Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
31 FORT AVE - BUILDING INSPECTION
The Commonwealth of Massachusetts r Board of Building Regulations and Standards LRevisedMar20111 OF Massachusetts State Building Code,780 CMR M Building Permit Application To Construct, Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only ,ten Building Permit Number: Date Applied: - !1 \�� 1 Building Official(Print Name) "Signature I QU Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 31 (�n_1 av> I.1 a Is this an acceptedff_ Map Number Parcel Number F � 1.3 Zoning Informat 1.4 Property Dimensions: Zoning District Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided = '17 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System::== A Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ Cm'r rn SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: D r^ 3AN.FS a Cali WC I�7, �/ S.M,G.nn PVl4. C; Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed 5-1atP Ixhb65 n.r ��icM1( i /SAMiGy l70 vv 70 SFIFF� e LV PA4,0r` i SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: labor and Materials Official Use Only 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Fown Application Fee 1 O ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: &J-dd 5.Mechanical (Five " Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ko L6 Op ❑Paid in Full ❑Outstanding Balance Due: cx-s' SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) (�f33t��_(p (-40"(7 1 p�y,(� S. �M t fA - License Number Expiration Date Name of CSL Holder List CSL Type(see below) b Sj V�G LC.�V71r iZ+G/,yl� No.and Street T e Description U Unrestricted(Buildings up to 35,000 cu.ft. (.`Gui./ Win o19r,4 R Restricted 1&2 Fairly Dwelling Cityfrown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding pp�� I/ p�/' /1 SF Solid Fuel Burning Appliances 'M ��j�'{ 876 LI r�A 0 �tl r All i I Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) 1a666�( S, .SPw '71� 63pt[ la l •ZH• { 7 HIC Registration Number Expiration Dale HIC Company Name or HIC Registrant Name A +£ W A(600f C S�lAt� O J�na2"J. Np,-r No.and Street mail address City/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 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: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 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: 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.a 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.niassj,ov/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" Business Cards are FREE at w .vistaprint.C.-I _ BOB SMITH LICENSED 781-254-8784 CARPENTRY PLUS ALL JOBS BIG OR SMALL '"- 0 0 0 13 O Y HIC#138610 CITY OF SALEM MASSAaiUSE nN a BUILDING DEPARTMENT 120 WAsmNGTONSTREET,3' FwoR TEL.(978)745-9595 KBEERLEYDRISCO.LL FAX(978)740-9846 MAYOR THomm ST.Pmm DIRECTOR OF PUBLIC PROPERTY/BUILDING CDASUSSIOMR 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: iilvn4,fi Stf dF GArc 4 . (name of facility) (address of facility) Signature of applicant Date The Commonwealth ofMassaehusetts I Department of lndustrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.govldia / Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): S S,•y -r_k Address: 16T rut icze-yVi� fLoA-* City/State/Zip: LYrW M yPg044 Phone#: 78l Z51 979`4 Are you an employer?Check the appropriate box: Type of project(required): 1.F-]I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.X I am a sole proprietor or partnership and have no employees working for me in g. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.❑I am a homeowner and will 6e hiring contractors to conduct all work on my property. 1 will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers compen ation in urance for my employees. Below is the pokey andlob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 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 herebycerti under the airs and penalties o er'u that the information provided above is true and correct. .InJ' P P .IP J rY f Signature: R. ,-*— p Date: Phone#: 7fo 1'�q �Z�Y Official use only. Do not write in this area,to be completed by city or town official. 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 152, §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 multiplepermit/license applications in any given year,need only submit one affidavit ind icating 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 dog 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. #617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia �ia CPomimzooemea�o��aadac�ulneCls . free of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR gistration: 1W610 Type: _ xpiratian 4/24/2017 Individual ROBERT S.SMITH - = ROBERT SMITH _ - 151 BELLEVUE RD. LYNN,MA 01904 '— Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS471Ps ROBERT S SMJJ), ' 151 BELLEVUE RD IMF LYNN MA 0190f �c Expiration Commissioner 01110f2017 CERTIFICATE OF LIABILITY INSURANCE DATE(MwDDIYYYY) ., 08/07/2014 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 polfcy(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 endomement(s). CONTACT PRODUCER NAME, BILL MULLEN Congress Auto Insurance Agency (781) 599 — 3400 (781) . 599 — 4114 WC,No,nf), I(RAC.Pon/: 159 Broad St E-MAIL ADDRESS: INSURER'S)APFORDING COVERAGE NAIC II Lynn, MA 01902 INSURERA:SAFETY INSURED INSURERB: Robert Smith Constuction - INSURERC: 151 bellewe rd INSURER D: INSURER E: Lynn, MA 01904 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 DESCRIBE HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR — LU Y EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE INSR WVD POLICYNIMBER (MMmDAYYYY) (MO-L- YY) A GENERALUAMUTY - Y BMA0016377 10/21/201410/24/2015 EACH OCCURRENCE s 300000 ERTMT — x COMMERCALGENERALLIABILITY PREMISES(Ea o=rreme) s 500000 CLNMS-MADE a OCCUR MEDEXP(Anymep mon) s 10000 PERSONAL&ADVINIURY s 300000 GENERALACGREGATE s 600000 GENLAGGREGATE UMIT APPLIES PER: PRODUCTS-CONPIOPAGG s 600000 POLICY IRI JECT LOC _ s AUTO MOBILE LIABILITY b t IM (Ea am'denB s ANY AUTO BODILY INIURY(Per person) S ALL OMMED SCHEDULED BODILY INJURY(Per acudent) s AUTOS AUTOS NON-0WNED PROPERTY DAMAGE s HIRED AUTOS AUTOS (PeraaMerd) S UMBfELLALIAB OCCUR EACH OCCURRENCE S ET(CESS LIAB CLAIMS.MADE AGGREGATE 3 DELI I I RETENTION S s mssu RS COMPENSATION S A U- DZ AND EMPLOYERS'LIABILITY YIN TORY OMITS ER ANY PROPRIETOWAATNERIEYECUTNE ❑ NIA E.L.EACH ACCIDENT S OFFICERAMEMBER EXCLUOEDt (Mandaw'in NH) E.L.DISEASE-EA EMPLOYEE s /yez,daxn0e under DESCRIPTION OF OPERATIONS below EL.DISEASE-PODGY LIMIT E DESCRIPTION OF OPERATIONS I LOCAMONSI VEHICLES(ABach ACORD It,Ad3Bonal Renurlrs Schedule,if more space is regwred) CERTIFICATE HOLDER - CANCELLATION CITY OF SAUGUS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BUILDING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD