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7 FOREST AVE - BUILDING INSPECTION The Commonwealth of Massachusetts °p. Board of Building Regulations and Standards RF CEI� i1'TE F Massachusetts State Building Code,780 CMRINSPEOT OtlNt TALE? Revised Mtn 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish b A � 1 One-or Two-Family Dwelling 1p15 JU1t This Section For Official Use Only Building Permit Number: - ate Applied: Budding Official(Print Name) Signature Date r� SECTIONI:SITE INFORMATION 1.1 Pro Address: 1.2 Assessors Map&Parcel Numbers � � ].la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq$) Frontage(ft) 1.5 Building Setbacks(ft) Front Yazd Side Yards Rear Yazd 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 d L3 O Private❑ Zone: _ Outside Flood Zone? Municipal Din site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: LOZ It/6- 4 CGf/,u M46rE`1 SA(FyK tM, o/a 7o Name(Print) City,State,ZIP 7 --3FdV—fS7 4V67 y7110 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: A M Brief Description of Proposed Workz: Mov — N CQ M FOR &6&v RA?—H T241 Oaa v 180e—/ , rusucFl� era s 6411 9 PDT 1=eta°21VG- DRe9 L�/Gi/ice SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only - (Labor and Materials 1.Building $ a 1. Building Permit Fee;.$ Indicate how fee is determined: 2.Electrical $ OL) ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ UL 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ Suppression) _ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 5 OvV ❑Paid in Full ❑Outstanding Balance Due: � i SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) IZ _ C� o7og 36 '��`'� 1�. �GO(.�tRh �'D LF License Number Expiration ate Name of CSL Holder G� �� ` ' � cSr . List CSL Type(see below) U No.and Street TYl Type Description cle d D- U Unrestricted(Buildingsa to 35,000 cu.ft. R Restricted l&2 Fami1 Dwellin City/rows,State,ZIP M Masomy RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 7� ,,NZ 6)q 3 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) / rl & 012 /6 -R ICU `O (& HIC Registration Number xpir lion Date HI�2,o{�`ap�ygrHICko aRegistran�ame No�anyv I IAl(d"R , a lq 0 �j�l 5�c�G Email address C- 3 Ci /Town,State,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...........❑ SECTION 7w.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. �lc�lo2Q COGC Z=A t ( G /b �S Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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(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. ovP /oca Information on the Construction Supervisor License can be found at wA�� 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.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" The Commonwealth of Massachusetts Department of IndustfialAccidents 1 Congress Street, Suite 100 Boston, MA 0211 4-2 01 7 www.massgov/dia Wivorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeiblv Name (Business/Organization/Individual); ICG.(- C./1,,yt't'- Cc�}Q,e�iG Address:�r3� �O k4AWP City/State/Zip: 6'111)(1 14 . OlgO,AFhone#: 4 re you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with ___!__employees(full and/or pan-time)? 7. ❑New construction 2.Q 1 am a sole proprietor or partnership and have no employees working forme in 8\0 Remodeling any capacity.[No workers'comp.insurance required] 3.01 sin a homeowner doing all work myself.[No workers'comp.insurance,requved.]t 9. El Demolition 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ]0 Building addition. enure that all contactors either have workers'compensation insurance or are sole 11:❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contactors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.[ 6.Q We are a corporation and its officers have exercised thew right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] -Any applicant that checks bore Nl must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they as doing all work and then hire outside contractors must submit a new affidavit indicating such tContactors that check this box most attached an additional sheet showing the rume of the sub-contactors and stare whether or not those entities have employees. If the subcontractors 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 the pokey and job:site information. 2 Insurance Company Name: '1M Policy#or Self-ins.Lic.#: 3,2N 3 6 S—a 3Y Expiration Date: 1(1 Job Site Address: I I City/State/Zip: V2; Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 the pains andpenalies ofperjury that the information provided above is true and correct Signature: Date: 6116 l Phone J<f 3 Official use only. Do not write in this area,to be completed by city or town oJjiciat 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 1'52,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017. Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia QTY OF SALEM, MASSAaiLSEM ti BUILDING DEPARTMENT 120 WASANGTON STREET,3ADRLOOR T EL(978)745-9595 KIIvIBERLEYDRISCOLL FAX(978)740-9846 MAYOR THcmAS ST.PIERRE DiREcrOR OF PUBLicPROPERTY/BUILDING OOjaussjONER 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 111.5 Debris, and the provisions of MGL c40, 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 deposit 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: 10007* (name of facility) :14pV6 --S V-\D. S� (address of facility) Signature of applicant 6116 /l f Date fk S ``�. (/may (Q(upL/J207llI/C¢GGIt a�CJ/Kad�Q.GL![!u- y- 'a 'Of "of Consumer Affairs&Business Regulation { ME IMPROVEMENT CONTRACTOR \ eglstratwn 126012 Type: t xpiration -. 