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34 HILLSIDE AVE - BUILDING INSPECTION (2) r-T> 1,571 The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF M W Massachusetts State Building Code, 780 CMR SALE Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demoli One-or Two-Family Dwelling This Section For Official Use Only 4. imit N ' I � 1, Building Pe umber: 'J, Building Official(Print Narne)lp SECTION 1: SITE INAORMATION 1.1 1.2 Assessors Map&Par el umbers 1.1a 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 Rest 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 0 Private 13 Zone: Outside Flood Zone? Municipal 13 On site disposal system 0 Check ifyesO SECTION 2: PROPERTY OWNERSHIP' 2.1 wnerr of Record: '770 9, Name(Print) City,State,ZIP 3 Y /v,,C C q7r- 7,4'7-':- 7//-'f No.and Street Telephone Email'Addres, I I SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building El Owner-Occupied 0 1 Repairs(ss')�01 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 11 Number of Units Other 0 Specify: Brief Description of Proposed Work 2: b IIVS72) &-Y/57-J � C— �C-4-rz,3 SECTION 4:ESTIMATED CONSTRUCTION COSTS . Item Estimated Costs: (Labor and Materials) Official Use Only. 1.Building $ j-o L Building Permit Fee:$—Indicate how fee is determined: 0 Standard City/Town Application Fee 2.Electrical $ 0 Total Project Costs(Item 6)x multiplier 3.Plumbing $ 2. OtherFees: 4.Mechanical (HVAC) $ List:' 5.Mechanical (Fire $Su ression Total All Fees: $ pp ) Check Amount: Check No. , Cash'Arrount: 6.Total Project Cost: $ P 13 - — ,❑ aid in Full ❑Outstanding Balance Due: , SECTION 5:'CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C -7z77z i /y License Number Expiration Date Name Holder List CSL Type(see below) No.and Street ` " Ty Description U Unrestricted(Buildings up to 35,000 cu.ft. Restricted 1R,2 Family Dwellin City/Town,State,ZIP M Masonry O1 C Z RC Roofing Covering WS Window and Siding //JJ qqV SF Solid Fuel Burning Appliances q 7Y 5-Z I I Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor HIC) Zl6 U2)� �..r4✓'✓ jk/-4-7 .0 F d$'Toi✓ HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name S— Cuwrr,.,✓G/ P-'t�cc No and an Str;et Email address a.• urc�✓ Ot Sru � 73'��93Z- 4�Ydl— Ci /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 provider this affidavit will result in the denial of the Iss a of the building permit. Signed Affidavit Attached? Yes ...... 10. 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 Bi)c �6rTv�✓ to act on my behalf,in all matters relative to work authorized by this building permit application. //36wf G/tTAQT /G /Z Print Owner's Name(Electronic Signature) Date 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 contained in this application is true and ac at to the best of my knowledge and understanding. c not Owner's or Authorized Age!' ame(1le6rcmic Signature) Date 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 can be found at �vww.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 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" CITY OF SM.E14 NAA SSACHUSETTS • BL'ILDLNG DEPA1k11lEDiT 120 W ASHINGTON STREET,3'o FLOOR \ 'ILL. (978)745-9595 FAX(978)740-9846 (O�{gERI.EY DRISCOLL MAYOR THoMAs ST.PmRRa DIRECTOR OF PUBLIC PROPERTY/BUILDING CONZIISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant information Please Print LeeibiK Name(9usim-mOrganiratioNlndividual): //t//N/Jr�.✓ l G2yl rJ`f / S !�s�r� ✓ Address: f C up"oi t yr_f �h2 City/State/Zip: AlorSu4n i 14to- OYf-u/ Phone#: 7Y/- 1,32- e/trd 1' Are you an employer?Check the appropriate box: Type of project(required): 1.❑ lam a employer with 4. 04 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees 'those subcontractors have 1$. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition [No workers'comp. insurance S. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp, c. 152,§I(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' 13.❑Other comp. insurance required.) •Any applicant that checks flax a I most also fill out the section below showing their wwkerst enmpenmion policy information. t I inncownce who submit this affidavit indicating they arc doing all work and then hire outside eommetors most submit a new affidavit indicting such. :Commeton that chuck this box must attachod an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I um an employer that Is providing workers'compensation Insurance jar my employees. Below Is the policy and fob site information. . Insurance Company dame: Policy#ur SelFins.Lie.#: Expiration Date: Job Site Address: 3y fi e s/x /}tJcr City/State/Zip:Sf/,r� Attach a copy of the workers'compensation polity 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 fine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under po' o ury that the information provided above is true and correct. >rr at um• _.. Date: t' _1 Official use only. Do not write in this area,to be completed by city or fawn official City or Town: PermittLicense# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.Cilyrfown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other , Contact Person: _"__ Phone#: i WINDO-2 Op ID: KO Aa_,ORQ� DATE(MM11DDlYYYY) �.� CERTIFICATE OF LIABILITY INSURANCE 03/267,2 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), AUTORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(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 lieu of such endorsements . PRODUCER 336-272-7161 UEACT Senn Dunn-GSO 336-346-1397 HOME IFAX 3625 N. Elm St. MC No Ext) (AID,Net: I P O Box 9375 E-MAIL Greensboro, NC 27429-0375 ADDRESS: C.Timothy Ward,CPCU,CIC - INSURERS)AFFORDING COVERAGE NAIL I INSURER A:Hanover American Insurance Co 3¢064 INSURED Window World of Boston, LLC INSURER a:The Hartford Ins Group 118 Shaver Street North Wilkesboro,NC 28659 INSURER C: INSURER D: 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR ADM SUBR TYPE OF INSURANCE LIMITS LTR NS POLICY NUMBER MMIp MMIODIYVW GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A COMMERCIAL GENERAL LIABILITY OZR7902527 04/01/12 04/OV13 PREMISEJA GES HENEeocarrence $ 3D0,000 CLAIMS-MADE aOCCUR MED EXP(Anyone person) $ ( 5,000 X Business Owners PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ I 2,000,000 GEN'L AGGREGATEUMIT APPLIESPER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO LOD $ AMOMOBILELIABILITY COMBINEDSINGLE LIMIT 1,000,00 Ea accident $ A ANY AUTO AWR8757615 06116/11 06/16/12 BODILY INJURY(Parperson) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident g X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ ' 1,000,000 A EXCESS LIAB CLAIMS-MADE OZR7902527 04/01/12 04/01/13 AGGREGATE $ DED I X I RETENTION$ $ WORRIERS COMPENSATION X I WC STATUS OTH- AND EMPLOYERS'LIABILITY I ER B ANY PROPRIETORIPARTNERIEbECUTIVE YINNIA 22WECLJ2635 01/27/12 01/27/13 EL EACH ACCIDENT $ 500,000 OFFICERAVEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ I 500,000 PROPERTY I 21,21 DESCRIPTION OF OPERATIONS I LOCATIONS IVERCLES (Aaech ACORD 101,Additional Remarks Schedulq❑more apace Is required) CERTIFICATE HOLDER CANCELLATION. PROOFOF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of coverage only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED 1� REPRESENTATIVE C e�§i ©19SR 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CITY OF S.V-&Nf, ;tiL1SS.ICH[:SETTS f3l'tLOLVG DEP.1ATtF.\T I'0 p.kiNLVGTON$rxW, 1`Ftmt UJ®tJlLBY DRLSCO[1. F.Vt(97� 114984 AMA lkC.%W ST.PMXAS DIAUTCA CP PLBUG PROPLrATY/aCRDLYO CO.%Oii,S,ONEA Construction Debris Disposal Atfidavit (required for 111 demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.J Debris, and the provisions of MGL a 40, S 34; Building Permit At is issued with the condition that the debris resulting from this work shell be disposcd of in a property licemed waste disposal facility as daBncd by MGL c 111. S I10A. The debris will be transportcd by: ��✓G (n una uf hauler) The debris will be disposed of in : (name of facility) Iddral al f�,diiy) u nuureu(;,ermiripplwinf a �l7 TM it w'�A V "Simply the Best for Less°°' Window World of Boston 24 Cummings Park, Suite 15A Woburn, MA 01801 (781) 932-4800 • Fax: (781) 932-4828 www.witidowworldofboston.com DP55 . 21164E Ili lilllllllllllllllllllllllllll IIII RMI NFRC Series 4000 Double Hung National Fenestration CPDe RSD—R-11-00B16 00001 Fitting Counollo' SOLID UINYL - UELDED - DOUBLE GLZD 13/16 113. OS LOE-ETC. RRGON 1 ENERGY PERFORMANCE RATINGS U-Factor Solar Heat Gain Coefficient 0 . 30 1 . 70 0 . 30 (U.S.11-P) I (Metridsi) ADDITIONAL PERFORMANCE RATINGS Visible Transmittance Air Leakage 0 . 56 Manulaclurer stipuUhs that these ratings conform to applicable NFRC procedures lot delernlining whole product penormance i ratings are determined for a fixed sebol environmental conditions end a specilic product size.NFRC does not recommend any product and does net warrant the suitability of any product for aay soncilic use.Consul)mamilaClurer's IiteraNre for other product performance information. wnvt.nlrc.org i� I __ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Rzgistratlap-. -.04.66025 Type: Off-ice of Consumer Affairs and Business Regulation At 10 Park Plaza-Suite 5170 �Z, -1,212014 LLC Expiration V Boston,MA 02116 WINDOW WORLD ALBERT MORE 24 CUMMINGS P WOBURN,MA 01 Undersecretary Not valid without signature Massachusetts usetts - Department of Public Safety lug Board of Building Regulations and Standards Construction Super-Nisor License: CS-072772 jEFF c STEELE 24 SHERWOOD DANVERS* 619 Expiration Commissioner 0410712014