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24 LEMON ST - BUILDING INSPECTION *-4--1 T 2L), The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SAL dMarRevised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a 41 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: D Applied: 1 Building Official(Print Name) Signature Date n SECTION 1:SITE INFORMATION lam' 1.1 PropeT'eyvAdvd\ 1.2 Assessors Map&Parcel Numbers � L la Is this an accepted street?yes_ no Map Number Parcel Number Z 1.3 Zoning Information: 1.4 Property Dimensions: V CA M Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) cr,t`r n Front Yard Side Yards Rear Yard y 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?Check if yes❑ Municipal ElOn site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 wnert of Record: Name(Print) City,State,ZIP •Ie3e, Prtr�ce 6a- 2 `)9I 72� �p�J3 5a1e5® t'E)9eSI�n . t No.and Street a Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIK (check all that apply) New Construction❑ Existing Building If Owner-Occupied ❑ Repairs(s) RI Alteration(s) 14 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units J Other ❑ Specify: Brief Description of Proposed Work : '.� SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: Q� ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ O 2. Other Fees: $ 4.Mechanical (HVAC) $ 2 QQQO List: 5. Mechanical (Fire $ Su ression Total All Fees: $ ti Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 6 a Q Qfl ❑Paid in Full ❑Outstanding Balance Due: GprL t_ FD(,— ,V SECTION 5: CONSTRUCTION SERVICES I 5.1 Construction Supervisor License(CSL) ^ oR1 t'1� © �?0 '6 Q `(`&IY AQ 6cn Y-O'CA License Number !! / Expiration Date Name of CSL Holder `J 6 &1 C C l' S� List CSL Type(see below) No.and Street IType Description 0- 4 1 (M1 rl U Unrestricted(Buildings u to 35,000 cu.ft.) I �l/1/l Nl 'I I O R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registeer�ed Home Improvement Contractor(_11PC) S V— `J r ,e rS%t;V\ k chyl�'s16_oC4--, o i HIC�o Ex ratio Date HKouany Name o (-HC Regis"Name �� C3 knr\c1CP No.and Street Email address City/Town,State,ZIP Tel hone 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 APPLIES FOR BUILDING PERMIT I as Owne the subject property,hereby authorize t act on my b half,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) j- t Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of pequry that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. 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. og v/dns 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"maybe substituted for"Total Project Cost" 4\ �. Office of Consumer affairs and Business Regulation . 10 Park Plaza - Suire �170 Boston. Nlassachusetts 02116 Home Improvement Contactor Registration Registration: 158774 Type: IDEA Expiration: 3/3/2016 Tr# 250317 RS DESIGN & CONSTRUCTION RICARDO GARCIA 138 BRIDGE ST #2 - SALEM, MA 01970 I pdate Address and return card.Mark reason for change. Address Renexaal Employment Lnst Card sea• c zaaov:+ " '//...... Office of Consumer.%nairc S HoOtlss Regulaion License or registration Valid for individul use on1% fNOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ""?Registration: 158774 Type: Office of Consumer Affairs and Business Regulation %r. i Expiration: 3/3/2015 DBA i 10 Park Plaza- Suite 51 i0 Boston.NIA 62116 RS DESIGP:&CC NSTRUCTION �— RICARDO GARCIA. / 1 138 BRIDGE ST#2 SA_E>:1,MA 01970 -s1 nderecraian Not valid without signature ACOR� CERTIFICATE OF LIABILITY INSURANCE Dare(MMroormY) 8/14/2015 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 policy(les)must be endorsed. If SUBROGATION IS WANED,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 endomeme s. PROWLER CONTACT mum: Nilson Insurance Agency °NOS (781)665-1034 FAX,No,: 662-0301 109 Nest Poster Street ODR INSURE S AFFORDING COVEPAQE NAIC 0 Malrose MA 02176 INSURERAAGBex Insurance Co. INSURED INSURER B A.I.M. IMUtU&I Ise. Ricardo Garcia, DRAT R a Design a Construction INSURERC: PO Box 761204 INSURERO: IN9URER E: Lralrose MIL 02176 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1581402943 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. M SUBR LTRTYPE OF INSURANCE POILICYNUMBER POLICY EFFMMIDQIYYYYI