11 MADELINE AVE - BUILDING INSPECTION The Commonwealth of Massachusetts ?tSPEC it VED
Board of Building Regulations and Standards AL(SEA'Pl1tE y
Massachusetts
sachusetts State Building Code 780C MR
SALEM
�� e� 1�evi M�ar2071
Building Permit Application To Construct,Repair,Renovate Or De '0 a 10
One-or Two-Family Dwelling
This Section For Officia]Use Only'
s..
Ir Building Permit Number: ' Date Applied: '
v[
60
' )
(� Building Officia (Pont Name) .'^ Signature Date
l SECTION 1:SITE INFORMATION '
1.1 P per Alldrgss: �C 1.2 Assessors Map&Parcel Numbers
Rd<- /I:UC
t 1.1a Is this an accepted street?yes_ no Map Number Parcel Number
L(`n 1.3 Zoning Information: 1.4 Property Dimensions:
am` Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(it)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHH'r ''
2.1N c Yf0 err of�tecord,: `flee,
'A Im,
Name(PrinLf City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: O cial Us¢Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town.Apphcation.Fee -
❑Total Project Cost'(Item 6)x multiplier Al
3.Plumbing $ 2. Other Fees: $ -
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $ T e Total Ali $ `
Suppression) r
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due.
��a�6
SECTION 5: CONSTRUCTION SERVICES
5.1 Constivction Shpervi or License(CSL) 91 � /
5C�`7ljJ C ,o L� License Number Expiration
Date
Naneof CS �HoI e ' 4; 4 01''1
' �.7,' �,� List CSL Type(see below)
�,� 977•
No. d$treet Type , ; Description
�y � el moo.) U Unrestricted(Buildings u to 35,000 cu.ft.
R I Restricted]&2 Family Dwelling
Cityfrown,State,ZIP M I Masonry
R Roofing Covering
CTV S Window and Siding
/J�S SF Solid Fuel Burning Appliances
/ZO I Insulation
Telephone Email address D Demolition
5.2R,,egister d Homg.Improvement Con ractor(HIC)
// y
y'Si L �j w��C HIC 3 7�' OU Registration Number Expiation Date
HIC Company,Name o C Regis me
No. 6Ly�geet M� Q�I`GG ,tq /-9/-090 o36) Email address
City/Town,State,ZIP 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 f the building permit.
Signed Affidavit Attached? Yes ......... No...........❑
SECTION jai 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,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 d ccurate to the t of my knowledge and understanding.
a�d UC all 16
Print Owner's or Authorized Agent' a(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
wti+nv.mass.eov,'oca Information on the Construction Supervisor License can be found at www.mass.govld�
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"
BERKSHIRE HATHAWAY, Worker's comoetYsation and Employees Liability Policy
NGUARD
ICOM ;� AmGUARO Insurance Company-A.Stock Company
Policy Number R2WC647329
Renewal of R2WC513122
NCCI No. [21873]
Policy Informatiorii Page(AR)
[1]Named Insured and Mailing Address Agency
John H Carroll JOHN J LAMB INSURANCE AGENCY INC.
27 Hamilton Road 24 North Street
Peabody, MA 01960 Hingham, MA 02043
Agency Code: MALAMB10
Federal Employer's ID 02-846BS97 Insured is Individual
Risk ID Number 178568
Additional Names of Insured
(N2) US Hotta'Improvement
[2] Policy Period
From October 7,2015 to October 7, 2016, "2:01 AM, standard time at the insured's mailing address.
[3] Coverage
g
A. Workers' Compensation Insurance -Part One of this policy applies to the Workers' Compensation,
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident- each accident $100,000
Bodily Injury by Disease - each employee $100,000
Bodily Injury by Disease-policy limit $500,000
C. Refer to Residual Market Limited Other States Insurance Endorsement-WC200306B
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms .
[4) Premium
The Premium Basis and,therefore,the premium will be Aetermined by our Manual of Rules,
Classifications, Rates,and Rating Plans. All required infornati m is subject to verification and change by
audit. (Continued on another page)
i
Total Estimated Policy Premium $ 606
Total Surcharges/Assessments $ 16.00
Total Estimated Cost $ 624.00
INTERNAL USE OR Page - 1 - - Information.Page
MGA : R2WC647329 WC 000001A
Date : 09/08/201S
MANOTE - -
'\- Imftg OMM P.O.Box A-H,16 S.ILYerStreet,Wilkes-Barce,PA 18703-0020 • www.guard.com
Q'TY OF SALEA A M8AMLEE M
BUIMCDEPAR MIM
120 WASFIDYWMS7REET,3RDRDCR
UL(978)745.9593.
FAx(978)740-9846
A�FR�FYDRISQ7LL
MAYOR 7)IMNAS STAEM
DIRECTORc+PUBI cntoPEm/BumDzwazw=cm
Construction Debris Disposa/Affl*davit
(required for all demolition and,renovation work '
in accordance with the sixth edition of the State Building Code, 780 CAM, Section 111.5 Debris,
and the provisions of MGL c40,S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 311, 5150A.
The debris will be transported by.
S . CU ;,
(name of hauler)
The debris will be disposed of in:
4/4-4b 5'eje
(name of facility)
'f-Abddy
(address of facility)
Sig ature of applicant
Date
Massachusetts Department of Public Safety
® Board of Building Regulations and Standards
License: CSSL-099979
Construction Supervisor Specialty
r'-
-.JOHNH 6ARROLL
27 HAMILTON RdAW, i
PEABODY MA Q1960
' I��
Expiration:
Commissioner 08/14/2017
1 p� &f4 ,paanir2ooursea(I ap QA c Xreraeltn
Office of Consumer Affairs&Busy ess Regulation •�{
HOME IMPROVEMENT CONTRACTOR ,
Registration ,�1�0768 Type: "
'I Expuatlo :. �r2�� DBA 1 ��
U.S. HOME IMPROJOHN CARROLLVEN�"
27 HAMILTONRD. _
r PEABODY,MA 01960 "`+ ti Undersecretary- '
f
The Commonwealth of Massachuseus
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02I14-2017 i
www massgov/dia
WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electriciam/Plumbers.
Applicant Laformation
TO BE FILED WITH THE PERMITTING AUTHORITY.
� � Please Print Le 'b
Name(Businws/Orgamzation&dividual): /—/"t 5t, C -
Address: �77 /ll/ I f�
City/State/Zip: 7G/7�7Qy{ ✓l�� al q(�6 phone#:
Are you an employer?Check the spproprlate box:
Type of project(required):
1.0 I am a employer with employees(full and/or part-Ume).
2-❑I am a sole proprietor or 7. ❑New construction
p'comp.inand have employees working for
any capacity.[No workers'"comp.insurance requkW.] g• �Remodeling
3.Q I am a homeowner doing all work myself.[No workers'comp.insurance r9. ❑Demolition
4.❑1 em a homeowner and will be hiring contractors to conduct all work on mI will 10 Q Building addition
ensure that all cmurecims either have workers'compensation insurance or 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the subcontractors listed on the atThese sub-contractors have employees and have workers'cop,iusumumt13.0 Roof repairs
6.0 We are a corporation and its officers have exercised then right of exemption 14.QOther
15Z§1(4),and we have no employees.[No workers'comp.htsursnce requi
*Any applicant that checks box#1 must also fill out the section below she then workers'w
t Homeowners who submit this affidavit indicating wing mpmsation Policy information"
g they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the more of the sub-conhaao,and slate whether or not those entities have
employees. If the sub=contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. / �
Insurance Company Name: C17k �j
Policy#or Self-ins.Lic.#: k g alc 6q cl-2 5
y� 9 Expiration Date:
Job Site Address: ZZ sl*keAd /9 m_ City/Sti te/Zip
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required tinder MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerd u der the pains an shies ojperjury that the injormmlon provided�na7bove is true and correct
Si attire: Date
Phone#: B�� gs
Official'use only. Do not write in this area,to be completed by city or town oricial
City or Town: Permit/License#
Issuing of
(circle one):
I.Board ofHealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Per Phone#•
,
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with then certificate(s)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. _
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 14-20 1 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia