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257 LORING AVE - BUILDING INSPECTION � The Commonwealth of Massachusetts y-1 WBoard of Building Regulations and Standards Massachusetts State Building Code, 780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or DemoiM 6 NOV 2 3 A li S One-or Two-Family Dwelling (� This Section For Official Use Only (� Building Permit Number: Date Ap led: _ Building Off.cial(Print Name) _ Signature Date` 1 , SECTION 1 SITE INFORMATION (� 1.1 Prope dress: 1.2 Assessors Map&Parcel Numbers L l a Is this an accepted s et?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? Check if yes[] Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 w er'o Re rd: �7(}/' r^ Name nnt) � City,State,ZIP� r4 � � No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check oy that apply) - New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work'-: � fKc l4t� G SECTION'4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Naterials) Official Use Only 1.Building $ 1. Building Permit Fee:$j77!5'- IQicate how fee is determined: ❑Standard City/Town Application Fee" 2.Electrical $ ❑Total Project CosP(Item 6)x multiplier - x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (RVAC) $ 5.Mechanical (Fire $ Su ression Total All Fees: $ Check No. Check Amount' Cash Amount: 6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: SECTION 5s CONSTRUCTION SERVICES. 5,1 Lrcensed_ConstructionSuoergisor(CSL) re - Name o _ Holder � Exo_ _=o _ ate List CSL Typg(see.belowl�-_ A cea T e - Description - . . U Unrestricted( to 35,000 Cri.Ft. Si_ atu /f R Resmcred 1&2 Fami!y Dwelling M Maso Onl _Telephone ✓ RC Residential Roofing Covering WS Residential Window and Siding SF Residential Solid Fuel Britain A fiance Installation 5.2 Re>nstere DOIe$n10i D Residential Demolition - nen_t nnteactor_(HIC_1 R a R_eetstrahon Numbe_ — - L— Siena r_e z ,s F.XDITatInII. ab Telephone Email,Address SECTION 6:WORKERS,COMPFNSATIONINSURANCE 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 the building permit Signed Affidavit Attached? Yes..........JJ No- SECTION 7a:OWNER AUTH®RIZATION TO BE COMPLTED iBEN OAVNER'S_AGENT_.ORCONTRACTOR.APPLIESFOR,,BU1-DINGPE I, PitizEr as Owner of the subject property hereby anwuttce _-- _ relative to work authorized by this building permit application. to act on my behalf,in all matters $ienature o_f Owae� Date SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the fore oin a &cation are hue and accurate,to the best of m knowledge and behalf. g g pP y g Print N Sia�atnre,_f Owner or-Authotized_A_.eent, (Signed under the pains and penalties of perjury Date 1. EPEE!! r who obtains a buildin NOTES:g permit to do his/her own work or an owistered contractor tered in the Home Improvement Conhactor(f1IC)Program),wille arbitration r guaranty fund under M.G.L.c. 142A.Other important informatand ion Supervisor Licensing(CSL)can be found in 780 CMR Regulaons 110.R6 and 110.R5,respectively. 2. stant al work is planned provide the information below:Totea(Sq.Ft) (including garage,fins,decks or porch) Grorea ces Ft.) Habitable room count Number of fireplaces Number of bathrooms Number of bedrooms Type of heating system Number of half/baths Type of cooling system Number of decks/porches Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cosy' CITY OF $AI.E.2%1, iNLxsSACHUSETTS BLILDLNG DEPARTMENT ` ��4 130 WASHNGTON STREET, 3i0 FLOOR TEI.. (978) 745-9595 Fax(978) 740-9846 KINfBERIEY DRISCOLL MAYOR T HomAs ST.PtERRE DIRECTOR OF PLBLIC PROPERTY/BUHMING CONMSSIONER 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: dry (name of hauler) The debris will be disposed of in : Hat— name facility) (address of facility) signature of permit applicant date dcbriml7Ju KITCHEN INSTALLATION ESTIMATE WORKSHEET - USA su.•: s-.��.vANe.� 2686 R.J.Construction. Mark, Vanessa Mazuzan, 978-741-4601 1 < 1012212016 Categ©ry Breala'do �tr Demo and Haul Away $2,227.00 Electrical $2,640.00 Plumbing $1,995.00 Tile $1,200.00 Drywall/Repair $890.00 Cabinetry/Appliances $2,950.00 Additional Charges/PermitsGrand Total $760.00 rr Customer Signature: / ! , 1� — Date: Associate Signature: Date: GC Signature: Date: Rs�� +J ` �Uv Z d 9990LLZSZ6 uosipew pieyoia dOb 90 9l OZ^oN Nov 20 16 06:41 p Richard Madison 9782770685 p.3 34," 27" 30" 27 27" 337" {� -- 6m " 73n' 34 L„ 27" 3 12" 2" n. W2742 W3023.5 W2742 WC2742R o B27RT RANGE3.30 PP1 BC45P0 n � . � I - I � it �_� N r, _ O W `1 NIJ 21 , -nND w _ W �v m . i i i i ' O INSNa ao N� ZD9 thq 5 £ZM 'CSl •t5$ .£ to N I'y CD NA n to ID �1............... - 0 0 r-O 00 T W Massachusetts DePa Regulations and and Standards ; Board of 3uilding Reg . License: CS-030000 Construction Super"+sof Y - RICHARD J MADISON - + 3 MADISON AVE 7s GROVELAND MA 0183ujs -=,Xpiration: 0712112017 Commissioner y� The Commonwealth of Massachusetts �\ Department of IndustrialAccidents office of Investigations s 1 Congress Street,Suite 100 Boston, tti14 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElePlease Print Legibly A pplicant Information 1 // /� ,/ / L ®0 T K 1' Name (Business1Oroemza/hionl]11dv' aa]) l�4/n6 t Address:t 2 tom° n�(tl �Pt City/State/Zi : t) Phone#: Are you an employer? Check the a ropriate boa: Type of project(requ],red with 4. I am a general contractor and I 6 New constructi 1. I am a employer * have hired the sub-contractors employees(full and/or part-time). listed on the attached sheet 7. emodeling 2. I am a sole proprietor or partner- These sub-contractors have S, Demolition ship and have no employees working for me n any capacity. employees and have workers' 9 Building additii comp.msurance# [No workers' comp.insist 10.❑Electrical repa5. 0 We are a corporation and itsrequired.] officers have exercised their I I.❑Plumbing repai3.❑ I am a homeowner doing all workright of exemption per NIGL I2.❑Ro zepaus myself [No workers' comp. c. 152, §1(4),and we have noinsurance required] t employees. [No workers' comp.insurance required] bowing their rAny nsation policy information- applicant that checks box 41 must also fill out the section belowwork and llrea hireourtsidemco e�racrgs must submit a new affidavit indicating such t Homeowners who submit this affidavit indicating They g all tContractora that check this box must attached an addmonsl sheet showing the time of the sub-cmaract"and state whether or not those entities have employees. if the suh•eontractom have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and jab site information. (!,C) _ — insurance Company Name: Expiration Date: Self-ins.Lic.#: W t ©1 � ` � ` xP policy#or Po y City/State/Zip: Job Site Address: Attach a copy of the workers' compensation p cy declaration page(showing the policy number and expiration date). GL c. 152 can lead to the imposition of criminal penalties of a Failure to secure coverage as required under Section 25A of M fine up to$1,500.00 and/or one-year imprisourn 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 UnON the pans and penalties of perjury that the information provided above is true and correct i JCL A A�/ Date- Si atme l n n Og � � Z hone#. � q y P -- � [6. fncial use only. Do not write in this area,to be completed by city or town ojliciat ty or Town: Permit/License# t I uing Authority(circle one): Board of Health 2.Building Department 3.City/Towu Clerk 4. Electrical Inspector 5.Plumbing Inspector ,II OtherPhone#: ontact Person: ' II DATE(MMIDDI'f'!YI f�coRo� CERTIFICATE OF LIABILITY INSURANCEFORMAT az`lalz9' CE! TE HOLDER. THIS �ATECATESSNOT AFFIRMATIVELY AT AT-TER OF IN NEGATIVELY AMEND,ON EXTEND OR ALTER AND CONFERS NO TIRE COVERAGE AFFORDED GHTS UPON THE ABY 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. to the Omns and cothendlNonsific the policy,is art certain DOITIO policies may INSURED, tuire endolrse(ment A itatement onjes) must be dthis If SUBROGATION does not conferDrights to subject certificate holder in Ileu of such andorsement(s). c NTper NAME: I AX AICC PRODUCER PHONE No: MARSH usA.INc. i'NOALLIANCE CEITER E-MAIL 3560,_ENOX ROAD.SUITE MOO ADDRESS: i NAIC q ATLAN'A GA 30326 INSURERS AFFORDING COVERAGE i26367 INSURER A oieadlasl InsumnCB Company -100492-HomeD-GA1N--I6-173941 INSURER a:ZunCh AniBIICaO insurance CofA INSURED NEW•dampshir9lns 0 23641 THD AT-HOME SERVICES,INC. INSURER c :23817 OBA THE HOME DEPOT AT-HOME 3ER`IICE3 INSURER D:1!Iinois National nsurance Company 26g0 CUMBERLAND PARKWAY,SUITE 300 ATILANTA.GA 30339 IxsuRER E'. INSURER F COVERAGES CERTIFICATE NUMBER: ATL-00374 UED REVISION ABOVE FO:B THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PH THIS ERT CERTIFICATE MAYNBESISSUED OR MAYS PERTAIN, THETERM OR CONDITiONSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALOL THE ICTERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED CY BY P PID CCLAIMS LIMITS jp DL BR POLICY NUMBER MMIDOIYYYY NMIDOfIYYY INSR TYPE DF INSURANCE 9,000,WO LTR'', GL04807714-06 03101R016 10310112017 DAMAGE Ft TE A X COMMERCIAL GENERAL LIABILITY I I 'I I DAMAGE TOR NTFD 1,000,000 —� -� �� PR MI xcu nce EXCLUDED !'�J CLAIMS-MADE h OCCUR i j ILIMITS OF POLICY XS MED EXP(Any ane Penom IOF SIR:SIM PER OCO j i PERSONAL S AD VINauRv j l i 9,000.000 • GENERALAGGREGAT_ OEN'L AGGREGATE LIMIT APPLIES?Eft: I PRODUCTS-cOMPIOP AGO i 9.'3OO.000 _T ��POLICY[1 JECOT I I LOC I III OTHER' �03,OL2016 ;O31OIIpO17 'COMBINEDaINGLE UMIT Is 1,000,000 �0AP 2936863-13 aul ant r7, ANY BILE LIABILITY 3COIL'/INJURY;Par Oersanl AUTO „ BODILY INJURY IPeruadentl,BCHEGULEOSELIPISURED AUTO PHY DMG ED MAGE .. ALL O`NN —JI I IPROPERN AUTOS AUTOS •� Per accident NON-0`PINED ! - HIRED.AUTOS' AUTOII S 1 i 1�i ETCH OCCURRENCE i ( !UMBRELLA LULB OCCUR I j AGGREGATE S I�EXCESS LNB CUIMS-MADE DIED RETENT ION i WC015519215(ADS) 0310L2016 03101/2017 X PER ORH ' C WORKERS COMPENSATION T T 1,WO,000 AND EMPLOYERS'UABIUTY YIW WC015519217(AK,KY,NH.NJ.'7T) 0310112016 0310112017 E.L.EACH ACCIDENT t C ANY PROPRIETORIPARTNERIEXECUTIVE N NIA - 0310112016 0310112017 1,WO,WD D OFFICEMMEMBER EXCLUDED? WC015519216(FL) EL DISEASE-EA EMPLOYE S 1.000.000 (Mandatary In NH) EL.DISEASE-POLICY LIMIT S u yea.desww ewer Cdnitnued on Additional Page DESCRIPTION OF OPERATIONS no- DESCRIP RON OF DIRERAIIONS I LOCATIONS I VEHICLES (ACORD i0l.Additional Remarks Scnedule,may to attached if more apace Is Mulred) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION THD AT-HOME SER`/ICES.INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN DBA THE HOME DEPOT AT HOME SERVICES ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD ATLANTA,GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Multheriae ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101).— _ Lha ACORD name and logo are registered marks of ACORD DAF{MMIDDI'C'I �rzfl� CERTIFICATE OF LIABILITY INSURANCE i2OLDE THISCERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONL'r AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CEFCi TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTEP. THE COVERAGE AFFORDED BY THE POLICIES ,I BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETNEEN THE ISSUING INSURER(SI. AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: ins and conditions heccertificate the Pother is d1l certain epoli espmay - tED Ain endorsement.( A Statement on this certificate does not confer rights)to the the certificate holder in I19U of such endorsement(s)' NTacr NAME FAX PRODUCER PHONE MARGIA AA INC PNO ALLIANCE CENTEP EMAIL 1560:_NOX.ACAD.3UI-c 24rrr ADDR SS: ,Nmca AT1�11I'A ,A 'A325 INSURERS AFFORDING COVERAGE �25367 INSURER A alaedlaal insurance Company Q0492-HomeD-GA'N'.16.17 ''r575 I INSURER B:2'Jnch American Insurance.A INSURED j278 iHD A.-HCME 3ERIIICES INC. INSURERc draw Hamosnira ms�'a 11817 DBA THE HCME DEPOT ALHCME 3ERVICE3 INSURER D:Illinois 1131 war nsurance S051 2690 CUMBERLAND PARK'NA".3UITE NO ATLANTA,GA 30339 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: ATL90374fi64iL14 REVISION NUMSER:S THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE RESPECT FOR THE POLICY PERTHIS T INDICACERTIFICATECT OR OTHER DOCUMENT WTH NMA�BESSSUED OR MAY PERTAINS THE INSURANCEAFFORDED BY THE POOF ANY LICIES DESCRIBED HERERM OR COND17ION EIN IS SUBJECT TO ALOD L T EI TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. RLIMITS SHOWN MAY HAVE BEEN REDUCED 1111 EFF PAID CLAIMS - I LIMITS INSR TYPE OF INSURANCE I POLICY NUMBER MMIOO/YYYY MMIODIYTYY 9,000,J00 Lam' 'GL0468771b08 1,0310112016 '.03101 017 I EACH OCCURRENCE > A X I COMMERCIAL GENERAL LIABILITY I !DAMAGE TO RENT=O 1,900.'100 PR MI E"; am Rance ;i'(CLUCEO CLAIMS-MADE '�"OCCUR j I IMED EXP,Cony me Pelsom j I - I'LIMIT3 OF POLICY XS 111 - 9.d00,9pp 51M=R-CC � _PERSONAL s ADV�.N;I IJ ! 11 'ENERAL AGGREGATE 300il00 GEN'L AGGREGATE-WIT APP!;E3?ER: I ,I i PRODUCTS-COMPIOP AGG —� PRO- I—, i X POLICY❑ JE..T I LOC i� 'TUSK I COMBINED 31PGLc LIMIT - I:7Q0,+00 BAP 293 - 3 AUTOMOBILE UABILITY 1300IL(INJURY JPW Fsncn, X ANY AUTO 130DILY INJURY!Psr Acauena i ALL ONMED � 3CHEOUL-0 �3EL.INSUPED ku':) 'y OMG AUTOS : PROPERT/DAMAGE I, s AUTOS I IPer accident .� —i NON-0`NNEO HIRED AUTOS i: . AUTOS 1 i 1 I EACH OCCURRENCE I !UMBRELLA UAB OCCUAGGREGATEAGGREGAI�EXCESS WB I� CLAIMS-MAOEI j' I I I s OTH- DED RETENTION; INC015519215(A0S1 031OL201d '03101i201' X �TAAT T' FR C WORKERS COMPENSATION 1030112017 1,000,000 WORKERAND LOYERS'WABIDTY YIN' WCO15519217(AX,'IC(INH.NJ.yT'I 031oL2Q1S E.L.EACH ACCIDENT i 1,000,WO 0' ANY PROPRIETORIPARTNERIEXECUTIVE N INIAI� Q310112016 IQ3101i2Q17 E_L,DISEASE-EA EMPLOYE r D OFFICEMMEMBER EXCLUDED? ❑ WCO15519216(FLI 1000.W0 (Mandatory In NH) ! F1.DISEASE-POLICY LIMIT S If yes.descnEe under l IConilnued an Addilianal:39e - IDES DF OPERATIONS oelow I I � I Iattached if mare alnce is inquired) DESCRIPTION OF OPERATIONS I LOCATIONS)VEHICLES IACORD HH,AddlUonal RanMM9 Schedule.may EVIDENCE OF INSURANCE CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THD AT-HOME SERVICES,INC. DBA THE HOME DEPOT AT-HOME SERVCES THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY P0.0VISIONS. 2455 PACES FERRY ROAD ATLINTA,GA 30339 AunroRlaeo REPRESENTATIVE or Mmh USA Inc. Manashi Mukherjeea"t'O'��` µ ©1988-2014 ACORD CORPORATION. All rights reserved. pCORD 25(20141011------The ACORD name and logo are registered marks of ACORD- _.