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23 COUSINS ST - BUILDING PERMIT APP 22 0 I The Commonwealth of Nossgrai WtF ® Department of Public Safety C Massachusetts State Building Code.� b A Building Permit Application for any Building other th,a a'O r Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) Zd No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Buildin Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Ate building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Revi required? ring A�� � �eIs, ❑ No Brief Description of Proposed Work .QJ�r F9 Ag60� / l f 77W WX SE 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) 4 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional 1-1❑ I-2 El 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ HIA ❑ RIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: / - (01 tcl y SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ,5 "7 /S /J Name(Print) No.and Street City/Town Zip Pro rty Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If ap�p/licable,the property owner hereby authorizes ,�N1,i n�� Z� Go�Jd,�✓r �� c�fi�s>7MW or�Z Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Al 10M& /,a11 _ �i2� �7s�7i7 N� a tran Tele hone No. e-mail address Registration Number � / � 'z G& .. ° �/+t{ e Street Address Ctyffown tate Zip Discip' line E pirauon Date 10.2 General Contractor Company Name 7-Yea, zg e r 010 yif kh'(' �3 Name of Person Responsible for Construction License No. and Type if Apphcab e Street Address City/Town State Zip ele hone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes l] No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ o — Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contac uni ipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SE ON 3:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I he eby a t under the pains and penalties of perjury that all of the information contained in this a ication is true and accurate o the hst f my knowledge and understanding. lease print and sign name Title Telephone No. ate Street.Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date National Management Team Inc. Thu form satisfiu all basic rcquiremenU of the smte's Home ImpmvemCot Contractor Law(MGL chapter IJ2A).but does not Include standord language to protect homeonmers. Seek legal advice lfnecessory. Any person phwhing homeimptov=rants should fast obminacopv of"A Massachmcns Constmntt Guide to Home Gnprovemmr"before agreeing to any work on}row residence.You may obmin a free copy by calling the OBice of Consumer Affairs arhd Business Regulation's Camamr Infonmtian Hotline at 617-973-8787 or 1-688-283-3757 or on act website. Homeowner Ill •nation Contractor Information 00 Ne Co Nana Sheo.4ddress(do uo uses Pan Olfiu Box atldrea) C Imetw%S pecsoW Oaver Nom City, State ZIP Cade Brashness dress(uwsl ineludea anttM address) 0/570 ill © b 0 Daytime phone Evening Phone City,Tmm C late 73 Code - a V /r Mailing (k diQetent above) Bwwess Maud' I Dnployer m or Z S.S.Number"' • yes+r ama .Conran cocv.ae<a.a sasasa s w'QL � oe,pn,aba arms.. h 0s h The Contractor agrees to do the following work for the Homeowner: H O 0 00 (Describe in detail the wad inroinPleted,specifying the type,brand,and grade of materials to be used,one ndditioml sheets ifueres• ,) 0; -(VIP m-la A-1100P, E IWv' 0-.,X-d ---2;vJ;17u 6 A&&— of° fe t, r^Iz; 6N!ett-rt v 1)r✓ Required Permlrs-Ilse follow' building 14 w following hg permits arc required Proposed Start and Completion Schedule-The following schedule will 00 and will be secured by the contractor as the homemvners agent be adhered to=less circumstances beyond the contractors Control arise ►a P.t ono (Owners who secure their own permits will be • try excluded from the Guaranty Fund provisions of ) Date when connector will beg in contracted work. MGL chapter 142A.) �77 7 W Date when contracted work will be substantially completed tTotal Contract Price and Pa)msent Schedule 00 Z F0 O5 'Eire Connector agrees w perform the work,famish the material and labor specked above for the total sum of. Oy p C Payments will be made according w the following schedule: $ 0 46 upon signing contract(not to exceed 1/3 of the total Contract price or the cost of special order items.whichever is Maki) S by /_/ or upon completion of .S/n� 2�by L/1J/Jq or upon Completion of_ OA/ S upon Conhpletion Of tile Contract (Law forbids demanding full payment until contract is Completed to both party's satisfaction) The following materfal/equipwet mat be special S inbepaid for ordered before tine cmtracted wink begins in a dw to meet the completion echedme.(°h $ robe paid fin NOTES:(•)including all finance charges(e•)Law requites this my deposit or dowayayamt required by the Connector befinewrork-begins nay not exceed the greater of(a)cue-third of We win]Conrad price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advome to mast the Completion schedule. ' Exn W tv-7 wbN ildNL tb t erotR lard ❑Y (pit, itb w tb n bed 0 h treell Subcontractors-The contractor agrees to be solely responsible for Completion of rise work described regardless of the actions of any thud party/subeomhactw utilized by thecmtmctor. Tile Contractor funher agrees to be solelyrespombie for all payments wall subcontractors for materiais and labs trader Oda anivensing Contract Acceptance-Upon signing,ties document becomes a binding Contract=der law. Unless otherwise noted within this document the contract shall not imply that my lira or other security interest ban been placed on the residence. Review the following cautions and notices carefully before signing this Contract. • Don't be pressured into sigimil;the contract.Take time to read and fully understood it. Ask questions if something is unclear. • Make sus,the tmcto h aid Home ImmessmeritContriewrRemistiotion,. The law requires most home improvement contractors and subcontractors to be registered with the Director of Home hnprovement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park-Plaza,Eaom 5170,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask-the Contractor for his insurance company information so that you can confirm coverage,or ask to sec a Copy of "proof ofinsumnce'document. • Know yew rights and responsibilities. Read the Impotent intonation on the reverse side of this fora and get a copy of tile Consmuer Guide to the Home Improvehnent Commucto Lair. - You may cancel this agreement if it has been signed at a place other t1=h be contractors oenuzl place of basin 'dad you notify tlhe Contractor in writing ai his/hw rtmin ot8tt or b=hch ofLtt by ordinacymail posted,by telegca t w by very,nor ter thin midniglu of tlu third business;day following rite signing of dhis agreement. See the ranched notice of do torah fu m eaplanmio of this tight. DO NOT SIGN THIS CONTRACT IF THERE *goadNK SPA S!!! Taro Heated xmpies ofdw cwmmnmmt tie eanpleed mdsigmM 0moopy0suldgowt vhc kepiNemamean. n aria Signature Con or Z / Dine —] Dare r'-- Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner fit court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business tion and th rats ter shall be required to submit to such arbitration as provided In Massachusetts General La • ,c apt 142A Hbdieownees Signatu es Si ature NOTICE:The signatures of t to p ies above apply only to the&greett'lf�t'hoe parties alternative dispute resolution initiated by the contrac or. The homeowner may initiive dispute resolution even where this section is not separately signed by the parties. Homeowner's Rights A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer Protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement. However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides art express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other natters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been tilled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor. Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract,and the three day rescission period has expired. Accelerated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deena him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283.3757 or visit the OCABR website at httn://www.a1Rss eov/ocabr/ If you want to verify the registration of a contractoror if you have questions or need additional infomation specifically about the contractor registration component of the Home improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the HIC website at httn://%mlv.mass eov/ocabr/ Go online to view the status of a Home hnprovement Contractor's Registration: http://db.state.m.usAioineinmroveinent/licmiseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-6524800,508.755-2548 or 413-734-3114 Vwioa ll-t tl2V2010 <►cono® CERTIFICATE OF LIABILITY INSURANCE 05/15/14 °"""' 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 policypes)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 