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B-20-644 - 0096 BROADWAY - Building Permit i 1 ` The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Dat Applied: Budding Official(Print Name) Signature 50 Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers _9'6 ��9ADwA�� , �S� � L l 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? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP'. 2.1 Owner'of Record: AAA KiA P R,EZ. ��hl,�,!/I/l A&A Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building d Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': (gMCIZAI weAlfieklZAN 1 n151T AIR `` AL r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ 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: $ 8 S� ❑Paid in Full ❑Outstanding Balance Due: JUL 2 PM12:11 JUL SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CIS- It, . 4S OSVALDO ?e9l lA License Number Expiration Date Name of CSL Holder List CSL Type(see below) VV ELmwoob Ave V No.and Street T e Description ^^jj '' nn,^� U Unrestricted(Buildings u to 35,000 cu.ft. Sr`yE)US , a � G 1g06 Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding Z L V�� i�` SF Solid Fuel Burning Appliances ® / "@ G MA i�9^� I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) -2 3 3H J f-ay AK C.QW-rRhD-QNG CbR,p' AIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name - -and Street{NUGVS � Q`Wor r_ (7 C 91, I_ `). Email address City/Town,/Town,State,ZIP V �j JTele 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 .. ...... O 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(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 contained in this application is true and accurate to the best of my knowledge and understanding. Osya9CDO 1E2t BRA it 7 ©2 -10 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.gov/oca Information on the Construction Supervisor License can be found at www.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" •1 V T Commonwealth'of Massachusetts e t�znzcitu%eal7 Ju far/e"u3PlG Divisiornof Professionallicensure Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards T HOME IMPROVEMENT CONTRACTOR TYPE:.Corooration ConstrU616A Supervisor Renistr-ion. Expiration ja11/24/2021 CSA12895 r Y-! Ej-pires 11ml2022 W. MK CONTRACTING GOf PPlDfR4TION c OSVALDO D PEREIRA �� 46 ELMWOOD AVENUE OSVALDO PEREIRA 01' . "r SAUGUS MA 906 " 45 ELMWOOD AVE /v�a� •t� s Fr, w. °' r SAUGUS,MA 01906 ' " Undersecretary . Commissioner C4 The Commonwealth of Massachusetts Department.of IndustrialAccidents l Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Busine ss/Organization/Individual):K 6ayna C"((/V(j Coiep. Address: `,nj Lt/Vs wood gVe City/State/Zip: Mig Phone#: 617 ,J61,; Are you an employer?Check the appropriate box: Type of project(required): 1.�1 am a employer with_employees(full and/or part-time).* 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in $, Remodelin any capacity.[No workers'comp.insurance required.] ❑ g 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.)t 9• ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10[]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11,0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contactor and I have hiied the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurances 13.❑Roof repairs d 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.ff Other_U/eATN eel Z,4 r(0V 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. 2 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 subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lain on employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: eek-T Policy#or Self-ins.Lic.#:_ WG_5 3/ Expiration Date: O J =J_0V Job Site Address: p _ 6 ��®��1/V�y City/State/Zip: SA( e fln 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 certify aims and penalties of perjury that the information provided above is true d correct: Si nature: Date: ® ®oZ �® Phone#: 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#: AC J®® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 121 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS 30/2019 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 pollcy()es)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 endorsemen --A- this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). t A statement son e PRODUCER CONTACT Lisa DiCenSO Peter A.Rossetti Insurance Agency,Inc. PHO E arc No Ext: (781)233-1855 No: (781)231 4222 436 Lincoln Avenue Idicenso r ADDRESS: @ ossettiinsurance.Com Saugus INSURER(S)AFFORDING COVERAGE NAIC# MA 01906 INsuRERA: Colony INSURED Specialty INSURER e: The Commence Ins.Co. 34754 MK Contracting Corp INSURER C: ARVIIC-Liberty Mutual 45 Elmwood Ave INSURER 0 SBUgUS INSURER E: MA 01906 INSURER F: COVERAGES CERTIFICATE NUMBER. CL19123000150 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 CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE 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. 1 POUC S LTR TYPE OF INSURANCE INSO Vivo POUCY NUMBER MMIOD FF MMLICY Y Y COMMERCIAL GENERAL LIABILITY LIMITS EACH OCCURRENCE S 1.000.000 CLAIMS MADE ©OCCUR PREMISES Eaoccttrtence S 100,000 A MED EXP(Arty one person) S 5,000 101 GL0089518-02 01/01I2020 01/01/2021 1,000,000 GEMLAGGREGATELIMITAPPLIESPER PERSONAL&ADV INJURY S GENERALAGGREGATE S 2,000,000 POLICY PR LOC PRODUCTS-COMP/OPAGG S 2000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SIN LE L1MTT ANY AUTO Ea accident) S 1,000,000 BODILY INJURY(Per person) S �. B OWNED SCHEDULED BBXN43 AUTOS ONLY AUTOS 01/17/2020 01/17/2021 BODILY INJURY(Per accident) S HIRED NON-0WNRED P OPERTY DAMAGE AUTOS ONLY AUTOS ONLY fPer acddent S PIP-Basic s 8,000 UMBRELLAUA9 OCCUR EXCESS LIAR EACH OCCURRENCE S CCCUR MADE AGGREGATE S DED RETENTION S WORKERS COMPENSATION s _ AND EMPLOYERS'LIABILITY YIN STATUTE ERH C ANY PROPRIETORIPARTNERIEXECUTIVE 500,000 OFFICER(MEMBEREXCLUOEDT ❑ NIA WCS31S623743-010 01/01/2020 01/01/2021 E.L.EACH ACCIDENT $ (Mandatory In If Ves,describe a under E.L.DISEASE-EA EMPLOYEE S 500,000 under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) insulation work CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Department of Labor Standards ACCORDANCE WITH THE POLICY PROVISIONS. 19 Standfodd Street 2nd floor AUTHORIZED REPRESENTATIVE Boston MA 02114 ©1988-2015 ACORD CORPORATION. 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