HALSEY WAY - STILLWELL DRIVE - NIMITZ WAY - BUILDING PERMIT APP \ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
SALEMassachusetts State Building Code,780 CMR Revised Mai 20I1
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Tiro-Family Divelling
This Section For Official Use Only
Building Permit Number: Dat Appli :
Building Official(Print Name) Sigm Date
SECTION 1:SITE INFORMATION
1. P�ope»r�X Addr ss•f 1.2 Assessors Map&Parcel Numbers
_2
�atras! � IuINISf. N,m,l
1.1 a Is tins an accepted street?yeses-no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District r Proposed Use Lot Area(sq it) -Frontage(ft) -
1.5 Building Setbacks(11)
From Yard Side Yards Rest Yard
Required Prodded Required Providcd Required Prodded
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?Check if yes❑ Municipal❑ On site disposal system El
SECTION 2: PROPERTY OWNERSHIP'
��...,, t r
21l_mcn e tZlL Ahnd l� SF/I/7�. {�Gi . 0 9V
Nhanc(Print) City,State,ZIP
✓1�lv�rs�-s�;llld,�l S) - A m,fz
No.and reef Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building O Owner-Occupied ❑ Repairs(s) ❑ 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: Onlyabor and Materials Official Use On
1,Building $ /l J' 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical $ ❑Standard Cityfrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
S ssion Total All Fees-$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $y�, ��� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES r1,
5.1 q�ons4tpcdon Sttperviso icense(CSL) a S 6 7 Si"
���J/l���a j1�pj r Licave Numbs Expiration c
Nfime olrCSI,Holder' -
qQ 7 69Ar �/,S) R /� _ List CSL Type(see below)
NO. to//}� (..� — Type Ddinis up t
�/1�/)S/� - � s� U Unrestricted(Buildings u el in 000 cu.ft.
(/ R Restricted 18:2 FamilyDwelling
own, tate� M Masonry
RC Roofirut Covering
WS Window and Siding
7 /- 3 / —R� SF Solid Fuel Binning Appliances
`��i I Insulation
Telephone Email address D Demolition
5.2 Registered ome Improv went.Contractor(HIC)
IAJ�4 , »)��u�74/1 HIC Registration Number Expirahon Date
Company ame or HIC gisnant e
' t t Y ''7�j�5%�i y� 9
n �lr l'r2
N S f / S76 Email address
.
C !Town,State,ZIP Telephone
Lam/
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..........O 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 U Y/ ✓7 S�47/L` 4rl
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:OWNER'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 is this application is true d accurate to the best of my knowledge and understanding.
Print er's or A oriud ent' ame ironic Signature) Date
NOTES:
1, An Owner who obtains a building permit to do his/her own work,or an owner who hues 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.mam.tmv/oca Information on the Construction Supervisor License can be found at www.mass.eov/do
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"may be substituted for`Total Project Cost"
t®f N;assachusetis -Bcparirnent of t uo::c Safety
a. L-� hoard of Building Regulations and Standards
Construction Supcn isor
!icense: CS-075985
WILLIAMAMANGIASI.r,.
_ 13 GIBSON CIRCLE
MEDFORD MA 02155 i,i
Commissioner 07/17/2018
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s
� /X e //2/920%2lUf:'CCf 112 O% 1/��f�A(/J rr/J,
Office of Consumer Affairs and Business Regulation
4. 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
- - Registration: 123356
- Type: Private Corporation
Expiration: 2/4/2015 Tr# 235798
WJN CONSTRUCTION CORP.
WILLIAM MANGIASI
407 REAR MYSTIC AVE. UNIT 36A 1s
MEDFORD, MA 02155 —
'Update Address and return card.Mark reason for change.
SCA1 Co 20M-05/11 '— [I Address j ii Renewal Employment I Lost Card
VJeC (poan4�wa��4e�[�(�ov�Vl�i44aGt2[4e�d
I
Office of Consumer Affairs&Business Regulation License or registration valid Tor individul use onlyIlOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
Registration: 123356 Type: Office of Consumer Affairs and Business Regulation
Expiration 2/4/2015_ Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
WJN CONSTRUCTION CORP.; --
WILLIAM MANGIASI
407 REAR MYSTIC AVE UNIT 3I Ir 6A
MEDFORD,MA 02155 -' Undersecretary ` ''
6 No[valid witho'utsignatp e
DATE(MM'DNTYYYI `
CERTIFICATE 4F LIABILITY INSURANCE 05116/13
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 polloy(109) 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 dons not Confer rights to the
certificate holder in lieu of such endorsamen s.
PRODUCER 978-975-1300 NA CONTACT
Sagreve It Hall Insur.A9soc.lnc PNONE
305 North Main St. 97$-875-7596 Eer M.xe1:
EMAIL
Andover, AD J. oRECO ,-...
Lawrence J.HallaH tlDuceR WJNCO-1
INSURE a APFOROING COVERAGE NAICq
INSURED WJN Construction Coip INSURMA;Arbella Protection Ins.Co. I41360
Thor Construction (NsuRER a,Commerce Insurance Co. 34754
407 Rear Mystic Ave 436A msuRERc:
Medford,MA 02155 INSURER D:
INSURERE:
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 SU:H POLICIES.LIMITS SHOWDI MAY HAVE BEEN REDUCED BY PAID CLAIMS.
PF POLICY EXP -' LIMITS
TYPE OF INSURANCE - POUCY NUMBER (MNlDDM/YY M
GENERALLIASIUTY EACH OCCURRENCE 6 1.000,00
A X COMMERCtAIOENEtiALUAe4iTY 8500036963 05127/13 05/21/14 MI EsLEed¢w q' 6 300,00
CLAIMSAVUIE ®OCCUR MEDEXP(A.ya-Pamo.) S S.00
PERSONAL S ADV INJURY S 1,000,00
GENERAL AGGREGATE 6 2,000,00
GENL AGGREGATE LIMIT.APFUES PER: PKODUOTB-COMPfOPAGG 6 2.000,00
FOLICY PRO- LOC S
AUTOMOBILE UA9IUTY COMBINED SINGLE LIMIT S
(ER-=ident)
ANY AUTO BODILY INJURY(Per Pere..) 3 '100,0001
ALLOWNEDAUTOS BODILY INJURY(Par ac"no 6 30D,00
B X SCHEOULEDAUTOS BDRZHT OtIM3112 08113M3 PROPERTY DAMAGE S 100,00
NIREO AUTOS (Per atcidwi)
6
NON-0WNED AUTOS - -
S
UMBRELLA WAS OCCUR EACH OCCURRENCE 6
EXCESS LWB CLAIMS-MADE ', AGGREGATE S
. 6
DEDUCTIBLE
R TEWON i WCSTATU• OTH-
WORKERSCUMPENBATION X LW
AND EMPLOYERS'LIABILITY 500,00
A ANY PROPRIETOFUII R NER/EXECUTME i�'"'"I NIA 910389 111/01/13 01109M4 E.L.EACH ACCIDENT S
OFFICERAIEMBER EXCLUDED? L� ESL DISEASE-EA EMPLOYE 6 500.00
(Men r"In NH)
Ir yyeea dM IN under E.L.OISFASE-POLICY LIMIT S 500,00
OE8 RIPT N FOPERATIONS W.
i
DESCRIPTION OF OPERATIONS r LOCATIONS f V EHICLE6(Aeecn 0.CORP 101,AdN11aRM RaPudm SCMOViq Ir mA,e�peu le rvq.drod!
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHCq=D REPRESENTATIVE
®1988.2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
20u-05-16 12:14 SEGREVEAHALL I Page 2
PICKMAN PARK CONDOMINIUM
2013 ROOFING CONTRACT—THOR CONSTRUCTION COMPANY
PERFORMANCE OF THE COVENANTS- The parties hereto for themselves, their heirs,
executors, administrators, legal representatives, successors, do hereby execute the full and complete
performance of the covenants as required.
NOTICE: Any and all notices served pursuant to or with respect to this Agreement shall be
delivered by hand or by certified return receipt, with respect to the Trust;
Pickman Park Condominium Trust
c/o American Properties Team, Inc.
500 West Cummings Park, Suite #6050
Woburn, MA 01801
with respect to the Contractor;
Thor Construction Company
407 Rear Mystic Avenue, Unit 36A
Medford, MA 02155
Any notice regarding default under this Agreement shall be confirmed in writing, but in order to
expedite corrective action a telephone call shall be deemed notice of default, and after receipt by the
defaulting party, said defaulting party shall correct the default or otherwise respond within four (4)
hours.
Witness: Whereof the parties have duly executed this Agreement the day and year above written.
Contractor: Thor Construction Company
By: Wdyw
Title:
st: Pickman Park Condominium Trust
s M gi g Ag m and not d vidually / /