48 HATHORNE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CINIR SALEM
�17 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 App ied. .
zz
i
F;;;
PrinaName) .Signature Date.
SECTION I: SITE INFORMATION
Prop r Addr ss: L2 Assessors Map& Parcel Numbers
1.1 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 a 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 Owgert of Rec9g�d:
Name(Print) City, State,ZIP
/, ikAxtw'- .5� F_
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK='(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg, ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
[rem Estimated Costs: Official Use Only-_.,
Labor and Materials
1. Building $ 1 Budding Permit Fee:.$ Indicate how fee is determined:
o. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 'S 2. Other Fees: $
1.%Jechanical (lIVAC) S List:
5. Mochanical (Fiio $
Su)pression) Total All Fees: $ .
Check No. Check Amount: Cash Amount
6. 'l'utal Project Cost: S �2 dvd 0 Paid in Full 0 Outstanding Balance Duo:_____
SECTION 5: CONSTRUCTION SERVICES
5.1 Construe(ion Supervisor License(CSL) Iv 35-3` __
J 3;7✓3,- License Number Expiration Date
Name of CSL I-[older
j S/ a� List CSL Type(see below)
— Type _ Description
No. and Sneet :
415 U Unrestricted Buildin s u to in , cu. ft.)
' U ! �Z R Restricted ISc? FamilyDweltin
City/Town, State, ZIP ivr Masonr
Sf RC RoofWindo Covering
NS Window and Siding
SF Solid Fact Burning Appliances
Insulation
,rcie hone Email address -0010, D Demolition
5.2/R�eg�istered Home Improvement Contractor(11IC)
C_ J L-1�a? l7� hi Up �4�%✓�� � IF IC Registration Number Expiration Date
I [C Company pintoLL�3 rJ:[I stra}(N�ne
L,Q ��t�A// ,
No Email address
City/ own, State, ZIP 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
I, as Owner of the subject property, hereby authorize
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 application is true and aCCUPk7tO th best of my knowledge and understanding.
Print Owner's or Authorized Agent's N te'(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under\LG.L. c. 142A. Other important information on the HIC Program can be found at
www.m1iss.11ov/0ca In format ion on the Construction Supervisor License can be found at ww IV mass.eo�'rdL
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. 11.) _ Habitable room count
Number I)(III Numberofbadrooms
Number of bathrooms -- - lumber of half baths _
type of heating system ___----__--_ Number of decks/porches --
h}'peofcaolingsy,tiie�n Enclosed---_.____---Open --
}. "Total I'loject Square Footuw&' may be substihuod for"Total Project Cost"
f-
i r CITY OF S.-1 Z2M. -NLisSACHUSETI'S
* - � 13u=IN,G DEP-A&T-N MNT
120 WASHINGTON$ 'TREET, 3 FLOOR
TEL (978) 745-9595
KimBERLEY DRISCOLL F•`CX(978) 740-9M
tiLAYOR THO.%Gu ST.PIERRs r DutECTOR OF PUBLIC PROPERTY/BUMDN<;CO\L\fISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition ofthe State Building Code, 780 CMR section 111.5
Debris, and the provisions of ibfGL c 40, S 54;
Building Permit 9 is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
s�P
(name of facility)
(address of taci lily)
signature of permit applicant
date
From:Suzette Mora FaxID:V,eiros Insurance A Page 2 of 2 Date:7/1002012 01:20 PM Page:2 Or 2
COVERIT-01 MOSU
07
acoRo CERTIFICATE OF LIABILITY INSURANCE DATE2112012Ml"2012 I
3I
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. Astatement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER (508)676-0309 NA EFR Suzette Moniz
Viveiros Insurance Agency,Inc. PHONE ,508-676-0309 bvc.Nol:508-324-9147
AIC No.EM.
375 Airport Road -MAIL
Fall River,MA 0272E ADOREsr SMoniz@Viveiroslnsurance.com _ _
INSURER(SI AFFORDING COVERAGE NAIL 0
INSURERA:Travelers Indemnity Of America 125666
INSURED Cover Rite Siding&Windows Corp INSURER B: _-I _
1015 Broadway wsuRER c
Haverhill,MA 01830- INSURER 0:
INSURER E'
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 SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PA
AIIDD CLAIMS.
