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4 GENEVA ST - BUILDING INSPECTION (2) S V a The Commonwealth of Massachusetts i Board of Building Regulations and Standards CITY OFSAL y j Massachusetts State Building Code, 780 CMR, 7"edition RevisedJ.vMrr s� I ilding Permit Application To Construct, Repair, Renovate Or Demolish a 1. ?008 i v One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number I Date Applied: Building Commissioner/tos&ctoi of Buildings Date !' SECTION 1:SITE INFORMATION 1.1 Property Ad re 1.2 Assessors Map& Parcel Numbers P �,ge%k Sf 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 11) Frontage(fl) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I,c.40,§34) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone1 Public❑ Private O Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' vlclAs t L-� ` eY IENL l'L>.��21 0j, Name(Print) T^ Address for Service: �rP_Cnvl'fi(�Signature Telephone � IA4D SECTION 3: DESCRIPTION OF PROPOSED WORKS(check that apply) New Construction❑ Existing Building❑ Owner-Occupied 13 1 Repairs(s) Uri Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S _ I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost](Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire S Total All fees:S Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: S ❑Paid in Full 0 Outstanding Balance Due: 1 SECTION 5. CONSTRUCTION SERVICES 5.1 Licensed Conatructlon Supo" s r(CSL) 'x44. �-_ Uccn.-sofNumber I:spi lion )ul Name of C'SL- I I Ider '',�'— 1� List CSL Type(see below) r e Description Addres U Unrestricted(up to 35.000 Cu.Ft. R Restricted I&2 Family Dwelling Signat re M Masonry Only RC Residential RoofingCoverinli Telephone ws Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation y D Residential Demolition 5.2 RegistQHoro e eat Co ctor IC) tZAdd � ist am Registration No ber , /DI�E��j5ed Bspimtion al'relephone ECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.1 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 f 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. �� fl signature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 1 e_ as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Q— L Print N Signam o )caner orA thonze Agent Dale Si ed and r the ains and nalties of 'u 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 have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 1 I0.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Flabitable 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" Di3-�-'173 a3-a1 DH �T' a.' I .�=n1La NaaaralJrauPl4cn 3i 3'' r.:ao� I -2 33 'A V_sLo RaGca=oy't'1a No r. ni Atad C-aII I SLn vL.L So iax'_n alo . No Cc LD.a I Sin c¢1i'_lan ENERGY PERFORMANCE RATINGS EVµilAO'AN OF.ReCIM1104TO @JFAGETCO Solar Heat Gain Coefficient U-Factor .�� Co &l , oe canards de.Uergia 5ahr - /0 . 32 1 . 6 0 . 29 ADDITIONAL PERFORMANCE RATINGS eyµlUeCtCH SUp1FMEMTAAIA De PM40MENM Visible Transmittance . iTangnWan de UaWmN - . 0 . 52 1loadsc9aer saaleaee To are re"m,tar, b>l7M�N+liR[aomdes ler dlamr+n'+fob Para oertt+^utst NRtL tdk�T � aRaed at Q dWMmerw omefamv W4a$��a>m.WC d.af10t rwwwnerd am�� . eed do.not wvsvd am U&bMy�+'Y 7 tr a�1'yedac ua OaaRn.eitecitaar) aetifaoA!C perMttoro :- . . - I tr ,pars detarmlar d ien®ndo P A dd ..._. Ear hdt L,,spud ys=p W RC on utif a' d P M=rAoeept><xd. _ . poAr�ldo no =Wn Pm 9M evd=yN'wpmun�go m artEler?AI.Y� �j+� - eeryerLlmMN[ronmmisdaNWtR��Yro w todpdo aw ae.mo+donrs�ay.•d +p�+dee�,p00m"w"j*"`q:. .' . _.Unit q..allft¢a foc CN£ROY STAR - - . c¢Qion U) : NocCR4cn, Noct6 _ - - ' - [.nt.a1, .9ouln Cantu L, 9eu to a.n. '• Ca unclad 0411SLCA _pa.a LAC,) .- ' - ce QLen Ual QNmROY STIR: Noctt, - Noc Ce Cnntcal, Sue C¢ntcal, 9uc. IND. Re.1n DO/CLaaa 3131"!H-Ra1. _ .,. Z t¢ittS 91se: 36` ss 63" INo: flefu¢cao oD/Vldclo 2.38 sex/H'RAS � 4- C /,_45 Sanaaa pcobado: 91.E cn x 160 CA - a➢773 . H4 - Holfean 29311Io.Keep Te k6el for paesmis ENERGY SURe mbct 1 TO lemn rron•M ww.meryrslaticy -.