80 LEACH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
�/ cl Massachusetts State Building Code, 780 CMR, 7 s edition ALEM
ReOF S January
IJ Building Permit Application To Construct, Repair,Renovate Or Demolish a 1, 2008
One-or Two-Fa Dwelling.
This Sectio For Official Use
Building Permit Nu er. a ed:
i
Signature:
Building Commissioner/fuspector of Buildi Date
SECTIO, 1: SITE INFORMATION
1.1 Property Address: 80 Leach St 1.2 Assessors Map & Parcel Numbers
L l 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.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 Record:
John oward 80 Leach St Salem, Ma
Na a(Pri Address for Service:
508.878.6921
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction g Existing Building Owner-Occupied '5( Repairs(s) XK Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
strip and re-roof
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (FIVAC) $ List:
5. Mechanical (Fire Suppression)
$ Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 5,999 ❑Paid in Full ❑ Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 100542 3/1 7/201 2
Joseph Arone License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) R, RC, WS
60 Central Street Stoneham, Ma 02180
Address Type Description. t
U Unrestricted u to 35,000Cu.Ft.
R Restricted 1&2 Family Dwelling
Signa M Masonry Only
978.835.9483 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) 160710
Joseph Arone
HIC Company Name or HIC Registrant Name Registration Number
60 Central Street Stoneham, Ma 02180 8/19/2010
Addre�csf
// 978.835.9483 Expiration Date
TigrAiurc 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 .......... d(X No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 John Howard as Owner of the subject property hereby
authorize Joseph Arone to act on my behalf, in all matters
relative o work authorized by this buil ' ermit application.
� 1 Z% ilwA .C?otc>
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I Joseph Arone ,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.
Joseph Arone
Print Name
Signature of Ow r or Authorized Agent Date
(Signed under the pains and penalties of a 'u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and L10.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"
CITY OF S.U.EM, NLNss-kcHusETrs
• BuILDL\G DEPARTMENT
P 130 WASHNGTON STREET, 3�FLoop
TEL. (978) 745-9595
FAX(978) 740-9846
KIN{BFR1 RY DRISCOLL
MAYOR THomA3 ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CMMSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
Arone Exteriors
(name of hauler)
The debris will be disposed of in
Rooftop Recycling
(name of facility)
369 Codman Hill Rd Boxborough, Ma
(address of facility)
Si ature'of permit applicant
date
dcbrisalf doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
swvw mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name Business(organization/Individual): 0sepp 1 fta(w— ci(- ila)ne EKt enb/-S
Address: C-U)t725.1 Str-e,_4 •t-
City/State/Zip: �R?VFM(1� Phone �1�$ ds3j•�jUj�'3
Are you an employer?Check the appropriate box: Type of project(required):
I_ y I am a employer with 4. ❑ I am a general contractor and I
qsL6. ❑New construction �
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ ❑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. [_1 We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a hom eowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. (No workers' comp. c, 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. (No workers' 13.❑ Other
comp. insurance required.]
*My applicant that checks box#1 must also fill out the section below showing theirworkers'compensation policy infpnnation.
t Homeownerswho submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
loontracto s that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: o bla5A!! an cA j_l> n�-
Policy#or Self-ins.Lic. #: W L 13 S 3 t-9 9 L..1 (3 1 Expiration Date: ]
Job Site Address: City/State/Zip:
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
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 fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct
Signature: Date:
Phone# � -m-' N �-.
