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4 CAULDRON CT - BUILDING INSPECTION (5) The Commonwealth of Massachusetts ( ! U Board of Building Regulationsmid Standards La OF Massachusetts State Building Code, 780 CMR eed rI201! WU Building Permit Application To Construct, Repair, Renovate Or Demolis One-or Tivo-Family Divelling riiis SectiortFbrbfficial UsaOtif Building Permit Numbet, Date,Applied Budding Official(Print Name) $tgnatu a: Data SECTION 1:SITE'INFO 1.1 Property Address: 1.2 Assessors Map 8t Parcel Numbers 4r19riI v e%T 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.S Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 160'� Private❑ Zone: _ Outside Flood Zone?Check if yesO Munic[p site disposal system (3 llel,?/�k., , A SEGTIONZ:; PROPEAT$'OWNE) SI'III'!''" 2.1 Owner'of Record: —era UNM �P, dla rc�l t t� Name (Print) City:State,ZIP LPWYI -9T0- =4f�"5' t►.f� �/YW-S0�etvrgs%wf/ No.and Street Telephone —� Email Address SECTION 3: DESCRIPTION OF PROPO3ED3VOR 61seck all that apply} New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': i a t .t t2r v7 w �' I ' - a,tj w`JO r 17 tubes.. SECTIO:Y4: ESTINLATEDCMISTRUCTIONCOSTS Item Estimated Costs: OfRclal Use Only., Labor and Materials) y' 1. Building S �j� �+ I. Building.Permit Fee:S' Indicate how fee is determined: 2. rlectrical S ❑Standaid.CityCfuwn Application Fee p�� ❑"rotak Piolect Cost'(Item.6)x multiplier x 3. Plumbing S �'� 2. OtherFiies:'S I. .M.chanical (11VAQ S List: i. ,Mcclt.mical (tiro S - .inp tression) _ Total :Ut Fees:S_ -- Check No. Cheek Antuuut: C.uh :lurount:.-__-- r Fntal Project t'uif. $� QS ❑ I'.ml in Fall p i)utstoncimg Italunca Uue: SrcrlON 5: CONs'fRUC'rION SERVICES 5.1 Cunstrucliun Supervisor License(CSL) ��� O S' — I? fQ License Number •.epi .itiun Date Name of'C/SL I IJ der ma List CSL Type(Sce below) y' Y CI YJ Cl ! -- rype Description No. and Street I U Unrestricted Buildings uD to)5,000 cu. R. �� yrr ba R Restricted 1&2 Fainity DwellingJ Citylfuwn, State,ZIP �I �"Luonr OWring RC S window Cndwd WS � 1Vindow and Sidin m SF Solid Fuel Eluding Appliances insulation I'cle hone Ematl HUM Gal D Demolition 5.2 Registered Home Improvement Contractor(t11C) 34� • d v 1,1 VV - Pf FIIC Registration Number E. pu, on Uate I IIC Cwnpany Narrle or I'll- cgistmnt Name � �-Spy,�No.and S eet Sy Email address ,l Tis 7 City/Town,State ' IP d Pale hone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. e. 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.......... No ❑......... RIZ SECTION ,im OWNER AUTHOATIONTO BE COdIPLETED WHEN OWNER'S AGENT OR CONTRACT611 APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorizerty to act on my behalZetzl'4 It matters relative to work authorized by this building permit app ication. Dat vvnl. ,m (Electronic Signature) SECTION 7b: OWNER' OR AUTHORIZED'AGEN'r 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. Data I'_riT,t—Own er'i Jf AlitIIJfILCd:\$Cllt'S N.una(Glcetruniu Sigoah NOTES: I. :\n Owner who obtains a building permit to do Itisiher own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty turd under M.G.L. c. 142A. Other important information on the HIC Program can be found at lv vvw nru<.euvhxa Information on the Construction Supervisor License can be found at ww%vjnax,.-_ ,,y v'llLU 2. 1Vhcn sub.;tantinl work is pLmned,pro,ido the information below: ____- —(including garage, tinished bnsedcnt/attics,decks or purch) rural fluor area(;q. 12J tiro:; living area Oil. ft.l ._ Number o rued count _ Number of[ireplacc;...._.. ------ Number of hAtbedrbuds -_--_-- Nuntbcrufbathrnuuls ------ Nuutl?erofhalEbaths __.--_—_-.--_-- f:pc of h..uiul; ;y;tclll -- Nndber of deck;% la,ri hes ... ------ _. --- F:nelo.;clF pen `I',v,II I'n q:et iyu.ue Fool In.ry he ;nb;till;d rl'] hwio,t lll+l'• OP ID: DC ATE Acofza' CERTIFICATE OF LIABILITY INSURANCE D07/2412 Y013 `�- 7/24/23 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 be endorsed. If SUBROGATION IS WAIVED, subject 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 endorsements). PRODUCER Phone: 978-745-3300 NAME:CT John J Walsh Ins Agency,Inc Fax: 978-745-9557 PHONE FAX P O Box 4407- A/c No Ead: AX No): Salem,MA 01970-6407 EMAIL ADDRESS: David C eruett CPRODUCER USTOMER ID H:9SQUI01 L INSURERS AFFORDING COVERAGE NAIC M INSURED Howard A.Squires INSURER A:Northland Insurance Co 8 Valley Circle INSURERS:Hartford Peabody, MA 01960 INSURER C:Commerce Insurance Company 34754 INSURER D: NSU RER E: NSURER F COVERAGES CERTIFICATE NUMBER: 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. AD POLICY EFF POLICY EXP INR LTR TYPE OFINSURANCE POLICY NUMBER MM/DD/YYYY MMIDD/YVYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,0003000 A X COMMERCIAL GENERAL LIABILITY WS177866 06/03/2013 06/03/2014 PREMISES Ea omoranca $ 100,000 CLAIMS-MADE 1XI OCCUR MED EXP(Any one person) $ 53000 PERSONAL B ADV INJURY $ 13000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POI PRO LOD $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 100,000 ALL OWNED AUTOS BODILY INJURY(Per accident) $ 300,000 C X SCHEDULED AUTOS RXQ118 07/17/2012 07/17/2013 PROPERTY DAMAGE HIREDAUTOS (Per accident) $ 100,00 NON-OWNED AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION I NG STATU- OTH- AND EMPLOYERS'LIABILITY T DRY I X E B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 08WECAA2945 06/03/2013 06/03/2014 E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EXPIRATIONTHE DATE THEREOF, NOTICE WILL BE DELIVERED IN Howard Squires ACCORDANCE WTHTHEPOLCYPROVISIONS AUT(Hf,ORRIIZZEDD REPRESENTATIVE ' ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD CITY OF Siul-, I, UMSACHUSETI'S MILDONG DEPALMIENT 3 } !_ 3• 120 WASHIINGTON STREET,3's FLOOR. TEL (978)745-9595 F.sie(978)740-9846 KI.NfBERL.EY DRISCOLI MAYORTHod1As Sr.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUI DIING COJMISSIONER Workers' Compensation insurance Affidavit-. Builders/Contractors/Electricians/Plumbers Annlicant Information 1 Please Print Le ibly_ Name(Business.Organiratiary Individual): _!*d Wo4v <:, Address: gV09)"'.J el Hi City/stace/z(p: °l�� Phone#: Are you• an employer?Check the appropriate box: 'Type of project(required): I.EJ yot am a cmptoycrwith Z 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ I am a sale proprietor or purtncr- listed on the attached sheet 1 ?• ❑Remodeling ship and have no employees These subcontractors 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.) ottteers have exercised their 10.171 Electricals repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MOL. I I []Plumbing repairs or additions myself.(No workers'comp. e..152,)1(4J and we have no 12.0 Roof repairs insurance required.)t employees.No workers' 13.❑Other.. comp;insurance rcquirnd.). •Any appllcam Ihst chocks bum rl mutt also ell out the section below showing their warkras'Compost=It a policy information. !I h>.+muwmw who submit this sirdavit indicating they am doing all work and that hlie outride eontacmrs most submit a new aMdavit indicating such =Contrneton that chuck Ihis box most allachcd an addi noted shad showing the name of the submcontrsedon and Ihels workers'comp.put icy information. lain an employer that-Is prov/dLtg worker'compeusaden lasarance for my employees Below is the policy and Job site injornrwlon. Insurance Company dame:. 63 ;.e wr e-h e Policy u or Scif--ins.Lic.t!: O`4,t..v"rg E2 2 5 4 Expiration Date:-b� Job Site Address: 4 42:$til h s•f a L. zl� Citylslate/Zip:.- 'Wr ur og'w attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a line up to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a line of up to$230.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Office of InvestigmionsufdleD farinsura+ owragaveritiealiun. /do hereby ce l y a rder dre pa/ sat Vila/ es of peril ry that the information provided above is true and correct I si,nar co Dare: O 11hon A• IS OJJfclal use on/y. Do not write in rl it area,to be conrplered by city or tawa n/flclal City or'ruwn: — Yrrmit/f.lccmed Issulag Authority(circle one): I. Bourd of Iicallh 2. nuilding Department 3.Citylrown.Clerk 4, Electrical Inspector 5. Plumbing inspector 6.Other Contact Person: - __-- Phone#: ( CITY OFS.I zAlf, J.A.1S&kCHUSETTS �' � Qt:ILD4VG DEp.1ATStE,VT ,�,,,� � GTOYSTIiEfiT, 3 FCOOR u r L (979) 10.9593 !QUOUt Y OWCOLL FL't(979) 740.934.f �'cl you T}t0.S&u Sr.PtE,jrig DIt=CTOIt OF Pt:auc PR0PE97y/8t:Mncki CM01ISSIO,N ER Construction Debris Disposal AftTdavit (required for all demolition :utd runuvlticn work) rn accanlanca with tho sixth edition afthe State Building Cade, l 1 Debris, ud the pravisium oe,L(GL c 40, S i4; 730 C�b(R section l .3 Building Permit k is issued with the condition that the dcbrI3 resulting from this wurt<simil be disposed Of in u properly licensed waste disposal faoility as defined by ,ti(GL a 111, S I SOA. The debris will be trinsported by: (n�ma ut hauler) l'ha�lubns will bu dispa.ed of in (n:,nru ur ticaii%) i i•lu�mruuipumit p lir.nu I