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6 LORING HILLS AVE - BUILDING INSPECTION (7) y\ The Commonwealth of Massachusetts a Board of Building Regulations and Standards CITY OF S Massachusetts State Building Code,780 CMR v" Revised dMar Mar 2011 (C Building Permit Application To Construct, Repair, Renovate Or Demolish a / I One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: ate A 'e Building Official(Print Name) Signat Date SECTION 1: SITE INFORMATION 1.1 rop Addr ss: 1.2 Assessors Map&Parcel Numbers mber 1.1 a is this an accepted street?yes no Map Number Parcel No 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq to Frontage(In 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 if Flood Zone? Check yes❑ Municipal❑ On site disposal system Cl SECTION 2: PROPERTY OWNERSHIP' XA"tc Name Pnn[) HAVE[/ City,State,ZIP jj d Nob w�a�a Nond Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolit`on ❑ Accessory Bldg. ❑ Number of Units 154er ❑ Specify: Brief De cription of Proposed Work': l SS CC, �Q SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ (1C) 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ List: yam) 5.Mechanical (Fire $ Total All Fees: $ Suppression) �f/ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ �� CJv 0 Paid in Full 0 Outstanding Balance Due: ECTION 5: CONSTRUCTION SERVICES 5.1 Co structionn Supervisor ense(CSL) � nj�JQ� License Number Expna mn Date Name f CSL Ider 9 Lis[CSL Type(see below) No.an/ tree Description 1 Unrestricted(Buildings up to 35,000 cu.ft.Q (� R Restricted 1&2 Family Dwelling City/Town, late,ZIP M Masonry RC Roofing Covering WS Window and Siding r ! SF Solid Fuel Burning Appliances /W_ I .Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP Tele 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..........A SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FO UILDING PERMIT 1,as Owner of the subject property,hereby authorize / t//✓ to a t on my behalf,in all niatters relative to work authorized by this building permit application. Pnn is Nme c(r6tfic'S'tgnaTuref Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name belo ,I hereby attest under the pains and penalties of perjury that all of the information Mntai n this ap�ca"on is true a d accurate to the best of my knowledge and understanding. C �r Pri wn is or Authonze nt's Name Electronic Signature) ate / NOTES: 1. kYn 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 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" n� K CERTIFICATE OF LIABILITY INSURANCE °A0711sa6;3 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 REPRESENTA`f1VE 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 endorsemem(s). CONTACT PRODUCER Phil Richard Insurance,Inc. NAME: 27 Garden Street PHO Fa Na Unit 1 B EADDRESS, Danvers,MA 01923 INSURER(S)AFFORDING COVERAGE NAIL$ INSURER A; Arbella Protection 41360 INSURED Ted A.Robinson INSURER B: dba Fences Plus 16 Delaware Ave. INSURER c: Danvers,MA 01923 INSURER o: INSURER E IN 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. INCADDL SIIBR POULV EFF PoLH:Y EXP UNITSLm TYPE OF INSDR,WCE PoUCY NUMBER MMID Y A GENERAL UABII-RY 8500044132 08/29/2012 08/29/2013 EACH OCCURRENCE a 1,000,000 DAMAGE TO RENTED tOO,000 COMMERCIAL GENERAL UABILDY PREMISES(Ea odv—.1 $ CI.AIM&MADE IV OCCUR MED EXP(AW one person) $ 5,000 PERSONAL$ADVINJURY $ 100,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE UNIT APPIIES PER: PRODUCTS-GOMPIOPAGG $ 2,000,000 POLICY 7 EO- LOC $ AUTOMOBILE LIA9ILRY COMBINED SINGLE UMR Ee acvtlml ANY AUTO BODILY INJURY(Pa person) $ AU O SCHEDULED BODILY INJURY(Pa aaatlem) $ AUTOSS AUTOS N ED PROPERTY DAMAGE $ HIRED AUTOS AUTOS aaoHEenl S UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCEWI-IAB CLAIMSMADE AGGREGATE $ DE° I RETENNONE $ WORNERSCOMPENSATR)N VYCSTATLL OTH- AND EMPLOYERS'LABILITY Y Y PROPRIETORIPARTNERIEXECUTNE AN ❑ N/A E.LEACHAGGDENT $ OFFICFAMEMBER EXCLUDED? (Man"Min NH) EL DISEASE-EA EMPLOYEE $ Kr,tlesa uWa DESCRIPTION OF OPERATIONS I, m EL DISEASE-POLICY UNIT $ OESLWPTIONOFOPERATIONSILOCATIONSIVEHICLES(AYBLNACOMIOI,Mdiffaml Rema ScNeda .ifm msmcei mreA dl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ECP Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 6 Loring Hills Ave ACCORDANCE WITH THE POLICY PROVISIONS. L..._.