ILTR NPE OF INSURANCE (NS lyly PJLICY NUMBER (M VLDO�M'1'YI IMMDD/YYl'YI
MI a
GENERAL LIABILITY 1 I EAIP OCCURRENCE o
-
COMMERCIAL eENERAi.LIABILITY i P.EMISCS Ed occurranas' S
JA.IMS-MBE E OCCUR MED EKP(Anv one peasonl $
PERSONFL S ACV INJURY
GENERF AGGRECAAT`[ 3
6EN'L AGGREGATE LIMIT APPLIES PER (PRODUCTS-COMP/OP AGO S
FOLIC( PRO-ECTLDC 6
1 AUTOMOBILE LIABILITY iEa°MBINEOe<cdandIINGLE LIMIT i S
ANV AUTO 1 EODILY INJURY(Per rxrson) 13
ALL OWNED SCIPEDULED 'oODILV'INJURY(Par acm0anq 15
AUTOS IAUrOS -
IIaEoAur0G �DN-OWNED r PF EAEAYD—CE s
ILI,CIS
UMBRELLA IIAB
OCCUR [-.Lr.00CURRcWCE S
EXCESS LIAR CLAIMS-MADE AGGREGA_ $
OEU I I RETEMION S %
WORKERS COMPENSATON wC JTAPJ- OT:i
AND EMPLOYERS'LIASILT X WGY LIMIT[
A �FICEOPPIETOR E�TN-EXECUTIVE ih, NIA IIH-UB-6624X63-A-12 3;1812012 ' 311 812 01 3 EL EACH.ACCIDENT Is 100,000
(Mandatory in NH) J IEL DIL9EASE-EA EMPLOYEE($ 100,000
'ya5,dF5Uin2 uncer
DESCRIPTION OF OPERAT IONS Oeio IEI. DISEASE-POUII LIMIT j 500,0E
it III
I I
I �
DESCRIPTION OF OPERATIONS I LOCATONS;VEHICLES (AHagh ACORD 701,Addhional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Cover Rite Siding&Window CorpHE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
9 p ACCORDANCE WITH THE POLICY PROVISIONS.
1015 Broadway
Haverhill,MA 01830- AUTHORIZED REPRESENTATNE
OO 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(201010S) The ACORD name and logo are registered marks of ACORD
F
CITY OF SiU2,NI, I/'LiSSACHUSETTS
�BL•ILDING DEPARI-NIEINT
120%yv ASH .NGTON STREET, 3ia FLOOR
T FL (978)745-9595
F.ue(978) 740-9846
KI\tBERLEY DRISCOLI
MAYORT'HO6tAS ST.FIE.QltB
DIRECTOR OF PUBLIC PROPERTY/13UILDLNG CO\LMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t ilicant information _ Please Print Legibly
ss Name iBusiiicorrvanizatiotvindividual): �(J L��r/1. 4.q
Address: e�S 2S A�l6622T /4A
City/State/Z[ Phone hl:
Are ou• employer?Check the appropriate box: Type of project(required):
1 yam a'employer with 4. ❑ 1 am a general contractor and i
employees(tilll and/or part-time).• have hirL'd the sub-contractor ti. ❑New construction
2.❑ I am a sole proprietor or partner• listed on the attached sheet 1 7. ❑Remodeling
Ails and have no employees These subcontractors have Et. ❑Demolition
working for me in any capacity. workers'camp. insurance. 9• Building addition
[No workers comp. insurance 5. 0 We are a corporation and its
rcytdrcJ.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.[]Plumbing repairs or additions
myself.(No workers'comp, e. 152,ei 1(4),and we have no 12.❑ Roof repairs
insurance required.]t 'employees.(No workers'
comp.insurance required.) I3.❑Other
•Any appllcum tha chucks bon rl muss also till out the section below thawing their worken'mmpernuolun policy inlumtatlom
'lh"euwnets who su0mil this atlldovit indicaing they ate doing all work and then hero ualside cantrctor men nctank a new aMdavil indicating such.
:0non etun that cheek this box must mtwhad an addillunal ahea showing the l u nc ut the rheamnctan and Chair worker'comp.policy infotsnation.
