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9 GLOVER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Ulf Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling U This Section For Official Use y Building Permit Number: ateApp ' d: - Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 9 (r_ � � 5 T. i(�N1T 1.1 a 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 II) 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❑ Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1p wner of Recor CANV.,dr4z MrsA1 �/3L�r+i I��B OZ Y7V Name(Print) ' � / City,State,ZIP G L oV =2 S r Vnl, 7— 7aE Sf f. o/�S� C/tNOit E N�iaOM a d© y 1md-r otit No.and Street Telephone Email Ad ress SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': J)r,aw w L4 346 - !t[,t - B,_v n c SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 9000- ,}p 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ .70 D.P. o.0 2. Other Fees: $ J. }� 4. Mechanical (HVAC) $ List: O 5. Mechanical (Fire $ -Suppression) Total All Fees: $ Dom Check No. Check Amount: Cash Amount 6. Total Project Cost: $ ��, 4V 0 Paid in Full 0 Outstanding Balance Due: , SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 7 alJi3 /' ` ,A &L'o C4NO AA G&D License Number Expiration Date Name of CSL Holder �I List CSL Type(see below) �! No.and Street Type Description Sln� rWTP''/ ✓"� O U Unrestricted(Buildings up to 35,000 cu. R. 19'�) R Restricted 1&2 FamilyDwelling City/Town, [ate,ZIP M Masonry RC Roofing Covering_ WS Window and Sidin SF Solid Fuel Burning Appliances 11/wz• 301 ( Co.Jr � t^OMuaS�_/IFj I Insulation -Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) � flti - � zr 4F9 7 s HIC 'ompany Name or HIC Registrant Name HIC Registration Number Expiration Dale / 9 9V ti&, w s 7- , C -0 CWVS r a Comer , AIL- 1 r No and Street Email address (�wn qJtWIM .✓LL1e- o14a� 7�/•8y1.•3�lJ Ci /Town, Cate,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 ..........ff-' 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 CA i2.1,J Y M G Q--:) to act on my behalf, in all matters relative tow �quthori ed y his building permit application. N)OIC-6 ND64AN � gtl ( 1 Z(, ' 12L 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. NtIW � � I- LG • ) L Print Owner's or Auth ized Agent's Name(Electronic Signal 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov%dos 2. When substantial work is planned, provide the information below: Total floor area(sq. ft.) (including garage,finished basementiattics,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" I _ The Commonwealth of Massachusetts Department of Industrial Accidents office efinuesfigatiens 600 Washington Street, 7tl'Floor Boston,Mass. 02111 Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors AnDlican/t`information• ''// Please PRINT lef2ibly name address f ccayr--y.J ST—' ,f� O city t�t�"t- q state✓f7� //�� zin.0 j/�1 70 phone# 7 '1 � 1913 S` work site location(full address)' -/ 610y-✓<H ST VN/T 7— J�L�� ' �� 0 ) F70 ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction®Remodel ❑ I am a sole proprietor and have no one working m any„ capac ty. Building Addition I am an employer providing workers' compensation for my employees working on this job. companv name: C4,pA4 l;ou Ct -,-x" address: LU /zf/YZA14-t' Ste ` C 7 city eX,/V It'7Z�1�' phone#: ��v'a1�� ,/ insurance co / G/✓A/DL.Ars9�S-' —�/� oolicv# ��e/ C-"✓✓y l-� 1 Z' /W,4 _ ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: I address: mT, cite: phone#: insurance co policy# •company name: address: City: phone#: I insurance co oolicv# Attach additional sheet if necessary � ', Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby e ,fy ad the pa' s a penalties of perjury that the information provided above is true and correct. Signature Date //•2-7-/7— Print name a CLD Phone# omcial use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Orifice ❑Health Department contact person: phone#; ❑Other (reeked Scp.20a5) OP ID: LR CERTIFICATE OF LIABILITY INSURANCE DATE 11115/12) 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) 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 endorsements . PRODUCER 781-935-8480 CONTACT DeSanctis Insurance Agcy, Inc. 781-933-5645 PHONE INC, Ezt: ac Ne: 100 Unicorn Park Drive E-MAIL ADDRESS Woburn, MA 01801 PRODUCER CUSTOMER to k:CAPON-2 INSURERS AFFORDING COVERAGE NAIC N INSURED Caponigro Construction Co.,Inc INSURER A:Selective Insurance Co of SC 12572 159 Burrell Street, INSURER B:Technology Insurance Com an 42376 Swampscott,MA 01907 INSURER C: INSURER D INSURER E: 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 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLITYPE OF INSURANCE IN%R UB POLICY NUMBER MM/DDPOLICYEFF 7"$ LIMITS POUICYEXP LTR GENERALLIABILITY CURRENCE $ 1,000,00 NTED A X COMMERCIAL GENERAL LIABILITY S19164830 11/21/12S EaEoccunencs $ 100,00 CI-AIMS-MADE � OCCUR (Any one person) $ 10,00 L S ADV INJURY $ 1,000,00 AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. S-COMP/OP AGG S 3,000,000 POLICY X PRCf O LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Peracddmt) $ A X SCHEDULED AUTOS A9092896 06/06/12 06/06/13 IROPERT'YDAMAGE X HIRED AUTOS (Per am nt) $ X NOWOWNEDAUTOS $ $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,00 . EXCESS LIAB CWMS-MADE AGGREGATE $ 2,000,00 A S1916483 11/21/12 11/21/13 DEDUCTIBLE $ XI RETENTION $ NONE $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA IM TWC3326129 09/15/12 09/15113 E.L.EACH ACCIDENT a 1,000,0011 OFFICEREMBER EXCLUDED? 1,000,00 (Mandatory In NH) MA E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Misc Tools 519164830 11/21/12 11/21/13 Limit 15,00 Deduct 60 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Illustration of Coverage CERTIFICATE HOLDER CANCELLATION ILLUS-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ILLUSTRATION OF COVERAGE ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE u ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD o��J, u/u, +a Massachusetts- Department of Public S:d'ct ' Office of Consumer Affairs&Bv'siness Regulation 1 fJrti r b HOME IMPROVEMENT CONTRACTOR {+I U Bo`tC of Construction Building Supervisor and Standards Registration:�.�1999 Type: Construction Supervisor license Expiration: ,M/2Q14 DBA License: CS 61061 C NIGRO CON,S�M1R�ON- k CARLO E CAPONIGRO CARLO CAPONIGQ 159 BURRILL ST 159 BURRILL ST SWAMPSCOTT, MA 01907 SWAMPSCOTT,MA�Ot 07 Undersecretary Expiration: 7/25/2013" Cununlsyioncr Tr#: 17390 '