36 1-2 BUFFUM ST - BPA-2010-31 The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T"edition
Building Dept
^ Building Permit Application To Construct. Repair, Renovate Or Demolish a
J One- or Tito-fmruh Duelling
This Section For Official Use Only
aMa� Building Permit Num c Date Applied: 2 C r!f
Signature: �7 r
Bwlding Ce mrs ner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
3L 'IZ f3�FFvr, rik'
I.I 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 n) Frontage ill)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
I.6 Water Supply:(M.G.L c.40,f 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
—/ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public 07 Private❑ Check if es❑ p po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Gr tcVC PcNQ v� �.qz 3�F•Fw.
Na rint) Address for Service:
Sillfiatwel Telephone -
SECTION J: DESCRIPTION OF PROPOSED WORK'(check■ that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) 61 Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S e I. Building Permit Fee: S Indicate how, fee is determined:
❑Standard City/Town Application Fee
2. Electrical S -L S o^ ❑Total Project Costs(Item 6)x multiplier x
J. Plumbing S 3 pp 2. Other Fees: S
4. Mechanical (HVAC) S List:
5 .Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: f �D �joa ❑ Paid in Full ❑Outstanding Balance Due:
f
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) t� 2dlp
"S Co �k- 7 ✓, �S L� k 4umber Espi anon Date
Name of CSL Helder
U ebky N& �•�PFe-tl List
TV,1D
y CSL Type(,cc beluwl
� Description
Addrr
U Unrestricted(up to 35,000 Cu. Ff.)
V`�� R Restricted I&2 Family DwelLn
Signal a �" M Mason Only
C Residential Roo(n CoverinTelephone S ResidentaIWindow and SidinF Residential Solid Fuel Bumin A liance Installation
Residential Demolition
Sal Registered Home Improvement Contractor(HIC) 1r�Q a �+
=+Ar-t- T V Cac-C c C, J ' Sur.. J
HIC Company Name or HIC Registrant Name Registration Number
2l�' °�(Lcrcni.r ^, Vt ^1rct ( 2O � U
Add ss v��/� --L 6 L SZ $ - l Expiration�� ; , 'ta.l Ea nation ale
Signature < — Telephone
ECTION 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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ��,-t,q 4�ev�`+ • �S o w. as Owner of the subject property hereby
authorize S r_o to act on my behalf,in all matters
relative work authorized by this building permit application.
, I1Qtr�
Si nature o wner Date
SECTION 7b:OWN ERt OR AUTHORIZED AGENT DECLARATION
1 5 4+ J le � ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behal�'
Print N ,� G
Signalifie of Owner or Avithorized Agent Date /
Si ned under the pains and penalties ofperjury)
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basementlattics.decks or porch)
Gross living area(Sq. Ft.) Habitable room count
,Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Tvpe of heating system Number of decks/ porches
Ty pe of cooling system Enclosed Open
3. "Total Project Square Footage" may he .uhstituted for 'Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Construction Debris Disposal Affidavit
(required liir all demolition anJ rcno\'ation work)
In accordance \\ith illc sixth edition of the State Building Code, 780 CTIR section I 115
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by Ml c
I11. S 150A..
The debris will be transported by:
(name ul hauler)
l he debris will be disposed of in
luumr ul laci6�y)
6% kEu P l<<•J Ta v 2nv�D wtAT 6 a c a b K f �✓l/�
LulJres. ulluc Jilyf
a�n dlwc nt p:nnn .y+phcanl
Isle
CITY OF S.0 EN1, �tL-kSSACHUSETI'S
BU DLNG DEPARTNIE.NT
120 WASJ41NGTON STREET, YD FLOOR
T L (978) 745-9595
FAX(971) 7.10`9&M
KINIBERLEY DRISCOLL THOMASST.PMRM
MAYOR
DIRECTOR OF PlOCIC PROPERTY/gl'QDLVG CONMRSSIONFJI
Workers' Compensation Insurance A111davit: Builders/Contractors/Electricians/Plumbers
Anolicant Information Please Print Leaiblr
Nalne (Busirwv Orfutiratiomindovtdual): Z Ar^ E- S CAre C( A--,A 1� &6'r T-'(Q
Address: 'a-l° 6¢4 A-.flw+-tit
city/state/zip: �= n &- l� If1%P1 Phone#: $l —Sir b' —Z 1 (7
,%re you an employer?Cheek the appropriate boa: Type of project(required):
1.�am a employer with 4. ❑ I am a general contractor and 1
6. ❑ ew construction
employed(full and/or part-time).* have hired the sub-coranemn
2.❑ 1 am a sole proprietor at parer- listed on the attached shceL 7. Remodeling
:hip and have no employees These sub—contractors have a. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
J.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.['Na workers'comp. C. 152.$1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees.(No workers'
comp. insurance required.j I3.❑Other
•Any applicant tht chocks bos I I must also rill out the sactian but"Showing their workms'ewnpaestitar policy infumtadow
'I rnnssuwsas who submit this aflldwit indicating they m doing all work and than him outlide eontractm now submit a new,amdavit indicting suck.
-(.inlrJL'tofa than chaek thin bwR mud attached an aaditiwd,hml showing the tsma d alas a4eottt/aclara and thak w d.-camp.policy infomtuuan.
/ant an employer that is providing workers'compenmdon Insurance for my employers. Below/s the poBry and/ob site
information. _
Inwrance Company Name: %p' • W\. V-,TU IPA`.
l 1
Policy M or Self-ins. Lie.H: G l 6 &-70 'LA n/ r Expiration Date: � �� �o�
��( .rM-YEN\
Jub Sire Address: Z 'Q S � City/State/Zip: ,S A'Lk C-,- I-KA
Attack a copy of the workers'compensation policydeclaration page(showingthe 1 t po key oumMr sad espinHon date).
Failure to wcure coverage as required under Section 25A of MGL c. M can lead to the imposition of criminal penalties of a
fine up to 51.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
Invcsugatiuns of the DIA for insurance covcrago vchtieation
1,10 hereby a• reify unJrr tha/ sins(# a—nd penaldes ojperJury that the information provided above is true and correct
';wnailire: Dale: 7 �is'3 �a7
Oflicial use duly. Oa nor write in this area, to be completed by city or town o/J7a iaL
I
City or ruwn. Permitll.IcemeM
LsuinkAulhortly (circle unc): - - —_
I. Ituard of llvAlh 2. 9uildtn` Department J. Cltyirown Clerk J. Electricai Impecior 5. Plumbing Inspector
6. Other _
._-... Gutlact Person: _ .-. -- Phone#:
•vsi I Ig1A% 9881 22F\ .B H BCCAN1'HY ym i .,
A.Jf 4vUYl J4VIV1 ® 02/02
ISSUE DATE 0512"009
7caggiano
THIS CERTIIRCATE IS ISSUED A9 A MATTER OF INFORMATION ONLY AND
snlBtloa Agency CONFERS NO RIGHTS UPON THE CERTTFICATH HOLDER THIS CERTIFICATE
DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
101,
ve
960 COWAI�IIES AFFORDING COVERAGE
o&Son Inc
10 Broadway COMPANY A AI.M.Mutual Insurance Cc
LETTER
cite 204
ynnHeld,MA 01940
=:MMZICjATHD.
THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
RTIRCATE MAY BB ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LC.m PDA ol�VS P" MMIDdYT)A
SYPE OPNEURANCE POWCY NVMREN LtMITB
OmPEDALLIAeMM ®JP.RALAOOA80Am i
PN vu=.OMPMP A. I
QLVMAePCIA1.0ENERAL LL101LTfY PEEEON AADV.MINRY 1
Or-'7 eNAD6Q0=R
EACH OCCURR&dCE
QO WNGTB A CONTAACTOA'9 PAOP.
nREDwuwoa µm®.mn)
_ Meo.en¢Nae WymePe.e�
AUTOMOBILE LWDILRY CONSINM MOLE
LiMR
ANYAU O
er•OWHFD AU198 EOOILYINIVRV
=HMVMDAUTQB @a NOS
NImA
NON Mb AVIOB DODRY WURY
OARA08 LNBILOV �rt sddv�
PEOPeRTY OAMAGe
=9n LIABILITY eACH00cummCE
VMD86L roam AOOEEOATa
OTXERTHAN UMDDELLAmw .
WORKERS COMPENSATION AND ATLDRTS I STATE 0188a
FAMOYERS T.TAB=Y MA
PAOPRImw HLFACRACCIDENT t I00,000
A ADBeAssaecurne
NCL OE%CL 6011087012008 10/03/2008 10/03/2009 EL ntsaasa••POLICYLH�T 500,000
ET.DTSEE•EACH 100,000
SIQPIAYEE
COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS:
ULD ANY OF THE ABOVE DOCRIBW POLICIES HE CANCEMM IMPOKK TIMMIPMATIONDATE
LEM FIVE MUWTERISSUJNGCOIaANYWELMMMVORTOMAU.JILUMn-TINNOTICKTOTHEMMICATZ
NAB®TOTBELE",BOTFARAWTOMAD.SUCHNOTXESBAV. NOOBLIi Twx
TTN: COLLEEN ERIESIAN IRLuBuITY OF ANY Km DPON TEE C//a/�A��NY,I'rs AAJaJ�Em of RR'EmTz9>/Qrlr'A/T/vBs.
