282 HIGHLAND AVE - BUILDING INSPECTION (2) � y /
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CfrY OF
Ij Massachusetts State Building Code, 730 CMR Revised LEt nr10//
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This SactionForOfficial UseOnl ..
Building Permit Number: Data Ap.lied,
7.
Bwlding Official(Print Name Date
SECTION 1:SITE INFORIMATION
Ll Pr perty Address: 1.2 Assessors bfap& Parcel Numbers
L
1.1 a Is this an acre ted street?ye9 no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54)f 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone. _ Outside Flood Zone?Check if yesO Municipal❑ On site disposal system ❑
' 3EGTIONI:; PROPERTB'0}VNERSIID'l': . .
2.1 Ownertof.Rccord: ,
R RAI K y—a'D I 5 A-L G1
Nome(Print) City,State,ZIP
zgz 114(2( �y) A-,,<� T78
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKs'(check all that apply}
New Construction ❑ Existing Buildin Owner•Occupiedx R'epairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
'Tn a u u�r'Iv
SECTION4: ESTINLATED CONSTRUCTION COSTS-
Item Estimated Costs: OfRclnl Use Onl
Labor and Materials y'
I. Building 5 I. Building Permit Fee-S fndicdte Haw fee is determined:
�. F,lectrictd g ❑Standard.City/Gown Application Fee'
❑Total Pidject Cost(Item.6)x multiplier x
3. Plumbing i 2. Other Fees: $
1. ,Mechanical (IIVAC) S List:
Ji ,Mechanical (Fira $ -
in� trcs,ion) _ !'oral All Fees: S_
- Check No. _Cheek Antoutu: -Cush Autount--
n I'ntol Project ('nit S �000 � f ❑ P.tid iu Poll ❑Outstandiu" Ikdancc Uud:
C
srcrION 5: CONs,rRUCTION SERVICES
5.1 Construction Supervisor Liecnse(CSL) Lp Z2`1 3 .--
— License Number Cspiratiott Date
Name of CSL I loftier List CSL'rype(x a below)
3 Q LkAei Type Description
No. and Street U Unrestricted Duildin s u to 35,000 cu. ft.
R Restricted 13c?F;unil Dwellio
City/rown,State, ZIP M R%oo
RC ootin Covering
INS Window and Siding
SF Solid Fucl Burning Appliances
r✓� trlJMCaT I Insulation
1'de hone Email address D Demolition
5.2 Registered Home Improvement
Contractor
ContractorllllC
1 U � JJ be / xP znU .0 HIC Registration Num
I IIC Company Name or IIIC Registrant Name
AO (A)C( o hGsr. ae r
Nand Street Em 1 address
S'A-r-k.c^'r Ni 64 O r,t 76 — -
Ci /Town State ZIP role hone
SECTION 6: WORKERS' COMPENSATION INSUILUvfCE AFFIDAVIT(NI.G.L.e. 152.1 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 oft he subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owne s Name(Electronic Signature) 1e
SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest undcr the pains and penalties of perjury that all of the information
contained in this ap ip ication is and accurate to the best of my knowledge and understanding.
c.ltY4' J2-✓d
L/ fl,A t 7 f3
�t
Print Qwner's or Authurited:\gent's Nana(Electronic Signature)
ale
NOTES:
I. An Owner who obtains a building permit to do I isiher own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),will mr have access to the arbitration
program or guaranty find under M.G.L. e. 142A. Other important information on the HIC Program can be found at
www nias+.-uv%oca Information on the Construction Supervisor License can be found at www ntass.,nn-dL
2 When substantial work is planned,provide the information below:
rood floor area(iq. It.) _____ —(including garage, tinished basement/attics,decks or porch)
ths; living:uca y. It.l ___ ilabitable room count
o _
tirrp Ot;_-------_— Number of bcdronms
Nninbcr of --__.__-- --__-_--
Nuutberofb,uhrnouts .- ------ NNumberofhalt'baths .-- ---- ____---
- -
1`,pc of lwming ;y;tcut nmbcr of deck..'porihcs
_... ---
Eneloiet t pen _ . ...
