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10 LATHROP ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALRevised EM2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Datc A plied: Al Building Official(Print Name) Signature- < Date SECTION I:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(it) 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 if yes❑ Municipal❑ On site disposal system ❑ SECTION 2:. PROPERTY OWNERSHIP' 2.1 Owner of Recor : �T/2`/ /&A//r.;, cj/h.L-7A A40- br F70 Name(Print) City,State,ZIP /y LAh7WId Jr (�jZF) F77S 01F! �j No.and Street Tel hone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building14 Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work: 11a) i� µ/ 6— 5E s. SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials _ 1.Building $ sf'�% 1. Building Permit Fee:$ indicate how fee is determined ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cose(Item 6)x multiplier 1 x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC). $ List: 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. check Amount' Cash Amount. 6.Total Project-Ct-os-t: $ YSF�— ❑Paid in Full ❑Outstanding Balance Due: 1 U ��x-tom GrG SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 0y�O/sVzi�" AVS License Number Expiation Date Name of CSL Holder V / A/r 09A,11 W?OY List CSL Type(see below) No.and SStrefj Type. Description //(`cy,.� U Unrestricted(Buildings u to 35,000 cu.ft. YO R Restricted 1&2 Family Dwelling own,S ,ZIP M Masonry RC Roofing Covering WS Window and Siding i SF Solid Fuel Burning Appliances 7 �2- �7a I Insulation 'Teie hone Email address D Demolition U 5.2 Registered �Home Improvement Contractor(IHC) S .R1'r \ / 2 `+�y��L HIC RegistrahO�Number Exa mti Date HIC Com an Name or C Registrant S� No.1=6Cul Email address City/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 provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ( No...........❑ SECTION 7a:OWNER AUTHORIZATION TOBE:COMPLETED:WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. 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 th t of edge and understanding. t. &Q31�✓it lu/w6LVI / 2 Print Owner's or Authorized Age is N am lectromc Signature) ate 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 wD w.mass.eov/oca Information on the Construction Supervisor License can be found at wyw.mass. ov/dQs 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" �1 TURNIP-3 OP ID:CA CERTIFICATE OF LIABILITY INSURANCE °"'�`""°°"""I 10124M 1 :"TFIIS'CE(tTIFICATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS :• :4 GER71FlCD1TE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES ; 9EL•'OIIIG' 7HI$'CERTIFlMTE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ?'.R'!:L?ItESENTA PWIE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: the ou of such holder M an ADDITIONAL INSURED,the policy(lea) must be endorsed. If SUBROGATION 19 WAIVED,subJect to tNe ti fli(a and conditions of the policy,certain policies may require an endorsement A statement on this Certificate does not confer rights to the eertlflcateholder In Oeu of such endoreeme a. . LOBodosBx L 90rt t,LNL1AC 0 978-462 EAI EC AM 978-465-6204 PHONEP7NMwS 1960 ADDRESS: ' No _ W.3hener NW AFFORDING COVERAGE NAICt INSURER A:Scottsdale Insurance Co. George Vasllladea INSUREDorgTurnpike Genera Contracting NSURER8:Commerce Insurance Com n 23"ostan Street WSUaELO: Topsfleid,MA 01983 WS R: INSUREItE• 1 ' F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED 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 19 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1 8R T EOFe15URANCEPOLICYNUMBER MID LIMITGENat1Y EACH OCCURRENCE { 1,000,00 A X cIALGENE;l&uA lUTy SCS0026080 1021111• 10/21/12 IEEE s 50,00 MSIAADE ❑X. OCCUR MED EXP am i 5,0 PERsoNALa NNINRIRY t 1,000,00 GENERALAGGREGATE { 2,000, . GENLAGGREGATE LINT APPUES PER PRODUCTS-COMPAOPAGG i 2,000,0 POLICY X °'P LOC i AUTOMOBILE UABUMY dim 1,000,00 B AALLOWNE lEO OBRJM 1020111 1020112 BWLYRwRY(Pepemo t AUTOS RXAUMS UTOS BODILY INNRYp9reclN t ONOWNEDXHIREDAUrOS { i UMBRELLA LIAO OAR FACHOCCURRENCE { 5,000,00 A X EXCESSwLe CLAIMS—MADE XL80077698 1021M1 102U12 AGGREGATE i 5,000,00 DEo I X i RETIENIMS 0 i WORKERS COMPENSATION WCSTATU• AND EMPLOYERS'LIABILITY YINER ANY PROPRIETORIPARINERIB(ECUIIVE OFFICERIMEMrBAErR.EXCLUDED? ❑ N/A EL EACHACGOENT t (Ma�Mryin F L DISEASE.EA EMPLOY E 9MyeqAesa@eunder DESCRIPIIO OF OPERATIONS EelaN E.L.DISEASE-POLICY LIMR E DESCRIPTION OFOPERATIONS(LOCATIONS IVEHR%FS(Alhch ACORD 101,Addlaonel RemaAn Schedule,Ir mom apace to mgWmd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD -MUS.CERTURCATS IS ISSOED AS A NAraR Or WORKATIGH ONLY'AMD CONFERS NO RIGHTS UPON THE CERIIIDCAa HOLDER.THIS "C L'lII3UW11111SNOTAPrmA1ATIMMY ORNEGATTVHIXAMEND,RITEND ORALTRR THE COVERACS AFFORDED BY MIR POLICIES e)9r10f}V,�"•. Ci3REIRCAa 01/IDISU8ANC8 DOES NOT CONSTIaa ACONaACr BETWEEN THE unrmc lNfUAHIIMAUn[OAILBD R'SPltB6� ftm okpliouvelIx Am nut Cakruqu NOLDBR. tMP.OPTANT:IT thif eertNleete holder[son ADDITIONAL INSURED,the pollwAles)must be endorsed NSUBROGATION IS WANED,subjectto ttie te"nond a 'eondillons of/ha policy,certain poNeles mey require an endorsement.A statement onthis certificate does not corder ripMe to the eertNleete holder In Nou a/such end"sem s). PRODUCER COU"OT CHASE&FONT,U.c wee POB"0 MORE eI FAI so NEWBURYPORT,MA 01950 °tlM ADDBeI: nooucea CUITORE R lotENSUREDllf APFORDMCCOVIItAGR I NAIC9 TURNPUMCIENERALCONTRACTINO INSORMA TRA.VELMSPRAPFRIYCASUALTY INC DBA OLYUM PAWTINO.& COMPANY OF AMERICA 239 BOSTON STREET INSUM B n TOPSFIFID,MA DIM INSDIRM C ' II1N�D 1145LMBI BNSMURY— — d . COVERAGES CERTIMTE NUMBER: PPIISIONNUMBHC TIRS IS TO CeRTDY TEAT TmcPoLICIef orjHsuRAN=usrRD BID.OWHAvR BEER non To wicMusED HAum ABOvEInT1IDPOLICY INDICATED.NOTWITHSTANDING ANYRIQWMMM,TERM OR CONDRION Or ANY CONTRACT OR OTHER DOCUMUNT WITRRESPECT TO WHICH THIS CNR.TDICATIC MAY BRUSO®OR NAY PERTAIN,THE IHSORANCEAFTORDED BY TUCPOLICIDS DESCRIBED BTBEDIIS SOBIECT TO ALL THE 7=6. 1=1031 01 1 3 AND CONDITIONS OF SOLI POLiCWB.LDDTS SHOWN MAY HAYEBEDN REDUCED BY PAID CLAW. INSR TYPE0r INr0RAECR ARID. an POLSCIIRONDQ POLICYNFF POLICTEIP LIMITS LTR ISSN V1VD GRSIDRa LTABHdIY IACHOCCOFSDHi UCCIIOaRCWO®RALWHIIIT DArA0RWt1E[® I AuvmtpnA wan, O eummm D aeem �ndaratAy.. s N! N ➢ERXM AAW. I DDNLT 0 e®N.AG6ICJ,I[. : am AroImAUlmt APRIIEPER: O Scar DPICM 0= w uetaee� T S AMKDB=LTABHdTY COUMMILE i D ArrADIo HD®TEMOT s 0 A6GWIDDAUWi KR'TDDW s o.e®olmAOla �Y°"R"61 s esIDAotat $ D RrmawmADlm $ 0 D oun uaum oaxDA samwuERea Is 0 I=tm%b a cunt4RA0H V AMMAu S D OEMi m, s 0 IEinnmrr S TIIDJUMM.CONPENSAUDN WC A AND EMPLOYERS LIABILITY pe, TZB19 4 va LD D AYYPICPIHImJVALumv - iEACHACCRRR[ sI,000,000 MMMMCEM:ZLUERM H HIA 7PJUB-4419PO94 IOrmi IOM/12 mTDUDr QrAeMSOAFID� tXm,a-EACH s1A1113,000 ru.m.®A.THaIOImRcr rtQAl6 taUET r1,000,DD0 �ENLAIII]HerA. ®C6II'IION Of OPERATIOIDAOCAIIOMAIERICLD iAAeLNCCRDIH,Anibrlbw11oL7�Eraryw;sla61) ' T®REPLACE"Mat ClITERCATE III DIDTO 72L CEUMCATLHOLOOL AFFECTING WOREW COW COVERAGE >G7�7Io{as37�!?��•z?:� �'>:�:'s?sr£��_:c;I'�ki>��#�� •rnts�#�•vW,w?<' E� now::,t�zs>�>?::>�•?r'cw'•:5�3•�etlt:A SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CATE THEREOF,NOTICE PALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Frm ^."FS" t31f1SEk� iti4 ?� x;?•;;:?:#;�:.s::'•...>:.:"r:;.:t::::w'�`t:,;c: �.?c�� ;s<:�r;."•::;:� ••"•:�St' " L•+tSYelP�tilf,'4T' Yi'1 i' " �ri•aiwid+iif`• ,fir: • Unrestricted-Buildings of any use group which Massachusetts-Department of Public Saret/ contain less than 35,000 cubic feet(991m3)of Board of Building Regulations and Standard i, enclosed space, Cnnstcuoion Supctliaor License:CS-O60t45 .,r a`^ � GBOIRGE VA*ijXDES.. SYTTCAIRNAYAY IP5WLCHM3169123:. �. Failure to possess a current edition of the Massachusetts - StateBuildingCodeiscauseforre•location of this license. ' �.l.---%�r, Expiration For DPS Ucensing information visit: www,Mass.Gov/DPs Commissioner io/2612013 O�'UI72(Y�IrC(A l.��(uV:ef�I/wVG�' Office of Consumer A air�and Business Regulation - 10 Park Plaza - Suite 5170 Boston,=oritractor chusetts 02116 ove Home Impr Registration Reillstration: 167567 z z Type: Supplement Card TURNPIKE GENERAL CONTRA Expiration: 10/4/2012 w GEORGE VASILIADES o 239 BOSTON STREET BOX 36i TOPSFIELD, MA 01983 Update Address and return card.Mork reason for change. 7PSCA1 6 ❑ Address ❑ Renewal Employment Lost Card ' �ae tioomaysaamealdi a`,l�oieaJweelA Office of ComamerAffairs&Badness Regulation License or registration valid for individul we only OME IMPROVEE MENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Regtatretlon"., g�gg7 Type: 10ParkPlara-Suite5170 Explm _ 1 Supplement Card Boston,MA 02116 TURNPIKE GE _ ING INC. GEORGE VASIL 239 BO'STON �— _ TOPSFIELD,MA 01 Uaderseeretary Not valid without signature a The Commonwealth of Massachusetts Department ofludustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsAFIectricians/Plumbers AAAllcant Information Please Print Leeibly Name(Business/organiaaticn/individual): 7'07,4 Address: Z3 rj " a City/State/Zip:_ �r//l Phone#: ��F) FF Are you an employer?Check the appropriate box: Type of project(required): 1.[] I am a employer with 4. �] 1 am a general contractor andI employees(full and/or part-time).* have hued the sub-contractors 6 New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. Building addition [No workers' comp.insurance 5. We are a corporation and its required.] officers have exercised their 10.11 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I Q Plumbing repairs or additions myself[No workers'comp: c. 152,§1(4),and we have no 12A Roofrepairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.] pAny applicant that checks box#1 must also fill outthe section below showing their workers'cwmpansationpolioy inf m di,a t Homeowners who submit this affidavit indicating they are doing all work and Wen him outside contractors must submit anew effidavitindicating such. tConimctora Wet check this baxmust attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: %�in� Policy#or Self-ins.Lie.#: 7/� �t//S - �5l/5'QO S �i Expiration Date: Z Z L Job Site Address: City/state/zip: 44A— Cr/ 7o 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 ofMOL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. Ida her by certijy er a tins n ofpe#ury that the information provided above is it a and correct. Si a ate: /f �- Phone#: 7 -7 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License 0- Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: