76 HATHORNE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
f' W1 Board of Building Regulations s and Standards CITY OF
Massachusetts State BuildingCode,780 CMR SALEM
Revised Mar 2011
U 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 A LFed: -
J cL.
Building Official(Print Name) 5,g
na a Date
SECTION 1:SITE INFO ION
1.1 Proper Address: 1.2 Asses rs Map&Parcel Numbers
7C fJAf�Pvs Jfi
I.Ia 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 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❑
SEC ION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rec�or�,
<If.,� iA✓ !/AI/S7<.tNs/a+�9�f _({A, yrq
Name(Print) //�!! City,State,ZIP
7G PAr/TOIL 41e -5 978-729•404a
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building d Owner-Occupied ❑ 1 Repairs(s) d I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief,Pescrip[ion of Proposed Work:j2u� CV0 learel'.� feawp ggo& Se FA- 9y/60f oyds 54M 9•c.e
( ca.. . uusfwru 8'X l 4
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ ea1T7 0_ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cos[ (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 13� or-V 0 Pad in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C 5 -/D^7S'w o 1 ob is"
License Number Expiration ate
Name of CSL Holder
List CSL Type(see below) f✓
No.and Street Type Description
w/ U Unrestricted(Buildings u to 35,000 cu.ft.
(/v R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
14i,
SF Solid Fuel Burning Appliances
7d/-a/9-POt 6pzol/d&(,LCflOidoe• Co:,.., I I Insulation
Telephone Email address D Demolition
5.2 RegbJered Home improvement Contractor(HIC)
df3/o 77
z • zoiy
l �`uD I HIC Registration Number Expiration Dale
HIC Company Name or HIC Registrant Name
/? N�ItL/f k/Rtraa 5f' 1-1 to/l14<'ccNofiuAll•Cow.
No.and Str et Email address
City/Town,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 ..........tB' No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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 accur to e b of my knowledge and understanding.
Print Owner's or Authorized Agent's Name( e—q nic 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 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.gov/dos
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"
1ne commonwealth of'MassachuseM
. Department of IndustridAccidents
Office oflnvesdgadons
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lerib '
Name (Business/organization/Individual): hr=- v
Address:
City/State/Zip: v �,GI p4W Phone#: 70, - Mf Fkgg
Are ou as employer?Check the appropriate box: Type of project (required):
1. I am a employer with_ 4. Q I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. Demolition
-haveworkers' — — ------ -- - --
- — working-f6i me in any capacl-.------ - 0IIPIOy��d 3 9. El,Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. E We are a corporation and its 10.❑ Electrical repairs or additions
3. officers have exercised their I am a homeowner doing all work 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.E Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.[9Other i�Y 2>a ik s
comp. insurance required,]
•Any applicant that checks box#]must also fill out the section below showing their workers'compensation policyyinformation -
t homeowners who submit this affidavit indicating they are doing all work and then hue outside contractorsmust submit a new affidavit indicating such.
;Contractors that check this box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have-
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my evployeem Below is the policy and job site
information.
Insurance Company Name:��y/ t✓L �/vyGlQ
Policy#or Self-ins. Lic.#:_ Expiration Date:
Job Site Address: 7G S�i9��tm6z✓e. sf City/State/Zip: - yK./SI
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
i do hereby cern;fy under the p ' an en of perjury that the information provided above is true and correct
ii ature: Date: S ai 1
'hone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
CERTIFICATE OF LIABILITY INSURANCE
O5/20/2013
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. A statement on this certificate does not confer rights to the
certificate holder in tie.of such endorsernerruif.
PRODUCER NAME: ____
Richard P Bertolino it insurance Agency PHONE 978 923 - 6995 - (FAx .(978) 531 - 0718
�AIG.Noy Esp:_( ) _ _`INC Nol
1200 Salem St #121 Ea aiL - -- ��- - -- - ---- -- __-
A011RE55:
Lynnfield, Me 01940 INSURERPr AFFORDING COVERAGE NAIc0
INSURERa Western World
wsuaEo INSURERa ---------
Inc -_,_,_--
NSURER C
5 G Conn Et Unit 11 INSURER D: I
Woburn Mass 01801 _ INS UAERE: i
781-367-8499/781-491-0741 wsuaea 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 PAID CLAIMS,
—mot—POLICY EFF- --PbUC1wEXG
IMF TYPE OF INSURANCE [ UNITS
LT. IINSR WVO P.LICY NUM1I9ER , (MMInOM"!Y) (1dMlnNYYYY)
p GENERAL upeluTv NPP8102912 104/14J201304/14/2014.EACH OCCURRENCE .s 1,000,000
—.