t ..I,,t.d I'r,q;et Oyu u'c I,110l rva" w.tv he ;iib;tiott.,l t.,r I
CITY OF S:U-ENt t
, >.�L1SsaCHLSETT'S
(` yr ��� BULOLNG DEP.%x nLF'NT
�, • r t` ( 120 CKISHLVG 1O TON JT;tEEr, 3 t=cOat
T'EL (978) 743-9395
t<11t0E'tLBY 0RISCOLL F�c(978) TW-9343
;rL�Yo.Z -ITIos USrPtEalta
❑RECTOR of pt:OLIC pROPE:aTY/Bt:LMLVG COSL%(ISSIO.VEA
Construction Debris Disposal At'tldavit
(required tot all demalitiun and renovation work)
fn accordance with till sixth edition of the State Building Coda, 730 CibiR section i t L
Dcbris, and the provisions of MGL c 40, S 54; S
Building Permit hi is issued with the condition that the debris resulting front
this wurk shall be disposed of in a properly licensed waste disposal facility as defined by NfGL c
I 11, S 150A.
Thu debris will be rnulsported by:
n--
(name ut'haulur)
The tlQbris will be disposed of in
(name ut t'lctlit%)
- (rdtLess ol'fir�ili t%)
,i(uamre ofpermit dppliednt
i! CITY OF S:1Iml, L -LUSACHUSETTS
BUILDING DEPARTMENT
3 ) 3• 120 WASHLNIGTON STREET, Sea FLOOR
T EL (978)745-9595
F e(978)740-9846
KI.N(BERT F.Y DRISCOLL 'IT• msST.Fomitu
MAYOR
DIRECTOR OF PUBLIC PROPERTY/Hl:1LDL`1G COMMISSIONER.
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
applicant information 1 Please Print Legibly
Naive(Busiixs&Organizatiorvindividual): I(4kE3
Address:City/State/Zip: sKt4 'l mA— Phone M: T7,1K 77[(//
`,?
Are you an employer?Check t appropriate box: Type of project(required):
I am a cm to cr with� d• ❑ 1 am a general contractor and I
P Y 6. ❑New construction
employees(full and/or pa time).• have hind the subr:ontractan
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These subcontractors have 9. 0 Demolition
working for me in any capacity. workers'comp:instuancc 9. C1 Building addition
(No workers'comp.insurance 5.'❑ We.are a corporation and its.
required.) offTceri have exercised their 10.❑Electrical repairs or additions
3.ElI am a homeowner doing all work right of exemption per MGL 1 LQ Plumbing repairs or additions
myself.[No workers'comp. c. 152,of 1(4y,and we have no 12
E1 Roof repairs
insurance required.)t employees:[No workers'. 13. Other._lri'l jltLQ'f1
comp.insurance rcquirrcd.)
'Any applicant char checks bon el mutt also fill out the saciioe below showing their"keni*compentatlan policy inrunnatiou,
r I Nuneuwners whd submit this affidavit indicating They am doing all work and then We oulsitfe contractors must submit a new aardavit indicating such.
!Contractors that cheek This box must anachad an additional Acci showing The time oft 6ndsa rlrrctom and]how workan'Wants,policy infoconanon,
f am an employer float is pravfdlnR workers'compensation Graarancefor my employees; Below lx the pollry and Job site
infornratlon. _-/t^
Insurance Company Name.,_ ! �e ��/,
Policy U or Self-ins.Lic. di �b 7 �7 3�f1' — I e/ Expiration Date: 3
Job Site Addruss: City/Statr/Zip:
Attacts 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
tine up to S1,500.00 and/or one-year imprisonmM as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S25o.o0 a day against the violator. Be advised that a copy of this statement may be furwardud to the Office of
Investigadans ul•dte DIA for insurance coverage verification.
l do hereby e t jy turder the pints wed penaldes of perJury that the hrfermatlwr provided abyve is treu and CtlrreeL
1: '
Sr:a;lhuc: 7 � Dora• T/(Jf
PhonaA
OJJlcial use wily. Do not rurife in this area,to be completed by city or town afj7r1,1
citynr'ruwn: Permlt/f.lcensed _
laming Aulhority(circle one):
1. Board of llcullh 2. Building Department 3.Cityrrown Clerk 4. Electrical hupcetor 5, Plumbing Inspector
6.Other
Contact Person: . _ _____. Phone M:
l
t(lgntlax INC-1 5/ LiF/ LU1'3 O : lb : U:3 Am YANG G/ UUL. rdX OUXV01
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
T e TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCAT
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 and endorsement. A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsements).
PRODUCER CONTACT
NAME:
EASTERN INS GROTJP LLC PHONE FAX
155 B OTIS STREET (A/C,No,Exh: (A/C,No):
E-MAIL
NORTHBOROIJGH,MA 01532-2456 ADDRESS:
73SHH INSURER(S)AFFORDING COVERAGE NAIC IS
INSURERA: TRAVELERS INDEMNITY CO.
INSURED
MASS WEATHERIZATION INC INSURER B:
INSURER C:
INSURER D:
3 OCEAN AVE INSURER E:
SALEM, MA 01970 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS O CERTIFY THAT THE POLICIES O INSURANCE B A e SS E 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. LIMITSSHOWNMAY
HAVE BEEN REDUCED BY PAID CLAIMS. '
INSR ADD SUB POLICY OFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MNTDDWY OT (MMIDD\YYYY) LIMITS
GENERAL LIABILITY ACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S
CLAIMS MADE =OCCUR. IREMISES(Ea occurrence)
VIED EXP(Arty one person) $
ERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $
POLICY 0 PROJECT LOG RODIICTS.COMP/OP AGG,..; $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea acciderd)
ALL OWNED AUTOS BODILY INJURY $
(Perperson)
SCHEDULE AUTOS
BODILY INJURY $
HIRED AUTOS (Per accident)
NON-OWNEDAUTOS PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS MADE AGGREGATE $
DEDUCTOLE
$
RETENTION $
A WORKER'S COMPENSATION AND N/C STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-5844938A-22 09/032022 09/03/2023 `Y uMITs
ANY PROPERIrOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT S 500,000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE I 500,000
(M3Od.WIY In NH)
bye,describe under E.L.DISEASE-POLICY LIMIT S 500,000
CESCRIPTIOtl OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES.ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
THE INSURED'S MA WORKERS COMPENSATION POLICY AND ITS LIMITED OTHER STATES ENDORSEMENT AUTHORIZES THE PAYMENT OF BENEFITS FOR CLAIMS
M.AI)E BY THE INSURED'S MA EMPLOYEES IN STATES OTHER THAN MA. NO AUTHORIZATION IS GIVEN TO PAY CLAIMS FOR BENEFITS IN STATES OTHER
THAN MA IF THE INSURED HIRES,OR HAS HIRED EMPLOYEES OUTSIDE OF MA THIS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHER THAN MA.
CERTIFICATE HOLDER CANCELLATION
UDR INC SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
C/O COMPLIANCE DEPOT IN ACCORDANCE WITH THE POLICY PROVISIONS.
PO BOX 115006 AUTHORIZED REPRESENT PVE t! /
CARROLLTON, TX 75011
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.
�i,
w\, Office of Consumer Affairs&Business Regulation
-..HOME IMPROVEMENT CONTRACTOR
II TOME
111617 Type:
k\ __ expiration: 1/1t2/2015 Private Corporatic
iv',ASS A t A7.HERIZATION. INC
RICHARD LAMBY
3 OCEAN AVE
SALEM, MA 01970 Undersecretary
t�f Massachusetts Department or Pudlu: Safety
Board of Building Regulations and Standaras
('o )shuctimt supercism speciain
icense CSSL 102293 +ta
RICHARD LAMB
3 OCEAN AVENUEd:-
SALEM MA 01970 tw
txo,ration
Comm, ssonit 05/03/2014