14 HARDY ST - BUILDING INSPECTION Q The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7'"editio loomemoo
n
Building Dept
Building Permit Application To Construct, Rrpair, Renovate Or Demolish a
One- or Tyro-Fumilr Dwelling
This Section For Official Use Only
Building Permit Num r:/� Dale Applied: y/��
Signature: V V 7 O
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
I.I Property Address: 1.2 Ass s ors Map& Parcel Numbers
i - f.!AL Sf j ,1 r,f 3
L l a Is this an accepted street°yes�l no Map umber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: o
0? aP,d dy d
Zoning District Proposed Use Lot Area(sq 11) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
y .f, a„
[PI,
.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.9 Sewage Disposal Sys em:
blic 2'� Private❑ Zone: _ Outside Flood Zone? Municipal @'On site disposal system ❑
Check if esl° '
SECTION 2: PROPERTY OWNERSHIP'
:.V � 1Q K(r•rdp)W6LVII Z /# �>9 yS �t e>n,
Name(Print Address for Service:
c U a-�21-0! Qaf 979-
Signature Cu/t Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek all that apply)
New Construction O Existing Building Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. O Number of Units / Other ❑ Specify:
Brief Description of Proposed Work':-
417
E� SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMCIBI Use Only
Labor and Materials
I. Building S / .U,q0 1. Building Permit Fee: S Indicate how Fee is determined:
2. Electrical S Cl Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
J. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) S List:
S .Mechanical (Fire S
Su resa is Total All Fees: S
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S /]^( 6-00 ❑ Paid in Full O Outstanding Balance Due:
����� 1�71
t
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Comtruction Supervisor(CSL)
" Lacrue Number Expiration Dote
Nyoc of CSL- HylJer Lm CSL Type(we tic-low)
a
T pcscn non
Address U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&2 Family D%cllm
Signature M Masonry Only
RC Rcstdennal Roofing Covering
Telephone WS Restdemtal Window and Siding
SF Restdenual Solid Fuel 8umin Appliance Installation
D Residential Demolition
5.1 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Dale
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 151.S 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? Yea .......... O No........... O
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 to act on my behalf,in all matters
Jha
o work authorized by this building permit application.
of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
tatements and information on the foregoing application are true and accurate, to the best of my knowledge and
ef Owner or Authorized Agent Date
der the ains and nahies of r-u
NOTES:
I. 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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.R3, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/altics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces .Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decksi porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage-may he substituted for 'Total Pro)ect Cost"
CITY OF SIU_XEM. ILkSSACHUSETI-S
8L'ILDLNG DEP.%RTNWNT
• 120-WASHINGTON STREET. 3a'FLOOR
TEL (978) 745-959S
F.tx(978) 740.9846
Kl.(J)F1tIEY DRiSCOIl
T HOMU ST.PtFJtRs
MAYOR Fy DI
DIRECTOR OFPLBLICPROPERTY/8VI DMGCO-%L%OSSlO%ER
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers
%lifilicant Information / 7 �1 Please PrintLeaibb�lY����
Nalnc (Busin, OrganrrationlnJsv,dal)��/�l1f-
a J A� �l�2�1' /✓� r'���L/7
Address:3 - lrpAme/ - z-4-
City/State/zip: 'q'4 Phone M: 47Y- v�3 d-0.319
Are you as employer'Check the appropriate has: Type of project(required):
1.❑ 1 am a employer with 4. 011 am a general contractor and 1 6. ❑New construction
LI
employees(full and/or part-time).• have hired the subcontractors
2.
�y1 am a sole proprietor or partner-
Iisled on the attached sheet.: 7. 0 Remodeling
,hip and have no employees These sub-contractors have g. ❑Demolition
workin for me in an capacity. workers'comp.insurance
t Y P tY• 9. 0 Building addition
I No workers' comp. insurance S. 0 We are a corporation and its 10.❑Electrical repairs a additions
officers have exercised their
).0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself. [Na,workers'comp. c. 152.41(4),and we have no 12. Roof repairs Pew,
insurance required.] t employs=. IN*workers' I y;/sx*
comp. insurance required.) I J.❑Otha ��
•Any applicant,fur tdirclla toe el mum alatr fi"oos the wiliem belttw Shawnee their wake n nattpaneadsn puliry inrumuda►
an
I Lmrtwraes who submit this aflldevit iodicatieg ater aka doing all tvmk and them him ounide constrictors trial satanil a naw atrldevil indicting sack
:r.mirscrion shot chork this has mud anachad an m1ditionol drat showing rite none of the enk4,tallaalere aN,holy wurkan•comp.policy infomriuem.
/one an employer that is providing workers'compeamdon inomrame for ray employers Below is/he peUay Unarm 1/0r
information.
In..surancc Company Name:fIR 6 e//i9 t9
Policy 4 or Self-inn. Lic.a: ek DOO Z / 5 013 Expiration Date: /D
Job Site Address: / y JY4,,Q t C;(- S"RZ/Q)Y( Cityislate/zip: O/970
,attack a copy of the workers'compensation policy declaration page(showing the policy number and aspiration slate)`
Failure to secure coverage as required under Scclion 25A of MGL e. 152 can lead to the imposition of criminal penalties of
nine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a firma
Of up to S250.00 a Jay against the violator. Ile adviavi that a copy of this statement may be rorwurded to the OI•lice of
In%vsnguiiona of the MA for insurance coverage veritication.
