10 HAZEL ST - BUILDING INSPECTION (2) lE J
a
The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
\ Massachusetts State Building Code, 780 CMR, 7 h edition OF SALEM
Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Co issioner/Irrspedtor of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property ddress: 1.2 Assessors Map&Parcel Numbers
/
1.la 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) e
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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1�Own1e_r�'�of Re�yypprd:
7n1 Nlctnniot� / D 1'��e� .
Na (Pr nt) Addres for Service:
% ? 617 -d91 -8Ag1
nature Telephode
SECTION 3:DESCRIPTION OF PROPOSED WORK'(chec,h all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) 4 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I�i `.3 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
i
5. Mechanical (Fire $ �
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
. h ^
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed
Construction
"�Supervisor(CSL) 7,9s 73 12
_ ,1 IILV�((1y c(ytj 0 License Number Expiration Date
Name of CS Holder
' List CSL Type(see below)
Addre a Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Si -to re M Masonry Only
7g1 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 K iste ed lJome Im rovement Contractor(HIC)
t��1o ' Vern. loy (z 9-73
MCC om�pti• �Name o IC Registrant Na a Registration Number
l 7 t-11 9 OAS /3/1
Ad s -7r 1-38 IQ
' (6 Expiration Date
nature 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
1 p (� ycvinlnh as Owner of the subject property hereby
authorize h! I Qr Yy,.�hi� to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si tare of Owner Date
II SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1,— +Ih(`l I P �fff t��ID as Owner or Authorized Agent hereby declare
that the statement ins d information on the foregoing application are true and accurate,to the best of my knowledge and
behalf n"ak
iv
Print N n /
i Y ,
SFgnature of Owner or MthorizeZI Agent Date`
(Signed under the pains and penalties of perjury)
NOTES:
1. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
h Tire Conmonweaith of Massachusetis
Department of Industrial Accidents
4, Office of Investigations
-4 600 Washington Street
Boston,MA 02111
www;neass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( t Please Print Legibly
Naiiie (Businessi0rganirationrindividual):.--q)vl-iii"`�L(0_
Address: ------
City/State/Lip: -ReVeCe ✓_hHp2►51 Phone;'.': 781 -38 ---t G10 ---_
Are you an employer!Check the appropriate box: Type of project(required):
t 4. ❑ I am a general contractor and I
-❑ 1 am a employer with
I employees(1,011 and/or part-time)."
have hired the subcontractors 6. ❑ New construction
_'.❑ I am a sole proprietor or partner- listed on the attached sliest. 7. ❑ Remodeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in anv capacity. employees and have w r orke •
p comp. insurance.- q. ❑ Building addition
No workers' comp- insurance 1.
required.1 5- ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing.all work oflicers have exercised their ME] Plumbing repairs or additions
nrvsell: [No workers' camp. right of exemption per MGI.
12.[] Roof repair.,
insurance required.] ' c. 152• ti 1(4),and we have no
employees. [No workers' 13.❑
comp. insurance required.
'Any applicant that check;box pI nmst:lso till out dye section belowshmvine their tro6crs'compensation policy information.
lionuowner.,who submit this allidavil indicatinc the,are doing all work and than hire outside contractor must submit a ncsv affidavit indicating such.
Contractors that cheek this host nmst attached an additional sheet shoving Lite name of the.uh-conattoors and state whether or not those nnitier hart
enmloyees. II the sub-contractor have employees.Ihcv must nro,ide(heir scorkers'comp.policy number.
I ain an eniplgrer that is providing workers corerpensation inserraitce for tety employees. Below is the policy and job site
information. . tt�
InsuranceCompam —¢
'Name: cJOf1P-I jVV _Vj34i0
Policy or Self ins. Lic.4: f) -�0"Q,L_ - I:a ;ration Date: l$ 'I
51$13�-- A— -
Job Site nddrcss:--_j Q__I f Z ----�r.__-----------------City/State//ip:__�e/m1__�iT ,_D!q2o
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 MG1.c. I52 can ]cad to the imposition of criminal penalties of a
fine up 10$1.500.00 and/or one-year imprisonment.as wetl as civil penalties in the forin of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o1
Investigations of the DIA for insurance coverage verification.
I r/o lteral!6 cent/fi'tut the p ns and penalties ojperjurr that the/ujornartioa prvmided shore is free and correct.
Siena Date:
Phone 781-3_8�- O
------- - - -------- — ----- - - —
Official use only. Do not%rile in thiv area.to be completed by cio•or lown 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#•
�Y
Massachusetts Department of Public S rfcty
Board of Building Regulations and Standards
Cohstiulb bn Su,perxisor License k<< ,..
