15A FIRST ST - BUILDING INSPECTION r"
The Commonwealth of Massachusetts R CEI >
Board of Building Regulations and Standards INSPECT ON'I ICE
4 Massachusetts State BuildingCode,780 CMR
` Revised Mar 2011
m ..
Building Permit Application To Construct,Repair,Renovate Or Dem '
One-or Two-Family DwellingA 3 A 2 Z
k This Section For Official Use Only -
Building Permit Number: Date plied: I,
tlt � �ti
.Building Official(Print Name) ,; Signature - Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 As Map&Parcel Numbers
l 3 c�o v a - a 4
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/24!S /F eS
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? Municipal On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner,of lAcord•
AAA, 7� C_tu /-)Ai
Name(Print) City,State,ZIP
No.and Street Telephone Email
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing'Buildin Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ I Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': o Oe_ G6-6,.i + "w r
'
-fst' e / ce e')tif r t 1'
SECTION 4:ES D AT CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 0 0 0 1. Building Permit Fee: $ Indicate how fee is determined:.
❑Standard City/Town Application Fee
2. Electrical $ 0 O O El Total Project Cost'(Item 6)x multiplier - W.x
3. Plumbing $ U 0 o 2, Other Fees: $.
4.Mechanical (HVAC) $ List:.
5.Mechanical (Fire $ `
Suppression) Total All Fees: $
Check No. -Check Amount: Cash Amount:
6.Total Project Cost: $ ` f p
[ / 0 11 ❑Paid in Full ❑ Outstanding Balance Due
hA: l f�
'- SECTION 5: CONSTRUCTION SERVICES
5.1 ruction Supervisor License(CSL) �� �j
License Number 7 Expira on Date b
Name o> Idcr /A r
TWVJ /J List CSL Type(see below) �
No. eet ( Type Description
U Unrestricted(Buildings u2 to 35,000 cu.ft.
(/ R Restricted 1&2 FamilyDwelling
tyIT IP M Masonry
RC Roofing Covering
WS Window and Siding
p-7e SF Solid Fuel Burning Appliances
8 I Insulation
Tele hone Email address D Demolition
5.2 RR/.egi�s�teerr-e/rdC�Home IImmppr�ovement/(T��ry�jtryra'citorrY(HIC) ,
2' _ V W-V/ 6 t X'S „` yC77V HIC Registration Number E6pir�LL on Dale
HItCy..C_o��1Q�n N e or HIC e isvas t Name/�
$J ❑ ` ,(
No. eet , '^r �ip6G Email address
City/Town,St ,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........... ❑
SECTION7a: 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.
Print 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.
Print Owner or Authorized Agen ' Name(Electrons Sig ature) Date
;. 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 ftmd under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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.R) 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 SaU.1` %I, 2MASSACHUSETTS
BL'lIMm.DEp.+R' i&NT
120 WASHINGTON STREET, r FLOOR
'IDS.. (978)745-9595
FAX(978)740-9846
KINiBERIBY DRISCOLL
i41AYOR THO6tAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CO\LL%MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Legibly
VamC (Busim�ss/OrganizatioNlndividun!):
C
�f
Address: .T1 Z .sl. ftT7�rf�t�
City/State/Zip: �7!9�1T Phone #:
Are you an employer?Cheek the appropriate box: Type of project(required):
I am a employer with 2 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet,t 7. U1 !modeling
ship and have no employees These subcontractors have /C❑ Demolition
working for me in any capacity, workers'comp.insurance. g. Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,§1(4),and we have no 12.[] Roof repairs
insurance required.]t employees. [A'o workers' 13.❑Other
comp. insurance required.]
•Any applicant that checks boa 81 most also fill out the section below showing their workers'compens
ation policy infumtmiom
}1 homeowners who submit this affidavit indicating they am doing all work and then him outride coauaetora mist submit a new affidavit indicating such
=Contmaon that check this boo must miachrd an aadition,l cheer showing rho name of the aub-oontragote and their workers'comp,policy i almniation.
I um an nnployer that is providing workers' ompensadon Inrance for my employees, Below is the policy and fob site
information. r
insurance Company Name: 2 su
Policy#or Self-ins.Liic.M �.--f� [1� r/ 2 12(J9<L� Expiratio ate: � "
Job Site Address: �S� City/StateJZip: 1
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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby jy under p ns and penalties of per u th lion provided above is lr a and orreca
c� Date: lZ l
P / 712
Official use only. Do not write in this area,to he completed by city at town officiaL
City or'rown: _ Permit/1.1cense
Issuing Authority(circle one):
1, hoard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
i
May 12 2014 14:13:49 EDT FROM: F2M/17628B78456 MSG# 385582S2-886-1 PAGE 801 OF 884
THE
HARTFf3ftO
The Hartford
FAX COVER.PAGE
To:
Fax Number: 9787459684
Company:
From: "Services, Agency(Comm Lines, San Antonio/SCIC)"
<Agency.Service(rathehartford.com>
Date: 05/12/14 02:13:17 PM
Subject: Certificate of Insurance Policy 76wegdu9613
Total Pages: 4 including cover page
PRIVILEGED AND;CONFIDENTIAL:This electronic communication,including attachments,isfor the exclusive use of addressee end may
contain proprietary,confidential and/or privileged information. If you are not the intended recipient,any use,copying,disclosure,
dissemination or distribution is strictly prohibited, If you are not the intended recipient,please notify sender Immediately by phone,destroy this
communication and all,copies.
Memo:
Dear Daniel,
It was a.pleasure speaking with you today. I was glad I was able to assist you.Attached you will find the
Certificate of Insurance you requested.If you have any questions or need further assistance, please feel free to
call or email us.Thank you for being a loyal Hartford customer and have a great rest of your day!
Andrew Cardenas
Business Insurance Service Operations
Agent toll free#: 1-877-853-2582
Policyholder toll free#: 1-866-467-8730
Fax: 1-888-443-6112
Email:agency.services@thehartford.com
The Hartford's Small Commercial Call Centers have been recognized by J.D.Power and Associates for providing
`An Outstanding Customer Service Experience Our easy processes and service solutions save time and let our
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We care about meeting your service expectations.Did I provide you with a great Hartford Experience?Please feel
free to send any feedback on my service to Lisa.Alvarez@thehartford.com
May 12 2014 14:14:11 EDT FROM: F2M/176288784S6 MSG# 385S82S2-886-1 PAGE 004 OF 004
1�'1�+p+ �w T FL'+C U11'1!(MM%UU.NV\'YI
L'-- - CER IPI�"ICA1E OF LIABILITY INSURANCE Ros4 17.7./2014
THIS CERTIFICATEIS 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(Sj,AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the poliey(ios)must be endorsed. If SUBROGATIONIS 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 andorooment(s).
lwpaquk
.T
PAYCHEX INSURANCE AGENCY INC
Inn:.M"c.rl, IArc:vw. (888) 443-6112
210705 P: F* (888) 443-61.1.2
PO 'BOX 33015 _ Marl 6ICI AFMRIIIM COOLrewr NR1Cd
SAN" ANTONIO TX 782.65 INWRCRA: T'd1.n City 1+.tce Ilia (,u 291:9
INSPRUP mm IMIRIERO:
IMIURE P C:
TERENZONT CONSTRUCTION N uaeuR:
35 MACARTRUR CIR IrvsualrR:
PEABODY NIA. 01960 IN>I4i rsR5
COVERAGES CERTIFICATE NUMBER: RE VISION NUMBER:
THIS IS TO CERTIFY THAT TFIF. POLICIES OF INSURANCE LISTED BELOW TofIAVC BPEN ISSUED TO TWC INSURED NAMED.ASOVE FOR THE-POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 1.11I8
CERTIFIOATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS. SUBJECT TO ALL. THE
TERMS,E)(CLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY 14AVE BEEN REDUCED BY PAID CLAIMS.
INTO - TI'Y/UPr•YSC/IA.VCe 'Mom YRdtt FCiylfr.rf.:ArvfYH pmerBYI" pLUJCYhA'P
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0t'SOrUm'ION Or'ORCRATl0N9/LOCATIONS/WHICEE9(ACORe 101,NMdbpNl R-M"404#014, Ift 10 AlOeI0 49$1910 fll*0 N M40Ya11)
Tbo3e usual. to Lhe Insux'ed'S Operations.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
Cloister CondominS.um. Trust. BEFORE THE EXPIRATION DATE THEREOF,N0710E WILL BE
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS,
C�0 East Coast, Properlien, I'LC AUTHORIZED REPRESENTATIVE
400 HIGHLAND AVE S'1'k: :L'1
SALLM, NA 01970
(gin 1988.2014 ACORD CORPORATION.All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD
05/12/2014 14:02 8782234038 Consoles-Insurance 91418 P. 001/001
CERTIFICATE ®F LIABILITY INSURANCE s%iaiaole
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(8), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: it the certificate holder Is an ADDITIONAL INSURED,the POROY0e6)must be endorsed. If SUBROGATION IS WANED,subject to
the terms and conditions of ins policy,certain policies.may require an Endorsement._A statement on this cartificate does not confer rights to the
certificate holder in lieu of Much Endorsements.
A T Tara Cil@PeB
PRODUCER
Nicholas 'A Consoles -Insurance Agency Inc P (978)a23-4037
153 Andover Street Lunt 111 .tsraoconaolo"nourance.coo _
WSURERISIAFPORDNI GCGVERAGE - NAILe
Danvers MA 01923 Wt A:Sa£et Insurance Company Comp§py 39454
INSURED 19 E:.
Tare 2ont COnatYuctiOu s c:
Daniel Terenaoni -DBA auRERo:
35 MacArthur Circle E:
Peabody MA 01960 F:
COVERAGES CERTIFICATE NUMSER:Naeter cart 2013 to 2014 REVISION NUMBER:
THIS IS TO 09RTIFY 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,
R P ICY E P PG L %v LIMITS
.Type DF INSURANCE. OP4 0 CY
GENERAL LWBnITN _ 'EACH OCCURRENCE 1,000,000
X. COMMERCIAL GENERAL LIABILITY
S 100,000
A CLAIMS-MADE nX, OCCUR aKIL0020237 /4/2013 0/0/2016 MEDEXP An ua anon S 10,000
KFISONALSAOVINJURY 11000.000
GENERAL AGGREGATE S '2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGOES
210001000
X POLICY LOC 4YTOMDe1LE LUU31LnT COMN EUMIT1 0 000ANYAVTO ROPILY INJURY IFeIPenon)Au706WD X AICITO6ULEP 6224605 S/a/2013 /S/2014 BODILY INJURY(Pal aceAmtlNONQWNEP POPEGEVIREO AUTOS AUTOS UMBRELLA LL42 OCCUR EACH OCCURRENCE
EXCESS LIAe CLAIMSdbWE AGGREGATE
iD ENTION f
WORKERS COMPENSATION - WCS7ATI. 9
TT
AND EMPLOYERS•LIABILITY
ANY PROPRIETORIPARTNERIEXECUTNEQ NIA _ sI-EACH ACCIDENT S
plarWtl ryyEn MF{EXCWDE07
E.4,DISEASE-EA EMPLOYE f
If WWa.dawlba undaf E.L.DISEASE,POLICY LIMIT $
OESC ONOF OPERATO below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ANBeR ACORD 101.A4410MIJ RemamA 3000.10,#more APaco Is roqulroo)
CERTIFICATE HOLDER CANCELLATION
(97 8)74 5-9684 SHOULP ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION PATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
Cloister Condo Trust
c/o Bast Coapt Property AUTHORII RMPRESENTATIVE
400 Highland Avenue, Suite #11
&a1em, MA 01970
Anthony COnpoles/OCOR
ACORD 25(2010/05) 019BB-2010 ACORD CORPORATION. All rights reserved,
INS025(2Dlosslol The ACORD name and logo are reglstered marks of ACORD