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16 FORRESTER ST - BUILDING INSPECTION 1 The Commonwealth of Massachusetts FOR Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code,780 CMR USE Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 20// One-or Two-Family Dwelling This Section For Official Use Only Z,ulding NN Date Applied: /O/5 Signature Date S ON 1 TE INFORMATION 1.1 Property Address:- 1.2 Assessors Map& Parcel Numbers 1.1a Is this an accepted.stmet?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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private[3 Zone: if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of R ord:LEnjlo L%QNn Ma nl9-hb Nam rint) City,State,ZIP C pho e No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ EAccessoryEBIdg. g Bding❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ ❑ Number of Units_ Other ❑ Specify: Brief Description ofP-oposed Work': ( SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials - 1.Building $ �Q � 1. Building Permit Fee: $ Indicate flow fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ s ❑Total Project Cost' 6)x multiplier y x 3.Plumbing $ L Other Fees: $ 4.Mechanical (FfVAC) $ tst: 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost:. $ , D in Full ❑Outstanding Balance Due: A VFP 1/S SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Ybow aL License Number E piration Date Nam CSL Holder List CSL Type(see below) (!n(4�0� Type Description - No.and Street q-� U Unrestricted(Buildings u to 35,000 cu.ft. I j. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry - RC Roofing Covering WS Window and Siding - SF Solid Fuel Burning Appliances Insulation - Tele hone Email address D I Demolition 5/./2�/Registered Home Improvement Contractor(HIC) ItIlAI/I . pL� 1rC;7 J 14 HIC Registration Number xpi tion Dale . CHIC Compan Name or C gistmnt Name No.and treet Email address Mm t-L Ci /Town, State,ZIP Tele hone 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 1, 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:OWNEW 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 Ti this application is true#nd �acccurate to the best of my knowledge and understanding. Print Owner's oil 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos; 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"maybe substituted for"Total Project Cost" ;E1 next step living ® A home efficiency,made easy � - - PARTICIPATINg WN'fIIACTOR This agreement is made by and among Denjin Set Next Step Living,Inc.("NSL") 21 Drydock Avenue 2(floor 18 Forrester St Boston,MA 0220 Salem,MA 01970-4002 Customer ID:C00000096516 Contract ID:20120926-1_W0RK Site ID:S00002086488 'I. DESCRIPTION OFWORK TO BE PERFORMED NSL will perform or cause to be performed the following work on the customers address above,In a professional manner and in accordance with the terms of this Contract,including the attached remmrrendatbnslwork order describing the work In detail(the°Work°)which are incorporated herein by reference: _ Description Quantity Location 2 _ABic Fluor Opeq Blew Cellulose B°------ ________._______ - .__1,794__Living Space _...___.-.. __.............._._ L.5B9_BO_._ 12"Mushroom Vent __ 2 ......Attic Install 8"Roet Vent 2 Attie — _____$162.00 NIA _Insulate Ocan Ovet amlg Wth9_Flbergiass Battiruy__________240LINng,SP_e _—__$513.60_,_ Insulate OveniangWllh 2°Thermal Bander Po so_ __ 240...___. Wing SPace _....... _Insulate Clapboard Sided Well With 4°Dense Pads Cellulose___ ----__Uving Space _ __ - Sub Total: $4,210.26 Energy Efficiency Incentive $2,000.00 Net Sales Tax After Incentive $0.00 Total $2,210.26 ' t Printed:912612012 Page 1 of 1 2. PAYMENT:CUSTOMER agrees to pay NSL for the work as follows:. Paymentii:$ 10D -Credo Card or Echeck depos8 is due at the Bme the Work Is scheduled.Required payment Information will be collected over the phone by a customer service representative althe Bme of scheduling. Deposit is not to exceed W otthe total retail costs. This contract Is not In effect un0lthis deposit Is paid by the Customer. (Note:Mastercard,Visa,and Dbcoveraccepted) Additional Payments and Final Invoice:$ 12 0 11(D r-)J� - - -Additional payments all be due upon completion of the Work. CusI n Date NSL Sig ture . /Date" . ._. Name of SL ReKmnta The Terms of this Agreement are contained on both sides of this page Next Step Living 21 Drydock Avenue"20 floor"Boston,MA 02210"(866)867-8729"irquiry@rrextslepllvirginc.com"www.nextsteplivilgincoom lation ®ffice of Cons><x r bO Paxk Plaza e Suite U�® � �osten,lssaclauSettts c,- y$e trafieu liome b3npTov ontractor '.y--`: Registration: 162111 - -_ •==sP?::'�:;:_ :.