— Guatde esta ehryAa Para pontks mmbafms ENERGY SAL'Para minter mce aorta&29o1 ddh vtvleneRfstclpor ,/� _ �iEa tOwxm�tt�ea�.s �„/vtoeaausuaeQe Board or Building Regulation and Standards . HOME IMPROVEMENT CONTRACTOR i - RepislrakQR;, 126093 ExRI[atfnn12010 :Supp�ementCard The Home Oepo\_A1; 0� e3rvry RICHARD FALLONE:= '�:=? Y' ^, 3200 COSB GALLERI;A�I?KI^1Y tK20 �,.-,Q ATLANTA.GA 30339 Administrator hl ax�achusctty-Dcpnmatromi:and Stxodard., . BuaN oI'Suildin,.Ar - Constructlo^ Supervisor license License: OS 74722 Resviaed to: W KOSTANYINOS S VAIT16 16 HANSON ROAD6- SAUGUS,MA 01906 EsPilMien: t TrM 1902 194f2 - ('ombi.iMv gcdd ted l0: W dp.Qocotrdcted 1G-1 T.Fa�4$e®ea F+iluK l��a u rnneat edition of the . 1y(aaae buaeta State lauiddwz C°� is caasc Por tatxattm of ddt Ucew e ,\ CITY OF SALEM jj�• PUBLIC PROPRERTY �- DEPARTMENT -.r.11: MI I1 "N i'•II I11 \I .1„tl ISt: \+111\1.:+4V 51'ala'T 5.\II11, \L\K.\1 J I ,+-PI Tfl:•Iry•)J4•/i9s • 1'.\!J:/)t•)J}vMJ6 Construction Debris Disposai Aftldavit (required lur all demolition mid 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 Al is issued with the condition that the debris resulting from this work shall he disposed of in a property licensad waste disposal facility as defined by MGL c 111. S 150A. The debris will be transported by: 1�\ Yur� I came of hauler) The debris will be disposed of in : plume uflasa Ity DLA(V't- t addms of pawl litV "Jualdre 171wrifut applicant s/-7/0 .I e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kil,r 600 6Vashington Street Boston, MA 02111 wwwanass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Leaibhv Name(©usiness/Organimtion/Individual): Address:- f,�il� C'�tt n ` Lev City/State/Zip: i _ . _� E 6>�i Phone#: Are y an employer? Check the appropriate box: Type of project(required): 1. I am a lover with em " 4. ❑ I am a general contractor and I p � have hired the sub-contractors 6. ❑ New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling slip and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Ro repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13. therLk)I a"— 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 arc doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub•contmctors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ^ _ Insurance Company Name: �wF l YiYV'rI�t75Y11 IMP • lL 3 Policy#or Self-ins. Lic. #: 0 Expiration Date: Job Site Address: � aaZUA �1 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 Section 25A of MGL c. 152 can lead to the imposirion of criminal penalties of a fine up to S 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 S250.00 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 and r t e p 'ns a penalties ofperjury that the information provided above is true and correct Signature: n Date: l) Phone#: `d 0i!!3a�r r 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#: APR-20-2010 11:25 THD AT HOME SERVICES 1` 508 756 2859 P.006 • �..'..�•���p�0��r{�� �.���Lr�tl�����W}�a�{�W�-�y/y�y������.ts�*�&�y WyyO�l Ayr/ St • ry ht� • �g VIAWY`IJe.r� l�t�1��'M•�.l•YV loj gs� CMMVZXV L 114a dams axv4s ees. -MQWgM aDY sort. 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'CT��••� �. aeOeoH �NII�aaB 'apf'watac�S oem�7Y olLl'... . �4476?�[F�PaRNmOd`OTes ' .hw i N '� N�iYiAOHaQN1 ZNON 90WtD0'd r.tolvtsTs6 99 Fmofivs Y(kAO ENOS 99:91 otoz-GT-9dtl APR-24-2010 14:23 - HOME DEPOT SAUGUS HR 7&199-1,1017 P.002 Pre-Renovation Form Date;yyv0 This form is used to.document compliance with the requirements of the Federal Lead-Based Paint Renovation,Repair,and Painting Program after April 2010. OCCUPANT CONFIRMATION Pamphlet Receipt 1 have received a copy of the lead hazard information pamphlet informing me of the potential risk of the lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before work began. year of Property Construction 1 t1< Enter the year my home was built. Owner-occupant Opt out Acknowledgement V1 (A)No child under age 6 or pregnant woman /— I confirm that I own and Eve In this property, that no child under the age of H resides