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5 JANUS LN - BUILDING INSPECTION
The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Vtl/ Massachusetts State Building Coe, 780 CMR SALEM d Revised Mar 2011 �l Building Permit Application To Construct, Repair, Renovate Or Demolish a G� One-or Tivo-Family Divelling 1 This Section For Official Use Only Building Permit Number: Date Appli `d i Budding Official(Print Name) Signature Date SECTION I:SITE INFORNIATI 1.1 Pr perty Address: 1.2 Assessors Map & Parcel Numbers 7"us, L Ah)Q_ 1.1 a 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 Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.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 yesCl SECTION PROPERTY OWNERSHIPL 2.1 Owne{t of Recorq Name(Print) City,State,ZIP S 34,vv3 r"i'u a^8- 74/-SIV/ No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply) . New Construction ❑ Existing Building❑ alAd5 ccupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ of Units_ Other ❑ Specify: Brief Description of Proposed Work': ti r . 30 c or SECTION 4: ESTINIA TED CONSTRUCTION COSTS- Rem Estimated Costs: Official Use Only, Labor and Materials 1. Building $ 7 350, 1 L Building Permit Fee: Indicate how fee is determined: Cj Standard,City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6),c multiplier x 3. Plumbing i 2. Other Fees: S �. I. ,%[echanical (IIV.\C) S List 01 5. Mkehanical (Piro $ Jn(�es�unt) _ loMl All lees: 'S 6 I�Mal Project Coif 3 ?356. bd Check No. _Check Anwunt Cash Amount — i_ 0 Paid in Full ❑ Outvtandm U dnnce I)ne SECTION 5: CONS'rRUCTION SF,RVICES 5.1 Construction Supervisor License(CSL) e S /3 P r Rut/ ty tP License Number Expiration Unto Name of CSL I folder /I List CSL Type(sea below) CJ O r�JJ.0�C jSFSo'lid - DescriptionNo. and Stree ''// nrestricted f3uildin s u to 3�,000 cu. lt.,0- M• estricted lit? Pmnil DwellinCity/ro, L� oofinroe / ootin Cuverin�//s ✓ indow and Sidin Fuel Burning Appliancesulation rely hone Email address D Demolition 5.2 Registered Home Improvement Contractor(II(C) HIC Registration Number Expiration Date I IIC Company Name or IIIC Registrant Name No.and Street Email address City/Town, State, LIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 1 25C(6)) Workers Compensation Insurance affidavit mast 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 of the subject property,hereby authorize 1� tAa/ le, toact on my behalf, in all matters relative to work authorized by this building permit application. 5 a� �i3 Print Owner's Name(Electronic Signature) Date SECTION 7h: 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 i pplic. ' is true an accurate to the best of my knowledge and understanding Print Uwntr' �oritcd:\uent's Name(Electronic Signature) Date NOTES: I. 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 [Ionic 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.cov%oca Information on the Construction Supervisor License can be found at,c ww.mass.eo�dL 2. When substantial work is planned, provide the intormation below: Total floor area(sy. It.) (including garage, finished baSelilent/attiC4, decks or porch) tlro;; living area('sq. ft.) Ilabitablo room count Number of tirapluccs_—_ ---— Number of bedrooms _-------_----_--_-- Numberofbathroonu NumberofhalBbaths - --_._-- -- Ibpc of he:uiug ,ysten, -- _- `umber of decks,'porchc, _-- r)peoFca�,lin� ;y;yen, - Open ---------- - t. "l or,d I'r gcrt 1yu,ue Fn�H i ni.ty h� vib;taut d t;,i 'I' d.il 1'inlect Coat" r CITY OF Slv,&%Iil NLXSSACHUSETI'S BUILDING DEPARTMENT t JT• 120 WASHING TON STREET,3r FLOOR TEL (979) 745-9595. P.m<(9'78) 740-9846 KINBERLEY DRISCOL L THOMAS Sr.FhExRs jNAAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CONDDSStO:iER Workers' Compensation Insurance Affidavit: fluilderslContractors/Electricia"Piumhers 4 licant Information // Please Print Ce ibl eAs1�T4C�rr Valne(OusintssOrg,tnizatioN Me lndividual): �6 I Atidress:� o r CityiState/Zip: l�']2s<Aue v h1A . Phone#: Are you an employer?Check the appropriate bo Type of project(required): 4. 