License: CS 72M .
Re-stricted.to: 00 .
PHILLIP J VERNAC6H16 III
17 CLIFTON ST f $
REVERE, MA 02151 1
Expiration: 4/272012
21059
fe '�omvinoewreal ol-A"adwjoM License or registration valid for individul use only,
i •. Office of consumer Affairs&Business,Regulation .before the expiration date._If found return to:-
HOME IMPROVEMENT CONTRACTOR
Office of Consumer Affairs and Business Regulation '
- ' _ 10 Park Plaza1 Suite'S170
Registration„ N129273
Expiration 8/312011 Tr# 287252 Boston,MA 02116 +
Type tr Indvidual (. � / <
Philip J Vernacchio III l'pj.. n
philip Vernacchio 111
17 Clifton St.
�...�. . Undersecretary Notvalid out signature
e� Revere,MA 02.151 ,'„ ..,�,�.,, _ .I
Frc sent by - 12-09-10 09:10 Pg: 1/1
OP ID:JT
CERTIFICATE OF LIABILITY INSURANCE °1' 2:01110
lvasfio
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(les) must be endorsed. H SUBROGATION IS WAIVED,subjea to
the terms and Condions of the policy,certain Policies may require an endorsement A statement on this Certificate does not Confer rights to the
certificate holder in ItiIS of sMCh endorsement(s).
PRODUCER 781-2454300 CONTACT
Chas. F. Hartshorne NAME,
781-246 5810 PHONE FA
3 Chestnut St 9w.ftlk 1a.5 Nee
Wakefield,MA 01880 ADDRESS:
Chas. F.Hartshorne a Son,Inc ROO ffiID*:GERAD-1_
.. - INSURER(s)AFFORDENG COMERAOE - NAICI
NasuREc 5 Birch Laserta INSURER A:NGM Insurance Company 14788
5 Birch Lane -- -- � -�
Topsfield, MA01983 INSURERS:.
INSURER C:
MSURER D:
INSURER E
M$URER F: -
COVERAGES CERTIFICATENUMBER: REVISk7NNUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSVREO 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.
MLYR TYPEOF WSIIRANCE S POLACT NUMBER POLIO FF N LILY E)yY .. LIMITS
GENERALUABIMTY MINKI,
EACH OCCURRENCE 8 1,000.00
A X COMMERCIAL GENERAL LIABILITY MPK5183X 10/18110 10N8111 AA'A oR -
PIIEMISESIEAncartgnON - 5 S00,00
CWMS-MADE OCCUR MED EXP NAM a,m pgmm) $ 10,00
PERSONAL 8 AM INJURY $ 1,000,00
'� GENERAL AGGREGATE _ $ 2.000,00
GEN'L AGGREGATE LIMIT APPLIES PER. PROWCTS•COMPpP AGG $ 2,000,0
POLICY PRO- LOG
AUTOMOBILE LIABILITY COMnINED SINGLE LIMIT
(Ee ecudeN) S 300,00
A ANY AUTO M9064816 G4/24110 04/24111
ALLOWNEDAUTOS BODILY INJURY(P,,r Pp j E
BODILY INJURY(Parac w) $
X SCHEDULED AUTOS
HIRED AUTOS PROPERTYDAMAGE $
(Pm Pcdden0 _
NON-OWNED AUTOS $
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCE55 UAB OIAUAS+AADE
AGGREGATE ... $
...-- DEDUCTIBLE .... .. ....- $ ...
RETENTION $ S
WORKERS COMPENSATION WC STATIY OTH-
ANDEMPLOYERS'LIABILITY YfN ?Ofly_
ANYPROPRIETORIPARTNER/ XECUTNE S
OFFIGE EMBER EXCLUDED? ❑ EL.EACH ACCIDENT
N/A
(Mandatory In NH) F.I,DISEASE-EA EMPLO E
Ify dlK "Under .. .
OLM IPTION OF OPERATIONS thew I E.L.DISEASE-POLICY LIMIT S
DESGRIPTIONOFOPERAMNSILOCARONS/VEHICLES (Aeed1ACORD101.Addtdoml ReRWnefthe ul,fmmespaul ,nmtO
CERTIFICATE HOLDER CANCELLATION
Grimm
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Gloucester ACCORDANCE WITH THE POLICY PROVISIONS. ..
3 Pond Road
Gloucester,MA 01930 AUTHORIZED REPRESENTATIVE
Chas.F.Hartshorne&Son,Inc
01988-2009 ACORD CORPORATION. All nights reserved.
ACORD 25(2002109) The ACORD name and IOgo are registered marks of ACORD
I