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412 LORING ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF �. Board of Building Regulations and Standards SALENI : Massachusetts State Building Code, 780 CN1R Revised Mar 2011 \�) Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo Family Dwelling vD Chis Seaton ForOfficial U my, Building Permit Numbei: . Date A t dDate BuildingOfficia (Print Name 'gnat SECTION I: SITE INF TION 1.1 Property Address: 1.2 essors'Map & Parcel Numbers 17 1.1 a [s 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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public [I Private❑ Check if yes❑ p p SECTION2:, PROPERTY OWNERSHIP" 2.1 Owner'of Record: S%14N !�-CNAle'r 7JKK � Name(Print) City,State,ZIP y�L 110xitY4 Srr BP7uS�-33�d 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) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTINLtTED CONSTRUCTION COSTS- Estimated Costs: Official Use Only Labor and Materials 1. Building $ I Building PermttFee S Indicate how fee is determined: ❑ Standard Cityrrown,Application Fee ' 2. Electrical S ❑'rota!Project Cost',(Item 6)x multiplier. x 3. Plumbing S 2. OtherF'ees: S k Mechanical (11VAQ S List: L i. Mechanical (Fire S rota!All Fees: .S S,i : lesio — Check No. Cheek Amami:_ Cash :\rnouut. fi. 'tutu! Prn oject Cost S �jtl l 'r �J,v ❑ Paid in Ptdl ❑.Outstanding Ba ance Duz: OM U,4eiQtodv SECTION 5: comTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /0/g33 5? -A/ q A ,��S _ License Number Expiration Date Name ut SL II luldcr List CSL Type(see below)�_ puUnrestric-1 - - Description No. and Street ,,�J,(J trictd Buidigs u to Ji,000 cu. tl) (Son�Af//J (L " ' " _— ctedl&2F;unil DwellinCity/ own,State;ZIP r Cv-"—w Fuel Burning Appliances tion I'ele hune Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) �1 C` l HIC Registration Number Expiration Date a I IIC l'umpany Name or IIIC Registrant Name No.'and Street .J'LI `` loJ.7Y." 02�� ,� Email address City/Town, State,ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6)) Workers Compensation Insurance affidavit mast 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 CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf, it I matters relative to work authorized by this building permit application.d 2.,k rat Owner's ame( ectronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED:\GENT 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. Pllnt DlY aef1 Jr ALLIhefILCd:\gems Name(Electronic Signature) Date NOTES: I. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under NLt3.L. c. I42A. Other important information on the MC Program can be found at www.rttasss,ov/oca Information on the Construction Supervisor License can be found at trww.mass.tu�idL 2. When substantial work is planned,provide the information below: Total floor area(sq. R.) _(including garage, finished basement/attics, decks or porch) (7ross living area(sq. d.l , _ Habitable room count Number of tireplacus._.--- Number of bedrooms .---- --_—_-- Number of bathrowns _-- Number of haltibaths fvpo Or heating,ystcnt - _.- ---_ _-- - Number ordecks/porches ftipeofeoolimgsVitent —_----_ P.nclo cd- --- ---Open 1. "Total PnyaC[ m:ry be sub,tinited rx"Fot,d Project Cost" - I F �lj VY CITY OF SU1 EM2 ,:LL1SS.ICHUSETTS ! s ' ©L:LLD 0"G 0FPARMNMNT ' 120 W-UHNGTON STREET, 3' FLOOR TEL (978) 745-9595 (<IJ[3ERLEY DRISCOLL F-Ax(978) 740-9344 NLWOR T 10.%Cu ST.PIELU DIRECTOR OF PC3L'C PROPERTY/BCILDLYG CMNISSIONER Construction Debris Disposal Aft7davit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 780 CMR section 111.5 Debris, and the provisions of IbiGL c 40, S 54; Building Permit !t 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 NIGL c l 11, S 150A. The debris will be transported by: (name of haulur) The debris will be disposed of in : ti (nano of tacilily) (:1It)ftSS of tact Il(y) /\ s'ylaturn ofp mit apph ,I i ° CITY OF SM.EI I A--1SSACHUSETTS yy,a BUILDING DEP.IRTMF-NT I'_O W.1SHIINGTON STREET. Ya FLOOR �« TEL (978) 743-9595 �- F.ti�c(978) 1•SQ-9836 f j.%fBFRr FY DFLISCOLL 'Iry-o%wST.PlE-aRH MAYOR DIRECCOR OF PUBLIC PROPERTY/OIaLDLYG CO\NtSS10NER Workers' Compensation insurance Af7idavit: Builders/Contractors/Electricians/Plumbers itlinlica it information A Please Print Leeibiv V;II11C iDwilx,tUryniru)orvtndividuaf):�(� Il •�,y�j'�'� Address: P r/ dW City/State/Zip:�0,V,Ajeo-vfo-c—A14 -4"LW5Phone#: 141 'CJk46� ,ire you an employer?Check the Appropriate,b,o�x: Type of project(required): 1.❑ 1 am a employer with ;. ap am a general contractor and 1 6. 0 Now construction e'lipiayea(Nil and/or part-time).* have hired the subcontractors 2.❑ 1 am a sole proprietor or partner. listed on the attached sheet t 7• ❑Remodeling ship 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 5. 0 We are a corporation and its required.) officers have exercised theft 10.0 Electrical repairs or additions 3.0 i am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers'comp. c. 152,010),and we have no 12.(] Roof repairs insurance required.) t employees.(No workers' 13.0 Other comp,insurance rcqulmd.) ;Any appllcam dug checks box r 1 mutt atw all eui Ihv U%lioo IwtoW thowing'hek wor4am'mmpanwtion Policy inAIM11lon 'I hvnvuwm"who mhmit this adIdavil indlaning they an doing all work and thin him ou1sidetontmcNn Meng ruhnill a new airdavil tndiaing tuck lConimion Ihslcheck this hex must atlachodm addiliunalxhal showingthe name ofiho mbatintnNan and Ihelrworkers'comp.policy Inro flan. l um ors enrp/ayer that/s prov/dln,f workerar compenmdair huurance for my employees Bdaw/s Ill a pollry and fob sire infarmudon. Insurance Company Name: SE t , ` , Policy A or Sclr•ins. Lic.d: � P `"1 ��`�� , Expiration Data: Jut;Site Address: City/State/Zip: ,luck a copy of the workers'compen iatloe Pulley deelatatlan page(showing the policy number and expiration data). Failuru to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition ofcriminal penalties ofs line 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 line of up to S250A0 a day against ilia violator. Ile advised that a copy of lhis.statemunt may bet forwarded to the 0111co of Invcstiywiults ui tits DIA fur insuranea coverage verilicatioa l do hdreby certifyraider the pahr J/perJ�a\\ides ufper/ury that the hifuriirullmt provldeJ above is true mfd correct ue Pf;tllle �: U/jic•iuf use only. Oa nor 1wite in t/rlr arro,m be completed by city ur town a le/u! ! Ciryor*ro%vn: _. _ P-rmll/t.lcensss --- kitiing,huthorily (circla one): 1. llourd of Ilvalth !. I)uildlnq Ileparti,mit f.Cilytfown Clerk 1. tlectrical intpectur S. Plwnbing luspector 6.Othce Contact l'enonr _ -_. .... I'hona tt• I . OATE(MWDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 4/12/2013 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), AU OR REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT. If the cortifitate holder M an ADDITIONAL INSURED,the polleypes)must be endorsed. N SUBROGATION IS WANED,subject to the terms and conditions of the Policy,certain Policies may require an endomemeM- A statement on this certificate does net Confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER - NAME: AL PONTE INSURANCE AGENCY INC "' E (617)492-7600 acNa:(617)354-0401 819 Cambridge Street AD%s:claudia.victoria@thepontegroup.com Cambridge, MA 02141 r IDit INSIMER(% MFOea1Na COVERAGa NAiGr INSURED US HOME IMpROVEMENT LLC INSURER A'USF ` INSURER B 11 HANKINS STREET msuRER c: SOMERVILLE, MA 02143 INSURE 10 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 EXCRTIFICATE MAY BE LUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWAY PERTAIN. THE NCE AFFORDED BY THE POLICIES MAY HAVE BEEN REDUCED BY PAIO C DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, LAIMS. T01 TYPE OF INSURANCE iNaq POLICY NUMBER fa1110 LIMITS Lm GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 COMMERCIAL GENERAL LIABILITYPREMISES Ea cawranoe S 100,000 GLAadSMADE O OCCUR MED EXP(Any ona Person) E 5,000 R CIP144647 7/12/127/12/13 PERSONAL aADVINJURY 3 100,000 GENERAL AGGREGATE S 2,000,000 PRODUCTS-COMPIOP AGO 3 2, ,000 GENL AGGREGATE LIMIT APPLIES PER: a X POLICY PRO- LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY S Ea a�1) ANYAUTO BODILY INJURY(Per person) S ALL OWNED AUTOS BOOILYINJURY(Pff&O eM) 3 SCHEDULED AUTOS P"GPERTY DAMAGE S (Per MndaRj HIRED AUTOS E NON,OWNED AUTOS f UMBRELLA LIAR OCCUR EACH OCCURRENCE f EXCESS LIAB CLAIMSIAADE AGGREGATE 3 f DEDUCTIBLE S RETENTION f 0 WORKERS COMPENSATION T 1 AND EMPLOYER&LIABILITY YIN E.L EACH ACCIDENT S aFFleew+rENaFR E%CL1AEOt NIA LRo,easrY w me E.L DISEASE-FA EMPLOYEE 3 I dascYLaulaer EL DISEASE-POLICY LIMB f DESCRIPTION OF OPERATIONS lteWN DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AIIad1 ACORD 10i.AW,a W Remarks StlredWe.I nsxa space Is reaWree) 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. AUTHORIZED R E31TATIVE 3/ 1988.2009 ACORD CORPORATION. All rights reserved. ACORD25(2009/09) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety `v Board of Building Regulations and Standards Construction Supervisor License CS-101433 SERGIO A SANT9 11 HAWIQNS STREET' O-1 Somerville MA OZ143 Expiration . Commissioner 08/30/2014 rs onuffairs au us n Regulation G Office of Consumer Affairs&Busidess Regulation a ME IMPROVEMENT CONTRACTOR z, eegistration. 167228 Type: "- Expiration: 8/23/2014 Corporation m, US HOME IMPROVEMENT,LLC. -- ro SERGIO SANTOS - a .r 11 HAWKINS ST#1 -` SOMERVILLE, MA 02143 - Undersecretary ;i .