1 LEVAL RD - BUILDING INSPECTION (5) /( q . p'J
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
1 Building Permit Application To Construct, Repair, Renovate Or Demolish a
V One-or Two-Family Dwelling
N This Section For Official Use Only
J Building Permit Number: I D Applied:
t
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
I� 1. Property AddresA: ,� 1.2 Assessors Map&Parcel Numbers
l.Ia 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record-
Zoo WaI - dk, ewl m�+ olk7o
Name(Print) City,State,ZIP
2 LeVM 2J "V N8'-( nw ylVrsf-rornWDjc(hoo• Gdrn
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other lP Specify: QOr t2
Brief Description of Proposed Work': P ne CbD4
rda4c CiC
3D Ups- A sh 2ef
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ =74-D 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 (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
--tt Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
MPtL-t p512- MG:I /d 7l014fOtrne`
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
0(9No63 -41'5-11x
Z & TOMO i �-6 License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
SF, ^Dik >bn 5E
No.
pand Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
' R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
ff WS Window and Siding
c6i0i1 11 r.I I mart Ha Jv�!,r,Poctftk, SF Solid Fuel Burning Appliances
78/ 1317-17f tea, r Co 11I Insulation
Telephone Email address D Demolition
5. Registered Home Improvement Contractor(HIC)
/J K'£S�ivC r
l4l44jrA,x– t "g a, C. HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name L/�1I[ /
�ti t.');�& r\ �, G✓K /Ila//Waw—/Ifair..�� irrra c�PllT
No.and Street Email address .Cairy
AICA-P'l-d rn ({ ai��o ��g3867$r1
Ci /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 ..........FyNo........... ❑
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 �llWl 4 fit_ lityaS AS S oct l t
to act on my behalf, in all matters relative to work authorized by this building permit application.
Q,OA (A (al � a� IC
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' 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 to the best of my knowledge and understWd
.
��vtJ `reswto(1 It o ;51( 6
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/oc Information on the Construction Supervisor License can be found at www mass.sov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage, finished basementlattics,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"
The Commonwealth of Massachuseft
Department oflndustridAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FHYD WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Narne(Businesslorgauinition/Ind[v_idual):Hallmark Homes Associates, Inc.
Address: 56 Wilson Street
City/State/zip: Medford, MA 02155 Phone#: (781) 838-0789
Are you an employer?Check the appropriate bon Type of project(required):
1.®I=a employer with 2 employees(full and/or part-time).• 7. ❑New construction
2.❑I m a sole propriewror partnership and have no employees working fm me in 8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3Q am a homeowner doing all work uryselE[No workers'comp.inw m required.]t -
4.❑I am a homeowour and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensme that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. - - 12.❑Plumbing repairs or additions
5.❑I m a general contractor and I have hired the subcontractors listed on the attached sheet 13.®Roof repairs
These sub-commcmrs have employ=and have workers'comp.�.i
6.❑We are a corporation and its officers have.exemised thew right of exemption per MGL c. 14.❑Other
152,§1(4),and m have an employees.[No workers'comp.insurance required]
-
*Any applicant that checks box#1 must also 611 out the section below showing then workers'compensation policy information.
t Homeowner who submit this affidavit indicating they aro doing all work and than hive outside contractors must submit a new affidavit indicating such.
tConuvctors that check this box must attached an additional sheet showing the name of the sub contractors and state whether or not those entities have
.employces. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compenradon insurance for my employees Below is the policy and job site
Information.
Insurance company Name; The Travelers
Policy#or Self-ins.Lic.#:/6 KU B-5 B29684-3-14 Expiration Date: 03/17/2017
Job Site Address: I t e(/a I Qct City/State(zip: So let'✓[ M,,9- 4[4 3 G
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 free 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[ficat,
I do hereby ce un the and ojperjury that the information provided above is true and correct
Sienature Dom. 9/17/2015
Phone#• (781) 838-0789
Official use only. Do not write In this area,to be completed by city or town on'iclaL ^
City or Town: Permit/ldcense#
Issaing Authority(circle one):
1.Board of Health 2.Building Department 3.City/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
y !� Serving Greater Boston for Over 25 Years!
f
HALLMARK Dave Tomoljllo
HALLMARK HOMES REMODELING CSL#: 064063 HIC#: 158936
Standards & Quality are out Priority!
OWNER'S AUTHORIZATION FORM
For Building Permit Application(s)
The sole purpose of this form is to provide Hallmark Homes Associates, Inc.
with the necessary permission from the Owner to file Building Permit
Application(s) for such Project work as agreed upon between the Owner and
the Owner's Authorized Company and its designated subcontractors.
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OWNER'S NAME
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Project Addresg,, Project/Job ID
(Sig are) (Dad)
Owner's Authorized Company: Hallmark Homes Associates, Inc.
