4 HAMILTON ST - BUILDING INSPECTION (2) 7 I'lie C•onunonweallh of Nfassachuxus
is ',a Board of Iuilding Regulations and Standards CI'11 OF
sr ;, Nl:tssachusctts State Building Code, 780 C'NIR SALEM
•a.,.• Building Permit ,application To Construct, Repair. Renovate Or Demolish a Reri,,ed v,n :uil
Una• or Tlsw-klanidr Dialling
This Section Fur OI)ieiul Usc Onl
Building Permit Number: Date A icJ
Iludding 011ieial(Print N�uoc) �— Signal re Owe
SECTION 1:SITE INFORAIITION
1.I Properly 1JJress: 1.2 Assessurs slap dt Parcel Numben
s�-
L la Is this on acce ted street? es no Map Nunsher Purcel Nunlher
1.3 Zoning Information: 1.4 Property Dimensional
Lnning District Proposed(Isa Lot Area(sy It) Frnlage(ll)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Reyuirtd Provided Required provided
1.6 Water Supply:(M.G.1.c. 40,§74) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Pdvale❑ Zone: _ Outside Flood'Lune?
Chock if es0 Municipal O On site disposals)stem 0
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
Ale-xL a"lver- Se(totvt MA ol9-7U
,Wune(Print) \/1 City..Slatu,ZIP
/
Nu.:mJ Street relephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction(3 Existing Building❑ Owner•Occupied ❑ Repo(rs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Spccily:
Brief Description of proposed Work':
SECTION J: ESTLIIATED CONSTRUCTION COSTS
(tall Estimated Costs:
ILabor:mdMaterials) Official Use Only
I. Building S 3S0 p 1. Building Permit Fee: S Indicate how tee is detenuined:
2. Electrical S Z vv ❑Standard CityTossn Application Fee
I'lumh;ny ❑Total project C•oslt(hon 6)x multiplier
S
Zsoo v. Other Fees S_
J. \tcchenic.J iIIC \(') S List:
\Icdlanical i I ire -- --- ------- - __ . . .
l `uppressiont S _ rutaru Fces: S
t, Totul Project CoNs: Sz OU Check No. (heck.\moue!: . _....._. (•,�,h \unuuu:
•-'j vO� ' ❑ Paid in Full Cl Outstanding 11.11.mcc Due:
sE.'CI*I0N `t:
.1.1 Construe I io I11 Sullen Nor I.ice"st 10 L)
N ill Flbc-r
Lk
AnA Description
1%
N.I. lild NINO it
S�1,4t,kJAD C o A �-
14
0 Mason
st"Ic. M
RC it,xil-111 op%vrin
%S 'A indow.uld Sidill
---- SF Soli)solij 1--tiel liorningAPPlialIccl
Insulation
-L�
Demolition
.1dir"A
I'ck hone ------v..,-----------------
Improvement Contractor(111C) ZtZ 2V
.1,2 Registered lloont _:M—�
L,kk L n�Ule -Ce rlitca-S LLC itcgibutation Nonitcr F\pirillion 0319
N,illig jor I lIC Itclilitrunt Njill-) OUS; CS e r V I C�-r * 00 t
kt
S L I lji addss No. a] Street tf
�Vw& _D 791 '4Y323t
s1 (I felt
Ci /TU1%%'n..�Stw e.fil
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atYidavit will result in the denial of the issuance of the building permit.
Signed Affidavit Attached? Yes.........N!L-- No...........0
�v o BE COMPLETED WHEN
BUILDING PERMIT
SECTOin; 0 -NIVNER AUTHORIZATION
OWNER'S AGENT OR CONTRACTOR APPLIES FOR
1,as Owner of the subject property,hereby authorize Lil,-�z%,4f
On-
hto act on my behalf,in all matters rel five t w It ized by this building permit aPPI10ti-zhg -
A I DLj Xevl �j, Uald
Print Owler's Nwild(CICUIM111C Nlbiluql—)
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 inrormatiun
n is true'an ccurate to th tit of my knowledge and understanding.
contained in this OPPlictili 0 i�" r
Dow
Bob Fe —�
Nons:
hires' ,n�uljrqistcrttd�:untraOor
to his her own work,uran owner who
I An Owner who obtains a building permit do 0 ill IU) have access to the arbitration
I nut registered in the Hollis Improvement Contractor I HIC) Program),%VI can be round at
xograill or guaranty loild under M.G.L.c. 141A. Other illipurtant information on the HIC Program
lillorni;Ition on the Construction Supervisor License can be found at 1;t,\ ,it,
belo
2. \\hen substaiitial\i,ork is platined, proNide the ili6jrmatiun 1 including gaw:
rage. finished basement attics,Jerks or porch)
r,,tal tiour area(s+ It.) . - Habitable room count
Gross It\ilig Area I ssi, Number%it'hedrooms
Nolliber ill liall,Killis
\%iiiiherol Nilmlivrot'de"s, porches
I lic ill heating 3),1011 1*1161sed
,I'll Ilroj%:i;t stilorc I'Oiit.lcc1113% tic 'illotillwd Ilir 1,11-11 1'roj"t ('011
i
CITY QF SAL&Nf, Aus.kcuusE-rrs
JLttot.YG DEP.tanteaT
I'0 '-V-k911t.VGT0N STRFB'r, }'FL00114
172L k9711) 741.9591
KI BFRI Y ORLSCOLL Fut(978) 714.9W
�fu1YOR fHamU ST.PMU4
DIRECT04 0/Pl.9t1C pR0Plll7y/9C MnLNr COJOlt33(O�ER .
Constructloa Debris DISPay21 Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition Of State Building Cade, 190 CZ R
Oebris, and the provisions of M section 1 11.J
CL o 40, 9 J4;
Building permit p is issued with the condition that the debris resulting from
1 11, S IJOA.
1 work shall be disposed of in a properly licensed waits disposal facility as defined by&ICE c
I
The debris will be transported by:
L-tleGo�se �V� Iq
(name ut'Aauler)
The debris wi It be disposed of in :
E4(C-- (41jP0fk/, C
sl �
--_.._
(name(ifdmli�y)
Anson COJr
L � 1A MA
,ddms or rj„h jy)
+yMNro or;.ermir 1
PPli.mr
-7 1 ��iz
lue
propofs l Page No. of Pages
Insured Litehouse Services
License # 95280 Litehouse Services 67 Monument Avenue
H.I.C. # 142824 Home Repairs Made Easy Swampscott, MA 01907
litehouseservices@hotmail.com
Bob Pierce 781-864-5238
PROPOSAL SUBMITTED TO PHONE DATE
V 8 IV- OFS210 8 L
STREET JOB NAME
CITY.STATE 0. 1411 ! 9 7 � JOB LOCATINI ^ L" I'
'f.'/K ..II./yl
APPROX.ST RT G DATE JOB PHONE
1 f �-
We hereby submit specifications and estimates for:
rd r . ✓01) s its
"Ifjl o c eF
tJla LJZ'Lozl �j s 1
L v
Pr, a f' +
We Vropoge hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
OJ
t/ dollars ($
Payment to be made as follows:
1/3 down, 1/3 middle of job, 1/3 upon completion
All material is guaranteed to be as specified.All work to be completed in a workmanlike manner Authorized /
according to standard practices.Any alteration or deviation from above specifications involving Signature �~� -
eMm costs will be executed only upon written orders,end will become an extra Marge ever and
above the estimate. Note:This proposal may be
ed within days.
�q withdrawn by us if not accet
CCeptailCe Bl,{pTopogal—The above prices,Specifications and conditions are
satisfactory and are hereby accepted.You are authorized to do the work as specified.Payment Signature / r
will be made as outlined above.
