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173 FEDERAL ST - BUILDING INSPECTION (3) } l The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CMR,7`n edition MUNICIPALITY USE ` J Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January One-or Two-Family Dwelling 1, 2008 SThis Section For Official Use Only Building Permit N xer Date Applied: r p Signature: /� / Building CommissionO Inspector of Buil ings Date —� SECTION 1:SITE INFORMATION 1.1 1 7 pjerty�ddre�s: 1.2 Assessors Map&Parcel Numbers Fed P1 L la Is this an accepted street?yes X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 caner of o d: Name(Print) / _ Address for Service: Sr ra<w Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': t rBI SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6) x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ -Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ OX) ❑Paid in Full ❑ Outstanding Balance Due: $a g� Cry r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor I(CSL) /+S 7 3 SD p�U J (�S _A/ V , L..[�1//�/ [License Number Expiration ate Name of CSL Holder (�� J List CSL Type(see below) 7D Description re s _ t�A O!9 U nestricted(u to 35,000 Cu.Ft.) 11LRestricted 1&2 Family Dwelling ature ,/ M MasonryOnly a T RC Residential Roofing Covering elephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered stered Home Ira rovement Contractor(HIC) f .� 7 :: S�t( � C ..rn) HIC Company Name or HIC Registrant Name Registration Number Addr ss 2 Expitation Data' Si tore 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, GIFr,r 1. W 1 ,, dnim as Owner of the subject property hereby authorize erg n Lrn tit to act on my behalf,in all matters relative to work authorized b building permit application. Signature of Owner Date SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION Q. L I/"t") ,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 behalf. Print Name Signature o Unct2o, uthorized Agent Date / (Si ned❑ r the ains and nalties of perjury) NOTES: 1. 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. t42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors 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" a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations k1ri 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ,1 Name (Business/Organization/Individual): tD )P-ScAgcI -'r) _ Address: 32 +tt` `-A City/State/Zip: ('l S4 Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1.4 I am a employer with c3 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 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 workingfor me in an capacity. employees and have workers' Y P Y� $ 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other rn b 1 employees. [No workers' comp. insurance required.] Any 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 are 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 must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. corn '67�^, ff �'_�^I�Jt�i++(lC.� Insurance Company Name: �)t+30 J' cLiz<; 1 11_L_ (VtI Policy#or Self-ins. Lic. #: Expiration Date: ld Job Site Address: [ Z?� r Q ,f City/State/Zip: V ?6 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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpenalties7ofperjury that the information provided above is true and correct Signature ,, fYYI Date Phone#: Official use only. Do not write in this 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#: CERTIFICATE OF LIABILITY INSURANCE OP ID J DATE(MM/DO/YYYV) jQ 9ADIN02 12 11 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE John J Walsh Ins Agency, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P O Box 4407 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salem MA 01970-6407 Phone: 978-745-3300 Fax:978-745-9557 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: First Financial Insurance co. INSURER B: Commerce Insurance Company 34754 A & D Insulation Company INSURERC: 'United States Liability William Brooking DBA y 33 Arthur Street INSURER : Travelers Beverly MA 01915 INSURER E: COVERAGES 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 RESPECTTO 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LTR NSR POLICY NUMBER TYPE OF INSURANCE DATE MM/DD/YYYV DATE MM/DD/YVYV LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY L143000334-1 09/05/09 09/05/10 PREMISESEaoccurence $ 100000 CLAIMS MADE 1XI OCCUR MED EXP(Any one person) $ 5000 PERSONAL B ADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 1000000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY, B X SCHEDULED AUTOS BBCXJN 09/01/09 09/01/10 (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 Q X OCCUR 17 CLAIMS MADE CUP 1104821 09/05/09 09/05/10 AGGREGATE $ 1000000 $ DEDUCTIBLE - $ RETENTION $ $ WORKERS COMPENSATION TORV LIMITS ER TA AND EMPLOYERS'LIABILITY Y/N D ANY OFFICER/MEMBOEREXCLUDEDE?ECUTIVFq, 9KTJB0683NO78-09 06/26/09 06/26/10 E.L.EACH ACCIDENT $ 500000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR GIANNA DELLAMONICA REPRESENTATIVES. JOHN J.WALSH NSUR NCE AGFNCY Mr, 173 FEDERAL STREET SALEM MA 01970 AUTHORIZED REPRESENTATIVE ^ Mark W. Bettencourt ACORD 25(2009101) 1 ©1988-2009 ACORD CORPORATION. All rights reserved:N( The ACORD name and logo are registered marks of ACORD I. iBo / f Bg �o sand F� Standards I Construction Supervisor License - � f Liodi3e: CS 87350 - -- - 1/2010 Trp 14803 JOSEPH O LINN 90 MARGIN ST _ ,t SALEM,MA 01970 `ice" Commissioner . �ieeinaounealC�i r��/�umoc/ueeC2 Board of Building Regulatlo s and Standards HOME IMPROVEMENT CONTRACTOR .. .Registr 141739 2010 Tr# 263016 dual ; JOE LINN '�t I JOSEPH LINN - 90 MARGtM STR� SALEM,MA 01970 Administrator k