/um un employer that lr providing workers'compensadon Ltsurance jar my employees Below Is dupolky and Job site
irrjonnariom /
Insurance Company Name: / ,�/1
Policy a or Scif•ins. Lie. d: ` �1�•��!0n ab..✓'-/X 4 1_22—Z,1,pirution Date:—
Job Site Address: ///Y7 6 Si City/State/2ip: S,2 4:,e AW—f_�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
f ailuru to sucura coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penaltiaa of a
fine up to S1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to SM.00 a Jay against ilia violator. Ile advised that a copy of this statement may Ix forwarded to the OI'f ica of -
Invesligwiuns ul'the DiA fur insurance coverage verification
/do hereby crrrljy under t Spain old, nu ties it/perjury that the/njorntatlorr provided above is true and correct
Si'snnure• / 3����
Phone r1• // / -J6v S -
OJJlciat use only. Oa not write in dds area; to be coalplered by city or lawn n/jlclat
I
City or'rown.. __ .__ Prrmltfl.lecme tJ
Issuing Auiliorily(circle one):
1. hoard of liealth Z. ❑uilding lieparhnent 3.Cilylrown Clerk 4. Llectrical htspcetor 5. Plumbing inspector
6.Other
Cunlact Person: Phone f<• -
�;, COVER-RITE
,. Siding & Window Corp.
Siding& Window Specialists
Haverhill,MA 1015 BROADWAY Atkinson, NH
978-372-3260 ed HAVERHILL, MA 01832
SIDING 'S4LO,(.I Home Improvement Contractor Lic#112392 603-362-9951
�D� Construction Supervisor Lic#103535 WINDOWS
GUTTERS OSHA Certified BBB_ ROOFING
FREE . coverritecorp.comFULLY
ESTIMATES coverrite1976@gmail.com INSURED
PROPOSAL SUBMITTED_TO PHONE DATE
TT
STREET JOB NAME
CITY,STATE,AND ZIP JOB LOCATION
- J
We hereby submit specifications and estimates for:
Color /4A??srz /t�EStyle S'� .yi — Insul. Window Trim Trim Color
JOB OUTLINE COST JOB OUTLINE COST
Siding ✓� 3—Gutters LJ
'8 Insulation /SJ44-1
�D 'Facia Cover ;2// W Siding Removal
Facia Board Replmt. Windows
Soffit Cover LJ Windows
Windows Full-Sills Doors
Door Casings Ceiling
Shutters Roof
NOTES:
We V ropoge hereby to furnish material and labor-complete in accordance with above specifications, for the sum of:
dollars ($ DOp.PAYMENT TO BE MADE AS FOLLOWS:
All material is guaranteed to be as specified.All work to be completed in a workmanlike manner Authorized
according to standard practices.Any altereticn or deviation from above specifications involving extra Signature .%
costs will ba executed upon written orders and will bergme an extra merge over and aboveestimale. �i
All agreements contingent upon strikes,accidents,or delays beyond our control.Owner Io carry fire, Nate:This proposal may be
tornado and other necessary insurance.Ourworkers are fully covered by Workmen's Compensations Withdrawn by us if not d accepte Within
+ { TT days.
LYCCC�tAiTCC Of �rOpO�tIl-The above prices,specifications Signature
and conditions are satisfactory and hereby accepted.Vou are authorized to do work
specified.Payment will be made as outlined above
Date of Acceptance: 0 .1R is Sig
Vlacsaahucetfx- Department of Public S.tfet,
Bo:trtl of it
tj
jCpnstrig Rigulatiilns.atiJ Stantl trd6'
uctfon Supervisor: License w,
.L:. _ .
License p
CS 103535 k,t
Restricted to:. 001, w #
}-JOHN SERRATORE, ; .
n _15 SMYTHE ST
:,HAVERHILL, MA01930,
Expiration: 1.1/5r2013 '
_Cnnnnisvionrrl` TrNi 103W&•..
�� � ✓dfa
? .Office of Coosmher fa it B srot$ Re9r, n 4
HOME IMPROVEMENT CON TRACTOR,:. Type"'r.
Reglstratlooc,ot12392 - private CorFiorati
Expiration 312T@013
C ' ER-RITE SIDIN(xL§_ t'�. W CORP
_1t [ John SERRATORE,,�`� - rt�. -