1 am a general contractor and I I.Cl l ate a employer with g 6. ❑New construction em to ees full and/or art-time).' have hired the sub-contractors P y ( P listed on the attached t' 7. ❑Remodeling 2.0 1 am a sole proprietor or partner- ship.and have no employees These sub-contractors have S. ❑ Demolition' working for mein any capacity: workers'comp.insurance. 9, Building addition [No workers•'comp.:insurance: 5. 0 We are a corporation and its 10.0 Electrical repairs or additions - - required.]: officers have exercised their - . right of exemption MGL I LEI Plumbing repairs or additions 3.❑ I am a homeowner.doing all work bh P per - , myself.[No workers'comp, c.,152,¢1(4),and we have no 12.0 Roof repairs -'insurancerequired.]t employees.[Naworkers'- 13.0 other, Meer �,�(aeaOLdAV comp.insurance required.] •Any applicam that checks box el muss also NI out the section below showing their workers'c?mpensadon policy mfumnatioa loneuwaon,who submit ddidlidavil indicating they are doing all work and then hire outside contractors mint submit anew affidavit indicating such. °Cumrxwrs that chcsk this box minaattachedanadJit(unal sheetshowing the nemeofthesubyron(rsctors and 1It 'w hen'comp,policy idformadoo. i am an employer that Is providing workers'compensation insurance for my empoyee& Below is the pollo and Job site information. z insurance Company Name..—k4 5 F� Policy N or Self-ins,Lie.H: JC0 ba 4116y1'77- O' i 3 Expiration Date:7I Job Site Address:y57 Uc.wm 5 L.ANe City/State/Zip: 5" MA 1 t `70 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 MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violmor. De advised that a copy of this statement may Ix:forwarded to the Office of investigutiomrof the DIA--for insurance coverage verification. !do hereby,t• nd ar pains and nobles of perjury that tha rirformadon provided abb��'at d pe and correct..S _ Date: 3�! "1 1-3 Phone — OJficial use only. Do not write in Kris area,la be canepleted byrity Or rows afflciaf City oe'rown• Permitit.lcense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityffown,Clerk' 4.Electrical Inspector 5. Plumbing Inspector 6.Other.. ___._ Contact Person: __ Phone#: { ,acoR CERTIFICATE OF LIABILITY INSURANCE DATE( )3 5/13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERfIRCATE 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 policypes) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions ofthe policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such ervforsemen s. PRODUCER CONTACT NNTACT Eric Jansen Hasbany Insurance Agency PN°NE 978 685-3188 FAX N (978) 685-9460 236 Pleasant Street AoDREss: eric@hasban .coon Methuen, MA 01844 INSURE SAFFORDING COVERAGE NAICR INWRERA:Northland Insurance IISIRtED INSURFRB:ACE Insurance Company Albert Pinkham INSURFRC: DBA Pinkham Installations INSIRERD: 75 Stage Rd INSURER E: Hampstead, NH 03841 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. ILTR TYPE OF INSURANCE HIM POUCY NUMBER PMMDNY DCT 811E YYYYftOCCUR�ENCe UNITS A GENERAL UAWLIf1' WS147615 5/1/12 5/1/13RENCE E 1 Q00 QQQ COMMERCIALGEPEPALLIABIUTY ENTED E 1QQ QQQ CIAIMS-MIADE OCCUR anepesm) E $ 000 DVI WURY E 1 QQQ QQQ REGATE E 2 00Q 000 GENTAGGREGATE LIMIT APPLES PER DMPIOP AGO s 2,000,000 POLICY PRO- LOC E AUTOMOBILE LIABILITY aMBI EO IN LELIMIT E ANYAUTO BODILY INJURY(Per person) S ALLOWNED SCHEDULED BODILY INJURY(Per accileM) $ AUTOS AUTOS HIREDAUTOS _AUTO-0WNED (PerePROPERTYI DAMAGE y E Ufiem A LUU1 OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE S DED RETENTION$ E B WORKERS COMPENSATION 4564P27313 3/5/13 3/5/14 X: WC STATU- DTH- AND EMPLOYERS UABIUTY ANY PROPRIETORRARTNERIEXECUTNE YIN NIA E.L.EACH ACID DENT E 100,000 OFFICE PRAEMBER EXCLIDED4 7 (Mandatory In NH) EL.DISEASE-EA EMPLOYEE E 100,000 WyS8 describe under DESCRIPTION OF OPERATIONS W.. E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPRON OF OPERATIONS I LOCAOONS I VEHICLES (AUach ACORD 101,Aedltlonel Rerrerb Schedule,IrmOre Bpace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN My Home Contracting, LLC ACCORDANCE WITH THE POLICY PROVISIONS. 