to conduct all work on my property.I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
S'❑e I am a general contractor and I have hired the sub-contractors listed on the attached Roof repairs>
sheet.These sub-contractors have employees and have workers'comp.insurance.` 13.0
6Q-- are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other Wtr%Au -
FEP1"tn�
'Any applicant that checks box g1 must also fill out the section below showing their workers'compensation policy information.
'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 name of the sub-contractors 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 insurance for my employees.Below is the policy and job site
information.
Insurance Company Name:New Hampshire Insurance Company
Policy#or Self-ins.Lic.#:WC012717161 Expiration Date:4/1/2020
Job Site Address: 15 _i3t 0.I �he City/State/Zip: S 1414 , I'►"Ir1 61 q?o
Attach a copy of the workers'compensatidA 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: W-44. U+ �- Date: " 1G• dal q
Phone#:978-735-5907
Official rise 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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
fir'® CERTIFICATE OF LIABILITY INSURANCE DATE2�9 YY,
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 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 endgrsement.A statement on this L
certificate does not confer rights to the certificate holder in lieu of such endorsement(s)-
PRODUCER CONTACT m
Aon Risk Services South, Inc. NAME.
charlotte NC office I c No.,.,): (866) 283-7122 FAX ti800) 363-0105 v
1111 Metropolitan Avenue, Suite 400 E-MAIL g
charlotte NC 28204 USA ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC tt
INSURED INSURER AI Great American Assurance Company 26344
Lowe's Companies. Inc. INSURERS: National Union Fire Ins Co of Pittsburgh 19445
and its subsidiaries INSURERC: New Hampshire Insurance Company).000 Lowe's Boulevard P p y 23841
Mooresville NC 28117 USA INSURER
INSURER E:
INSURER F: -
COVERAGES CERTIFICATE NUMBER:570075483114 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. Limits shown are as requested
ADDL
LTR INSR -TYPE OFINSURANCE iµc,p YYVO POLICY NUMBER LIMITS
COMMEICIALGENERALLIABILI'TY Y Y Self-Insured 04/01/2019 04/01/2020 EACH OCCURREI-ICE
CLAIMS-h.IADE OCCUR I tN!tU
PREMISES IEa ocCumancel -
MED EXP(Any One person)
PERSONAL&ADV INJURY v
GEil&AGGREGATE.LIMIT APPLIES PER. GENERAL AGGREGAtE
POLICY ❑JECI �tOC PRODUCTS-COMP AGG n
OTHER. p
B CA 4993101 04/01l2019 04/01/2020 COM81NED SINGLE LIMIT n
AUTOMOBILE'LIABILITY S5,000.000
ADS (Eanctidentl
B X ANY,Arno CA 4993103 04/01/2019 04/01/2020 BODILY114JURYI Perperson) Z
04VNED MABODILY INJURY IPerpcddont)AUTOS ONLYPCClIEDULEOAUTOS CA 4993102 04/01/2019 04/01/2020-iIREDAUTo5NON-OWNED VA per. den DAMWGE O
ONLY AUTOS ONLY
r
tL
A X UMBRELLALIAS H OCCUR UN82276205 04/01/2019 04/0112020 EACHOCCURRENCE $10,000,000 tJ
EXCESS LIAB CLAIMS-MADE SIR applies per policy terns & condi ions AGGREGATE $10,000,000
D E D I X erENTK)N
C WORKERS COMPENSATION AND wc012717161 04/01/2019 04/01/2020 X PER STATUTE OTH-
EMPLOYERu'LIABILITY YIN ADS
IER
A1ry PROPRICTORI PARTNER 1EXECUTIV£ E.L.EACHIACCIOENT S2,000,000
OFF CERIMEIADER EXCLUDED? Q NIA SIR applies per policy ter s & condi ions
(Mandatory in NH) E L.DSEASE-EA EMPLOYEE S2,000,000
II es, Me under
OSCRIPTION OF OPERATIONS below E-L.CISEASE-POLICY LIMIT S2,000,000-_
a Excess WC XWC5565603 04/01/2019 04J0112020 EL Each Accident $3,000,000
ADS EL Disease - Policy 53,000,000
SIR applies per policy terns & conditions EL Disease Ea Emp $3,000,000
DESCRIPTION OF OPERATIONS J LOCATIONS I VEHICLES(ACORD 101.Addhional Remarks Schedule,may be attached if more space Is required)
Commercial General Liability policy is Self-Insured.
f�
CERTIFICATE HOLDER CANCELLATION `T
r,
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE -
EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
Lowe's Companies, Inc. AUTHORIZED REPRESENTATIVE
and its subsidiaries
1000 Loaves Blvd.
mooresville Nc 28117-8520 USA
01988-2015 ACORD CORPORATION.All rights reserved.
ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD
$card of�sSvjiding Rvqulafiens,alnd StaindarOs
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MICHAfl-T M111
Commissioner �0004
i
f 1re; 4
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Supplement Card
LOWE'S HOME CENTERS,LLC Registration: 148688
1000 I-OWES BLVD Expiration: 10/17/2019
MOORESVILLE,NC 28117
Update Address and Return Card.
Office of Consuiner Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Suoolement Card before the expiration date. If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
148688 10/17/2019 10 Park Plaza-Suite 5170
LOWE'S HOME CENTERS,LLC Boston,MA 02116
RICHARD CHALONE
1000 LOWES BLVD
MOORESVILLE,NC 28117 Undersecretary Not valid without Signature
Sanctuary Condominium Trust
c% Crowninshield Management Corp.
9 Atlantic Avenue
Marblehead,MA 01945
(978)532-4800
August 16, 2019
Mr. Dmitry Bruklich
15 Bengal Lane
Salem, MA 01970
RE: Replacement Windows— Sanctuary Condominiums
Dear Mr. Bruklich:
Thank you for your inquiry regarding window replacements at your unit. Please be
advised that the Board of Trustees for the Sanctuary Condominiums does not object to
the replacement of these windows and doors so long as the exterior matches in
appearance from the existing, they must fit in the existing opening, molding size and
glass size must remain the same. They will not allow grids and they must open in the
same manner (slide).
We require the permits be pulled in advance, and that a copy of the final approved permit
once completed is also submitted to our office. We also require that you hire only a
licensed contractor, with adequate insurance. Please be sure that new windows are
properly flashed to protect against leaks.
Youi will most likely need to show a copy of this letter to the Building Department in
order to obtain your permit.
Should you have any questions or require additional information,please feel free to call
me directly at(978)532-4800 ext#232.
Sincerely,
JWI game
Jill Fama, CMCA
Regional Property Manager
Crowninshield Management Corp.
Managing Agent for the Sanctuary Condominiums
cc: File