B-13-104 1 WEATHERLY DRIVE RENO oL
I'he Commonwealth of Massachusetts
Board of Building Regulations and Standards CI'T'Y OF
Massachusetts State Building Code. 7SO C NIR SALEM
1 ,'
1 ,.. 11•�ris•X1.1/dr-111/
Building Permit Application To Construct. Repair. Renovate Or Demolish a
Onv.or Tn•a-Firrnih-Dirt4thkv
rhis Section For 01Tcial Use Only
Building Permit Number. D ed:
tjwlding 011icial(Print Nuune) at Date
SECTION I:SITE IN ORMATION
1.1 Pro rerty Address: 1.2 Assessors,flap&Parcel Numbers
RAW_
I.la Is this an acce ted street?yes ✓ no Map Numlkt Purcurl Nun0wr
1.3 Zoning Information: 1.4 Property Dimensions:
zoning District Propow-J Use Lot Ansa(sq 11) Frontage(11)
1.3 Building Setbacks(R)
Front Yard Silo Yanis Rear Yard
Required Provided Reyubed Provided Reyuim-d Providw
1.6 Water Supplyt(M.G.1.c.-40.134) 1.7 FloodZone Informallon: 1.'Sewage Disposal System:
Public Ili Prig ata O zone: _ Outside Flood Zone? Municipal Own site disposal sp stem O
Check if yeses
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
33 8&w.S77M47,W1
Nwne(Print) City.State.'LIP
33 B etbyzawnm
No.azul Simt Telephone Email AJdress
SECTION J:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building Owner-Occupied O Repairs(s) O Alteration(s) Addition O
Demolition O Accessory Bldg.C3 I Number of Units I Other O Specify:
Brief Description of Proposed Work,: Td AVxt .r *.iL B.ey.4i :0 l�►rF L
SECTION 4:ESTIMATED CO,NSTRVCT10N COSTS
Item Estimated Costs: Ofltcial Use Only
tl.ahor;aid�latrrialsl
1. Building S I. Building Permit Fee:S Indicate how fee is determined:
..Hvuarical S fDzv O Standard CityrTo%rn Application Fee
O Total Project Cost (Item On multiplier _ M-x _
t. Phunhing S q(1(,rp 1. Other Fees: S.
a. Me-01.utitml 111% \C) S List:.- -
� t \1«h.uti�.tl i Fire i
tiu �r.�sion) rota).\II Fees: S—•---_—_--
t'11VA No. Check;\mount: Caih \mount:
" ..-..
!���Q a Riid in Full O Outstanding HaLutce Doc:
i•
SECTIONS: l'1)NS'1'RlK"rll)N tiE'RYI('F:S
5.1 ('unstrue lion Supervisor license(('SI.) Q9o/ , _/x_11 --
aet'�']'__ _,—..
hIJer
g / I ist 01. 1'%pc!see l+clua► __ -�_-+ _
I,pc Ihseripliun
Nu. .utJ ltrcct
l 1 hirestricteJ(liuMin s ub to.15.1)(H cu.I1.1
R Rc.lricicJ 1&2 F.unil pwcllin
t'it)i I'uttn. ate./.IP �) �ta�uo
KC Rt>,din l'u�erin
WS Window.uttilidin
SF tiuliJ Fuel Iluming�lppliatues
78/-�s�/'o3/D ✓/�/�/CZ��l/1,17/L .caw. 1 Insulutilm
I'elc burr Finail addivm U pcnwlition
:1.2 Re tts'ed Iionst mpnWe"MI Castroletttr tHlQ,
✓/�/ j�/CISZPJFl1D �7• IIIC Relislnttiun Number F%pirutiun Date
I IIC C'ootpan) Niume of I IIC Itegistrunt Name
,39.5 ✓&,6W, f Awl, ✓iy aJC 2 @ 647,5yi •eow.
No.and Street limail aJJrrs,n
�J. /s1�. d�9iJD 7�/-�G31.030
Ci /Town State ZIP rale one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 132.§ 23C(6))
Worker 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...........Cr'
SECTION'1s:OWNER AUTHORIZATION TO 8E COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I.as Owner of the subject property;hereby authorize CION" A/. 3>1CWiaz
to act on my behalf,In all matters relative to work authorized by this building permit application.
X 47irMi r —.vw q. /`ma rRn[- . ti 9-14 - 12
Print 3itittcr's Num(EWron c Signwuro) 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
containtrd ttietlti apphc pn is trate a40,accurate toJhe best of my knowledge and undentsnding.
t
�O�/N �,/. r�Ki9�t'iltto �rJ1.�� 716 •JZ
11rim0htnor'+ Delo
NgrES:
I. .Itn Owner who obtains a building permit to do his.her awn work.at an owner who hires an unregistered contractor
rout registered in the Hume Improvement Contractor(H IC)Program),will r , have access to the arbitration
program or guaranty fund under M.G.L.c. I4:.i.Other important information on the HIC Program can be hound at
���� t t .i•.�, � . . t Information an the Construction Supervisor License can be found at rat.;�.s% ,1p.
2. When substantial%,.art is pkwwd.pro%ide the information below-
rutai flout area 114. A.) . _i including garage.tinishrd basement attics.Jocks or porch
Gros'li%ing.trt:a 154. 11.1 _ }Habitable room count
%wnhcr ul'lirc),laccs _ Nunther of hcdrautns
`anther tit'hathrrunts \untbcr ul'half'h;uhs
i 1'%pe of heating;)Stein pontes
I'�hel'cililttj itent 1 tW1a�eJ I)I�en
i
"1'oial Project Stluare Footage-lite} lie quhstituttA ritr I'otal Itrujcct Cast"
CITY (�F 5.1t.E.ti(, �tiL155.1Cf��'SETTS
t3t:tl,DC�LG Ot:P.+Rtatlrvr
I '01a7,l3HCLGTON STIW, Va Ft00R
r RL k979) 145.9595
` P.ut(979) 1#98�i
1(3EnSY O RISCO LL
.ti G�Ya It tkOuv ST.P[rauts
DtRECTCA Of P1.81.Ic PROPERTY/at:MDL.YG C0101LSSIO.NER
Construction Debris Disposal AlVdavit
(required for W demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 130 CIMR section 111.1
Oebris, and the pmviaions of MGL a 40, S 54;
Suilding Permit a is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licemed waste disposal facility as defined by NIGL c
I It. S 1 SOA.
The debris will be transported by:
Ll IV (V -
(n.,ms of ha4tI$t)
The debris will be disposed of in :
{n�rn�o(rsc+l►ty)
(,tdre»orrl�+i,ty�
n�n�+uteuf,em+r �ppl+��nr
��. CI'I'Y OF SMI t) NWSACHC:SEITS
01:11-DING DE.PARMENT
7rA' 120 W.ISHLNGTON SHEET, 3'FLOOR
TEL 1,979) 745-9595
Fkx(979) 730-9846
'.,lJtI3E,U_EY DRISCOLL
Atyo.Z T�to�t. ST.P1E.vts
DIAECTCZ OF PULIC PROPERTY/SU11-DiN''G CONLNIIS510'ER
Workers' Compensation Insurance AllUivit: guilders/Cuntructitry/Electricians/Plumbers
ko )Ileant inAwmatlnn_ Please PrintLezihil
Nainc tl J1. hVI�Ae/FILO e-b_
Address• !200 1315
City/statc/Zip: aftM nhWD, ". D/9 4' Phone M: 9,31-631-0314
,1`r-c you an employer!Check the appropriate box: 'rype of prnjcct(required):
I.1 7 t am a cm to ur with_.�_ ;. El am a gt:neral contractor and t
p y• . have hind the sub�contnctors 6. ❑Now cunytruction
�Inployces(Nil and/or part-time). 1. (z emadeling
2.❑ I ain a sole proprietor or partner- listed on the ittached+heel.
.hip and have no employees Them subeontraeton have I. ❑Mmolition
working for me in any capacity. workers'comp.insurances 9. (] Building addition
I Vo workers' comp, insurance 3. Cl We area corporation and its 10.El Electrical repairs or additions
required.) officers hove exercised their
).❑ 1 a1n a homeowner cluing all work right of exemption per MOL 11.❑Plumbing repuirs or additions
myself(\o workers'comp. c. 112,41(4).and we have no 12.0 Roof rvpoirs
insurance required.) ► Vmpluyees. [Mot workers' 13,❑Other
cutup.inxuranca inquired.)
•.\ny applkum due tducks but i1 must lso 1111 out thv wetive butow showing NO"Irmo'componsadun pulkcy mtl,nnution.
r 11.wnvuwft-m who.uhnsit Ihks stlldavit indta+ting they urs doing 4II work.1nd then hire uultide tonInCh re mtut tuhrnif a naw a171daril indiealing suck
('anVKlury that t.hktk this box must ritachud an.,ddttturwl.hvA ihuwing the nwne of rhe sub-cunUactwv Ind thate workers'wrap.puncy inrommion.
/urn un nnpluyer rhut is pruvlding workers'cump,ru.radun Insurance for my e/npluystes. Selow Is thevolley and Job site
infurntarlan.
In..Nurtllev(:unrpany Name: io". ov _... N.i�.PA�/G!" l'b.
Policy 4 ur Salr•ios. Lic. d, "We— 22991(Q. E:tpirttion Dote:
tub Site Addruss: l m� V �anve_x Cityistute/Zip: -S•6r1�Y1
Attacb a copy of the,vorkers' compensation pulley declarallon page(showing the policy num bar and eirpiration data).
Fiiluru to wcure cuveragd u required under Suction IJA ut',%tGL c. 132 can lead to the imposition of criminal penalties of s
circ op to i I,5CO.0 ond/ur ane-year itnpri.rnnment,is well all civil penalties in the form uta STOP WORK ORDER and a itne
„r.tit to 52jo.00 a Joy igainst rhe viol.ttor. Ile advi.,cd that j copy of this.tawinent may bu furw,udcd to the 001co of
LItr.liy�tiun.r„1'ihc 111A IorimurVCC%:0Vdr3gr vCriitt:.illun.
Biu hr errby cerrily nJer rhr paint uu4 pen ultlrr,jf perjury thut the infur,r►ullon prutiddea ubuVW it rrut'1114 Correct
0310
!?/jicf�l r,t r„!y. lbs err,/brill in this 1rrI, (J �!CuntNINdJ Sy ells ur/ohne•/fh'iuL
('try nr hos t: _. i'ermitir lcenle
I„uio;.\ulhvrily icirC!u n tc):
I. Ih).trd ul II.nl,lln, 1)rll.iilntcut 1, l Ay,'f"ten Clerk 1. 1,'tectricd Vt,I,cth,r i. PInothin; lotpecvir
i. I)1IIir
JOB �G
• J.N. PICARIELLO CO.
' P.O. Box 1315 SHEET NO. OF
MARBLEHEAD, MA 01945 CALCULATED BY �r DATE
(781) 631-0310
CHECKED BY DATE
SCALE 104yt`
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PRODUCT 204-1(Single Sheets)205-1(Padded)
ACORD ' DATE(MMIDDNYYY)
n" CERTIFICATE I IF LIABILITY INSURANIC,rE
07/16/2012
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS IIJO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE 40ES NOT AMEND, EXTEND OR
66 Loring Avranue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P-0, Box 958
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIL# _
INSURED INSURER A'Merchants lwiuraice
J. N. PICARIELLO COWANY INSURER B;Guard
P.O. BOX 1315 INSURER C;
INSU "H D:
blAR�3Y.�iKY]r"h0 MA 01945-53 .5 INSUREREi;
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEBN' JED TO THE INSURED NAMED ABOVE FOR THE POLICY PEP 106 INDICATED.NOTWII"MSTANDING ANY
REQUIREMENT,'TERM OR CONDITION OF ANY CONTRACT, OTHER DOCUMENT WITH RESPECT TO WHICH THIS C,lERTIFICAT8 MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES 01-SCRII HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REEDU(:ED Ci'i SID CLAIMS.
INSR ADIYL POUCY EMECTNE POLICY EYPIRATIOI;
LTR N9 TYPE OF INSURANCE PC, NUMBER DATE MhIIDDM) DATE MMIDDNY) _ LIMITS
A GENERAL LIABILITY / / / / EACH OCCURRENCE 3 500,0001
X COMMERCIAL GENERAL LIABILITY DAMa.G TOR tD 100 000
PREMIStS Eaoccurrbncn 9 r
CLAIMSMADE r7X p,CUR CCBT0I016011 09/19/2011 09/19/2012 mFDI:,XP An one rrson $ 5,000
)"
PERS)NAL&ADV INJURY $ 500,000
GENE,IgAL AGGREGATE $ 1,000,000
GENT AGGREGATE LIMIT APPLIES PER; PROD JCTS•COMPIO AGC; $ 1,000,000
POLICY JECT LOC
AUTOMOBILE LIABILITY � / / / / COME INED SINGLE LIMIT 0
ANY AUTO (Ea be adant)
ALL OWNED AUTOS / / / / BOOK(INJURY $
SCHEDULED AUTOS (Per p,reon)
HIRCDAUT0S / / / / SODILIINJURY 0
NON•OWNLD AUTOS (Por n,cidont)
PROP IRTYDAMAGE
(Por aucidont) $
GARAGE LIAO ILITY IAUTOONLY-EA ACCIDENT $
ANY AUT) / / / / OTHER;THAN EA ACC 0
AUTO ONLY! ACG 0
EXCESSIUMB.IELLA LIABILITY / / / / EACH,)CCURRENCE 0
OCCUR CLAIMS MADE AGGRjIGATE o
a
PEPUCTIKE
RETENTI()N S 8
T? WORKERSCOMPENVATIONAND 1Tb1wC0:1575CI 11/01/203.1 11/02/201? -X I OETN'
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PF,RTNEWEXECU'I'IVE E.L.FfICH ACCIDENT $ 1()0,000
OFFICERfMEMOER EXCLUDED? / / / / E.L.DILEASE•EA EMPLOYEE 0 1()0,000
It yes,describe undo►
SPECIAL PROVISION.!below E.L.01ClEASE•POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSI DNS A 1.1 .I BY ENDORSFMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER � CANCELLATION
(978) 740-9846 ( ) SHOULD ANY OF THE ABOVE pE1ICR19EI) POLICIES BE CANCELLED BEFORE THE
Attn: Bti ildinq Inspector EXPIRATION DATE THEREOF, THE, ISSUIIIIG INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
City Of Salem FAILURE TO 00 50 SHALL IMPOSE NO QBt.ItSATION OR LIABILITY OF ANY KIND UPON THE
INSURER ITS AGENTS OR RSPRESEN]ATIVES
AUT�RJZERFP ESENTATI E
ACORD 25(2001108) ...__, 0 ACORD CORPORATION 4988
iN8026 poa),0e Pup 1 oft