- Swampscott,MA 01907 AUTHORED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CITY OF S.UzNf, L-kS&kCHUSE-r T'S }•� ;( QC[LDLNa 0EP.1AT.%M,4T 101Y/1 HLVC;TO,NSTUZr }'aFCOO:t u 1�L (973) 745-9595 XIMOEALSY DRISCOLL FVC(973) 7.10.934.E AMA I110.%& 3ST.PiEAAB DIaECTOROFPLOUCPROPERTY/8t:Lw gr,COSLAUSSIO.NER Construction Debris DlspOsal Affidavit (required tot all demolition and renovation'vark) in accordance will' the sixth edition of the State Building Coda, 730 C&M section I Debris, u'd the provisions of MGL c 401 S 54; Building Perrnit o is issued'vith the condition that the debris resulting from this work shall Ge disposed of in a properly licensed waste disposal racility as defined by ,ti,WL a l l I, S l SOA. The dehris will be tr�nsportcd by: (name of Itaulw) The duhris will bO dispose] Orin : (nonsa nr ticdii�) I or raliliw •rtuausfc of permit.' VPlic.nit '11w CITY OF S.U.ENlt ANSSACHCSETTS BUILDING DEP1kRTJIE\T p• ' 120 WASHLNGTON STREE:r,3'a FLOOR ara TEi_ (978) 745-9595 FkxMS) 740-9846 Kj,xiBFni FY DRISCOLL T L►s MAYOR �+on ST.PtFxR6 DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Ptease Print Legibly V atpe tBuSitkss,UfganizatioNlndividual): \ e. C�` � .�d bc� `r1S O r� Address: Co Q\ wo A e City/State/Zip: 'C��r 8cS ! `A , Phone#: 0`1 - `7 GG - (O6 S c6 Are you an employer?Cheek the appropriate box: "Type orproject(required): I.❑ 1 am a cm to cr with 4. Q 1 am a general contractor and 1 P Y 6. ❑New construction 34ployees(full and/or part-time).' have hired the sub-contractors 2_[�4 am a sole proprietor or partner- listed on the attached sheet.S 7. ❑Remodeling ship and have no employees Those sub-contractors have M. ❑Demolition workingfor me in an e.a i workers'comp.insurance. Y ' Pan ty• 9. ❑Building addition INo workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑Electrical repays or additions 3.❑ Ism a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions myself.[No workers'sump, c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.[t employees.[No workers' l3.❑Other comp_insurance required.) -Any appli,ard that Checks box 91 must also fill out the section below showing their wmken'mmpenetion policy miunnatioo. t I I.wncuwnera who mbodt this affidwit indicating they am doing all wark and then hire outside connections must submit a new affidavit indicating such k-,,.1mcmn,hat duck this box mast attached an dditiomt shag showing the nature of the subeomramrr and their workns'comp,polity information, I um an emplayer that is providing workers'compensation insurance for my employees. Below is Nye policy and job site injornradon. Insurance Company Name: ._ Policy 4 or Self-ins.Lie.#: _.._ Expiration Date: Job Site Address: City/Statc/Zip: Attach a copy or the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ftnc up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a floe of up to S350.00 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. /do hereby certljy nde a pains�aJ,nd pens/ties ojperjury that the hrjurnration provided ub ve is true and correc•L Sienamre' � �G<%L-fits✓ ISr[C: �1/ 7 /3 Phone A: (T -76E —G9i SC Official use only. Do Prof write in this urea,to be completed by city or town officiaL City ar Tuw•n: Issuing Authority(circle one): 1. Berard of Ileatth 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5,Plumbing Inspector 6.Other Contact Person: ._ ._. . --- --- Phone#: 1