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6 LINCOLN RD - BUILDING INSPECTION _ --- I'he C ommumw:dth of Mussorhuscils Boardul'BuildingRegulationsandStandards CI'll'OF 10assachuscus Slate Building Code,'730 C'NIR Kr' S 11 ). ri rod l6au'. _llll Building Pcnnil Application To Construct. Repair, Renovate Or DlnlUhsh a One.or Tnv-biunill' Dn vlthnv This Section For Olfieiul Use Only Building Permit Number. f, — Date Applied: Iluilding OI))cial(Print Mare) L'— Signature I aid aar. SECTION k SITE INFORNIA 1 1.1 Prope ty Address: LI Assessors,$lap «1 Numbers 'eu�Liv ago _ I.la Is This an.accepted sireel? es no Map Number Parcel Nuartsvr I.1 2onlna Information: 1.4 Pro peyt Dlmenslons: L ming District 11n,powd(Jsd Lot Area(sy 11) Frontage(11) 1.5 Building Setbacks(n) Front Yard Side Yards Rear Yard Required Provided Required Provided "R,,uirvd0,, Provided 1.6 Water Supply:(M.G.I.c. Jo, §54) 1.7 Flood Zone Information: al System: Zane: OutsideFtood"Luna?Public❑ Private❑ — Check it disposal s)Win ❑ SECTION I: PROPERTY OWNERSHIP' 2.1 Owner'of Record: N;und(Print) - ram, GOZWg4.0 City.state,ZIP l <51' 1 Si �yUSa No.and Street relephune Email Address SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ 1 Alleratlonis) ❑ I Addition C3 Demolition ❑ Accessory 81dg.❑ Numberaf Units er ❑ Speciry: �� Brief Description of Proposed Work": Pg� a 'f!/l/�_ SECTION 4: ESTIMATED CONSTRUCTION COSTS item Estimated Costs: OMNI Use Only it abur:rod .\(ateria(s I 1. Building I. Building Permit Fee: S Indicate how fee is determined: ❑Standard City+Tuwn Appllcation Fee '. lilrctrieae S ❑Tutnl Project Cost'(Item 6)x multiplier Plunihing S +. Other Fees: S- J. \Iech.mi:al 01% \('1 S List:.- ----- `ur+raxsiunl S rotal \It Fees: S_.-___—_ n I'utrl I'rnjvct Cost: S � (� O Ch ,ii No. _-___( heck :\nu stand _. _._ 1mceh tie. : ❑ P.:id in Full ❑Uulstmding Ilal.mce Doc: a6sa39� StA HON .S: 5.1 I tceii.w Nuothcr 1:�pir,aioii Date 11oldcr Its(CS1. I PC Dcsarilition uiJ.S1rcv1 11 1 innstricicJ I lituldings uIlt to 3`t-000❑1 It 0 a � R l(v,trivwd t7a)"kmi.S1.1C.T1I; %lawn C K,xliill L',.,,nna AS Wildow,ul.,"U.". SF SoliJ Fact lituningAppliances I Insulation I Vic hone D Donolititin 5.2 Registered flume Improvement Contractor(HIC) Ig:v e5�0 C/111 I C/J %� � IIIC Registration Nunitwr F%liiratitlii W19 FRIC L0,1111pill) No. and pime, - [:moil iddruss 6 7 Zllty frown,slate'ZIP ryleLhone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 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 or the building permit. Signed Affidavit Attached? Yes ..........6P/ No...........E3 SECTION 7s.OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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: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 understanding NOTES: [1:, .:\n Owner who obtains a building permit to do his.htr own %sork,or an owner who hires an unregistered contractor o' (not registered in the Hume Improvement Contractor il-110 Program),will dai have access to the arbitration �'r" o prograin ur guaranty land under M.G.L. v. 142A.Other important information on the HIC Program can be round at I Information on the Construction Supervisor License can be round at 1% i01 2. \%lien substantial work is planned,pru%idc the in6armaliun below: rota) floor area(,4. 11.) (including garage. finished bascinent attics.decks or porcht Grois li%ing 'Irea I sq. it.) Habitable room count Nwither of Bedrooms Numberol hathroomi \t1mlict ot liall,hoilli I'\licot'livalilIg \m%ihvrol'd%%ks liordics Open I,c 01'�oollog i.\ 1�11614�d voial llroleo S,ltmrc Foolacc-ni.,N he iuh.ututQJ 11or 1'oial llrojM 0',I­ CITY OF S'V-&,i, `tiLISSACHUSETTS t3l,tLOLYG DEP.1ATtF.rT 120 %7MM VGTON SrXEjrr, JI FLOCX rRL k978) 745.9599 'UJCHAF 9Y DRLSCOLL FAX(973) 11Q9844 I MAYOIt mC.�W Sr.PMUS OIXALTCx OP pCBLIC PRC?FATY/BCRDp/G Co1p(fuIO.V EX Construction Debris Disposal Atf7davit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda 730 CMR section III.S Debris, and the provisions of MaL o 40, S 54; Building Permit At 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 MCL c 111, 3 I JOA. The debris will be transported by: (n+ma ur hauler) The debris will be disposed of in : (nTme o— Y) ..�—. ( Jdreft orf�¢ t,�yl +yn+rora of permit 4011;,nt < C[-I'Y 0E NWSACHUsETTS ' BUILDING CEP.%WrMF-NT 120 WASHLNGTON STREET, 3w FLOUR T-L (978) 745-9595 F.k-r(978) 710.9844 GIBE(i[RY DRISCOLL Tuams ST.Pimms AillyoA DIRECTOR OF PCOLICPROPERTY/9h[LDiXG CONLMSSIONER Workers' Compensation Insurance AlTidavit: Builders/Contructorv/E(ectric(ans/Plumbers Anolleant Inri:rmatinrs Please Print Legibly _ NainC IHIl1111v,4U1�.7nN.1111]h INIIVIIIp.III• /�/V C���S����� �CJ� - Address: 9!t< /'7eq,/ti�/�7l CityiStatc/Zip: l"7.0 Phone III: . \re 1 an employer?Check tke appropriate box: Type of prelate(required): 1. l at a cm a• 0 general I am a neral confractot and 1 Dto (th 6. ❑New construction mnpinye fell tiior part-time).- have hired the sins-comractors 2.0 lams sole proprietor or partner. lisidd on the attached.rhae� t 7. ❑ Remodeling ,hip and have no employees These subcontractors have V. ❑ Demolition working for me in any capacity. workers'camp. insurance. 9. 0 Building addition (No workers',comp,insurance 3. 0 We are a corporation and its 10.0 Electrical repairs or additions required.) officers have exercised their 3.0 1 ale a homeowner doing all work right of exdlnption per MOIL 11.0 Plumbing repairs or udditions myself. (No workers'sump. c. 152,41(4),and we have no 12.0 Roof repairs insurance required.1 f cmpluyees. (No workers' cutup. insurance required.) 17.0 Other .%uy applluln 1W.husks but rl must also 011 uul,hv socket bulaw showing Chair wmkan'companrulun pulicy intli mulloo. 'I lo.nuuwn v who whmll INS arlidavit Indicating they an daing all writ and than hire uulri le cantmeras mtul nthrnk a now affidaril indlaing swh, t'„mrnulom that chwk this bug cowl anuMd an aJJiuunal.hat showing the nwna*(the tub.,untralani and thole workers'wrap.pulley Inlomultoe. l urn an enrpluyrs that Is pruvlding tvorkrrs'cumprusarlon insurance far my empluyerese Below!s the pollgr and job site infunnudnn. In,amI1L'L'Company Naine:— 'e:,�j�f� Policy 4 or Sclf--ius. Lic. it: 71,,I6 /S�,`� Egpirution Date: lub Site Address: (y C/NLULfU Rl7 Ciiy/StuteiZipt /r7/9 .t ttacb a copy u(the worktn'componsatloo pulley deelaratlan page(showing the policy number and expiration data). F.liluru to wcurd cuvdnga as required under.Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of s lire up to i I,S00.00 and/or one-year imprisnnmenq as wall as civil penalties in the farm of a STOP WORK ORDER and a lina of up to S250.00 a day against Ilse violator. Ile advised that a copy of this otatcatcni may bu forwarded to ilia Of lica of lavc,tigatinns ofthe 01A larineurancc covaragc vcritiuliun. 1,10 11rreby ramify radar 111e^pains U41a7J�irrnurle.c i/perjury rhur the iajuralurlmr provide)above .11 aro undedrrece Official u.e nn1y. O,a nor writr br thir area, 1J.5r cunrplrtdd by city or town nf/1ciaL CJryar ll,wo:, PcrmitiLlccnati Lsui,i- Aulhurity (circla u.ic): —_. .. -..__ : I. Uu.Ird set Ileallh !. Ouildln•g, Dep.trnu.nt .1. ('ilyi 11n.n Clark !. E.leetric al hl,pcvtur i. ('l,l,ohintt fulpeetor 4. t)1Ur Cunl.ld I'ennn; Phood.:1 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - - Registration: 121604 Type: DBA Expiration: 5/24/2014 Tr# 223332 QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RD. DRACUT, MA 01826 'Update Address and return card.Mark reason for change. -- Address Renewal Employment Lost Card SCA 1 G 20M-0S 11 V ns der Affairs&Bus o(ess Regulation License or registration valid for individul use only Office of Consumer Affairs&Business Regalatiou g Y 7 ROME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: v egistration 121604 Type: Office of Consumer Affairs and Business Regulation xpira0on 5/242014. DBA 10 Park Plaza-Suite 5170 y Boston,MA 02116 QUINN'S CONSTRUCTION THOMAS QUINN - - 868 MAMMOTH RD. g��ao 'Z'04 . 9,Azln DRACUT,MA 01826 — Undersecretary Not valid without signature lassaehusetts - Depariruent of Public Safetl Board of Building Regulations and Standards Restricted to: 00 Construction Supervisor License 00- Unrestricted License: CS 39732 y� - 1G-1. 2 Family Homes - Restricted to: 00. THOMASJ':QUINN 868 MAMMOTH T Failure to possess a current edition of the j Massachusetts State Building Code DRACUT, MA 01826 is cause for revocation of this license. i i Referta WWW.Mass.Gov/DPS Expiration: 3/25/2012 t'nnmis imer' - Tr#: 18330 - 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - . - Registration: 121604 Type: DBA Expiration: 5/24/2014 Tr# 223332 QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RD. DRACUT, MA 01826 . Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA t 0 20M-05/11 Office of Consumer Affairs&Bosidess Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: �3ieOgistretton. 121604 Type: Office of Consumer Affairs and Business Regulation . xpiratlon 524/2014. DBA 10 Park Plaza-Suite 5190 - Boston,MA 02116 QUINN'S CONSTRUCTION THOMAS QUINN 868 MAMMOTH RD. - DRACUT, MA 01826 - Undersecretary Not valid without signature OP ID: JP CERTIFICATE OF LIABILITY INSURANCE DATE(MMI°°"""' 031121l2 THIS CERTIFICATE t$ 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 Donn' CEFI,AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate hol(ler is an ADDITIONAL INSURED, the pOlicy(ie9) must be endorsed- If SUBROGATION IS WAIVED,subject to the terms and conditions of the PCHCy,certain Pollcle9 may require an endorsement. A statement on this certificate does not confer rights to the Ceniflcate holder in lieu of Such entlorSemeR S. PRODUCER 978-975-1300 ONTACr Segreve&Hall Insur,Assoc.lnc NAME: 305 North Main St. 978-975-759G PNONE FAX Andover, MA 01810 , " ]:- fArc NP: Edward Ramirez ADDRESS: cu I,tERIDa:THOMA-3 INSURERS AFFORDING COVERAGE NAIC A Nsuaea Thomas Quinn INSURER A:Distel Group dba Quinn's Construction 868 Mammoth Road INSURER B:Hartford Ins Co. Dracut, MA 01826 INSURER c t INSURER D: INSURER E: INSURER P: COVERAGES CI_RTIFICATENUMBER: REVISIONNUMBER: 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 TWE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS 'TYPE OF INSURANCE I Y POLICY NUMBER MIOD MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ - 1,000,00 A X COMMERCIALGENERALLIABILITY M021000227 01115112 01115/13 PREMI Too mu",F $ 100100 'rZCPN'L CLAIMS-MADE OCCUR j MED EXP(my P e p5reon) PERSONAL s ADV INJURY 9 1,000,00 GENERAL AGGREGATE $ 2,000,00 GREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,00ICY PROjaa- Lac $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO IEeamldeltl) E ALL OWNED AUTOS BODILY INJURY(Perperrnn) S SCHEDULED AUTOS BODILY INJURY(pop CmMent) $ HI.RECAUTOS PROPERTY DAMAGE S (Per ecc�dorp NON-OWNED AUTOS 8 UMBRELLA LIAS OCCUR EACH OCCURRENCF. Is EXCESS LIAR CLAIMSN.AD'_ AGGREGATE S OF,DUCTIMLE RETENTION S $ V!()RXERS COMPENSATION X WC GT � OTN• AND EMPLOYERS'IJABILITY TOR B ANY PROPRIETOR/PARTNERIEXECUTIVEYIN 116P704 OV75/12 01/15f13 E.L.EACH ACCIDENT $ 10D00 OFFICERPoIEMBER EXCLUDEO? C NIA r (Mentlatnry In NMI E.L.DISEASE-EAEMPLOYEG $ 100,00 4y6. daacgba unCer OE RIPTIONOFOPERATIONSDpICw E.L.D13EASE-POLICY LIMIT I$ SOO,OO DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES (Attach ACORO 101,AVOMOMWR.m0l 9 Seeativly,If moM apeCC b rwqufraM) Sole Proprietor Thomas Quinn is Excluded under Workers Camp CERTIFICATE HOLDER CANCELLATION LOWELLC 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 EPRESENTATI VE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD ;