11 CHURCH ST - BUILDING INSPECTION 419 if
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR S
Revised dM Marar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date lied:
Building Official(Print Name) Signatu7enso
Date
SECTION 1:SITE INFO
1.1 rope,A=Ss: g� 1.2 Assessrs
r
1.1 a Is this an accepted street?yes V no Map Numbmber
1.3 Zoning Information: IA Prop
Zoning District Proposed Use Lot Area(s (fl)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'1 Record:+ J n �rT-76
YY ,ti � (ACn7tZ 4+.. l7
Name(Pn�--int) City,State,ZIP
No.and Street Telephone ',J J Eroafl-Adth&
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Sk Repai s(s) ❑ 1 Alteration(s) Addition ❑
Demolition Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of froposed Work:
b�, e3 4-411- OL-
I / L/ UJ !
3
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ e OUG.O 6 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
SO 00, o U ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ db, b d 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $/e Q'00, 0o ❑Paid in Full ❑Outstanding Balance Due:
r SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ('1 r—r—Z7c �ra—v.c� ZJ to Z
� ey, / License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
( 7 /✓r)( /
No.and Street
let/ a/e//n Type Description
• 617 /�/ U Unrestricted(Buildings up to Restricted 1&2 Fa 35,000 cu.ft.)
Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
/ r! 1 Insulation
Telephone Em-wTa-ddiess D Demolition
5.2 R�ee26to/red Home I,��mJp�rovement Contractor(HIC)
rC�PO�j r�r�.-�y / HIC Registration Number Expiration(Date
Inc �///'�o✓�CA-c Pe /�Oc �r7 /r,a c/yy r plc""'e e 34-,,rr
No.and Street ` ! Email address
city/Town,State,ZIP 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..........❑ 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.
Prin[Owner's Name(Electronic Signature) • . Date
SECTION 7b:OWNER'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.
llma"� : 62L',Jz 9y= - 2-or
Ow Z
Pilot Owner's or Authorized Agent's Name(Electronic Signature) —r Date
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.mass. og v/oca Information on the Construction Supervisor�License can be found at www.mass.gov/dys
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"
9PICOOI OP ID:JM
CERTIFICATE OF LIABILITY INSURANCE °"'E'°°M°°"""'
09112112
THIS CERTIFICATE IS ISSUED AS A NATTER 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 cer6Rcate holder is an ADDITIONAL INSURED,the policy(fes)must be endorsed If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endomement. A slatemerd on this certificate does not confer lights to the
certificate holder in lieu of such endorsemen s.
PRODUCER 978-745-m CAME
John J Walsh Ins Agency,Inc 878-745-95 �E F -
P O Box 4407 - Eaa me):
Salem,MA 0197D-M7 AyaL
Mark W.Bettencourl
AFFOROINGCOVERAGE UMCa
NSUMA:Commerre InsurenceComparly 34754
INSURED Robert Picone DBA Picone INSURER B:
Construction INSURER C:
COnshlIction
14 Amold Terrace INSURER D, _
Marblehead,MA01945 INSURERE:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE 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.
ITR TYPE OF NIMIANCE POLMYMMIBER ID �F LRAns
GENERAL LIABILITY EACH OCCURRENCE s 1,000,00
A X COMMERCIALGENERALLABILIIY BEING ISSUED 09111112 0IM3 PREMI^ES adc s 100,000
CLAIMSA1g0E ❑X OCCUR MED EXP Wy ore S 5,00
X Business Owners PERSONAL S ADV INJURY s 1,0DO,00
GENERALAOGREGATE s 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOPAGG s 2,000,ODC
X POLICY _ PRO- LOC S
AUTOMOBILE LIABILITY COMBIN LEL I
ANY AUTO BODILY INJURY(Pa PusIm) s
�OhNEO A BIMILYBRJURY(P.NxW N) S
HIRED A(rTOS AUTOON� PROP
AUTOS PEERW S
r s
UMBRELLA LIAR OCCUR EACH OCCURRENCE s
EXCESS LAB CLANS-MADE AGGREGATE S
DED 1 _ RETENTION s
INORNERSCOMPENSATION YJC STATU- OTH-
AND EMPLOYERS LIABILITY ANY PROPRIETORIPARTNR ECUIIVE YIN S
OFFICERIMEMSER EXCLUDEDT ❑. NIA EL.EACH ACCIDENT
(Mandatory In NMI EL DISEASE-EA EMPLOYEE $
If yeS d iba Utder
DESCRIPTION OF OPERATIONS W. EL DISEASE-POLICY LIMIT s
DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES UU!ad ACORD IN,AdcWtkal mmNw.Schiulve,IT aPaaa Nfwm)
JOB PER€ORZIED @: THE ESSEX
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CROWNINSHIELD MANAGEMENT CORP THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
18 CROWNINSHIELD STREET ACCORDANCE WITH THE POLICY PROVISIONS.
PEABODY,MA01960 AUTHORREDREPR RWATIYE r.Y INC-
Mark W.Bettencourt �� !/
01985-2010 ACORD C ORAT ONp(_jWgft reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
i CITY OF S.UL.ENI, N'Lkss kCHUSETTS
• BUILDING DEP%RT%mN*r
• 120 W.ssimmGTON STREET,3tD FLOOR
-0j T m- (978) 745-9595
FAx(978) 740-9846
KIMBERf FY DRISCOLL
MAYOR Tt-toaus ST.PtERRH
DIRECTOR OF PUBLIC PROPERTY/BUELDING COMMSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
date
.L•F.iea l7 der
THE COMMONWEALTH OF MASSACHUSETTS Registration: 165587
A Office of Consumer Affairs and Business Regulation
Home Improvement Contractor Registration Program . Expiration: 3/2/2012
10 Park Plaza,Suite 5170 Received:
Boston,MA 02116
APPLICATION FOR RENEWAL OF REGISTRATION
Home Improvement Contractor or Subcontractor
MGL Chapter 142A,780 CMR R6
ROBERT PICONE REQUMED RENEWAL FEE:
ROBERT . PICONE �loo
14 ARNOLD TERRACE
MARBLEHEAD, MA 01945
No.of Employees:
_If.the_numherof employees stated-here is-incorrect,please insert the-correct number here:_—___=—
CHANGES: If the Applicant is a Partnership,Corporation,or Trust,and the name of the individual
responsible for the applicant's work has changed, please specify those changes below.
�Ijti�� lfenl C Social Security Number: (p9y �7$7y.
First Mid cast o t
Phone Number:
j
ONLY CERTIFIED CHECKS OR MONEY ORDERS WILL BE ACCEPTED
MADE PAYABLE TO"Commonwealth of Massachusetts"
Pursuant to Massachusetts General Laws Chapter 62C§49A,I certify under the
penalties of perj that 1,to my best knowledge and belief have filed all state tax returns
and paid all state taxes required under law.
Signature of Applicant - - Title held with Applicant Date
A false answer to any question in this application constitutes.grounds for suspension or revocation of
the applicant's registration.
Natid zdl Grand Ba�ik 210801
Marbled. MA 01945 .
F 781 pt 8000 5s43011130
www_ngbankcool
DATE 9,11,2012
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3 D nd -
x One Hured dollarsv� *�**����.*# ��k�������/���'k*/ e�rxsyi�l� �'A�'�
' - PUad1ASERS AOOaF55 -
MONEY ORDER , 41o4etLO '� a�Ss�S
-'- NOT VALID FOR.GVER $1,000.00 SnY s1'ATE AND ZR _
RT _
n• 2 1080 Los i:0 L L 304 3001: 0000 2 000.2a•
a wte s;noq"pgentoN
Massrchusctts Department of Public Safctd � 9TIZ0 VI4 ao;sog
9 Board of:Buildm.=Rc_Rdstiuns and Standards , ' o6TsamnS �LC�rgd OI
ooltelr. ag ssaong.p sn Sisue spqoo as suoD
Construction Supervisor License
io;oJ,ow puno;n -49p uolye.udxa ay3`.a.ro;aq
One.and Two Family Dwel it gs t
' A11,10 asn lnpielpm roJ-PgeA uolt¢ijs ai io asuaa�Z
Liiense: CS 85580 ';_ pst'
ROBERT PICONE
14 ARNOLD TERR us
MARBLEHEAD, MA 01945 Otfice of Cmsumer Aifays&Baess Re&
HOME IMPROV�MEN•f CONTRACTOR.
_-
_ Rey�stration 765587 T 294064 -
��G_ �l Expiration: 1VVZ012 Expi 10 3/22012
C'ununi'xianrr Tr#: 4565 r � _TYP . IndNidoal _ _
ROBERT PICONE _ .-
ROBERT PICONE
14 ARNOLD TERRACE Uoder
MARBLEHEAD,MAb'1945 -
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