�' TVPe= SvPPlement Card ExPiratian: •411412013 NEXT-STEP LIVING INC. — BRIAN HESSION ;v- --- 25 DRYDOCiC AVE. 5TH FL BOSTON, WIA 02210 :_- = Update Address and re em card.mark reason for change. ltenowiir❑]F,mploymenl ❑ f.ost Card ❑ Address ❑. . aeawo�mz�a ' tron valid for individul nse only f itencahe oxidr ll It found return to: Oce of Consumer Affairs&Bus 6atore the expiation date., WE IMPROV"ENT CC)UTRACTOR �®trite of Cousoasar Affairs and Bustuess'eguiaban '' YVPa 10ParkPlaaa-Saw 51"" . Egistratiori' '6$191 Sup gy11G EXPt �3. Su ment sue Card Boston,lifA r, e:.:=rM1 r. �utll .:�gf�;uF:'� OKAUEY?SPFgP,:;•i�' g" tare ,�•%'. � 'Natvalid withoutsi AA 02210 `.:.:" r]ederseererary '' r , 1 Massachusetts - Department of Public Safety Board of Building Regulations and Standards Cun0ructiun SuperA isor SpeciuitN License: CSSL-102811 ROGER A OVELLETTE. 55 STANMORE ROADI Warwick RI 02889 Expiration 09/1312014 commissioner GuenLlF: 01142 NCA DATE(MMIDDIYYY`n �AC®RM CERTIFICATE OF LIABILITY INSURANCE 9/0612012 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION William Gallagher Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Insurance Brokers,Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 470 Atlantic Avenue Boston, MA 02210 INSURERS AFFORDING COVERAGE NAIC III INSURED INSURER A: One Beacon Insurance Company 21970 Next Step Living, Inc. INSURER B: A.I.M.Mutual Insurance Co. 33758 21 Drydock Avenue INSURER C: 2nd Floor INSURER D: Boston, MA 02210.2600 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY PIRATION - LIMITS naff OM TYPE OF INSURANCE POLICY NUMBER ATE MMIDD DATE MMIDD LTR NSR 11/11/2011 11/11/2012 EACH OCCURRENCE .$1000000 A GENERAL LIABILITY 792000560 DAMAGE TO RENTED $1 OOO OOO X COMMERCIAL GENERAL LIABILITY I S oxu CLAIMS MADE ®OCCUR MED EXP(Any one Person) $1 O 000 PERSONAL B ADV INJURY $1000000 GENERAL AGGREGATE s2.000.000 PRODUCTS-COMP/OP AGG $1000000 GEN-L AGGREGATE LIMIT APPLIES PER: POLICY jEC LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS BODILY HIRED AUTOS (PeramcIent) $ (PeramlQent) - NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) AUTO ONLY-EA ACCIDENT $ GARAGE LIABILnY OT I THAN EA ACC $ ANY AUTO AUTO ONLY: AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY 792000561 11/11/2011 11/11/2012 EACH OCCURRENCE $1 OOOOOO X OCCUR CLAIMS MADE AGGREGATE $1 OOO OOO $ DEDUCTIBLE RETENTION $ WC STATU- OTH- B WORKEP.S COMPENSATION AND AWC7025153012011 11/11/2011 V1112 112 X EMPLOYERS'UABILIT' E.L.EACH ACCIDENT $SOD OOO ANY PROPRIETORIPARTNEWEXECUTIVE n . OFFItlCER/MEENI�NFR EXCLUDE07 E.L.DISEASE-EA EMPLOYEE $500,000 ( an atory in ) If yes,descdbe under E.L.DISEASE-POLICY LIMIT $500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate holder is included as additional insured as regards General Liability where required by written contract.Coverage is subject to the policy terms and conditions. CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 'A0_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD ZS(2069I01)1 of 2 #5290682IM242379 © 1 8 -200 CORD CORPORATION. All rights reserved. The ACORD name and loan are registered marks of ACORD MCL The Commonwealth of Massachusetts Print Form (Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/die Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers rint Leeibly Applicant information Name (Business/Organization/Individual): Next Step Living Inc Address: 21 Drydock Ave City/State/ZiP: Boston, MA 02210 Phone#: (617)850-9101 -Are you an employer?Check We appropriate box: Type of project(required): 1.tr✓� I am a employer with 400 4. [] I am a general contractor and 1 6 ❑New construction have hired the sub-contractors Remodeling employees(full and/or part-time).* listed on the attached sheet. 7 ❑ 2.❑ 1 am a sole proprietor or partner- These sub-contractors have 8. Demolition ship and have no employees employees and have workers' 9. ❑ Building addition working for me in any capacity. comp. insurance.$ [No workers' comp.insurance 5 ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 11.❑ Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOIL 12.0 Roof repairs myself. [No workers' comp. c 152, §1(4),and we have no Insulation insurance required.]t 13.[! Other employees. [No workers' comp. insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. uc - all work and en hire outside $C ntac�tors that check this box must attached an additional t Homeowners who submit this affidavit indicating they are doing showing theame of the Sub-contractorscontractors and state whetheror no those entities nhave h employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. eem d am a eemployer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A.I.M Mutual Insurance Company Policy#or Self-ins. Lic.M AWC7025153012011 Expiration Date: 11/11/2012 City/State/Zip: Job Site Address: 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 nment,as well as civil penalties in the form of a STOP WORK ORDER and a fine fine up to$1,500.00 and/or one year impriso 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. f do hereb certi under the ain an en !ties o ardor=Qate- Phonen provided above is true an correct. - - nly. Do not write in this area, to be completed by city or town offieinl.lt 1. . Permit/II.iceuseority(circle oue):ie ity 2. le one)g IIDepartment 3.City/Town Clerk �4.]Electrical inspector 5. ]Plumbing inspector 1. Boar Boar ]Phone#: Contact Person'