1 GALLOWS HILL RD - BUILDING INSPECTION � �OC,'�� v ���- �i'd.� - %7d J
; ��y,3 �y ��
! , � � The Commonwealth of Massachusetts
�� Boazd of Building Regulations and Standards CIT'Y
� Massachusetts State Building Code, 780 CMR, 7`"edition �F SALEM
Revised Jamtary
Building PeRnit Application To Construct,Repair, Renovate Or Demolish a 1, Z008
One-or Two-Family Dwelling
is Sectio or c' Use Only
Building Pertnit Numlier.-� � -- �Applied: - . . � - -
Signature: . . 6���
BuildingCommissio n orofBuitdi gs . � Date . �
SECTIOPT lb STTE INFORMATION '
1.1�rope Address: `, �� 1.2 Assessors Map&Parcel Numbecs
r �
� 1.I a Is this an accepted slreet?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Proper[y 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 Zoue Information: 1.8 Sewage Disposal System:
� Public❑ Private❑ Zone: _ Outside Flood Zone? Nlunicipal O On site disposal system ❑
. Check if yesO
SECT[ON 2: PROP&RTY OWNERSHIP�
2.1 Owner�of Record: �
.. M¢�N�AEi.. S. M �'.a�.�Q �C � �ALwws H�u 2oa�
� Name(Print) Address for Service:
Or�ti�.a..� Cil�.-��-.- � R7B - � W 9 -s'6s'i
Signature Telephone
SECTION 3e DESCRiPT[ON OF PROPOSED WORK2,(check all that apply)
New Conshuction ❑ E�cisting Building❑ OwnerOccupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
� Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
BriefD scriptio ofProposed•Wor : ✓.✓S . �— OC�h N
Lv�{�- �l/�
SECTION 4:ESTIMATED CONSTRUCTTON COSTS '
Item Estimated Costs: Officiat Use Ouly
Labor and Matenals
1.Building $ L Building Pertnit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑$tandard City/TowaApplicafion Fee
O Total Project CosC'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ L���
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
. 6.Total Project Cost: $��� �3 p pa�d in Full �Outstanding Balance Due: ��
q
{,
1
r' SECTIONS: CONSTRUCTIONSERVICES
51 Licensed Constructiou Supervisor(CSL) � 5,,,2�� /G 3 !
���5 � �/Z j�N License Number Expiration Date
Name of�SL-Holder Lis[CSL Type(see below)
10 1�'/,�I�iYA/6GLL�� QFiI/�(� : .
ddress �,_ -- T . . Descri on
U �Unrestricted u to 35,000 Cu Ft.
R RestriMed 1&2 Fami( Dwellin
Si ture �p M Maso Onl �
8 — Lo � RC Residentiat Roofin Coverin
Telephone WS Residential Window and Sidin
. SF Residential Solid Fuel Bwnin A liance Instellabon
� D Residenlial Demolilion �
5.2,Registere�HomeImprovemeqtContracton(HIC� �L��, . .�`
Alk -T 9..,HTGLC W�Ti'GRli2..T� cYM �v
I-�C Co pn N e or FIIC Registrarn Name . R gs 'on Number
�p J�iw'� �.�aL(, �2 3 a6 L
�a�55
� c.�l�'ya�-��1i\ Exp�ration Date
ture Telephon—e��V)
SEC7'ION 6:WORKERS'COMPENSAT[ON INSURANCE AFFIDAViT(M,G.L.c.152;§ 25C(�)
Workers Compensation Insurance affidavit must be wmpleted and submitted with this applicatioa 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 CON'I'RACTOR APPLIES FOR BUILDING PERMI'P
I, �1 1 G M���.. �, M t'�L� , as Owner of the subject property hereby
authorize M O�'A�I NflQ1 L.�MgE� to act on my behalf,in all matters
. � relative to work authorized by Uils building pertnit application.
�l�.�e.�:2J �.e�. � sl�sl� �
� Si MeofOwner Date
SECTION 7b:OWNER'OR AU7'HORIZED AGENT DECLARATION
- I, �/�'^-�-�����'C�� �/Y�P-�-Qi�-�� ,as Owner or Authorized Agent hereby declare �
that the statements and i rmation on the foregoing application are lrue and accurate,to the best of my knowledge and .
behalf.
M� �uA�L. �. M��t'i2
n;n[�tcMa�.I 0�1A-a�cn.,� '� Sl l3 J/ ! � .
Signature of Owner or Auth rized Agent Date
Si ed under the 'ns and nalties of
NOTES:
L �An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
, (not regis[ered in the Home Improvement Contractor(HIC)Progra�r�),will aot have access to the arbitration
program or guaranty fund under M.G.L.a 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations ll0.R6 and 110.R5,respectively.
2. When substantiel work is planned,provide the information below:
Total floors area(Sq.Ft) (including gange,finished basemenUauics,decks or porch)
Gross living area(Sq.FtJ Habitable room count
Num6er 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 Cosf'
The Commonweafth ofMassachuseus
Department of Industrial Accidents
O,,(Jice of Investigations
600.Washington Street
Boston, MA 02111
www.moss gov/dla
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectriciaus/Plumbers
Applicant Information Please Print—Letllbly
City/Staie/Zip: �� v e \ V ���� Phone #:i�----
Are you aq employer? Check the aper
1. [A I am a employer with ;;L
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
into box:
4. ❑ I am a general contractor and I
have hired the sub -contractors
listed on the attached sheet. t
new sub -contractors have
workers' comp. insurance.
5. We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers'
conA. insurance required.] .
