22 AMANDA WAY - BUILDING INSPECTION (2) 10 4 o CK n 50�
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: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
I Prope' 1.2
Address: Assessors Map& Parcel Numbers
a / urcQ a ua� �T �--
Address: 0 3 a 3
—1.1 a Is this an accepted street?yes_ no Map Number Panci Number
1.3 Zoning Informatipj : 1.4 Property Dimensions:
Zoning District Proposed Use I.oi Area(sq It) Frontage(11)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if ycs❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of R co d:
bs6vfne. }IIIItS Remit 4 i TN�s, FynM¢4, MA 619 4v
Name(Print) City"Stale,ZIP
9X-GbX 1ffD %1-334-clog �1lFD@dtbiasehomes.c
No,and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction P1
Existing Building❑ Owner-Occupied ❑ i Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ: /iJ
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
6 �/ Check No. Check Amount: Cash Amount:
6. Total Project Cosh $ COIM ' 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /1S_ CRI-7 �'t.(I
Paid Dt ty)Q$� ((License Number
'1• I E piration Date
Name of CS I.Holder
PD h^ D� 10 v List CSL Type(see below) u
No.and Street ID Type Description
r"C D 19 L t O U Unrestricted2 Family
(Buildings u el ing cu. ft.
11 tip `1 R Restricted I&2 Famil Dwelling
Ctty/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
HIC Company Name or I HC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ..........V 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 her y test under the pat s and penalties of perjury that all of the information
contained in this application is e d ac ura to th of my knowledge and understanding.
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Print Owner's or Authorize gcnl's Name(Electron tgnalure) ate
NOTES:
I. 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.ntass.eov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/dos
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"
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�' ROOME & GUARRACINO, LLC
Structural Engineers SHEET NO. SzM of Z Z
48 Grove Street 3 0
Somerville, MA 02144 caicuLATEo av DATE
Tel 617.628.1700 Fax 617.628.1711 CHECKED BY DATE
SCALE'-
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° CITY OF S:U_EM, INL- sS:ICHUSETTS
1e� BUILDING DEPARTMENT
120 WASHLNGTON STREET, 3aa FLOOR
?r TEL (978) 745-9595
F.ur(978) 740-9846
KI\BERLEY DRISCOL.L
IrLALYOR THO&W ST.PIFRRR
DIRECCOR OF PUBLIC PROPERTY/BUILDING CONLUISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A ) rlicant Informatiorl- J Please Print Le ibI
Name (nusincssor'anizationAndividual):
Address. � 6- /J�
ti
City/Srate/Zip: 46�_j4ellllPhone B:
t
Arc you un employer'Check the appropriate box: Type o project(required):
I.❑ I am a cmploycr with 4. El am a general contractor and 1 g, [ New Construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ lama sole proprietor or parrnur- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contmctoLs have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. It. Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
requireJ.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL I L❑ Plumbing repairs or additions
myself. [No workers'comp. C. 152, 41(4),and we have no 12.❑ Roof n:pairs
insurance required] t _ employees. (No workers' 13.❑ Other
comp. insurance required,)
Any upplicam tout chcoks box 91 must also fill u-I IN%-than belowshowing their workca'mmpeamdon policy inlbrmatlon.
'I lomduwm"who wbmir this atrfaknvit indicating mcy an doing all work and Ihcn hire outride contnctms moat submit a new afnJavit indicating such
K"otm, ion Ihol check ibis box most anachcci an additiuwl-hut showing dw mane of the sub-comnetun and Ihdr workrn'camp.policy information.
l unt on eutpluyer that is providing workers'eutnpeusatlon insurance for my employers. Qelotp is the policy cord fob site
information.
Insurance Company Name: _ _
Policy 4 or Self.ins, Lic. d: Expiration Date:
Job Site Adircss: City/State/Zip:
Attach a copy of the workers'compensation Policy declaraflan page(showing the policy number and expiration date).
Failuru to sucuri:coverage as required under Secfion 25A ofMGL c. 152 can load to the imposition of criminal penalties of
fine up to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up m S2A .00 a day against rile violamr. Be advised that a copy of this statement may be forwarded to the Of lice of
I❑%e5IIV(ioim.)I'll DIA fJr InSefallCC[UverlgC VCfIIICatIUn.
l do hereby r r tf older e p Is all hies of perfu I t the btfurnruthur providedd abactm.s t rand correct
Datat
3M- `1 'en
Of/iciul use unty. Do nut write in this area, to be completed by city ur rosvn offlriuL -
Cory or l'usrn: .Permit/l.Icense#
Issuing Authority (circle one): --
1. Board of llcalth 2. Buildllrq I)cparoucut 3.City/row, Clerk J. F.lecn"ical luspectur S. Plumbing III pecou
6.Other
C•antact Person: Phone tl:
``CCIOR& CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDYYYY)
4/2/2D14
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((es) must be endorsed. If SUBROGATION IS WAIVED, subjeet 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 eridorsement(s).
PRODUCER 'NAMEACT Select Dept ext 66807
Eastern Insurance Group LLC PHONE (508)651-7700 FAX TB1)586-8244
233 West Central Street o IL°` '` IAIc x r I
.selectmork@easterninsurance.com
INSURER(S)AFFORDING COVERAGE NAIL P
Natick MA 01760 INSURERAAcadi.a Insurance Cqmnpa:ny 31325
INSURED INSURER B:
DiBiase Corporation, DOC Residential LLC INSURERC:
Osborne Hills Realty Trust INSURER D:
p G BOX 780 - INSURER E:
Lynnfield MA 01940 INSURER F:
COVERAGES CERTIFICATE NUMBERidaster{ 14-:15 / GL_Only 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, NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION'OF ANY CONTRACT OR OTHER DOCUMENT LMTH 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 REDUCEDBY PAID CLAIMS.
INSR ADM SUBEI POLICY EFF POLICY.EXP
LTR TYPE OF INSURANCE POLICY NUMBER MMID MWD LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
X COMMERCIAL GENERAL LIABILITY 'PREMISES(EB occurrancral $ 250,000
A CLAIMS-MADE 7 OCCUR 0191229-17 /23/2014 /23/2015 NEED EXP(Any one parson) $ 5,00
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1,000,000
X POLICY 7 PRO-IPCTLOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY Perfi.dent $AUTOS AUTOS ( )
HIRED AUTOS NON4ANED PRO ERTYDAMAGE
AUTOS Parexitlent $
E
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE E
DIED RETENTIONS I Is
WORKERS COMPENSATION 0286788-15 /23/2014 /23/2015 A WC STMTd
OTH-
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETORIPARTNERJEXECUTIVE E.L.EACH ACCIDENT S 100,00
OFFICER/MEMBER EXCLUDED? NIA
(Mandatary In NH) E.L.DISEASE-EA EMPLOYE $ 100 000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remake Schedule,If more space is requlred)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, MA 01970
AUTHORIZED REPRESENTATIVE
i_
John iLoegel/EAB3 ---"'---� -��
ACORD 25(2010105) - 01988-2010 ACORD CORPORATION. All rights reserved.
INS025 t?ninmi nt Tho arenas acme and rnnn ero roni.4.md meek.of air 1npn