COMMERCIAL GENERAL LABILITY
x" I PREMISES{E.ocnmerKe} IS 1,000,000
'I.CLAIMS-MADE OCCUR MEDEXP(Aly ePers ) 5 1,000
jPERSONAL a ADVINJURY 5 1 DDD DDD
GENERALAGGREGATE E 2 000 OOO
JTA ES PER: PRODIC S COMPIOP AGO E 1,000,000
P
GENLAGG4EGATE LIMIT APPLIES
RO ........
Oc
`A.iOMOBILE UAdILrIY (Ea Gemi � 5
ANY AUTO BODILY INJURY(PaP I S
AU,OWNED SCHEDULED a0O4Y INJURY{Pet a<otlmU 5
AUTOS - AUTOS
NON-OWNED "PRDuERTYDAMAGE -S ---
HIREDAUTOS _ AUTOS (Por,seEmsl}
UMBRELLALIAB ( OCCUR EACH OCCURRENCE S
'ExcEs5 Lta6 �LLNMSMADE ". AGGREGATE S
J DEO I I RETENTION S $
B i WORKERS COMPENSATION B 7pjub 4672p53 6 13 0411912013,1 0 4119/2 014 ToavuMrts ion
AND EMPLOYERIPLUMLITY YIN
ANY PROPRIETORPARTNERE%ECUTIjc EL CH EA ACCIDENT E 100,000
OFFIJERTIEMBEREXCLUDED? ❑I,
("Ame .'reNH) EL DISEABE-EA EMPLOYEE $ 500,000
=.A
1DD,DDOERATIONSEtlaw E.L.DISEASE POLICY
j
i
OEGCRIPTION OF OPERATHINS(LOCATIONS)VEHICLES(Amon ACORD 10i,ACGKonsi Rem moms Sesemi,H mom some is Ammo¢m
Separate text is being ordered for holder from Mass Workers Comp Raiting Bureau
202410359
CERTIFICATE HOLDER CANCELLATION
Catilin Vansteenbury
76 Hathorne St SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Salem Mass 01970 ACCORDANCE WITH THE POLit)Y PROVISIONS,
pUTHOR¢ED REPRESENTATNF t\
�19 01O ACORD CORPORATION. AO rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Estimate
Date Estimate#
r , .
'��� - 4/15/2013 259
^" 13 Conn St
AL Woburn, MA 01801
1877 780 8499
Name/Address JBF COMPANIES INC: Divisions
Catlin Vansteensburg JBF Painting Services
76 harthome st JBF Cleaning Services
Salem,ma JBF Seal-Coating Services.
WWW.JBFCOMPANIESINC.COM
Item Description Qty Rate Total
10 Exterior Trim... Front Porch Service: 8,000.00 8,000.00
Remove existing decks with bricks and all debris.
Build 02 new front porch 8 x 14,on the first and second
floor.
First Floor Deck with PVC Ceiling,
First and Second Floors Railing build with PVC.
Face of deck with 1 xl0 PVC boards.
Under of first deck will be install PVC lattice/
Floors will be used PVC decking boards
Vendor Home Depot
type of materials:Veranda 15/16 in.x 5-1/4 in.x 8 ft.
Brown/Gray Straight Edge Composite Decking Board
The materials that will be used in the construction are
decks:
Pressure treated,PVC,concrete cement,adze boards and
lattice,compound floor,PVC railings and posts sleve.
Second floor deck will be build a rubber deck floor,with
compound floor on the top.
Deck size 8'x 14'.
floor size 8'x 14'.(PVC Compound floor)on 02 deck
floor.
This price will include carpenters labor,all materials
supplies,construction debris removal,permits and
Authorized Signature: Total *,00,9M
Note:This Proposal may be withdraw by us in not accepeted within _days.
All Materials is guaranteed to as specified.All work to be completed in a workmanlike manner,according to
standard pratctices.Any alteration or deviatin from above specifications involving extra costs will be executed
only upon written orders,and will become extra charge over and above the estimate.All agreements Down Payment�z _.�
contingents upon strikes,accidents or delays beyondour contyrol.Owner to carry fire,tornado and other ,job Start........................
necessary insurance.Our works are fully covered by Worksmen's Compesation Insurance Job Completion...............
The Above procces,spec i c'fitions and conditions are satisfactory and are hereby accepted.You are authorized
to do the work as speci ed. aW et Ibem ea5 outline above.
TotalU� •• (• ••••••••••
Customer Signature: (
Date of Acceptance:- t /
Page 1
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor �..
a
License: CS 102574
FABIO I ALVES ,
13 NORTH WARRE
Woburn MA 01801
Expiration
Commissioner 02f06/2015
r �� CPoo,vvmo�uoea///a n�'P/��.amacl a4eCtJ
office of Consumer Affairs&Business Regulation
FIOME IMPROVEMENT CONTRACTOR Type:
tegisttahon 132277
�xpirauon -12Y20/2014 Private Corporatic
FABIO'S PAINTING
4 1
FABIO ALVES
13 NORTH WARREN
WOBURN,MA 01801 - Undersecretary
•t '
1