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17 GREENLAWN AVE - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards RECEI EM CITY OF Massachusetts State Building Code, 780 CMR INSPECTIONA SERVAU& l V Revised Mar 201! n Building Permit Application To Construct,Repair,Renovate Or j�g�nQljsh�.� Re Ma l 1 One-or Two-Family Dwelling (0'J RYH (� 42 This Section For Official Use Only Building Permit Number: Date A i : Ln 6 � s Building.Official(Print Name) _ Signature Date SECTION 1:SITE INFORMATION "��(� 1.1 Property Address: �v� 1.2 Assessors Map&Parcel Numbers l.l 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 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 Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2:'PROPERTY OWNERSHIP' 2. Owner'of Res�r� Name(Print) City,State,ZIP l 7 r"rh la w 9; S No.and-Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(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 7 P lbp✓S SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. pa Building $ /c6 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 $ 2.11 Other Fees: $ ' 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ /gl000,DO ❑Paid in Full ❑Outstanding Balance Due: 131LL- q-7C 815- o% (o f SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street �t�11��/ C T Description {�W6 1 W 0r/�3 Unrestricted 2Fami sir Dwellto ing cu.ft.) C R Restricted 1&2 Family Dwellin City/town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 3959 �P Tie7,7/(�ydGr00 1 Insulation Tele hone Email address I D Demolition 5.2 Registered Home Improvement Contractor(HIC) /v�o/e C ` V HIC Registration Number Expiration Date HI-3C C9mpy`N e or l-il jRcgistrantNafne and Street 7 p /�i?t/'�L��/Z/,G7�l�I/�PllO� Email addres City/Town,State,ZIP i h / 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 1,as Owner of the subject property,hereby authorize 4101111 e!Aw /)117C A:D!'Z/E to act on on behalf,in all matters relati a to work authorized by this building permit application. a3 / ' Pant Owner's Name(Elec nic Signa Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby atte t under the pains and penalties of perjury that all of the information contained i is application is true and aq orate to the best of my knowledge and understanding. �3 /5 Print Owner's or Authorize 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.c. 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.mass.gov/dros 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"maybe substituted for"Total Project Cost" V i CITY OF SM E:M, NLkSSACHUSETTS • BL'IIZINIG DEPARTJIEN'[ 120 WASHINGTON STREET,3"o FLOOR TEL (978)745-9595 FAX(978)740-9846 KIMBERL.EY DRISCOLL MAYOR T HOMAS ST.PtERRH DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information [/ ,Please Print L�eJ ribl �lanle(BusitnssiOrganizarion/Individual): % L°�l i?/7z YDU /�/P11/rfIx /l'(C/"1[?/'I�/� Address: (_3�1 City/State/Zi;-!Q,'/ (&3 M)7 ) ��/d� Phone#:_)7LY Are yowtull employer?Check the appropriate box: 1. am a employer with� 6. ❑New construction employees(full and/or part-time). 7. rfpp�1 Remodelin 2.❑ 1 am a sole proprietor or partner- listed on the attached shceL: wr g ship and have no employees These sub•contmetm have 8. ❑ Demolition working for me in any capacity, workers'comp.insumoor. 9, ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its !0.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152.§I(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] •Any applicam that docks box#1 must also fill out the sectieu below abowing their workaa'compensation policy information. *I lumeowrera who submit this affidavit indicting they are doing all work and then hire outside comme ant must submit a new,affidavit indicating such. =Contnxnors that cheek this box must attached an additional shad showing the name of fho subtorunctors and their wadtasI comp,policy information. I am an employer that b providing workers'corapensadon insurance,for my employees. Below Is the pollty and job site information. Insurance Company Name: �/c7 i��/PG� /� !�/l��1�uJ✓r 1(6/5 i Policy#or Self ins.Lie.#:_3//a Expiration Date: '713 D//S Job SiteAddress:_L_] ✓�lU/l�Gfl/1 �y� City/State/Zip:L567 jt� d/97Q 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 imposition 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 under the pains and penalties of perjury that the information provided above is true and cornet Siinature lljj J &NA&I-1 Date Phone#: 9 7�/ 7� a.35 s Official use only. Do not write In this area,to be completed by city or town ojjiclaL City or Town: PermitfUcense# Issuing Authority(circle one): 1.Board of Heallb 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other. Contact Person: _ Phone#: AcoRv® CERTIFICATE OF LIABILITY INSURANCE /m2l 2015YY) a/u/2o1s 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 endorsement(s). PRODUCER OME cT Christopher Kennedy Farquhar 6 Black Insurance Agency, Inc. PNONE (781)599-2200 IFZ ,(781)581-3940 85 Exchange Street - Suite 101 poMA4. .Chris@FandBInsuIance.con. INSURE S AFFORDING COVERAGE NAICO Lynn MA 01901-1475 INSURFRA:Safety Insurance 39454 INSURED INSURERB..Qiincy Mutual Fire Ina. Co. 15067 The McKenzie Group, DBA: William McKenzie INSURERCApplied Underwriters 28258 34 Harbor Street INSURER D: _ INSURER E: Danvers MA 01923 INSURERF: COVERAGES CERTIFICATE NUMBER:Thon.as Murtagh 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 TYPE OFADDLSUBR POLICY EFF POLICY EXP TR POLICY NUMBER MWD MM/D LIMITS GENERAL LIABILITY EACH OCCURRENCE E 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE A E PREMISES Ea r15- E 100,000 A CLAIMS-MADE ROCCUR BM0019412 6/2/2014 6/2/2015 NED EXP(Any one Person) $ 10,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC E AUTOMOBILE LIABILITY COMBINED SINGLEUNIT aBItl 11000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 06056 (Per accent 2/20/2014 2/20/2015 BODILY INJURY Pid $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE $ IAUTOS Per acdtlent UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LUIS CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ C WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory In NN) 6-842232-01-04 /30/2014 /30/2015 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,N more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thomas Murtagh ACCORDANCE WITH THE POLICY PROVISIONS. 17 Greenlawn Avenue Salem, MA 01970 [AUTHORIZED REPRESENTATIVE rian Cruz ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025/7mm51 m Thn arnpin and Inns aro wnie}orod mzr4o rrf A(-npn -;' *'Massachusetts-Department of Public Board of Building Regulations and Standards Construction Super0sor k License: CS-030038 W ILLIAM D MCUN23E 34 HARBOR STREET . Danvers MA 01923 Expiration Commissioner- ' 1 0/1 612 01 5le . Affairs Bu'jn � J2C`4lJe/6 w - Oflice of Gossamer Affairs&BusioessRegulatioa 1 cense or registration valid for individul use only V- � OME7MPROVEMENT CONTRACTOR fore the.expiration date: if found return to: egistraticn 144018 k' Expirafion: 8/27/20:16 TYPe:.. L ' €ffice uf.Consumer AfTairs and Business Regulation .. DBA j 10 Parli Ylaia-Suite 5170.THE MCKENZIE G OUP,- ' - = ff Sostun,MA 02116 WILLIAM MCKENZI�-y � _ 34 HARBOR STREET" DANVERS,MA 01923 . _. Undersecretary ui Not valid w tth out st gnature.