Signature
Date of Acceptance:
IQ,luvz/vvz
A�a CERTIFICATE OF LIABILITY INSURANCE D/18/ D°12
7/le/2o12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
I CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
i BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER,
IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED,the Policy(WS) must be endorsed. If SUBROGATION IS WANED, subject to
the terns and conditions of the Policy.Certain Policies may require an endorsement. A statement an this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 0O FACT Christop�r Ifenrtedy
PHONE 2200
Farquhar S Black Insurance Agency, Inc. t7919599-ry�)-lT� sil sei-3y�a
85 Exchange Street - Suite 101 ,AcrosE:ChrisSFandSInsuranoe.com
PROWLER 00091341 .
L — MA 019 0 1-14 7 5 INSURERf3)4FFOpO1NG COVERAGE N.ICy
INSURED INSURERA:Sa'Fety Insurance 94-94
INsuRERs Associatad Employers Insurance__ 0959
Litehouse services, LLC INsuREac:
67 Monument Avenue INsuREao: .
Swampscott MA 01907 uaEaF•
COVERAGES CERTIFICATE NUMBER:Town oY Swampscott 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 7YPE OFINSVRANCE —.. . ADD SUBR� .. EFF WW EIS Uums
POLICY NUMBER
'GENERAL DASILnY _EACH OCCURRENCE s
CO MMERCNL GENERAL LIABILTY ! DAMAGE TO RENTED7--J PREMISES(Fa
S "'
,CLAIMS-uME ! !OCCUR MED DCPWwy Dmiml S
' I IPFRSDNALSADV INJORY S
joeti HL AGGREGATE f
GEN'L AGGREGATE LIMB APPLIES PER: IOP AGG I S
--I I PROOUCTS-COMP
PDUC JECTPRO- LOc S
AUrONOBILE uA91LRY
COMLiINEDSINGLE LIMIT
(Es ANY AUTO I seU0.vu) s . _
A ALLOWNEO AUTOS I6204924 L/12/2o11i11/12/2012 WOHMURY(pcpvAn] Is _- 100....,000
EDULEDAUTOS PROILY INJURY(Per aaddml)'S 300,000
LJSCH
HIREDPROPERTY DAMAGE
�NON-0wNEDAvres i(Pa aaadrn0 --.-_ s- 100,000
Un'aavM mobrel mr,hined S
UnderaRued'mamnet S
UMORELU OCCUR EACH OCCURRENCE s
EIR;ESB LI4B CL UR.• OE AGGREGATE S
13 WORKERS COMPENSATION WC SrATLL OTH-7
ANY PROPRIETORrPARTJER/D<FL{JnVE YIN X Twoa MRS ER
OFRCGRNEMUR E:CUJDEDT NIA I EL EACH ACCm S 500,000
(umea[wymmf) 009958012012 /7/2012 $/7/2013 •RL DMEASE-EABAPLOYEA S 500,000
U 9GIRIP'hPON OC OPERAT O.S ndax
E.L DISEASE-POUCYLIMr 0 000
DESCRIPTION OF OPERATIONS I LOCATONS l VEHICLES (AtMCh ACORD 101,AQm11mM RnnMka SeMMuk.Bmee apaePh rvqu4a�
CERTIFICATE HOLDER CANCELLATION
(781)596-0590 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Swampscott ACCORDANCE WITH THE POLICY PROVISIONS.
22 Monument Avenue
Swampscott, MA 01907 AUn10RIa=D REPRESENTATIVE
Karl= Cruz
ACORD 26(4009109) 0
IN3025(2Bo9�) The ACORD 1968-2009 ACORD CORPORATION. All rights reserved.
name and logo ere registered marks of ACORD
CCCY 0 F S'lul'N(, 1%L1SS.1CHl;SETTS
• 1J BUILDING DEP.hltrMENT
120 WA31-INGTON STREET, 3''FLOOR
TEL (978) 715-9505
(978) 7 W8.16
113EItLEY 0RISC0LL
�L1Yo:t TIIoNLksST.PIE.axa
DIRECTOR OF PC9LIC PROPERTY/3UMONG COSLUMIONER
Workers' Compensation Insurance ,%Mdavit: Builders/Contructorv/Electriclans/Plumbers
Apolleant Informatlnn ( Pleave Print L-glhly
Nam,:111miiu.rUrganvalian•InJividunll: i �J Jj.e �V to tP % LL
Address: le -7
City/State/Zip: cSPJA .1C0 1hondN:_ -7f 1 P-6 V Q?r-
lea nu an employer'!Check the appropriate bate Type of prnleet(required):
I. am a employer with �_ 4. ❑ 1 am a ga imil contractor and 1 6. 0 Now,construction
ulnployees(NII.md/or part-time).• have hired the sulsconlrsclars
2.❑ I am a Bole proprietor or partner- listed on the attached.rheut t 1. Remodeling
.hip and have no employees These sub-contractor hive V. Demolition
working for me in any capacity. workers'camp. intumnee. 9. Building addition
[No workers'.comp, insurance 3. ❑ We are a corporation and its
rcquircJ.] officers have axereised their 10.❑Electrical rcpsirs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or udditlons
myself.(No warkars'Gump. c. 152,§1(4).and we hove no 12.0 Roof repairs
insurancarequired.( t employees. (No workers'
comp• insurance required.) I3.❑Other
•.\uy uppll.:ud nW Clmekr boa II we Aw 011 oul ihv weli"twlar she W ire Chair WmYan'ramprnudun puliay in0umadan.
'I hvnuu W nera oho.uhmit this tlnMvil indieallny shay jest 411,wrk and than him uunide eanlraatare MW1 mhrnit a new mlldavll indtains welt.
$'imeu:wn thal hwk this box musts nuvhud in I"llurw.list•hu W ire Cho mmne ar the m0.uemncwn and Chair wnrkm'comp,prllry inrumu0aq.
/urn un enpluyn that/i pruvldbrX tvorken'rumpwuarlun ln.rurancefer my employrrm Bduwli die polity and Job site
in/urmurinn.
Imurmlce Company Name:—, R /pVy(„p ✓x �(/) ✓fQ /n C O
1'nlicy 9 or Sclr-ins. Lie. if +'VV cc w Jo g J O Expiration Date: ,,A
• late Slid Addrl'aa: _� ArlMs ,140111 � Cityi C1bStatei2ip:vM MA-d(97o
\Itacb a copy wiliest r i tloo workers' comparl policy daclaratlon pigs(showing the policy numbeir and eiple stlon data).
F.tiluru to ivcurc cuvorigili m required under.Section 25A of bIGL e. 132 an f"d to the impasilion of criminal penalties of.r
rife up to i 1,500,00 und/ur one-year iinpri.mnment as well as civil pen',
Itins in the form ul a STOP WORK ORDER and a lino
of.gl to i 0,00 a Jay Iguinss the violator. 11e 34VCSVJ Chu a copy of this alawment may be iurwurdcJ to I,e 011ice of
Idvc,11 gal iota.dihe 01A tbrinaurvmc cov,;ragc vcriticution.
!:!u/rrrrby cirri/y ur Jt Mr puirrr oil Jp /elver�rf perjury r/tur du hifunnuNarr provided ub vs,it rr a,Ila eurrert
:_.... I _ -.� l
U.I ta:
I'l11;e.s: -7d r er,�
U//iciu!u.e nnfy. Ihr:r„!evirt in r/n:r:uru, m*t runrplra•J Sy city ur/men,y/&iv2
City or Vwv;l: _ .. Pcrmitrl.lccme i
I. L'oartl of IICal1h !. Iludding ncp.lriwrn( 1. 0, Clerk 1. (iltetrir.tl 1-il"htr i. Plant hinq Inrpaehlr
(. Other
.. ...__._. 1 hone h
r