10 ESSEX STREET
S-✓ ( ✓�-�
ALEM,MA 01970 UTEORO=REPEESENTATTVE
7251
05/15/2009 10:09 FAX 9785322217 B K MCCARTHY Cross Igluvlivuz
ACM. CERTIFICATE OF LIABILITY INSURANCE 5is 2""00
PRODUCER (978)532-5445 FAX: (978)532-2217 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
B.K. MCCarth Insurance Agenay, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
10 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
West Entrance
Peabody MA 01960 INSURERS AFFORDING COVERAGE NAIC 0
INSURED - INRURERA:Nautilus Ina Cc _
James V. Caggiano & Son, Inc. INSURERS:
210 Broadway, Suite 204 INSURERC__,,,_ _
I URER O'
Lynnfield MA 01940 INSURERS
RAGES
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.
E UNITS SHOWN MAY H EDUCED BY PAID CLAIMS.
INSR DDL TYPE OF INSURANCE POLICY NUMBER PCEYM FED NEPOnUACY7E N LIMITS
OENERALLIABILTTY ENCE. Is 1,000 000
COMMERCIAL GENEMLLIABBITY DA ETO RENTED m S 100,000
A CLAIMS MADE ❑OCCUR MC766329 5/1/2009 5/1/2010 MED' P AM one arse 5,000 '
Is 1,000,000
E Is 2,000,000
GENIA43GREGATE LIMIT APPLIES PER 2,000,000
X P P O•
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANYAUfO (EaacddW) S
ALL OWNED AUTOS BODILY INJURY 6
SCHEDULFDAUTOS (Perperson)
HIRED AUTOS BODILY INJURY $
NON-OWNEDAUTOS (Peracddent)
PROPERTY DAMAGE $
(Pmacddent)
GARAGE LIABILITY AUTO ONLY-EAACCIDENT S
ANY AUTO OTHERTHAN
AUTO ONLY: AGO 5
EXCSSWMSRELLA LIABILITY EACH OCCURRENCE 0
OCCUR CLAIMS MADE AGGREGATE
DEDUCTIBLE $
R $
WORKERS COMPENSATION AND
EMPLOYBRS`LUUNLITY
ANY PROPRIETOMPARTNMIUM(ECUTNE E.L EACH ACCIDENT
OFFICEIVNIEMBER EXCLUDED? E.L.DISEASE-EA EUPL
Ayes,deem 0o under
SPECIAL ON L DISEASE-POLICY UMITi
OTHER
DESCIUP ION OF OPERATIONEILOCATN)NSMHCLEWDfCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
781-715-6400
CERTIFICATE HOLDER CANCELLATION
(978)498-0278 SHOULD ANY OF THE ABOVE DESCRIBED POLICB'S BE CANCELLED BEFORE THE
Salem Five EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Colleenn Eriesi an 10 DAYS WRITTEN NOTICE TO THE CERTIROATB HOLDER NAMED TO THE LEFT,BUT
210 Essex Street FAILURE TO DO 80 SHALL IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE
Salem, MA 01970
INSURER ITS AGENTS OR RBPRESENTATNES.
AUhn McOREPREy/RBIVE19
John McCarthy/RBI t
ACORD 25(2001108) 0 ACORD CORPORATION 1988
I148025 poapft Page I of 2
Bf�liRQfi(g�R�C�2� ogs aWA°3tIRf�#f83� License or registration valid for individul use only
_ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 122005 Board of Building Regulations and Standards
Expiration 7/9/2010 Tr# 0 One Ashburton Place Ran 1301
Boston,Ma.02108
I[[- Type. Private Corporation
ty 1;140
JAMES V. CAGGIAN0`6 SON INC.
SCOTT JONES \N\
210 BROADWAY SUITE 204/l/;,f A
LYNNFIELD,MA 01940,"+yr Administrator [valid without signature
l _ Massachusetts- Department of Public Safety
Board of Building Re.ndations and Standards
4.Constructfon Supervisor License
.License: CS 49061
Restricted to: .00.
w r
.SCOTf E JONES
,t0 NORMA LN
-SAUGUS, MA 01906
v
�-•� Expiration: 8/27/2010
(.'unnnissioncr' Tr#: 983