here,that no pregnant woman resides hero,and that this property is not a child-occupied facility. Note:A child resides in the primary residence of his or her custodial parents, legal guardians, foster _ parents, or informal caretaker if the child lives and sleeps most of the time at the caretakeeS residences. Note:A child-occupied facility is a pre-1878 building visited regularly by the same child,under 66 years , of age.on at least taro different days within any week,for at least 3 hours each day,provided visits total at least 60 hours annually. If Box A Is checked,check either Box B or Box C,but not both; _ (B)Opt-in I request that the renovation firm use the lead-safe work practices required by EPA's Lead-Based Paint Renovation, Repair,and Painting Rule; or (C)Opt-out I understand that the firm performing the renovation will not be required to use the lead-safe work practices required by EPA's Lead-Based Paint Renovation, Repair, and Painting Ru ("t, Printed Nam f Owner upant a aM Signet re of Pe Cortifpng L od amphlet oolr'vory CERTIFICATE OF LIABILITY INSURANCE � D2l-9:10 j 39>-JM I THIS CEF,Tj=jC.%TE IS ISSUED AS A ISSUED MATTER OF CEH N TIE C'PiLY AND CO V_PERS h0 : CGHTS li%C USA, Inc. � t-7Lce= r�:, ��-:=1c,-ALTER 7�—P -_ ocEs �.o- 3enot.cnrcr�c+:er_a�naTn': con — a. _Un_ ..v - . . . t i Bapot U.S.A., T_ A:re._—_�.._.._____ ._ __ ..._.....- . paces Ferry Road�2:A H_—;:SE3 C.Nax Hi.c3_'__ Co 2i5si-.... .. Sing C-20 I L` YSUIEER D: L'`TIC_T_2 R" lv-5 GA 30339 nta. 1 1NBURER E:3111P.OL3 Unioc Inn CC t 'ERAGES E POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO1WI71{STANOINO IY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR tY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH )LICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - ""-- - ----�- " POLICY EFFECTIVE rrPOLICY EXPIfiAT1ON� AOD'L POLICY NUMBER ID -T IN NYYY 1 _. . LMOS GENERAL LIABILITY GL04887714-00 03/01/10 03/01/11 EACHOCCURRES ENCEE_ S 410001000_.____ % COMMERCIAL GENERAL LUIBILffY Pl;(_MISEB(EagcylgnP,L_�51,000,000 , -._. CLAIMS MADE �OCCUR MED EXPP w-j arsanL E MCL1MED -- PERSONAL a ADV INJURY S4,000,000 GENERAL AGGREGATE E-4,000,000_ R GE M AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPICPAGg 4.,000,,000_- X I POLICY PR4 LOC AUTOMOBILE LIABILITY HAP 2938863-07 03/01/10 03/01/11 COMBINED SINGLE LIMN 511000,000 (Ee aoJ4enp - JHI�REOAUTOS Y AUTO OWNED AUTOS BODILY INJURY '$ (Per Person) HEDULED AUTOS BOD ILY.��I)RYN-OWNED AUTOSELF INSURED ATTfO PROPERTY DAMAGEHYSICAL DANAGEE LIABILITY .. AVTOONLY•EA�ACCIOENT S__-____,_, ANY AUTO OTHER THAN • EA ACC S AUTO ONLY: AGG S EXCESSIUMBRELLALIABILITY GL04807714-00 03/01/10 03/O1/31 EACt10CCURRENCE S 5.000,000 - _- . X 1OCCUR CLAMS MADE AGGREGATE__, S 5,000,000 _ S S DEDUCTIBLE ______—_._..._— _..__...___._._.._...... RETENTION ._ ... —. .. .__. ... S _.__-__..... WORKERS COMPENSATION 03/01/11 _X WCSTATU- OTf4 AND EMPLOYERS'UABIUrY NCO20392355 (ADS} O3/01/30 RY ACCIDENT _ B_—..---.-.------- I ANY PROPRIETORNARTNER/Ex6cuTNE� WCO20342356 (CA) 03/01/10 03/Ol/il EL.EACH ACCIDBNi__ E1,000,000`_ OFFICERMEMSER EXCLUOED7 WCO20342357 (FL) 03/01/10 03/01/11 EL.OISEASE-EAEMPLOYE S 1,000,000 (Man Eamry in NH) -- • It ye a,4esalae aMar E.L.DISEASE-POLICY LIMN S 1,000,000 SPECIAL PROVISIONS bd w OTHER TNSC46242373 "(TX)— 03/01/10 03/01/11 Occurrence/SIR 30N/2M S TX EMP10YOrs Excess 0 Workers Compensation WC0910566 (OBI) 03/O1/10 03/01/11 C Workers Compensation 1WCO203423S8(XY,NO,NY,1I, ) 03/O1/10 03/01/11 ESCRIPTK)N OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENT I SPECIAL PROVISIONS g; EVIDENCE OF COVERAGE :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WLLL ENDEAVOR TO MAR 30 DAYS WRITTEN HE HOME DEPOT, INC. ONE DEPOT U.S.A., INC. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAIIURETO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR 455 PACES FERRY ROAD NW REPRESENTATIVES. GILDING C-20 AUTHORIZED REPRESENTATIVE .TLANTA, 0A 30339 - VSA ...... fid ®1988-2009 ACORD CORPORATION. All rights reserved.