4/8/¢016 Partnership r,tA � COLE&MACKEY BUILDERS ,I r` ( 1 t II RICH COLE ��� �f � f 39 GOLDTHWAIT STREET g E LYNN, MA 01902 Undersecretary A . E ! Massachusetts -Department of Public Safety Board ofBijldidgReultns and Standards Construction SupytXieor ®® Llcense:J6-070iA. RICHARD G,00 k'r 39 GOLDTHWA. S LYNN MA 01902 n lit Expiration �I Commissioner ' 08/19/2015 - I( �(a I. WORKERS COMPENSATION AND EMPLOYERS LIABILITY Liberty Mutual. INSURANCE POLICY 10� INSURANCE AR INFORMATION PAGE 175 Berkeley Street Boston,MA 02116 Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-328305-034 Issuing Office 016C RENEWAL OF: WC5-31S-328305-033 Issue Sub Account 04-28-14 Account Number 1-328305 000 1. Insured and Mailing Address RICHARD COLE DBA RICH COLE CARPENTRY RISK ID 000251970 39 GOLDTHWAIT STREET LYNN,MA 01902 Status 01 — INDIVIDUAL Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period:The policy period is from 05-14-2014 to 05-14-2015 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100, 000 each accident Bodily Injury by Disease $ 500, 000 policy limit Bodily Injury by Disease $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per$100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 500 Premium will be billed ANNUAL Producer 0004-162816 BEACON INSURANCE GROUP INC 528 LORING AVE SALEM MA 01970 WC 00 00 01 A 01987 National Council on Compensation Insurance,lnc. WC 00 00 01 B (NJ) Ed. 07/01/2011 All Rights Reserved Page 1 of 1 Insured Copy f y� 1 ® DATE IMMIODIYYW) A�/20 CERTIFICATE OF LIABILITY INSURANCE DB/,BI2014 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 policy(ies)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). C PRODUCER O T CT Jordan Hegedus Beacon Insurance Group Inc NAME: 528 Loring Ave. P" . 9787443030 IF," Rol: (978)7447786 Salem,MA 019704222 ADOREss: Jordan@GotoBeacon.com INSURERS AFFORDING COVERAGE NAICAl INSURER A: Patrons Mutual Fire Insurance Company of CT 14923 INSURED Rich Cole Carpentry INSURER B: 39 Goldthwait St.#2 INSURER d Lynn,MA 01902 INSURER D: INSURER E: 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, a EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MOIL SUBRI O CY INSR TYPE OF INSURANCE POLICY NUMBER MMIDDA'YYY MWDOA`Y1'Y LIMITS j EXP TR ' A GENERAL LIABILITY BOP273919701 05/09/2014 05/09/2015 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES A occurrence) $ 50,000 CLAIMS-MADE M OCCUR MED EXP(Any one Pamon) S 5,000 businessowners form PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 DEVIL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000.000 POLICY PRo- LOC S COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accWant BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per accitlent) S AUTOS AUTOS NED PROPERTY DAMAGENON-CMI S HIRED AUTOS AUTOS P ra 'de UMBRELLA LAB IOCCUR EACH OCCURRENCE S EXCESS LIMB CLAIMSMADE AGGREGATE $ DED I I RETENTION$ S INORKERSCOMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT S AI OFFICEREMBER EXCLUDED? ❑ NIA (Manastory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,dexribe antler E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS.low DESCRIPTION OF OPERAnONSI LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required) carpentry-residential CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BED First Church of Christ,Scientist. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERS' 153 Lynn Shore Dr ACCORDANCE WITH THE POLICY PROVISIONS. Lynn,MA 01902 AUTHORIZED REPRESENTATIVE as ©1988-2010 ACORD CORPORATION. All righ 4' ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD I �I_ CH COL E _ . . . " _ 789-59&5993 CARPENT Proposal Submitted To � _phone Date � jo�- Name �c�2-�),tAi s City State; Zip Code i lob Location Architect Date of Plans Job Phone of rt-vno-v T/t" //J- 54-n� 'em 4Te'c--+ I U bu CA-r / Jff 6_ ec�GIC / jC, F 1 NSZA-CL Nt-, / /NSZl) L� t/ tv (nl1�fiU0�t/ NL �2�nrl 1 C�SI b� dvT /NS7A'cC i(/t►v. I�©� 2 / Tif2F'�fH�4� i 13AS� c�Ael� ro Y¢o.rj p� �C ri'1� �.G a-- C6 i &i ,IC, Pt tS We prOpOSe, hereby,to inmich material and labor—complete In accordance vridil aboC%e:,Dec- l:siior's--for: _5 No: 6 o Dollars ($ d 6 ). I ` Paurnent to be made as follows: -AP- II All material is guaranteed to be as specified. All work to be comple£ed in a workman like manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed onlya upon written orders,and will become an extra charge over and above this estimate- All agreements contingent upon strikes;accidents,or delays beyond our control. Owner to carry fire,tornado, and other necessa insurance_ Our workers are fully covered by Worlanaies Compensation Insurance Authorized Signature: i NOTE: T his proposal may be withdrawn by us if net accepted within days. a� Acceptance of Propos The above prices, specifications,and conditions are satisfactory and are hereby accepted- I You are authoriz o work as specified- Payment will be made as outlined above. t jSignat Date: Signature: