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14 INTERVALE RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY M S� Massachusetts State Building Code,780 CMR RECEI Egf1�ti S�Il.C�fWT r 2011 Building Permit Application To Construct,Repair, Renovate �[n One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Properttyl Address, 2 Assessors Map &Parcel Numbers %%)e.n "'\\S tlq(Lt c yrAf VA. ('IPw1�U 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) 1.5 Binding 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 OWNERS11W1 2.1 Ownerr of Recor M,rhv.P� Ke-)6K! _ Name(Print City,State,ZIP 11 �-' t Jf Lye— 5bS- ��tlsF Mk e No.and Street Telephone Email A'dgiess SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building. Owner-Occupied ❑ 1 Repmrs(s) W1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed WorkZ: m E i ( So c' s r' A, C SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ 00,v o 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) $ Ltst: C, k U 5.Mechanical (Fire $Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ i3 p0.!o 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ' L\�,,r�r\ Lpp Cryh'r� License Number Expirenon Date Name of CSL Holder � List CSL Type(see below) 13A I./�MPCCORI Type Description No. ��and ((Street /J ' /l.{I� �Z r55 U Unrestricted(Buildings u to 35,000 cu.ft. C /1 R Restricted 1&2 Family Dwelling Citylfown,State ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 51-1475-6 V t indsLA-- lhcnorc��l rMG1�•LOi11 I Insulation Telephone Email address U - D Demolition 5.2 Registered Home Impro ement Contractor(HIC) tt 5 G 2 1) n r1C0 n �d�d(' 1HIC Registration Number Expimhon Date MC Compa HI ny Name or C Reg�os�ant Name 13A �rnn°,rc �r-�� t,`incl�w�Vlof�ofotinlw ¢ L� .. No.and Street Email address V NtW clAA o2u5 N-V75-6Gt(C/ City/Town, State,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(1VLG.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 ,F`OR BUILDING PERMIT I,as Owner of the subject property,hereby authorize �V�)Y-\r1-nP }I wo r rl to act on my behalf,in all matters relative to work authorized by this building permit application. o qS 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 accurate to the best of my knowledge and understanding. t.1)inc\5v � T ny a � ,e& to 5f�6 �(1/S Print Owner's or Authorized Agent's Name(Electronic 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 www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.goy/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.fL) (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" BRIAN DONNELLY 1 Simson Rd Estimate Pelham NH.03076 Number: E2043 (978)807-6883 Date: July 02, 2015 FHope ls FSalem, MA ve MA. 01603 . PO Number Project Description Amount Remove existing sidding 23 square Install 23square Certainteed MainStreet Double 9" Woodgrain Clapboard vinyl siding Install soffit and metal trim on all rake and facia Trim all windows and doors 13 8800.00 Color to be determaned deposit of $5800 to start r Total $13,800.00 ( t `` CERTIFICATE OF LIABILITY INSURANCE DA07/312015) 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 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 endorsement(s). PRODUCER Dominic Boudreau Charles J Coughlin Insurance NAME: 14 Dinley Street PHONE (978)957-3588 FAX AIC No P. O. Box 10 -MAIL dominic@coughlinins.com MA 01826 ADDRESS: @cou 9hlinins.com INSURERS AFFORDING COVERAGE NAICd INSURED Brian Donnelly DBA:Donnelly Construction INSURERA: ACE American Insurance Company ACE 1 Simpson road INSURERS: Pelham,NH 03076 INSURERC: INSURER D: INSURERE: 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. NER ADD US LTR TYPE OF INSURANCE POLICY NUMBER MWDC MNOVDD� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY D AS RE D PREMISES Eauccunence $ CLAIMS-MADE OCCUR MEDEXP(Anyoneperson) $ PERSONAL E ADV INJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER:POLICY PRO PRODUCTS-COMP/OP AGG $ IFQ.T LOG E AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ AUTOS A OS SCHEDULED S AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ b UMBRELLA LIAB OCCUR EACH OCCURRENCE E EXCESS LIAB CLAIMS-MADE AGGREGATE E DED RETENTION$ A WORxERSCOMPENSATION ASSIGNMENT 07/31/2015 07/31/2016 WC STATU- OTH- $ AND£MPLOYERS'LIABIUTY YIN OFFICER/MEMBER EXCLUDEED-+ (Mandatory In NH)ANY XECUTIVE ❑ NIA E.L.EACH ACCIDENT $ 100,000 If yes,descnoeunder _ E.L.DISEASE-EAEMPLOYEE $ 100,000 DESCRIPTION OF OPERATIONS .. E:L.DISEASE -POLICY LIMIT SOO,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remark;Schedule,If more apace Is required) Vinal siding installation CERTIFICATE HOLDER CANCELLATION Fax#:(978)740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem, Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington Street,3rd Floor ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA 01970 AUTHORRED REPRESENTATNE ©1988-2010 ACORD CORPORATION. All rights reserved. LACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Business Regulation Office of Consumer Affairs& CTOR OME IMPROVEMENT CONTRA TYPO: egistratton 180592 Individual - - Expiration 1216/2016 T WINDSON H0NORATO..�._"'tF: - W INDSON HONORATO �- T 13 A EMERSON MA MEDFORD,MA 02155`15, Undersecretary _ i Massachusetts -Department of Public.Safety Board of Building Regulations and Standards i Construction Supers isor License: CS-107995 r WINDSONHONOAT, EMER ON O2S.TR Medford MA 02135 o I Expiration Commissioner 12/21/2017 ' I