Type of project (required):
6. ❑ New construction
7. C1 Remodeling
8. Demolition
9. ❑ Building addition
lo.[] Electrical repairs or additions
1 l.[] Plumbing repairs or additions
12.(] Roof tars
19.® OtherAD-conci�q
•nny applicant dut chenka boxdl must dao ml outthe seetiat below showing theirworkars' compmstion policy intbtmation.
t liomeownen who submit this aH'idevit indicating any sm doing all wmk and &w him a dside contractors myatsubmit a newatadavh indieetlng such.
tConuaebon dut dwok this box mustatnehod an a4dItiond street showlag arc roma of the subaonttaotms and their workors' asmp. polky inth"'on.
lam an employer that Itproviding workers' compemadon insurance formy employee& Below is thepolicy and job site
lnformatlon. rr
Insurance Company Name: _�� Cp c \S L 1 U 1(1 L �V
Policy # or Self -ins. Lic Facpvation La
Job Site Address: City/Statetzip:
Attach a copy of the worker' compensation pokey declaration page (showing the policy number and expiration date). .
Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA, for insurance coverage verification.
I do hereby certify ander the palm and penailfes of perJary that the Information provided above is uwe and correct.
b
Official use only. Do nor write In this area, to be completed by city or town of stat
City or Town: PermitMeense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact
Phone
OP ID: KZ
CERTIFICATE 6F LIABILITY INSURANCE
FY
DATE(04/105/1105111 YY
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) most 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).
PRODUCER 781-224-5700
Mazonson LLC www.mazonson.com 781-224-5777
701 Edgewater Drive
Suite 230
Wakefield, MA 01880-6236
Mark -Bailey
CONTACT
NAME:
PHONE FAX
ER A1C No):
E-MAIL
ADDRESS:PRODUCER
c,smmER ID #--AIRTI-1
INSURER(SAFFOROINGCOVERAGE NAIC4
INSURED Air -Tight Weatherization, LLC
9 Story Ave.
Beverly, MA 01915
l(
msURERA:Arbella Protection Ins. Co.
INSURER B :
INSURER C
INSURER 0:
INSURER E :
NISURER 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRTYPE
LTR
OF INSURANCE
ADDLTS
IWVD
B
POLICY NUMBER
POLOYEFF
MMIDOIYYYY
POLICYEXP
MWD
UMITS
A
GENERALLNINUIrY
X COMMERCNLGENERALLIABILITY
�
CLAIMS -MADE 1x:1 OCCUR
8500046432
03108/11
03/08112
EACH OCCURRENCE $ 1,000,000
MASES(ERELATE° 100,000
PREMISES Ea NTED nce $
MEG EXP (Any one person) S 5,00
PERSONAL&ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,000
GEML AGGREGATE LIMIT APIPL�I ES PER:
"0 JEPOLICYF—]LOC
PRODUCTS - COMPIOP AGG $ 2,000,00
Emp Ben. $ 1,000,00
AANY
AUTOMOBILE
LNBILOY
AUTO
ALL, AOWNED AUTOS
SCHEDULEDAUTOS
HIRED AUTOS
NON-OWNEDAUTOS
2708MOD004
03/08111
03/08/12
COMBINED SINGLE LIMIT $ 1,000,000
(Ea aoadent)
X
X
X
BODILY INJURY (Per person) $
BODILY INJURY(Pera¢iieM) $
PROPERTY DAMAGE
(Perac kIerA) $
S
UMBRELLA LNB
EXCESS UAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE E
AGGREGATE $
DEDUCTIBLE
RETENTION $
I S
E
WORKERS COMPENSATION
ANDEMPLOYERTLIAMUTY YIN
ANY PROPRIETORJPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(MaM ory in NH)
If yes, dessbe under
DESCRIPTION OF OPERATIONS be
NIA
WC STATU- OTH-
TORY LIMITS ER
EL EACH ACCIDENT $
EL DISEASE -EA EMPLOYIEd $
E I DISEASE - POLICY LIMB 1 $
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Aaac11 ACORD 101, Additional Rema*s SCNedule, 0 more spare is n uked)
Pla N2l]LOS\l9
Moynihan Lumber Co.
82 River Street
Beverly, MA 01915
ACORD 25 (2009/09)
MOYNIHA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPIREppSENTAnTNE ,.
U 19B8 -tow ACORD COHPUKA I IL)N. AU ngnts reservea.
The ACORD name and logo are registered marks of ACORD
Office of Consumer Affairs and business Regulation
10 Park Plaza - Suite 5170
Boston, Massaelllusetts 02116
Home Improvement.CQ} t actor Registration
AIR - TIGHT LLC. WEATH
JAMES FORTIN
10 PINE KNOLL DR.
BEVERLY, MA 01915
DPS -CAI Q 50M-0M0V',,5101216
e7 �oomcsieoou bi o��/i�amaat<ereelb
Office ofConsumer Affain &Business Regulation
HOME IMPROVEMENT CONTRACTOR
US
Registration:— -165640
Expiration 311512012 Tr# 294587
Type:,
AIR-TIGHTLLG WEfATHERAZATION
JAMES FORTIN
10 PINE KNOLL DR
BEVERLY, MA 01915`":"`: ` Undersecretary
Registration: 165640
Type: LLC
Expiration: 3/15/2012 Tr# 294587
Update Address and return card. Mark reason for change.
❑ Address ❑ Renewal ❑ Employment ❑ Lost Card
License or registration valid for individul use only -
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Not valid without signature
A ^ 'SJW42 h'tvtis-.Dr•pa t- ,t lr'Psftf. ..f<'.
B(); -rd of B tilding RePlula6a-s and Standards
Construcic.l3JPI•rdisor L!c:-:;:e
License: CS 52576
Restricted to: 00
JAMES E FORTIN
10 PINEKNOLL PR
BEVERLY, MA 01915
E:; nirati , 1: 10/3/2011
f'ummi.xioncr Tr#: 200