25 FLYING CLOUD LN - BUILDING INSPECTION The Commonwealth of Massachusetts
➢V j Department of Public Safety
'Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building.other than a One-or Two-Family Dive]Iing
(This Section For Official Use Onl )
Building Permit Number: Dar Applied: Building official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
q SE c
cCa/j /-N S"TV
No.and Street 't /'Town Zi c7d Name of Building(if appy able)
SECTION 2:PROPOSED WORK
Edition of NIA State Code used---1;2 If New Construction check here❑or check:dl that apply in the two rows below
Existing Building❑ Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as pan of this permit application? Yes ❑ No ❑
Is an Independent Structural Enginecrin r Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Ae�L./�C' E- C X( S'T/�� //fT;- O
000a ?S Lr 7 �! �!/�� s �/f Ti O /�Or/?f Ca C—/
SECTION 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 Flours/Stories(include basement levels)&Area Per Fluor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION S:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A 2❑ Nightclub ❑ A-3 ❑ A-4❑ A-3❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Fli h Hazard FI-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-t ❑ 1-2❑ I-3❑ I-4❑ NI: Mercantile❑ R: Residential R-I❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ Illy\ ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 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 numicipal❑ 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 Hl m n i imni's n i 6 c,��_I r xos:
Nut 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): 'rylle of Cunstnictiun: Occupant Load per Floor:
Does the building contain an Sprinkler System?:_ Special Stipulations: --
M A t L— 'fb Gt_-tt✓—NT
SECTION9: PROPER'TYOWNERAuUr11OBIZA'FION
Nme au I Address of Properly Owner
i r
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes
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 a2plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(if building is less than 35,000 cu.ft of enclosed s ace and or not under Constnrction Conlro(then.check here❑and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) 'Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
`role hone No. business Telephone No, cell e-mail address
SECTION i1:Ial:n:I:FILs,MIPIi.NsAIUNINSur.:WCFA[I n.:n,.Irr M.G.L.c.132.§ 25C6
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 si ned Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6) 5
1. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical - $ appropriate municipal factor)=.$
3. Plumbing S
Note: i\lininuun fee=5 (contact municipality) .
-1. Mechanical (FiVAC) $
5. Mechanical Other S Endow check payable to
6.Total Cos[ I $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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.
Please print and sign name Title Telephone No. Date
Street Address city/Town State Zip
\lunicipal respecter to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
4 Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: tl'D
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1 opev Address: LC
1.2 Assessors Map&Parcel Nu ers
1.1 a Is this an acc d street?yes 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? Municipal M On site disposal system ❑
❑7' Check if es®
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own 'of R
M /TecorAA: — y l- "I�reU tS1 �Mt�f e �Uei�>Jcc;�) 1
am Ram t) { City,St ZIP
Y 1 u C' A -Y)keW 2-q C1 nmt
No.and Street I Telephone Email Address
" SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building P Owner-Occupied C9 Repairs(s) C)) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work z: A n' Uu S14 ri
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: IOfficial Use Only
Labor and Materials
1.Building $2 Sa 0 U V 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $
List: t
5.Mechanical (Fire $
Supression Total All Fees:S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 7j 8 z) ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ' L
l �7 ��-y o. to I 2o i
License Number Expiration Dale
N e of CSL Holder
List CSL Type(see below)
Type Description
No. d Street
0 1 5 G Z U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 FamilyDwelling
CityiTovin,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
1 ` SF Solid Fuel Burning Appliances
yt�(1�1�IOktt'1 my,eI�-�/l°k I Insulation
Tele hone Email alidr6ss D Demolition
5.2 Registered Home Improvement Contractors(HIC) 1 / ,
t19
' 61 CM-4 C±— l � �1 lY 6V c_ jMOfot HIICRegistratioonnNumber xpimtionDate
HIC Comp Name or HI Re 'str t Name _Ic
3 V�ru (� 1� �Dhnpfiy�e-.�
No.and Street s
�/'�[ _ 37.�� Emaq4ddfess
6tytown State ZIP d Lq30 Telephone
L-WT N 6: RKERS'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.......... 11 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.
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
co med in thi��ryryplication is true and accurate to the best of my knowledge and understanding.
0
-Print Owner's or Authorized Agent's Name(Electronic Signature) 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 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.Rov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"
t ' Massachusetts -Department of Public Safety=
'Board of Building Regulations and Standards
Construction Supervisor
License: CS-029240
JOHNJGOYETT
-� 115 PAXTON ROAD'� _ s
SPENCER MA 2562 !
Y i ,.. `
Ezpiratio'n;`,
. , Commissioner 06/17/2014',
S�J 1� r0 C-e LLO U C)P-S�
"1
i CITY OF S.U.E.I, NAASSACHUSETTS
BUILDING DEPARTN NT
• p 120 WASHINGTON STREET, 3aa FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
IQMI(BERLEY DRISCOLL
NUYOR THOMAS ST.PMRRRE
DIRECTOR OF PUBLIC PROPERTY/BCILDCVG COXMSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / , / / Please Print Legibly
Nalne(Busimx ,Organizaliorvindividual): �17/`t Jt C7 Q Ye /T r/
Address: // 5-e/JX TC/iV �o
a iS6 d
City/State/Zip:—L42�C,/, �� Phone N: 7 7 V 9 ; 3-3 G
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(fail and/or part-time).* have hired the sub-contractors
2.U l am a sole proprietor or partner- listed on the attached sheet.I ?• ❑ Remodeling
Ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑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.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers'
comp. lasurmcc required.] 13. ther__,
•Any applicant that efieeks box ill must also till out the action below showing their workeri compensation policy information.
'❑cMwowrwlf who submit this anidavit indicating they are doing all work and then hire outside commctom mot submit a new anidsvit indicting such.
=Cmmnaton clmt chick this box must winched an addiciormi sheet shawina the name of the sub-commcton and dwit workers'comp,policy inromution.
1 um an employer that is providing workers'compensation insurance for my employees. Below Is the palley and fob site
information.
Insurance Company Narne: ____
Policy#or Self-ins. Lic. q: Expiration Date:
Job Site Address: City/State/Zip:
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
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. Ile advised that copy of this statement may he forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ida hereby certify under the pains an penahles of perjury that the iuformatlon provided above is true and ccorrect
tr n n q (late: / �,! /y fX �'/ 3
P on d:
Offrtcial use only. Do not write in this area,to be completed by city or town offrciat
City or•rows: Permit/License# _
Issuing Authority(circle one): _
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone N;
)
10/04/13 11:18AM HP LASERJET FAX 5082344467 p.01
CERTIFICATE OF LIABILITY INSURANCE YYYI
DATE(MAUDDIY
10/4/2013
THIS CERTIFICATE i5 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: It the certificate holder Is an ADDITIONAL INSURED,the policy(les) must bo endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endomement. A statement on this Certificate does not confer rights to the
certificate holder In lieu of such endorsements.
PRODUCER CONTACT
NAM •
Wiersma Insurance Agency T,LC PHONE *^ --�(508)234-6800 - - t90el 23,4 4461 -
781 Main Street, Suite Two ' AIL jl
_ _INSIIRCR(SI AFFORDING COVURAGE NAIC B
Whitinavill® MA 01588 _..�� INSUREMA:NGM Insurance Co..�._......_.._...- 4788�
INSURED JOt�7 J GOYETTE IN 11RER.6.;
dba JG Home Improvement INSURERC:
1,15 PAXTON RD k1NI
SPFYNCtR, MA 01562 E! ,••T•„•_•_—••-• ^•• v
COVERAGES CERTIFICATE NUMBER:2013 Certificate REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE I.ISTED BELOW HAVE BEEN ISSUED 1"0 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.41MITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
T TYPE OF INSURANCE P121,1cy Nymotg
PQ YBF 'LIUVro LIMITS
06NF.RAL LIABILITY HPB52073 05/13/2013 5/13/2014 EACH OCCURRENCE $ 1,000,000
COMMERCIAL>RNF.RM,LIAHA.tTY ^TTA�)COETII•f0' $ 500,000
$gtgj.
A CLAIMS-MADE, OCCUR MEO
PLIi$EXP(A•xy OnO lMra0n1 S 10,000
----.�•�,�,.... ONAL,A AOV INJURY Y S 1,000,000
--- ...,. ENERALAGGREGAIE s_ 2,000,000
GE.N'L AGGREGATE LIMIT APPLIES PER. PRODUCTS^COMPIVPAGG 5 2,000,00
POLICY PRO LOC, $
AUTOMOBILE LIABILITY O I
ANY AUTO BODILY MA)IY(Pm p0mnn) 6
ALI.ObMdRG SCHEDULED --•--^--•-•
AUTOS AUTOS BODILY INJURY Per W&n1) 5....
H)RED AUTOS AUTOSMW .—PROPP T HUgM -^N^^NN-O
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
E%CE$$LIAR CLAWS-MADE AOOREGAI'E�.M $
DUD Rj.TVNnoNZ
m. $
MRKRRBCOMPENSATION WC.. A U OTii
AND EMPLOYERS'LIABILITY
ANY PROPMETORIPARTNERIEXECUTIVE
OFFICCR)MFMRS NIA
rtY'^I-N-I� R.L.EACH ACCIDENT $ � ~-
RE%CLl/DED? l l
IMAndALurylRNlq 11Q6,a05alb0 UIRI¢r E.L.DISEASE-E0.EMPLOYE
y
DFSL IPTION w OForEra❑ E%bA
---��_... ....,., ...-..„,. ,-,qM. E.L.DISEASE,POLICY LIMIT I 5 _. ..w..«....
OE Remodeling
ell od OP¢gAT1 /LOCATIONS r VBRICLEa IAHA<n ACORD mI,gngRbnAl NAmarkA Schonma,rt more apaoe Iu roqulrvU)
Ring and
carpentry
CERTIFICATE HOLDER CANCELLATION
(978)740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISION$.
Building Department
120 Washington St AUTHOAIxBD REPRESENTATIVE
Salem, MA 01970
Wayne Wierema, G_..L /p /v,�c-=•-,x.......
ACORD 26(2010108) C 1885-2010 ACORD CORPORATION, All rights reserved.
INS025(2m1w5).01 The ACORD name and logo are registered marks of ACORD