40-42 HAZEL ST - BUILDING INSPECTION 0 � �, I'he C'onunonsve;d(h of Niwsachusctls
Board of Building Regulations and Standards CI I'1'OF
} Massachusetts State Building Codc. 780 CNIR ti,\Lli.�l
..... /d•I i.%"d I All--11//
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Tun-faniih' Divellii tv
This Section For 01111cial Use Only
Building Permit Number: _ DateApplied:
Building 01116a111'rini NMune) Signature D" 5toF-F'�
SECTION 1:SITE INFORMATION
L I Property Fff� zr� s� 1.2 Asse ddr(ss: ssurs .lap S Parcel Numbers
- - - �Yz 3�
I.la Is this an accepted street?yes no Map Number' Parcel Number
1.3 Zoning Infortnatlon' I.� Property Dimensions:
12 Z r�(���Y�'t_
Luning District Proposed U.se Loi Area(sy 11) frnntuge(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yant
Reyuircd Provided Required Provided Rcyuirad Provided
1.6 Water Supply:(M.G.I.c. )o, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Piibllc❑ Pris ale❑ zone: _ Outside Flood"Luna? Municipal❑ On site disposal s)stem ❑
Check if yesO
SECTION3: PROPERTY OWNERSHIP'
1.1 Owneri of Record:
Nana(Print) City.State.ZIP
No.and Street rcicphone Emuil Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) W I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.0 Number of Units_ Other ❑ Spccily:
Brief Description of Proposed Work':
V l e y t--- L;?I A) CMd FW 2 OyZ-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
ILabor and\Paterials) y
I. Building S -2_Cj0 —1 1. Building Permit Fee: i Indicate how I'ee is determined:
2. I(leclrical S P ❑Standard CitylTosvn Applicalion Fee
O Total Project C'osti(Ilan 6)x multiplier _._— .x
1. 1'himhing S ?. Other Fees S_ -- -
). Nlech.utical ill\ NC) S Lisi:-_ .-__— ---- � . . .
�u„ressioni S rotal .\II Fees: 5—.---_—_--
('heck No. Check Amount:
I, Tnlal PrnjeR Cost: S ❑Paid in Full 0 Outstanding 11.11:mce Otte:
SEC HON15: CON.SI-RUCHONSERVICF-S
5.1
65j I iccow Numhcr F\piralwii Date
list(L'Sl 1)[w(Sce
L cv-. ,I PC
larvstrictO(Iluildimis it,It, IT000"t
Su1cR
Citci ...... .t"t': %I Slasoll
C Ittitilin
%A'S
SF solid Fuel 1311minglApplialiccit
r
r
R
Iu'
7&2 1
) at"
rrimladdrv.mi Demolition
4111 Registered Home Improvement Contractor HIC) Sd-
Pl�eVL J
46,�Z �_&7 .
c Ir"Ilo
lGlibirillion
I 11C Coitipan) Name or I[IC licaliqM1 N
2
Nu. wid Sure• 20 Entuil address
/-W-- lyr Telephone
City/Town.State,ZIP (2/�7 g 2 S,
SECTION 6:WORKERS,COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 153.§ 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 A Mclavit Attached? Yes ,.........0-- No...........C!
SECTION 7s: 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 Ui.lier's Nwiie(Elcorunic Signature) Dula
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 information
a
cont 'lre
d in his application is true and accurate to the best of my knowledge and understanding.
�
11rin cti"I'licSigilaturv) Data
NOTES:
I. An Owner\shu obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
trot registered in the Hums hnprovenxnt ContmctorlHiC) Program),will no have access to the arbitration
program or guaranty t1und under.M.G.L. c. 142.A. Other important information on the HIC Program can be round at
%,\%,% w.,,, i Information on the Construction Supervisor License can be found at%%t%,, tit.1,; go% .111,
2. \k lien substantial%lurk is planned, pru%lle the infuritimiun bclo%v::
rota) floor area(1+ 111 1 including garage. finished basement attics.decks or porch)
Gross living areal 54. It Habitable roust count
of lircph'" Number kil'bcdrooms
\ijintivrol'bathrooms Nulliticr tit liall,hall1i
I Ilk:tit'livaling i,%stein Numberoft.1ccks, porches
I PQ ofcooliliq �Ocla 1,11clo'ed .01'ell
';kpiart: Fool-lec" Ilia) be 'uh,littitcd tier I'ot.11 Project Coll"
CITY OF S,V-&N[, �LkSSACHUSETTs
JLLLDLYC DEP.IATIErt
120 UV.U.4LNCTON SrxW, )'d Amt
CAL k978) 745-9595
U1�ERLfiY DIlLSCO[l, P.Vt(973) 140.9w
MAYO X MO.%W ST.PMAAS
DIR=TOI<OP PCSuc PROPlR7Y/BCRDLYC COSp11331ONe4
Construction Debris Disposal At'tldavit
(required for 311 demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 790 C,�1R section 1 l I.1
Debris, and the ptvvisions o(hiGL o 40, S 14;
9uilding Permit a is issued with the condition that the debris resulting from
INS work shall be disposed of in a properly licensed waste disposal racility as defined by NIGL c
111, S I JOA.
The debris will be transported by:
,)(Z-"x f( (, [,
(nuns of hauler)
The debris wii l l be disposed of in
M :
t��
(nam o— f f— johly) ..
iddrars orrj jjh y)
yn� permiripph.mf
'ua
Q-I'Y OF S,U E.Nf, \rL\SS.ICHUSETTS
1J BUILDING DEP.%wrNLE..NT
��I'i) T;�`I�; ')�'•J 120 WASHLNGTON STREET, 3'u FLOOR
TEL '978 145-9595
Ruc(973) 7.0-9846
i.j. ElLLEY DRISCOLL �otLSSST.PiEaRB
NLAY0A
DIRECTOR OF PCOLIC PROPERTY/OCRDIJ:C,CO\LtIISSlONER
\Vnrkers' Compensation Insurance AMdavit: Builders/ContructurWElectrlciansl Plumbers
\ptsllcant information / Please
APrint Legibly
�Iunr:llluniite.s()r�,tn,7aliun,ln,livid'u`^."'l''l))): � �(�'--Q �}�---N� � r+ �'^t-�Y-
CityiStatc/Zip: Fce Phuneto: ! 210 420 � 5 320
,\re you an employer!Check the appropriate bass Type of project(required):
1.( i at"a employer with � 4. ❑ 1 am a general contractor and i S. ❑Now construction
dntployces(full and/or part-lime).• have hired the sub-contractors
2.❑ [,am n m a suits proprietor or partner- listed o the❑/ached sheet. = L �Remadeling
,hip and have no employees These sub-contractors have V. ❑ Demolition
working for me in any capacity. workers'comp.insurance. I). Q Building addition
(No workers:comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 mn a homeowner doing all work right of exmnplion per MGL 11.0 Plumbing repairs or additions
myself.(No workers'sump, c. 152,41(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. (No workers' 13.❑Olhcr
comf insurance required.]
-nay uppll,are ilia shams liner 1 must alw rill nut the odium WOW Ahaiving their"ken'comptnudon polity masrmoeon.
'I hvnaownvrs who.Basil this amdavit indicating thry an doing all.wrk and the him uuniJr cantneton mot aohsult an"allildavil indicting ruc&
t'mtnwtun that cht<k this but mud anach d an adrhllunel.hael.hawing IN nwna or the n0.coetncwrt anJ their wnheni'wmp.pulley Infatma tan.
!mn un rnrpluyrr shut it pruvldhtX Ivorkus'cumpuuadun Luuruncr�or my unpluyrrr, Belt,at is du policy and fob site
In,urunce urr C.
I n, tce Company None: __......
Policy 4 or Self-itu. Lic.if: Expiration Date:
tub Site Address: Ci(y/State/2ip:
A ltacb a citify of the ivorken' compensation pulley declarallan page(showing the policy number and expiration date).
F.tilura to secure cuverago as required under Section 25a\ut'NIGL c. 152 can lead to the imposition of criminal penalties of a
fire op to i 1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S350.00 a day against Ole viol ifor. Ile idviacd that a copy of thin,ratement may ba iurwardcd to ilia Ohio:of
I,n e,tigJllenr sal ilie MA for I muraocc coverage veriiic.aiun.
/du hereby eerw)y wider thr pubic cord pewaitie.s a/perjury Mot the iwfurmurlor provided above it rrue cord correct
_�..•. t Uatu:
r)l)iciat ore only. Oa our write in this area, to he cmnpfded by city up town iflit'iat
City or 1,own:.___. _ _. I'cr mill(.Iccme i
I sswin;,\ulhurily (circle unc):
I. 11mtrd wf 1lcaith 2. Iluildlmg Dolvirinlent 1. ('ilyirown Clerk J. Uaectrical htylccior i• Plnn1bin4Inrpectar
ACORD. CERTIFICATE OF LIABILITY INSURANCE 01/09/2012
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:II the certificate holder is an ADDITIONAL INSURED,the policy(tes)must be endorsed. If SUBROGATION IS WAIVED,subject to the
terms and conditions of the policy certain policies may require and endorsement. A statement an this corOficats does net confer rights to the
.1fi.te holder in lieu of such endarsement(s).
PRODUCER CONTACT
NAME:
PHONE FAX
CHASE&LUNT LLC (A/C,No,E#): FAX
(NC,No):
POE 590 EMAIL
ADDRESS:
PRODUCER
NEWBURYPORT,MA 01950 CUSTOMER ID M. -
77BPK INSURER(S)AFFORDING COVERAGE NAICI
INSURED INSURERA: TRAVELERS DMECr ASS1GMff2gT
INSURER B:
TURNPO E GENERAL CONTRACTING INC INSURER C:
INSURER D:
239 BOSTON STREET INSURER E:
TOPSHELD,MA 01983 INSURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTFY THATTHE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THEINSURED NAMED ABOVE FORTHE POLICY PERIOOINDICATED.
NOTWITHSTANDING ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER GOCUMENT W ITH RESPECT TO WHICH TMS CERTIFICATE MAY BE ISSUED
OR MAY PERTAIN.THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.
UMUS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDLSUSR POUCY EFF DATE POUCY EXP DATE
TYPEOFINSURANCE POUCYNUMBER IMMtDO1YYYY) (MADmYYYY) LIMITS
LTR MR WOGENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
CLAIMS MADE OCCUR. PREMISES(Ea occurrence)
MED EXP(Any one person) s
PERSONAL&&.ADV INUURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea acddenl)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (FIX person)
HIRED AUTOS BODILY INJURY S
(Per accident)
NON-OWNEDAUTOS PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ S
WCSTATUTORYUMITS OTHER
WORKER'S COMPENSATION AND
EMPLOYER'S LIABILITY YIN UB 4939PI55-11 IW2212011 10222012 E.L.EACH ACCIDENT $ 1,000.000
ANY PROPERITORIPARTNEWEXECUTVE N E.L.DISEASE-EA EMPLOYEE $ 1.000.000
OFFICER/MEMBER EXCLUDED?
E.L.DISEASE-POLICY LIMIT $ 1,000,000
IMandatdrylm NH)
11 yee,desPdee antler
DESCRIPTION OF OPERATIONS heloN
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIRESTRICTIONSISPECIAL ITEMS
TM REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIRCATEBDIDER AFPBCTR`1G WORHITS COMP COVERAGE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Charles J Clark
ACORD 25(2009109) 19BB-2009 ACORD CORPORATION. All rights reserved.
• �'� TURNP-3 OP ID:CA
a�oRO CERTIFICATE OF LIABILITY INSURANCE DA 0112DIYYYYI
1/25/12
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. 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 lieu of such endorsements.
PRODUCER 976-452.4434 CONTACT
NAME:
Chase 8 Lunt LLC 97$-465-8204 PHONE FAX
P O Box 590 A/C No Ex[: AIC No:
47 State Street - E-MAIL
Newbu.Vort,MA 01960 ADDRESS:
Marcos W.Shaner INSURERS AFFORDING COVERAGE NAICA
INSURERA:Scottsdale Insurance Co.
INSURED Turnpike General Contracting INSURER B:Commerce Insurance Company
239 Boston Street
Topsfield,MA 01983 INSURER C:Peerless Insurance Co.
INSURER D:Hanover Insurance Company
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 PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY EFF P LICY EXP LIMITS
LTR POLICY NUMBER MM/DDIYYYY MMIDDiYYYY
GENERAL LIABILITY EACH OCCURRENCE S 1,000,00
A X COMMERCIAL GENERAL LIABILITY 3C$0026080 10121111 10121112 PREMISES Ea occurrence $ 50,00
CLAIMS-MADE OCCUR MEDEXP(Anyonepereon) E 5,00
PERSORALSADVINJURY S 1,000,00
GENERALAGGREGATE S 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,00
POLICY FX I PRO LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMITEd It 1,000,00
B ANY.AUTO BDBRJM 10/20111 10/20/12 BODI LY INJURY(Per pemon) S
ALL OWNED SCHEDULED BODILY INJURY(Per accident) E
AUTOS AUTOS
X HIRED AUTOS N
NON-OWNED PR PERTYDAMAG S
AUTOS Per accident
E
UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00
A X EXCESS UMB CLAIMS-MADE- --- KLS0077698- - - - - 1012411-1 -10121112—AGGREGATE-___ ._-_____-_$__ __-__-6,000:000-_
DED I X I RETENTIONS 0 $
WORKERS COMPENSATION WC STM TH
-
ANDEMPLOYERTUABILITY YIN
ITRY LA ITSANY PROPRIETOR/PARTNERIEXECUDVE EL EACH ACCIDENT S .
OFFICERIMEMSER EXCLUDED? M/A
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $
UseRy ohe es,del under
.
OF OPERATIONS Eelow E.LDISEASE-POUCYUMIT $
C Inland Marine IM8883161 12/01111 12101/12 Materials 250,00
D Commercial Crime 3200939 01117/12 01117113 Limit 100,00
rDESCRIPDON nP nPERAnnNS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORI?cn REPRESENTATIVE
0.1988-2010.ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Unrestricted-Buildings of any use group which ;o" "z
contain less than 35,000 Cubic feet (991m)of Vv 3c, ir-1 or S H,,Y.'�at�,�'
enclosed space. m llsj,il 11 -
C"80145 V.n7,
IV
GEORGE VAS1lbbii![)dKS
5 PTYCAIRN WAY
ipsWICH MA 69125
Failure to possess I CUrrenn.edition of the Massachusetts
State Building Code is cause for revocation of this license,
For DPS Licensing informationvisit: W,,V.M,iss.Go,,v`DP5
10/ &2613
"re"IL 1W f=MC60144S 4'd�Bus ess�Regutatlon 0
0
10 Park Plaza - Suite 5170
Boston, lVissachusetts 02116
Hoine hriprovetb ontractor Registration
Registration: 167667
xt Type: Supplement Card
TURNPIKE GENERAL CONTRA , Expjration: 101412012
GEORGE VASILIADES
239 BOSTON STREET BOX 365(1'
TOPSFIELD, MA 01983 ...............
Update Address and return card.Mark reason for change.
Address [:] Renewal E., Employment Lost Card
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
,a, OMEIMPROVF,MENT CONTRACTOR
before the expiration date. If round return to:
Office of Consumer Affairs and Business Regulation
Registra'uon�iZ7567 Typed 10 Park Plaza-Suite 5170
Expired- Man 12, Supplement Card Boston,MA 02116
TURNPIKE GE' -
ING INC,
GEORGE lif
kZ
239 BOSTON ST
TOPSFIEL A fr! Umlims,i,nifitury Not valid without signature