P D EKP UNR9 COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE S 1,000,000 DAMAGE TOA CLAIMS-MADE LY OCCUR RENYmu.mIm) $ 50,000 3AA103071 8/4/2015 1 0/4/2016 LED EXP(my mue E 1,000 PERSONAL LADY 6WURY E 1,000,000 GENLAGGREGATE UMR APPLIES PER: GENERAL AGGREGATE E 2,000,000 R POLICY d LOC I PRODUCTS-COMP/OPAGG E 2,000,000 PRO- F OTHER E AUTOMOBILE LLTBILJTY COSINGLELIMITE ANY AUTO BODILY INJURY(Par pm w) Is ALLOWN® SCHEDULED I BODILY INJURY(Pw axMM) E I AUTOS ALFTOS NON-OWNED PROPERTY DAMAGE S r .HIREDAUTOS q AUTOS I ( 6 UMBRELLA UAB OCCUR 1 i 11 OCCURRENCE S EXCESS DAB CLAIMS-MADE AGGREGATE S 1 DED REfE N E WORKERS COMPENSATION E O - ' AND EMPLOYERS'LL481UTY ANY PROPRIEfORIPARTNER,E1((ECUTNE YIN NIA E.L.EACH ACCIDENT E 500,000 B iIOF Merin UE EXCLUDED? NCC 5011136012015 9/30/201.5 6/30/2016 yyeaaa I EL DISEASE-FA B4PL0 E 500,000 iffDESLRIPT100N OF OPERA O 11 mclorI EL DISEASE-POLICY LOAR E 500.000 OESCM"ONOFOPERATIONSILOCAnONSIVENCLES(ACORD101,Addill..d Rauurb Schedule,maybe Mlmhed(more Space Is mqulmd) 122 Kendall Road, Lexington, MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF LI=Nt'3J•ON THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN LTSXINGTON, MA 02420 ACCORDANCE WITH THE POLICY PROVISIONS. AU�RESENrATIVF,U/G+& i ' 01986-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(20T40r) Massachusetts -Department of Public Safety Board of Building Regulations and Standards p Construction Supervisor License: CS-095771 �:M:rI% OFF RICARDO GARC A 138 SALEMD A 01970E1� f Y% SALEM MA 0191'0 yl D r� J2. .>nn� Expiration Commissioner 10/20l2016 I i ► The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information pp / Please Print Legibly Name (Business/Organization/Individual): Address: / 3 8 !C)C,E—V S 1 City/State/Zip: —SP1t—L5 M Q Lq-10 Phone#: Are you an employer?Check the appropriate box: FDemolition ect(required): I.❑I am a employer with employees(full and/or part-time).• nstruction 2.❑I am a sole proprietor or partnership and have no employees working for me in eling any capacity.[No workers'hoop.insurance required.] 3. I am a homeowner Join all work tion ❑ g myself.[No workers'comp.insurance required.]t 4.❑Iran a homeowner and will be hiring contractors to conduct all work on my property. I will g addition ensure that all contractors either have workers'compensation insurance maze sole . al repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-cormactors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurnce.; 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomtation. t Homeowners who submit this affidavit indicating they ane doing all work and then hive outside contractors must submit a new affidavit indicating such. tContractors that check this box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub=contractors have employees,they most provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Information. Insurance Company Name: ( L C,�-O N Policy#or Self-ins.Lie.#: V`C� l l -� ©l 20 ( rj Expiration Date: gyp_—S� C) - 2 Q( (0 Job Site Address: t � ��I ED � � City/State/Zip: c-�-'r�y� �� ©Iq-7U Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ver c�tioq. I do hereby cenlfy u ler the parns{urd penalties ofperjury that the information provided above is true and correct. \ Signature: \`,t1 dam\ Date: 2 / fl l I Phone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# 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#' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee 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,partnership,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,construction 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." MGL chapter 152,§25C(6)also states that"every state or localdicensing 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 who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(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 compliance 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)name(s),address(es)and phone number(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 date the affidavit. The affidavit should be returned 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. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia