7 GREENWAY RD - BUILDING INSPECTION S 7 -7
q The Commonwealth of Massachusetts
a" Board of Building Regulations and Standards CITY OF
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
This Section For Official Use Only
Building Permit Number: Date pplied:
Building Official(Print Name) Signature Date
1 SECTION 1:SITE•INFORMATION -" m
1.1 Property Address: /f n / 'A 1.2 Assessors Map&Parcel Numbers � —+
�yQQT6�� (�� 1�1 z t
I1.1 a Is this an accep9d'street?yes no Map Number Parcel Number ,_p
1.3 Zoning Information: 1.4 Property Dimensions: '0 c ri
m
Zoning-District Proposed Use Lot Area(sq ft) Frontage(ft) <
1.5 Building Setbacks(it) O rn
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'
2.1 Owner of Record:
kName(Print) .6P1 ..ttM1� City,State,ZIP
9�k-7�y-a/6 a s c6h
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 Other ❑ Specify:
Brief Descrip *on of roposed Workz: LaeS
� fx.
O i ✓
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only.
Labor and Materials '
1.Building $ 1. Building Permit Fee: $ . Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ - 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression) Total All Fees: $
o Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ .O a"O ❑Paid in Full ❑Outstanding Balance Due-
'I O I4 Cyr= OWrJ 2
rn A l Ll p -7 8
t, SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) , �(
�►Om4 S k, ,DUL 4 r V'T l0
License Number Expiration ate
Name of USL Holder
List CSL Type(see below)
No.and Sheet Type Description
2 _ _ n`NC r rf] O((}6 U Unrestricted(Buildings u to 35,000 cu.ft.
/ ,(� �7 Q R Restricted 1&.2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) .7
C,� fVV /ty"I t�.br— HIC Registration Number Expiry
HIC tompany Name or HIC Regis t Name
No.and eet Email address
-end rye f wt 006
City/Town,State,ZW 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 .......... yy No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I
I,as Owner of the subject property,hereby authorize `�01 Jf V t (-Qf —T/�� (, icTt f'1�2�iy-� LILC
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
applicatiorss true and�e t�be§ pf my knowledge and understanding.
ow4s K Dull
� : & -X—( /
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.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. og v/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"maybe substituted for"Total Project Cost"
6/4/2015 8:29 AM FROM: Fax M.J. Foster Insurance Services, Inc. TO: 17819427101 PAGE: 002 OF 002
TKDCO-1 OP ID: PS
�4�oRo CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
0 610 41201 5
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: itthe certificate holder is an ADDITIONAL INSURED,the policy(les)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 COWACTNAME
Pete Sullivan
Foster Sullivan Insurance
163 Maln'St. P"c°x .978-686-2266 FAc No:978-686.6410
North Andover,MA 01845 Suilivan fostersuillvan COm
Stephen Sullivan AooREss:P 9rou P
INSURER(S)AFFORDING COVERAGE NAICi ,
INSURERA:THE HANOVER INSURANCE COMPANY 22292
INSURED TKO Construction LLC - IwuRERa:LIBERTY MUTUAL INS CO 23043 I,
Tom Dukas
55 Vine Street INSURER C
Reading,MA 01867 INSURER O:
INSURER E
INSURERF: .A
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.
LTR TYPE OF INSURANCE INSIR POLICY NUMBER MMIDDI MILD UWTS
GENERAL UABRITY EACH OCCURRENCE $ 1,000,00
A X 0SN8477632 01/0172015 01/012016 PREMISES aocaomnoe $ 300,00
CLAIM6MADE OCCUR MED EW rpny One parson) $ 10,00
PERSONAL&ADV N.URY $ 1,000,00
GENERAL AGGREGATE. $ 2,000,00
GENL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPA)PAGG $ 2.000,00
JECT X POLICY PRO LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ee.e d $
ANYAUTO BODILY NJURY(Per person) $
ALL OWNED SCHEWLED BODILY WJURY(Per audde'e) $
PUi05 AUTOS
NON-OWNED PROPERTY DAM AGE f
HIREDAUTOS AUTOS PER ACCIDENT
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CWMSMADE AGGREGATE $
DED RETENTION $
WORKERS COMPENSATION X VrCSTATU- TH-
ANDEMPLOYERSLIABILITY TORY LIMITS PER
B ANY PROPRIETORRARINER/EXEWr1YEYO NIA C5-31S-382910-025 01/01/2015 01/0111016 E.L.EACH ACCIDENT f 100,00
OTTIMIUME 4BER EXCLUDED? 100,00
(MandeMry In NH) E.L.DISEhSE-EA EMPLOYEE $
Mes .arms' S00,00
IPTIONOFOPERATIONSWow ELDGEASE-POLICY LIMIT $
DESCRIPTIONOFOPERATIONSILOCATIONSAV ICLES(AOac ACORD 101,Addidonal Remarks Sc dule,a mom apne M mWimq
rr EVIDENCE rr
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TOWN OF NORTH READING ACCORDANCE WITH THE POLICY PROVISIONS.
fax#978-664-1713
BLDG. DEPT. AU RIZED REPRESENTATNE
NORTH READING,MA 01864l�
1988.2010 ACORD CORPORATION All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
i
' Olfice ofCwsumergla s&B
OME IMPROVEMENT CONTust6 ss Rcg= end
egistration: RAGTOR
179377
t xpiration 7/25/2016. Type:
Y LLC
it( TKD CONSTRUCTION LLC
r _
+ - THOMAS DUKAS 1
55 VINE ST 'r ,
4 READING, MA 01867 " "'" �"�=��,�_
Undersecretary
1 ,
Massa
chusetts -Department of Public.Safety
• Board of Buildin
g Regulations and Standards
Construction Supervisor
License: CS-0g365g,
`s`It ire? `
THOMAS K D e,\, • ,
55 Vine Street i $ -
Readirrg]yA 01Sb7 -
Expiration
Commissioner 11/29/2015