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49 LARCHMONT RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board Board of Building Regulations and Standards Town of (� Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a \ One- or Two-Fmnily Dwelling ANN& ^ This Section For Official Use Only Building Permit Number: Date Applied: Signature: i L• Building Commissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: pA 1.2 Assessors Map& Parcel Numbers �I°caFM611 �cy T 1.I 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 tt) Frontage(It) 1.5 Building 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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Reco2��� / On L Anr k ll /� T Name(Print) Address for Service: 9l 7 5-7S^ Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition O Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': OW ) SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ 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) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ '',^ ov Check No.11�! Check Amount: Cash Amount: 6.Total Project Cost: $ �, 13 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Date Name of CSL-Hglder List CSL Type(see below) Type I Description Address U Unrestricted(up to 35,000 Cu. Ft.) R Restricted I&2 Family Dwelling Signature M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature 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 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 J APPLIES FOR /BUI`LDING PERMIT 1, yam— 1 A&J (_A-eA&Jas Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. �( A ? - Si natu of Owner Dale SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1 ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) 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 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I 1 O.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total Floors 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" n t CITY OF SALEM �;,MAD� PUBLIC I'ROPRERTY i . DEPARTMENT ,I%W;Katy'DaISCul.l. .AIa sea 12^.WASHING IONS I IQVr• Sou:vI.MAMMA n-sh:i is 01970 'fta.:978-745-9595 • Pax: 978.740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers An tlicant Information rL Please Print Leaihly Va met t3ucitxssOrganintinNlndividualy M/gSs t1 �IL��V 7N� Address: © C"-ft2l fiv e__� c r Cityisrate,zip: S CW 14A- 0I'g7D Phoneii: / -74v' 1W-37p� Are you an employer? Check the appropriate box: 'Type of project(required): 4. ❑ 1 am a general contractor and[ 1.❑ 1 am a employer with G. El New construction employees full and/or art-time).` have hired the sub-contractors ( P 7. ❑ Remodeling 2.❑ I :can u sole proprietor or partner- lured on the attached sheet. ship and have no employees These subcontractors have S. ❑ Demolition working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 1 um;t homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions myself. [No workers' clnnp. c. 152, §1(4),and we have no 12.❑ Roufrepairs ',,/l insurance required.] r employees. [No workers' 13.❑ Other�jj)(/L-lkrico" comp. insurance required.] -Ally.1pplicanl that chucks box#1 must also till out the Seclintl W.ow showing their workars'camPlnsation pulley inlnrrnJliun, 'I lomeuwncrs who submit this affidavit indicating they arc doing all work and then hire outside conlraetom must suhmit a new al'rdavid indicating such. Contractors that chuck this box mind attached on additional Arc,:1 showing the name of the Sub-contrxwrs and their workets'comp.policy information. l am un employer that is providing workers'coinpen.satian incurtinee far my eurplayees. Below is the policy and job site inforinmrion. Insurance Company Name: —_- Expiration Date: Job Site Address: City'State/Zip: Attach it 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 fine 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 S250.00 a day against die violator. 13c advised that a copy of this statement may be forwarded to the Office of Invcsligations of the DIA for insurance coverage vei ification. l da herch rtifv IuLdix the nuns turd penalties of perjury that the information provided above 's trtt urn!correct. �� �g Phin:c : Official use anly. Do not write in this area, to be completed by city or town afficiaL City or Town: _--.. Permit/License X.----_._ Issuing Auihurify (circle one): 1. Board of llcaltb 2. Building Department 3.City/'fown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other .----. _ Contact Person: ------ Phone tt: r• ' 1 ' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an emplucee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." - An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a Joint enterprise,and Including the legal representatives of a deceased employer,or the receiver or trustee of an individual,patmership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,cunstruction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." `1GL chapter 152. Q25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant wbo has not produced acceptable evidence of compliance with the insurance coverage required." .additionally, bIGL chapter 152, 625C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of conipliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) narne(s),address(es)and phone nunnber(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial .Accidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should be retuned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be Sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plcase be sure to fill in the pennit/license number which will be used as a reference number. in addition,an applicant that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address" the applicant should write "all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a clog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. I he Office of Investigations would like to thank you in advance for your cooperation and should you have:my questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 R L,%iscd 5-26-05 www.mass.gov/dia MASSMEATH ERIZATION9 INC. THE ENERGY SPECIALISTS Complete Insulation Services EST. 1986 3 OCEAN AVENUE I SALEM,MA 01970 (978) 741-3471 1 Fax (978) 744-7082 1 (800) 467-0495 masswx@comcastnet Name Address City M R - � . Home Phone �'( 1 c, G - � -5 z> n Cell Phone I 4;_7 Z 2— E-mail JOB DESCRIPTION TOTAL Wall Insulation R15 Class 1.Blowm ]n;Cellulose ",Remove and Replace Siding ❑ Drill Through ❑ Wood Shingle ❑ Clapboard ❑ Aluminum" ❑ Asphalt ❑ Asbestos ❑ Inside Blow and Spackle TOTAL MATERIAL: Attic Insulation TOTAL LABOR: El Add 3" ❑Add 6"" El Add 10"" Dewc C (� �IOG✓P Y�"V�:kY TOTAL: Z•-f S L�j• Bring to R32 10" ❑ Slopes R19 7" (46 I6 - i7et�s�-• ❑ Kneewall Floors Floored 7" R19 UnflooredlT R32 jTi� S I }}L t ❑ Kneewalls rR13 Fiberglass ❑ Attic gl�Vents ❑ How Many Infrared Camera Guarantees 100% Coverage ` ono l c_ f ❑ Key Span 20% up to $750.00 ❑ Oil Heat ' f` ❑ NI STAR 50% up to $1500.00 Tj Other Notes: ° d Customer Signature Dick Lamby,Owner-President CSR LM DATE IMMIDDIT Ali0R0^ rrTI F CERTIFICATE OF LIABILITY INSURANCE MASSWES 09 09 08 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION pRDDucBR ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.TH13 CERTIFICATE DOES NOT AMEND, EXTENO OR Kittredge Insurance Agency Inc ALTER THE:COVERAGE AFFORDED BY YHE POLICIES BELOW. I1558 Otis St. , P.O- Sox 1129 NAICN Northboro MA 01532 ..._...-... -- INSUR_ERS.A.FFORDING COVERAGE 3T744 rax:508 393-6983 Phone• 508-39 NsuaeRP N..c. A La Ra= _ - " 25658 IN5URBD INSURER B. TrwYolRr. SnearAAae eompwav .... INSURERL�r_•tR Mass Weatherization Inc• 1N SURER7: N.tLon_.l 3 Ocean Avenue INSURER E: ^� 8alam MA 01910 COVERAGES THCPOLIGICSOf INS RMCO�L�NED CONDITION OF My CONTRACTOR OTHER IDOLUMENT WITH0.ESPECTROFW11lCOH ITHIS CER pF1LAITETMAY BE 33 JGOF 5 ING grvv REOUIR[MENT,' , 3,EXCLUSIONS AND CONDITION OF SUCH MAY PERTAIN,THE INSURANCE AFFORDED BY TI IE POLICIES PESCRIBPAIO CLAIMS. EO HEREIN:S SUBJECT TD ALL THE TER POUCIh S.AGGREGATE LIMITS.SHOWN MAY HAVE BLEN KC'•UCED SY ^_ g�ygplgA710N , LIMITS CY0 ,r -_........ POLICY NOMSER DATE MWPDffY PATE MMID, Y _ __ "pULTCVEiaECYIVE"! INSR'AOD'G �.pEOFINSURPNCE .1EACHOCCURRENCE S1,OOD,ODO ITR INSRO DAMAGETO RCNTED"' }. 100,000 ! �'cENeBaL UAnlury 'I 05/28/09 05/26/09 rR mleE r ra gn_^ -. A X X COMMr.RCIALG1:Nt;RALLInUanY NPP1167517 I MED_E%P(AnY enepmI S5,000 _ CLAIMS MADI� X OCCUR PE RSDNAL LAOV INJURY SS ,DDO OOO - GENERAL nGGREGAT[ 5 2 ,000 000 L __. PRODDCTS COMPIOP AGG 52,000 000 i �OE L AGGRCGATC LIMIT APPLIES PER f -"' PRO- LOC POLICY JECf COMBINED SINGLE LIMIT ',S IOOOOOO I AUTOMOBILE LIABILITY (Ea SA-469H7036-07--SEC 10/04/07 10/04/08 - 8 I ANY AUTO BODII.Y INJURY S 1 ALL OWN%O AUTOS (Pel PRrwnl II X SCIIEOULED AUTOS BODILY INJURY X HIREDAUTOS (Pat a"-&00 $ 'NDN.OWNt'n AUTOS 1 Y DAMAGG I'ROPF.H .. . .leer AUTOONLY,EAACCIOEN'I 5 Y~ 1 GARAGE I.IAD1I TV ,- _ER THAN LA ACC 5 My PUTD .I I I AUTO ONLY -- � AGG S '. • EACIt OCCURRENCE 5 5 L OOO ,O )0 — i EXCESSIUMBRELLALIAIBILITY ' 03/19/08 1)3/19/09 AGGREGATE :55,000,000 D j X OCCUR I _1 CLAIMS MADE I >;BU5878O33 ....-. ,... _ $ DEDUCTIBLE S y 1 RETENTION S X TORV LIMITS Eli., . . WORKERS COMPENSATION AND E L EACH ACCIDENT a 500000 C EMPLOYERS'LIABILITY ReN or WC6302008 09/03/08 09/03/09 • __„-., . , .._ . . ,.. . qNY W:CI`fl[`3-,vriRTNER,2X000TIV:: I,E,L_DISEASE-EA EMPLOYEE. s 500000 .,I OFFICERR.IEMIIEN XLLUDED'+ E.L.OISEASE-POLICY LIMIT $ SOOOOO 11 gl.III Ifi5,1 UA 1' SPECIAL PROVISK'NS Wm w I I OTHER I DESCRIPTIONOF OPERATIONS I LOCATIONSJVEHICLES IEXCL0d iPDDEs lbsidiarie SPECeyspVIn S Deliver Action Inc. ;National Grid VSA and its subsidiaties;Keyspan energy y th regard to General and its subsidiaries are named as Additional Insured wi Liability where required by written contract. CANCELLATION CERTIFICATE HOLDER ACTTONi SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED OEFORE TYtE EXPIHAngN PATE THEREOF.THE ISSUING INSURER WIt.L ENDEAVOR TO MAIL 2D_ OAYSWRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE.TD DO 50 SHALL IMPOSE NO OBLIOAnON OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR REP0. TATIVBS. ��- AUTH DRCFRE5EN TIVE „f�-�c�l /` (C.S C� ®ACORD CORPORATION 1988 Z00/L00@J xvi OE .EO SLOZ/4l/60 t , rk\ ✓ /�I -�/'� �a���'GGUJGG�i�GCUI�'LfA ?l tYons and Standards Board of Building Regula One Ashburton Place - Room 1301 > Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration 111617 Type: Private Corporation Expiration: 1/12/2009 Tr# 127805 MASS WEATHERIZATION, INC _-. . RICHARD LAMBY 3 OCEAN AVE SALEM, MA 01970 Update Address and return card Mark reason for change. Address Renewal E] Empioyment n Lost Card .-&CAI O Z00/Z00lJ xvi L6 60 9LOV91-/60