31 FORT AVE - BUILDING INSPECTION (3) 2-0 3 - 1 y
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
VE"
Massachusetts State Building Code, 780 CMR SALEM
Revised,Llar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fcnnily Dwelling
This Section For Official Use Only
Building Permi Number - -D a li
B'uil ing Otticial(Print Name): i : Signal Date
SECTION h:SITE ORNIATION
1.1 orertyfoftY A•Addres Va5
s: 1.2 Assessors Map&Parcel Numbers
I.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 R) Frontage(It)
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?
Public❑ Private El Zone:
if yes❑ Municipal ❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
cc6 �4 + �tMgs D.EM5Fv/ $ALrM.�tyA
�me(Print) T City,State,ZIP
31 Font Ay.f_ 979 758 7` 9(o
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': AD177 A - 6192 4 VnQ,9Wkz;L V fIici-L)r*
t:kI1_Ak 6$ Rf7Dir.1G. 1 41"_ V74�{
SECTION 4: ESTIiNIATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials -
I. Building $ 2q 50C r 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee.
o. Electrical S �jt�,
- ❑Total Project Cost'(Item 6)x multiplier" x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) S List: ..
5. Mechanical (Fire $ Total All Fees:S
Suppression)
Check No. Check Amount:. Cash Amount:
��� 6. Total Project Cost: $ 3 •Zr 0 Paid in Full ❑Outstanding Balance Due:
r ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) e� D�3�up IO- ZOf5-
IG� 0smir d r 5mrre/ License Number Expiration Date
Name of CSL Holder
n/J List CSL Type(see below)---U
1Jr1 Type Description.
No. and Street
U Unrestricted(Buildings u to 35,000 cu. ft.)
Lypw 04A cggoLt R Restricted 1&2 Family Dwelling
Citylrown,State,ZIP M Masonry
RC Roofing Covcrin
WS Window and Siding
SF Solid Fuel Burning Appliances
'78 2.54 8764 L l �✓i) j�/�, I Insulation
"I'cic hone Email address D Demolition
5.2 Registered [iomeImprovement Contractor(HIQ 4-sq
f,2 .Zdl
/ (ZOO15 ZT S -f2ffitU-r HIC Registration Number '`ffExpiration Dale
J IiIC Company Name or HIC Registrant Name
GPEY,gRJ�v�6,a-I�a. nl�
No.and Street L n,mr � ,^{y,,,r 1r Email address
City/Town,State,ZIP f/ !'/7Ny 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
/ [,as Owner of the subject property,hereby authorize 5rAi ki
-tot act on my behalf,in all matters relativ IMP work authorized by this building permit application.
Print Owner's mne(Elect c SignatVee) Date
SE [ON 7b.OWNEWOR AUTHORIZED.AGENT DECLARATION
:
ley 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'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.omss,gov;= Information on the Construction Supervisor License can be found at www.nmss.eov(dns
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"
' C.111 OF Si11+Gml, LVLlSSACS1 UrJL' L LJ
BUILD .(NIG DEP\RTMEN1T
} !. 120 WASHLNGTON STREET,Y°FLOOR
TEL (978)745-9595
F.Le(978)740-9846
,KIN
tBERLEY DRISCOLL THONWST.PMM
MAYOR
DIRECTOR OF P1:8UCPROPERTY/9l;II.DL`1G CONL\IfSStONER
Workers' Compensation Insurance AlMdavit: Dui]ders/Contractors/ElectrlciansiP[umbers
Applicant Information �7 Please Print Leeibly
Name(Orrines.&Organizatiarvindividuai): aay ey� s-
S'VWt7�
Address: 13 -L-Lezyor R.d,,Srt,
City/State/Zip: L!Jit^1 A4 otgoq phone M: •781 _ 79
Are you an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with 4. 0 1 am a general contractor and 1 6. New construction
mltployeea(full and/or part-time).* have hired the subcontractors
2.�yQ/l ran a sees proprietor ur partner- listed on the attached sheaf t 7. ❑Remodeling
t `ship and have no employees These subs-contractors have S. ❑Demolition
working.for me in any capacity. workers'comp.insurance• 9. Building addition
[No workers'comp.insurance 5.0 We area corporation and its
required.]
officers have exercised their 10. Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'cump. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' MCI Other,
cump:insurance requircd.I
•Any applicants that chocks boa Nl must atwr fill out ihv radian below showing IN&workers'compmra loa poaey imo mmisam
I bumuwmtrs who submit this anidav;t indlwing they am doing all work and then hlio"tilde mnuactom mine submit a new amdavil indle4n8 such -
�Connacwrst hot chock this box main aaachod an addtnurad wheel showing tho more of the sub tmtrsctore and their worksn'oomp.policy infarndatian.
I um an employer that/s providing worker'compeasollon luxurance for my employees Below/s the policy and Jab site
infonnmlom
Insurance Company Name:
Policy 4 or Self-itus.Lie, 0: Expiration Date:
Job Site Address: City/State/Zipi
,lttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1.500.00 undl/or one-year imprisonmen4 as well as civil penalties in the form of STOP WORK ORDER and a line
of up to S250.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Ol'liee of
Investigutions of the DIA for insurance coverage verification
Ida Itereby certify raider die pains and lenulliss of perjury that the iufornrutlon provided above is true and correct.
Si�n:uurc: r [Ma. �' Z� • f�
Phone 4; '7 Z5'� $7%?,L
OJ17ciul use only. Do not write its r/riv urro,to be cunrplefed by city or rows O lciuL
citynrTutvn: Permit/I.lcense#
Issuing Aulliorily(circle one): ---
1. Guard of health 2. Ouilding Department J.Cilylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other ------ .
Contact Person: _ ._ __ _-,_ Phone th
[
CITY OF S.XL.E1I, .L%LxSSACHUSETTS
Bu )Nc DEPARTStENT
• 130 WASHINGTON STREET, 311D FLOOR
T EL 978 745-9595
F.1X(978) 740-9846
KI* FRT F-FY DRISCOLL
T
MY DI HOMAS ST.PMRRE
DIRECTOR OF PUBLIC PROPERTY/BUHMNG CO WMISSIONER
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 c 40, 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 disposal facility as defined by MGL c
I11, S 150A.
The debris will be transported by:
fIiI vI- 1f 11 W.A"7YP
(name of hauler)
The debris will be disposed of in
(name of facility)
Wt,4-
(address of facility) -
I
signature of permit applicant
date
t�n,�y,rrd.w
Or
�Safefy Insurance BUSINESSOWNERS DECLARATIONS
AUTO • HOME • BUSINESS - POhcy Nuitiber Policy Period
Safety Insurance Company From To
• BMA0016377 . 10/21/2012 10/21/2013
12:01 A.M.Standard Time at the described location
Transactior7:
._..
Renewal Declarations
Named Insured and Mailing Address Agent
ROBERT SMITH CONSTRUCTION CONGRESS AUTO INS AGENCY INC
151 BELLEVUE RD 159 BROAD ST
LYNN MA 01904 LYNN MA 01902
Telephone: 781-599-3400 68834
Form of Business: INDIVIDUAL Type of Business: CARPENTRY-INTERIOR
DESCRIBED PREMISES
LOC BLDG ADDRESS AUTOMATIC INCREASE
001 151 BELLEVUE RD LYNN MA 01904 4%
PROp.ERTY
LOC BLDG COVERAGE VALUATION DEDUCTIBLE LIMIT OF
INSURANCE
001 001 Personal Property Replacement Cost $ 500 $ 3, 120
Deductible shown above applies per any one occurrence
BUSINESS INCOME: Actual Loss Sustained Not Exceeding 12 Consecutive Months
LIABILITY AND MEDICAL EXPENSES
Except for Fire Legal Liability, each paid claim for the coverages listed reduces the amount of insurance we provide
during the applicable annual period. Please refer to Paragraph D.4. of the Businessowners Liability Coverage Form.
BUSINESS LIABILITY COVERAGE LIMITS OF INSURANCE
Liability $ 300, 000 Per Occurrence
Medical Expenses $ lo, 000 Per Person
Fire Legal Liability $ 1o0, 000 Any one Fire/Explosion
ADDITIONAL COVERAGES
Some property coverages are subject to deductibles specified in the policy forms.
Optional Property Coverage Description Limits of Insurance
LOC BLDG DESCRIBED COVERAGES
Optional Liability Coverage Description
Limits of Insurance
Contractors-payroll $28, 600
CHANGE IN PREMIUM: $ TOTAL PREMIUM: $ 860
BPDEC2011ik a r
INSURED
"Sbfety Insurance BUSINESSOWNERS DECLARATIONS +
AUTO. • HOME • BUSINESS Policy Number Frombh�y POH04 To
Safety Insurance Company
BMA0016377 10/21/2012 10/21/2013
12:01 A.M.Standard Time at the described location
Tansactiori
Renewal Declarations
Named Insured and;Mailing Address A.gettt
ROBERT SMITH CONSTRUCTION CONGRESS AUTO INS AGENCY INC
151 BELLEVUE RD 159 BROAD ST
LYNN MA 01904 LYNN MA 01902
Telephone: .781-599-3400 68834
FORMS AND ENDORSEMENTS SCHEDULE
Coverage line Form Number Ed. Date Description
Businessowners BP0417 01 96 Employment Related Practices Exclusion
Businessowners BPC108 (03/98) Massachusetts Changes
Businessowners 3P0439 (01/96) Abuse or Molestation Exclusion
Businessowners BP0009 (01/97) Businessowners Common Policy Conditions
Businessowners SB0002 (11/99) Businessowners Special Prop. Cov. Form
Businessowners SB0006, (11/99) Businessowners Liability Coverage Form
Businessowners SBO518 (04/07) Asbestos or Other Respirable Dust Excl.
Businessowners IL0003 (04/98) Calculation of Premium
Businessowners SB0517 (04/07) Silica or Silica-Related Dust Excl .
Businessowners BP1004 (04/98) Excl of Certain Computer-Related Losses
Businessowners SBOS42 (01/08) Excl of Pun. Damages Related to Terr.
Businessowners BP1005 (04/98) Excl-Year 2000 Computer Related Losses
Businessowners SB0514 (OS/04) War Liability Exclusion
Businessowners S130544 (04/07) Roofing Operations Exclusion
Businessowners SBOS76 (06/07) Limited Fungi or Bacteria Cov. (Property)
Businessowners SBM001 (06/01) Equipment Breakdown Endorsement
Businessowners SBC577 (11/02) Fungi or Bacteria Exclusion
Businessowners STN109 (01/08) Notice of Terrorism Insurance Coverage
Businessowners SB0701 (01/97) Amend. Of Policy Provisions-Contractors
Businessowners BP0703 (01/97) Property Damage Liab. Ded (Per Claim)
$250 Deductible
Businessowners SBOS34 (11/02) Limited Exclusion of Acts of Terrorism
Premium has been waived for this coverage.
Businessowners BP0419 (06/89) Amend-Liquor Liab. Exclusion (Exception)
Countersigned By:
BPDEC'2019 v -
INSURED