The URL can be used to link to this page

27 LIBERTY HILL AVE - BUILDING INSPECTION 9� The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR MUNICIPALITY Massachusetts State Building Code, 780 CMR USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Numbed: Date Applied: N 7 Building Official(Print Name) Sign Date SECTION 1: SITE INFORMATION 1.1 Prope Add ess: 1.2 Assessors Map&Parcel Numbers ' I-Ia Is this an accept d 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 r.1 uired Provided Required - Provided Required Provided ater Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' _ w er'of Bee rd: Ai ct Ca /�,�l s .�,m a�� ,�e:,r+ �f7 6� 70 m!(Print) —� City,State,ZIP No. and Street '"` -' - ----- Telephone Email.Address- SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction ❑ Existing Building I Owner-Occupied Repairs(s) Alteratiou(s) ❑ Addition ❑ Demolition - ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Dgscription of Proposed Worl2: l<hbg; rA4 c SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ a f (t 3 6 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 (14VAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ / Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ a tD 3 Q 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /63 d'd �7 ' License Number l Expiration Date Name of CSL Holder List CSL Type(see below) L No. d Street Type Description U Unrestricted(Buildings up to 35,000 cu.It-) R Restricted I&2 Family Dwelling Ciry/T wnn M Masonry RC Roofng Covering WS Window and Siding pp G SF Solid Fuel Burning Appliances jol ? 'p2.7. 9741 - I Insulation Telephone Email address D - Demolition 5. R�gistered Home Improveme®t Contractor(HIC) $„/)y. HIC o an N e or HIC R str N HIC Registration Number Expiration Date ✓o. and Street Email address �t�/ • City/Town, State, 11P 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 CONTRACTORAPPLInES 9FOR BUILDING P/FRMIT I, as.Owner of the subject property,hereby authorize ; / /�/t///� r'1 0� rAo ll� yz to act on my behalf, in all matters relative to work authorized by this uilding pKimit ap lication. Print Owner's Name(EidEtronic 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 is ap n is true and accurate to the best of my knowledge and understanding. - Print Owner'su uthorize gent'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.aowoca Information on the Construction Supervisor License can be found at wvrw.mass.eovidus 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" ) L ® DATE(MMDDIYYYY)A `../ CERTIFICATE OF LIABILITY INSURANCE 4/3/2012 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 endomement(s). _ CONTACT Maureen McDonnell PRODUCER , NAME: J. Williams Insurance '� - - 'I PHONE (7B1)848-9192 FAX No:(181)848-9116 14 Wood Rd E-MAIL .Maureen@jwilliamsinsurance.com DDRE Suite 4 INSURERS AFFORDING COVERAGE NAIC It Braintree MA 02184 msuRERA ENDURANCE AMERICAN SPECIALTY INSURED INSURERBArbella Protection 136D Orlyn Contractors Inc. INSURER C ALTER RA EXCESS 6 SURPLUS 916 Pleasant Street INSURER D:LIBERTY MUTUAL Unit: 4 _ INSURER E: Norwood MA 02062 INSURER F: COVERAGES CERTIFICATE NUMBER:CL12 3 30013 90 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 POLICYEFF POLICY EXP LIMITS LTR TYPE OF INSURANCE D R POLICY NUMBER MWDo MMIDD GENERAL UABIUTY - EACH OCCURRENCE E 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 A CLAIMS-MADE ❑X OCCUR BC10000197601 /1/2012 /1/2013 MED EXP(Any one person $ 5,000 PERSONAL A ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 X POLICY[71 PRO- LOC E COMBINED SINGLE LIMIT 1 000 000 AUTOMOBILE LIABILITY - Eaaccident BODILY INJURY(Per person) $ B ANY AUTO AUT0 ED X SCHEDULED 02844400004 7/7/2011 /7/2012 BODILY INJURY(Per soGdenO E NON-OWNEDAUTOS AUTOS DAMAGE S X HIRED AUTOS X AUTOS Per accident. Metlical morns E UMBRELLA UAB OCCUR EACH OCCURRENCE $ 2,000,000 L, X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DED X RETENTIONS 3EC50000112 /1/2012 /1/2013 $ D WORKERS COMPENSATION X VJC STATU- OTM- ANDEMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500 000 ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA OFFICERMIEMBER EXCLUDED? 231S473291011 6/19/2011 6/19/2012 E.L.DISEASE-EA EMPLOYE $ 500,000 (Mandatory In NH) If yes,descd8eunder E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS below , DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Evidence of insurance for the insured's scope of normal business operations. Notice of cancellation is 30 days except SO days applies for non-payment of premium. 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. * Sample Certificate of Insurance AUTHORIZED REPRESENTATIVE Jonathan Williams/MEM ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(minn61 nt Th.Ar,.nion ramn anti Innn am r.M.tc rod mark.of Ar)r)Rn The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 -' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ap2ficant Infformation Please Print Legibly Name (Business/Organization/individual): 1-J za, 7- Address: 9� 1, City/State/Zip: "-Z— Phone#: re you an employer?Check the a propriate box: Type of project(required): I am a employer with /C;I- 4. ❑ I am a general contractor and employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7.. ❑ Remodeling These sub-contractors have ._slop and have no employees 8. ❑Demolition _ - workingfor me in an capacity. employees and have workers' y p Ty insurance.$ 9. ❑ Building addition [No workers' comp. insurance comp. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 1;elRoof repairs insurance required.] t c. 152, §I(4),and we have no employees. LIo workers' 13.❑ Other comp. insurance required.] _ 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am as employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. J _ Insurance Company Name: 1 [ Policy or Self-ins. L ic.#: 1A �3 s J , 3 d-q 7 16) I Expiration Date: Job Site Address: ✓ l'/' / �V`� City/State/Zip: D �o Adtnch a gimpy of the workers' cumpemadi u Polley declaraGlon page(showing the pulacy number nad ezpirsifion 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 WORIK 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 DI or s ce coverage verification. 1410'qre cz ad 7 the ain and penalties of pedj yy Ague Iiie information provided bore is V e and coa;'er1. r �( Sienafire. q Date: I �J� ] Phone#: �. 7 I h-17 -- Official use only. Igo not write in this area,to be completed by city or town official ; i 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#: CITY OF S.u.&Nl, NLkSSACHUSETTS BuILDIING DEPARTNIEUNT 120 WASHNGTON STREET,3iD FLOOR T EL (978) 745-9595 FAX(978) 740-9846 KI\tBE 1-EY DRISCOLL MAYOR T HoatAs ST.PIERRE DIRECTOR OF mmic PROPERTY/BUUMING COMMSSIONER 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: C L . L , ty (name of hauler) The debris will be disposed of in : e•L f ry12i (n5me of facility) (address of facility) signature of permit applicant date dcbris4ffd,x Massachusetts- Department or Public S:ifetc 1910111111. Duard id' Buildim' Rc�Sulatiu ns and Standards Construction Supervisor License License: CS 103929£ ,W,', ji Restricted to:..00.,,,.E :F . _ d y TODD MELLOR 4 GARDEN S MA 02388. t " RANDOLPH,, i R Expiration: 812712013 Trit: 103929 Cmmnlsi,mer ..'�� .•, .••rr�."_" �/t¢ UJO��w)raiu o�✓KaddaC�utdeltd`. •..} Office of Consumer Affairs&Business Regulation e Nz _ OMEIMPROVEMENTCONTRACTOR e Re gistration'a101297 Type ' Expiration-=8Qk612 Supplement O'LYN CONTRAC11TORS��I b J TODD MELLOR � '�� - 916 Pleasant Street flint Norwood, Undersecretary, t,c