14 Coffeetown RD Deerfield, NH 03037 AUTHORIZED REPRESENTATIVE Eric Jansen ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: ,acoRo® CERTIFICATE OF LIABILITY INSURANCE oATE(MMi/6 13 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 INURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLIER. IMPORTANT: If the certificate holder is an ADDITIONAL INURED, the policy(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 endorsemen s. PRODUCER CONTACT NAM: Eric Jansen Hasbany Insurance Agency PHONE 97 685-3188 r'X Nni, (9-78) 685-9460 236 Pleasant Street pD ss: eric@hasban .com Methuen, MA 01844 INSURERS)AFFORDIM3.COVERAGE NAICS INSURERA:Tudor Insurance Company INSURED INSURERB:Travelers Insurance Company MY HOME CONTRACTING, LLC INSURER C: C/O Don Lucciano INSURER D: 14 Co£feetown Road - INSURER E: Deerfield, NH 03037 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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MIDDr AMMOIYYYY UNITS A GENERALUABILITY NPP8102099 1/1/13 1/1/14 EACH OCCURRENCE $ 1,000,000 X COMMERGALGENERALLIABIUTY DAMAGE TO RENTED E SOO OOO CtAIMSMADE ❑OOCUR MED IXP(AV one perm) $ 5,000 PERSONALS ADVINJURY S 1,000,000 GENERALAGGREGATE S 2,000,000 GEN'LAGGREGATE LWITAPPUES PER PRODUCTS-WMPIOP AGO S 2,000,000 POLICY PRO-JECT LOC $ AUTOMOBILE LIABILITY aaccidert I L LI n $ ANYAUTO BODILY INJURY(Per person) $ ALLOWPED SCHEDULED BODILY INJURY(Per aoidenp $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _AUTOS eracddent $ UMBREIIA WIB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTION 8 B VIORKERS COMPENSATION 6ICUB-4904P77-0-13 1/1/13 1/1/14 X WC$TATU- OTH- R AND EMPLOYERS LIABILITY ANY PROPRIETORPARTNER/EXECUTNE Y� NIA E.L.EACH ACO CENT S 100,000 OFFICE RMIEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 100,000 If yes dwibe under DE SdRIPTIONOFOPERATIONSbelow EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTIONOFOPERATIONSILOCAnONS/VENUES (ANACNACORDIM,Adamb Rermd Schedule,Wm mapacebmgdre I Windows and Siding Installation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TIRE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORGUEO REPRESENTATIVE Eric Jansen ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: 1 Massachusetts -Department of Public Safety 1i Board of Building Regulations and Standards 1` i Construction Supervisor 4 License: CS-070456 BRIAN A WHITE,` CAND A NH 03034 1 �1 i l ++ Expiration 09/05/2013 I ' commissioner � Lnamm�wnnw,o ,/Il�ava(xchueefi License or registration valid for individul use only Office of�,Consumer Affan's&Bdsmess Regulation before the expiration date. if Sound return to: IMPROVEMENT CONTRACTOR Type Office of Consumer Affairs and Business Regulation Registration 144679 10 Park Plaza-Suite 5170 'c Ltd Liability Co of � -�� Expiration 10l27/201A ty � Boston,MA 02116 p/11�F30ME CONTRACTING LLC DONALD LUCCIANO l 128 KLONDIKE AVE --- —"— HAVERNILL,MA 01832,..; - llndersecrctary Not valid without signature CITY of S.ILE,tif, �bL1SS.ICHUSETTS l]l'tLOLYG 0FP.IRnONT 120 CU.UHLVGTOv ST'RBET, 3"Room `s%' TEL (978) 735-9595 (978) 7-W-93M <11cDE2LEY DIt1SCOLL bUYo.4 T'r onuST.PtERRB MxECTO R of PL OLIC PROP ERTY/8C tLDCJG CO3 LN11SSIO.V ER Construction Debris Disposal Affidavit (required for all demolition mid renovation work) In accordance will' tine sixth edition of the State Building Code, 730 Cj%fR section 111.5 Debris, and the provisions of tbiGL c 40, S 54; Building Permit H is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal racility as defined by �tiIGL c 111, S 150A. The debris will be transported by: Lt��ti� �iL� Us �v) ,pars (name ut hauler) The debris will be disposed of in : ._-- (name e----7 lily) --(aJdres.a u1 iacilit%) riynatttrc ufpermit applicant Luc "