/da here epit o er th pains and pens Its of perfury that the beformalsom provided above is true wood correct
01rhiai use auly. Do nor write in this area, to be.ump/eted by city or lawn ,ff,-wI
City or fuwn: _ eermit/lAccnseM__„
lauing .whunty (circle )ne): - - -�_
L Ilsrard of IltaUh 2. Building Deparrmenl ). City/rown Clerk 4. Electrical Innspector 5. Plumbing Inspector
6. Other _
t.,nlact Peron: _ __ . Phonee: __.._
A�.1 DATE(WAMOIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 3/11/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Phil Richard s Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
491 Maple Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 102 --
Danvers, MA 01923 INSURERS AFFORDING COVERAGE NAIC#
INSURED _ .. _. . .... ._...
INSURER A.A:
Robert Sacramone INSURER B'. Arbella Protection
13 Murray St INSURERC.
Peabody, MA 01960 ,INSURER0
INSURER E:
COVERAGES
THE POLICES 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 TOALL THETERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR POLICY NUMBER POLICY EFFECTIVE POUCi EXPI RATION LIMITS
GENERALLIASILITY 15/09 OesoCCURRENCE S 1 000 000
B X COFTAERCIAL GENE MLUAB ILITY 8500041323 10/15/08 10 Pa IsR NrED
/ (Iaxnmencet $ 50,000
CLAWISWUE ❑OCCUR ! M213 EXP Wynne A.) $ 51000
PERSONALS ADVINJURY S 300,000
GENERAL AGGREGATE S 2,000,000
GENLAGGREGATE LMIT APPLIES PER PRODUCTS-COMP/OP AGG S 1,000,000
POLICY 71 PRO- L.
AUTOMOBILE LIAR UTY
COMB INED SINGLELMN $
ANYAUTO (Ea eccibeM)
ALL O WWD AUTOS
BODILYINJURY $
SCHEDULEDAL90S - (Perperwn)
HIREDAUTOS
BODILY INJURY S
NON-OWNED AUTOS ryeraccldenl)
PROPE RTY DMLAGE $
(Peramitlenq
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANYAUTO OTHER THAN EAACC $
AUTO ONLY: ACC. $
EXCESSIUMBRELLAUABIUTY EACH OCCURRENCE S
OCCUR CLANS MADE I AGGREGATE 4,;
DEDUCTIBLE $
RETENTION WORKERS COMPENSATIONX WC STA1L- OTHANDEMPLOYERS'LIABILITY YINANYPROPRIEIORIPARTNEREXECUTME COVERAGE APPLIED EL.EACH ACCIaNT OFFICIL MEMBER EXCLLAED? I 'pAennamry in NH) FOR 3/il/09 E.L.OISEhSE-EA EMPLOYE ItyyBBs,tlesaibe underSPECIALPRDVISIONSbd. E.L.DISEASE-POLICYLWIT,
OTHER
DESCRIPTION OFOPERATIONS I LOCATIONS I VEHICLES I EXMUSIONS ADDED BY ENDOfSEM ENT I SPECIAL PROVISIONS
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFTHE ABOVE DESCRIBEOPOLICIES SECANCELLEDBEFORE THEEXPIRATION
DATE THEREOF,THE ISSUNGINSURER MILL ENDEAVOR TO MAIL 15 OAYSWRITTEN
NOTICE 1W9tI!FMFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TOM SO SHALL
IMPOSE NO OSUGATTON OR LIABILITY OF ANY HIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIV
AUTHORIZED RE SENTATVe- ,
ACORD 25(2009101) .®19as-200 CORD CORPORA ights roserved.
The ACORD name and logo are registered marks of ACORD
j d eEb :ZO 80 9Z daS
y CITY OF SALLM
?'I PUBLIC: PROPRERTY
DEPARTMENT
'I ,� I.C \1 v. n•.e. ".Y..:IIr � \VIN. \I\••U .I'I .
Construction Debris Disposal .al•tidmit
(rcyuiled Iilr all demo IiIion and rcno%ation wurk)
In accurdance 11 ith the sixth edition of the Slate Building Code, 780 C'AIR section I 1 1.5
Debris, and the provisions uf'vIGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
This work shall he disposed of in it pruperly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will he it by:
1 / �gsf� ,9ry Ge MOW
(name of hauler)
I lie debris will be disposed ofin
(IIJInQ uI IJC I II VI l
Luldrei. ,Ir I,Iclhrol
a � I I c "d 1 r'I .ylphi ails
q'DO9
.IJI:
i
I � �e �arxm.oarwea/0� °�✓�aaa4.`ss/B
p>y'
Board of Building gegulaNaoa and Stasdsrda &
Construction Supervisor License .
Licena` CS 30722
TrN 21351
Expiritlon 1412010 t;
Rear�kea� oP��
PHILIPJ MARQU/,R
3 DAWEL TERR
Commi
PEABODY,MA 01880 u e
ionr i
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 136664 '
Expiration: 8112/2010 Tr# 272596
Tips: Individual
PHILIP J.MARQUADO-
PHILIP MARQUADO.
3-DANIEL TERR. Administrator
PEABODY,MA 01960 I