endorsement(s). PRODUCER co T NAME: Circle Business Ins. Agcy, Inc PHONE g78 777-5619 FAX N (978) 777-4898 247 Newbury Street 4daL ,Danvers, MA 01923 AOIX1ESS: INSURE SAFFORDING COVERAGE NAIC9 I...... A:Hartford Underwriters Ins. Co. INSURED INSURERB:Main Street America National Management Team Inc. INSURER C:Torus National Insurance Co. 2 Austin Square INSURER D.Trave---,S Lynn, MA 01905 INSURER E: R.F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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. LTR TYPE OF INSURANCE im W SUM POLICY NUMER PMRn/Y FF MBIDO'YYYY UMTS B GENERAL WBIUIY Y Y MPT7965M 2/24/14 2/24/15 EACHOCCURRENCE $ 1 000 000 X COMMERCIALGENEPALUABILITY UAMAGETORENTED $ SOO QOU dAIMSMADEOCCUR WDe ( ry ore Perrm) $ 5,000 PERSONAL&ADV INJURY 3 1,000.000 GENERAL AGGREGATE S 2,000,000 GEN'LAGGREGATE LIMITAPPUESPER PRODUCTS-OOMPIOP AGO S 2,000,000 POLICY x PR0. LOC S y AUTOMOBILE UABIUTY Y Y MPT7965M 2/24/14 2/14/15 eecdde/ I T E 1 DDD DDD ANYAUTO BODILY INJURY(Per parson) S ALLOVJtED SCHEDULED AUTOS AUTOS BODILY INJURY(Per mddent) E X HIREDAUTOS X AUTOS PROPERTY DAMAGE $ ererJEeAt E XCFES C X XCES AUpS X OCCUR Y Y 858241140ALI 2/26/14 2/26/15 EACHOCCURRENCE s 5,000,000 CLAIMS-MADE AGGREGATE E 51000,000 DM RETENTION E . A WORKERS COMPENSATION 2E041993 2/21/14 2/21/15 WCSTATU- OTH- ANDEMPLOYERS'UABIUTY YIN XTS OOFFICEPMREM�BERR EXCLUDED?EDXEWTIVE N NIA EL.EACH ACCIDENT S 1,000,000 (Marwatory in NH) 2EO81002 NH 3/12/14 3/12/15 U/yyes$'I"under EL.DISEASE-EA EMPLANES $ 1 DDD D00 SG�RIPTIONOFOPERATIONStebw EL.DISEASE-POLICY LIMIT S 1,000,000 D Crime Policy 106102524 5/15/14 5/15/15 Limit $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AUech ACORD 101,AddPoonal Rem rb Schedule,If wre spew Ismgdreel CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESETITATNE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: [K 1 i I i • • - I I Massachusetts-Oe a Board o'f Building rhnent cif Public Safety I g Re ulatidns and Standards Coa'sfruedoo.Supervisbr i License:CS-06,��g5 $ GEORGB ' SpTPCA1R� �g IPSVVICHMA OD36 G y 'C'�""•'�y -ri•ii,�d Expiration commissloner 1 012 612 0 1 5 l F� �c ffi e o onsumer airs�W ess e u a ion g 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improveme Contractor Registration Registration: 178186 Type: Supplement Card NATIONAL MANAGEMENT TEAM Iz �` f Expiration: 3/24/2016 MICHAEL CONNORS � ( 2 AUSTIN SQUARE a LYNN, MA 01905 f� Update Address and return card.Mark reason for change. ' SCA 1 Ci 20M-05/11 Address Renewal Employment ❑ Lost Card ' .A �/LE 1pOmL/Rpn(6eaGUL 6�V(�[g412Gzetde�5 Mee of Consumer Affairs&Business Regulation g License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation ;,_egistration1j81'&6_, Types 10 Park Plaza-Suite 5170 `- Expiration /pOjg;-T Supplement Gard Boston,MA 02116 NATIONAL MANAGM EN--,5, M INC. MICHAEL CONNORS P.O. BOX 365 TOPSFIELD,MA 01963 - Undersecretary Not•a i wi signature - - I The Commonwealth of Massachusetts Department of IndustrialAccidems Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busine,s/Organization/Individua!): U /� 9�1(�/�jny/t{ e� 1,0,/42 Address: t � City/State/Zip: Nn/ 0 O Phone#: � 1 70 Are you an employer?Check the appropriate box: 1. 4. I Type of project{(reguired): I am a employer with�� ❑ am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working forme in any capacity employees and-have workers' - - - 9--❑-Building-addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.L@%of repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑Other pomp.insurance Iequired.) *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they we doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they most provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:_ &�N&jd L Zd(-JZ-A I P / o Policy#or Self-ins.Lie.#: '��c/� Expiration Date: / Job Site Address: p 2 l"OdJU City/State/Zip:.._+f /Q� Bt 91-;b 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 MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,50.0.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against •olator. Be advised that a copy of this statement may be forwarded to the Office of -- -- —Inveshgahons of the DlA Poi ce coverage verification. I do hereby certo under a pa and penalties ofperjury that the information provided above is true and correct. Si ature: Date: bg /y Phone#: Official use only. Do not write in area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#•