13 CROMBIE ST - BUILDING PERMIT APP The Commonwealth of Massachusetts ��
Board of Building Regulations and Standards C�
Massachusetts State Building Cade,780 CMR,7°edition GF SAi.EM II
�✓ Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 i
One-or Two liamily Dwelling j
This Section For Official Use Only ----j
Building Permit Number: Date Applied:
Signature: �1 L� !> . �iTp22
- ..Bwidiag Commissioned Irepeeror of 6ul'B lugs ate
SECTION 1:SITE INFORMATION
i.t Property Address: -- — i 1.2 Assessors Map& Pareet Numbers
i.la is this an eCoepted sttsxt?yes no— Map Number —..-- Parcet Number
1.3 Toning Inferno ion: 1.4 Property Dimensions:
I
Taming Uimiet Proposed Uu Lot Area(xt Rl Frontage lfll
1.5 Building Sefteks(ft)
Front Yard Side Yards 1 ' Rear Yard
Reyuirod Provided Rcquind Provided Rcyuired Provide)
1.6 Water Supply:(M.G.L C.40.§Sa) IA Flood Zane Information: 1.8 Sewage Disposal System:
- Zone: Outside Fbod Zone"
t Public Private❑ �-- Check il'ycs[3 Municipal❑ on site disposal s aam ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: _
. .
._.
I '+ t Address for,
ervice
Sigtmturc elephnnc
SECnON 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
I New Conswgion❑ Existing Building❑ (3wner-Occupied ❑ Repairs(s) ❑ .41t—_f eratlon(s) ❑ Addition ❑
Demolition ❑ Accessory Bing. Number of Units Other ❑ Specify_-,
iBrief Description of Ro - Work':_ 2- -c -4j ...Kl.-(J vris,
�— — SECTION 4:ESTIMATED CONSTRUCTION COSTS I
Estimated Costs:
Item Official Use Only
labor and Materiels I
1. Building $ f] gnu 1. Building Permit Fee:$__--indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
—.-.! ❑Total Project Cost(Item 6)x multiplier x
rJ.Plumbing $ 2. Other Fees: S.__.._.._.._. .
14.Mechanical (HVAC) S Lisc.._. ------ ..
g.Mechanical (Fire $ —------- _--------------_. j
Suppression) _J Total.All Fees:
�— Check No. I __ Check Amount: _ Cash Amount:.-__—.
6.Total Project Coat: $ �Q g I ❑Paid in Full — ❑outstanding Balance Due:
' SECTION 5: CONSTRUCTION SERVICES
5.4 Licensed Construction Supervisor(CSL) �A 83(-,) I
- 2-I 3- 1"i
0-0 V-% n U 7 ( S License Number Expiration Date
Name of CSL-HolderSQ List CSL Type(see below)
Address Type I Description
U Unrestricted(up to 35,000 Cu.Ft.
Si tore R Restricted 1&2 Family Dwelling
Dt )�.7L/u _ 100 ( M_._Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I y � y 2
RIC Company Name or HIC Registrant Name Registration Number
S2_ Or � ST S� ( ejy_�
X Address — 9 - 21 - 13
C17 7,-7 >jq- too I Expiration Date
nature 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 .......... IV No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 2 V" l.J C, I I as Owner of the subject property hereby
authorize 0 h i to act on my behalf, in all matters
rel a to work aut rized^b�yn his builds g permit app ication.
( ��LG
XSi nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
- ,A as Owner or Authorized Agent hereby declare
that the statements and information on di foregoing application are true and accurate,to the best of my knowledge and
behalf.
Ch a,d-1 to
Print Name /j
�.��tL
Signature of Owner or Authorized Agent r Date
(Signed under the pains and penalties of 'u
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(RIC)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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I O.R6 and I IO.R5,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 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"
CITY OF S.uzm. -NWSACHUSETTS
BUIL=NG DEPARTNtEINT
\ s 120 WASHIINGTON STREET, 3' FLOOR
TEL (978) 745-9595
F.tir(978) 740-9846
KI\rBERLEY DRISCOLL
NL.XYOR THo%w ST.PiERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONER
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 It 1.5
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)
-eo ( q e +00
(addres j s offacility)
Signature of permit applicant
q I l �Z
date
4 OP ID:SS
,d►`oRo° CERTIFICATE OF LIABILITY INSURANCE DATE IYYYY)
O61141hM12
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: N the certficate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. H 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 Center rights to the
certificate holder in lieu of such endorsemen s.
PRODUCER 978-688-7000 NAMEcC
Durso 8.Jankowski Ins Agcy LLC 978$88-7001 PHONE
198 Massachusetts Avenue cN EM: NO:
North Andover,MA 018" EMAIL
Dumo 3 Jankowski Ina.Agcy. ADDNEu'
s Io :CHIMN-1
INSURERS)AFFORDING COVERAGE NAIC S
ERMINED The Chimney Company INSURER A:Travelers Ins.Co. 19038
DBA Charlene Tobey 52 Orchard Street NsuReee:Liberty Mutual Ins.Co.
Salem,MA 01970 INSURER C:
INSURER D:
INSURER E I
INSURER 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.
DDIPOLI
LIP
NMR TYPE OF INSURANCE POUCYNUMBER MISRPMOl1CY EFF MM CYEXP LOUT
GENERAL LIABILITY EACH OCCURRENCE f 1,000,00
A X COMMERCIALGENERALUABIUTY 16802773RSSSACJ12 06104N2 061W13 PREMISES eamarerce s 300,0
CLAJMSMADE �X OCCUR MEDEXP(Anyowperaon) $
PERSONAL B ACV INJURY $ 1,000,00
GENERALAGGREGATE $ 2,000,000
GEML AGGREGATE UNIT APPLIES PER: PRODUCTS-COMP/JP AGG S 2,000,000
POLICY PRO, LOC $
AUTOMOBUE LIABILITY COMBINED SINGLE LIMIT f
Ee¢ddW)
ANY AUTO BODILY INJURY(Per perewl) $
ALL OWNED AUTOS
BODILY INJURY(PereoddenU f
SCHEDULED AUTOS PROPERTY DAMAGE
HIREDAUTOS (Per a=denp f
NON-OWNED AUTOS $
S
UMBRELLA LWB OCCUR EACHOCCURRENCE S
EXCE9M UAB CWNSMADE AGGREGATE $
DEDUCTIBLE f
RETENTION S S
WORKERS COMPENSATION WC STATLLPETR
AND EMPLOYERS'LIABILITYITORY
ISMYPROPRIETORIPARTNERIEXECUTMEYIN C131S378103011 06106H2 IHM05113 EL EACH ACCIDENT f 1,000,00
OFFX:ERVEMSER EXCLUDED7 NIA
(MArKIMory In NH) E.L.DISEASE-EA EMPLOYEE f 1,000,00
rc yee Oeecabe UNMY
DESCRIPTION OF OPERATIONS below El.DISEASE-POLICY UMR f 1,000,00
DEMCPI"ONOFOPERATIONSILOCATTDNSIVEHICLO(AeeeIIACORD101,AddIdMIRelnnke Selledule,ff w "Mlereg0 d)
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
REPRESENTATIVE
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(20OW09) The ACORD name and logo are registered marks of ACORD