Company's Address: P.O. Box 885, Medford, MA 02155
Affiliation: Contractor
Hallmark Homes Associates,Inc.• P.O.Box 885,Medford,MA 02155• (781)838-0789• www.Hallm"kHomesRemodeling.com
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Hallmark Homes Associates,Inc.• P.O.Box 885,Medford,MA 02155• (781)838-0789• www.HallmarkHomesRemodeling.com
Hallmark Homes Associates, Inc. — David Tomolillo
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DAVID F
56WilsonStreet } - CwNOEOFMUM PwsreeLMKaxANENrwN.
'�, (Medford,MA 0215
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c' Massachusetts Department of Public Safety Construction Supervisor
-�� Board of Building Regulations and Standards Restricted to:Unrestricted-Buildings of any use group which contain
License: CS-064063 less than 35,000 cubic feet(991 cubic meters)of
Construction Supervisor enclosed space. \
DAVID F TOMOLILLO
56 WILSON ST I �y
MEDFORD MA 02155
Failure to possess a current edition of the Massachusetts
Expiration: I State Building Code is cause for revocation of this license.
Commissioner 03/15/2018 OPS Licensing information visit: WWW.MASS.GOVIDPS
e Vw..... rezen��a/oPJ/�rruaar.�rt
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
! Registration L158936 Type: Office of Consumer Affairs and Business Regulation
! 10 Park Plaza-Suite 5170
Expiration 3%18/2018 Private Corporation Boston,MA 02116
HALLMARK HOMES ASSOCIATES�1NC.
1
DAVID TOMOLILLO;'. �.
iSTONEHILL DR 1F
STONEHAM,MA 02180 l Undersecretary Not valid out signature
• ••�+� - yr w. rry
,4coR0 CERTIFICATE OF LIABILITY INSURANCE D310312 V01
0 6
03/03/26
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(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 endorsement(s).
PRODUCER CONTACT
Peter A. Rossetti Ins.Agcy. NAME: Peter A. Rossetti Ins.Agcy.
PHONE
436 Lincoln Avenue INC.No E,t;781-233-1855 Fac Not; 781-231-3752
Saugus, MA 01906 apoRRss:pnickerson@rosseftiinsurance.com
Peter A.Rossetti Ins.Agcy.
INSURER(S)AFFORDING COVERAGE NAIC q
INSURERA:Commerce Insurance Company 34754
INSURED Hallmark Homes Associates Inc. INSURER B:Travelers
Dave Tomolillo wsuRERc:Western World
PO Box 885
Medford, MA 02155 INSURER D:
INSURER E:
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.
INSR _M 9UBRTYPE OF INSURANCE D POLICY EFF POLICY EXP
LTR p D POLICY NUMBER MM/DD/YYYY MM/DD/YVYY LIMITS
C X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE OCCUR NPP1403770 06111/2015 06/1112016 PREMISES Ea occurrence) S 50,000
MED EXP(Any one person) $ 1,00
PERSONAL B ADV INJURY $ 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY❑PRJECT O- F-1LOC PRODUCTS-COMP/OP AGG $ 2,000,00
OTHER I Emp Ben. $ N
AUTOMOBILE LIABILITY EOMaB`NdEDISINGLE LIMIT S 1,000,00
A ANY AUTO BBXN23 04/2312015 04/23/2016 BODILY INJURY(Per person) S
ALL OS X wl SCHEDULED BODILY INJURY Per accident $
AUTOS AUTOS ( 1
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS Per accident $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS-MADE AGGREGATE S
DED I I RETENTION$ S
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
B ANY PROPRIETOR/PARTNEREXECUTIVE YIN 6KUB-SB29684-3-16 03/17/2016 03/1712017 E.L.EACH ACCIDENT $ 1,000,00
OFFICER/MEMBER EXCLUDED? ❑ N I A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 110001000
les describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00
DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required)
GENERAL CARPENTRY
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
INSPECTIONAL SERVICES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHHORIZED REPRESENTATIVE
1 -
Serving Greater Boston for Over 25 Years!
HALLMARK Dave Tomolillo
HALLMARK HOMP REMOOELRVG CSL#: 064063 HIC#: 158936
Standards & Quality are out Priority!
SolarCity Quote — Re-Roof
January 05, 2016
Ron Walton
1 Leval Rd
Salem, MA 01970
(781) 484-7271
nurseronw@yahoo.com
Roofing Specification:
MP1,MP3,MP4 Only
• Remove old comp shingles down to the existing roof sheathing
• Remove all nails and replace up to 32' of spruce ledger if needed
• Additional ledger will be charged at$4.00 per foot
• Apply 6' of Water Shield along the lower eaves
• Apply 3'of Water Shield along the valleys
• Install new vent pipe water diverters where needed
• Apply 15 lb. felt underlayment as protective base
• Install 8"aluminum drip edge along entire roofline perimeter
• Includes [90'] roof ridge color matching caps
• Removal of roofing debris by dumpster
• Total number of roof squares [ 19]
Owens Corning''TruDefinitionG DurationG 30-year Architectural shingles.
• Providing all Insurances,Licenses and Permits
Home Owner Responsibility Materials and Labor: $ 720.0
OAak
Hallmark Homes Associates,Inc.• P.O.Box 885,Medford,MA 02155• (781)838-0789• www.HallmarkHomesllemodelingxom