Official use only. Do not write in this area,to be completed by city or town oJjiciaL
City or Town: Permit/Licenve#
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#:
�ta..achlfec[i. - Departtncnt of Public ,Me;}
9 Bilard of Buildin_ Rc lllatinnc and standards
J
Construction Super-:-'sv- L,cc^se _
License: CS SL 100542
Restricted to: RF,WS
JOSEPH ARONE .,
60 CENTRAL STREET 6
STONEHAM, MA 02180
Expiration: 3/17/2D12
Ti--: 100542
.�°~ - �Jl fiF.• �cYvra9rr.(Yrt•L(xdli•GLft. o��.�C.(x4
board of Building Rocula torts and St aidards
L:lr� `
Js17Ai.n Cwe ;Ashburton Placo - Room 1,301 -
'�H Boston_ Nlassachusetts 02108
IIome Improvement Contractor Registration
" '""- - It-lpebwim: 100770
. - Irlk. iJtlA
vJ14:2010 Tril V3120
ARONC FXTF_RIORS `:.�`�I..e'.:6'.;,- --- ---
J05F•.PH ARONE
60 CENTRAL STRC--CT ' <..-...:::- -
sTfmEHAM, AAA 02180 -
js ClAole.Vldreubnd retut'o uml.Alark re:oon Ii:r maonr.
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'�/ ''-1 boned NnniLlinf Rcyulmiunund tiundardJ UMUSeor rc�ietn0iun valid liar i:ulividul uae only
y 1` HOME IMPROVEMENI UONII rrpR before metxpirmion dote. If fuuud fewfn tu:
'` y^' hl:pialrnUan: ',L•Oan nnaM nrmelld1bg ltetluietio.18and Stnndpnl.
ts�2 ftnv Ulhhu.m.Mote It'.13111 -
ExpImtI*6: eg9.20'•: TO L 312U nmtun,VI..-11311b1 j
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nneNl:�xrcrlons �
JOSEP ARONE".`;
%iu CEN-RAI.STftFFT i,..�•b-r:.• .--.
STfMPIlvd.1,11 YJ+nO' ` Ado'midl.lur V..,valid ,ill.au I'l,n.fu.V
• ' DATE(MMIDD/YYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE OPIDARO DWi 10/01/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Chase S Lunt LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P O Box 590 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
47 State Street ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW.
Newburyport MA 01950
Phone:978-462-4434 Fax:978-465-6204 INSURERS AFFORDING COVERAGE NAICA
INSURED INSURER A. Liberty Mutual Insurance
INSURER B: Nor lmd mmrmee Campaalea
Arone Exteriors INSURERC: The Travelers 39357
StonehamaMAS02180 INSURER D:
INSURER E.
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSLTR NSR TYPE OF INSURANCE POLICY NUMBER DATE AIPOLICYM E PDATEY NI PIRATION LIMNS
GENERAL LIAffl R EACH OCCURRENCE $1000000
B R I COMMERCIALGENERALLIABILITY CP569418 10/10/09 10/10/10 PREMISES Ea neone. $50000
CLAIMS MADE ®OCCUR MED EXP(Arryone person) s 5000
PERSONAL BADV INJURY $ 1000000
GENERAL AGGREGATE $2000000
GENT AGGRE LIMIT APPLIES PER: _ PRODUCTS-COMP/OPAGG .$20000D0
POLICYGATE JEM LOC
AUTOMOBILE LIABILM COMBINED SINGLE LIMIT
C ANY AUTO BA0673P265 09/23/09 09/23/10 (Eaamd.rt) $ 1000000
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS rBODILY
on) $
R HIRED AUTOS - NJURYX NON-OWNED AUTOS enl) $
TY DAMAGE $
ent)
GARAGE LIABILITY AUTOONLY-EAACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESSMIMUHELLA LIABILITY EACH OCCURRENCE $
OCCUR El CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND - TORY LIMITS I I ER
A EMPLOYER
ANY PROPRIETORRAR XCUTNE
WC131S369961018 10/31/09 10/31/10 E.LEACHACCIDENT $
OFFICELMEMBER EXCLUDED?
E.L DISEASE-FJI EMPLOYE $
UYes,desonEe under
SPECIALPROVISIONSbel. E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Evidence of coverage
CERTIFICATE HOLDER CANCELLATION
HAVEROl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
City of Haverhill IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
City Hall
4 Summer Street Room 210 REPRESENTAmES.
Haverhill MA 01830-5876 AUT USID,RIPPRESEFF411VE ¢
ACORD 25(2001/08) O ACORD CORPORATION 1988
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