4 MARION RD - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
4 Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR, 7`" edition Rev sr ed January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One- or Two-Family Dwelling
� This Section For Official Use Only
0- Building Permit Num Date Applied:
Signature: e� )•') ' 2010
Bu ng Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
LI. n/,r•ION ilt� 5r.t.En Yt]
Lla Is 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP[ -
2.1 Owner of Record:
bela0 -k hro1.t � Li r)),P4d)
Na (Print) Address for Service:
Signature Telephone
.SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupie i Repairs(s) ❑ 1 Alteration(s) ❑ Addition OF
Demolition ❑ 1 Accessory Bldg. 4 Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
NSO�'t�� ��1S�lk)C 13VtLDJ�G
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only'
Labor and Materials
1. Building $ 000 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:
5.Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 e3cjO 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 1 0-0 to la 11
1 �-nm NJ.wLR- License Number Expiration Date�1
Name of CSL-Holder List CSL Type(see below) —1
67') wJSNtN�IN Si SiF91)]
Type Description
Address U Unrestricted(up to 35,000 Cu.Ft.
A11 LLr5 UnU n .
R Restricted 1&2 Family Dwelling
Sig,nnf--ature b M Mason Onl
S�� k )�ti� RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) ' -Y1 j ')
IJ SA ! N c w g g orts b lrs�wL t-6 ?t+t
HIC Comp an Name or HI Reg, N me14 Registration Number
G 9 l,irs,,eJr�Icu ��. gS� � J, -loyotr� hr, o1'�"s 115� 12�1)
Address 1/1
—�..n (SOT) %O L )lY 9 Expiration Date
Signature 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 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
1, b 0 K)W. X N a'7 L- as Owner of the subject property hereby
authorize N. . H 5 n r'£�-�btu-I�NL �f�C� to act on my behalf, in all matters
relative work authorized by this building permit Application.
d 0(
Si nature of Owner "—' Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
C�l ,as Owner or Authorized Agent hereby declare
that the statements and information on the foreg ' g application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ains and penalties of ejt
NOTES:
L 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O R6 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
I
OMB .of Coosomer Aff l"&Basiaeu Regulation
Cp HOME IMPROVEMENT CONTRACTOR
Reg n-. 164937 Trp 700404
Expire 1 11
Types
New England Homepoormance.Inc.
Tamer Nawar 8111 J
679 Washirgton 9tee�" Uaderseereary
Attleboro,MA 02703
Mmmachmetts - Department of Public Safet%
Board of Building RcTulatiorr. and Standards
Construction Supervisor Specialty License
License: CS SL 102M
Restricted Im IC
TAMER f0111011AR
678 WASHOMPOMST. SUITE 8
ATTLEBORO,M OOM tz,
E[prration: 11113rM2
Tr#: 102940
�/rD® CERTIFICATE OF LIABILITY INSURANCE DATE(MWODlYYYY)
OA 0 1 03/05/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Nikopoulos lnB=aVCO Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
206 Ayer Rd. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P.O. Box 671 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Harvard MA 01451
Phone: 978-456-9700 Eax:978-456-9170 INSURERS AFFORDING COVERAGE NAICfl
INSURED INSURER A: Merchants of New HELM shire 23337
INSURER B: AMerlcan $Ur:Lch 1nBVranCe
New EnglengdtHome Performance INSURER C:
679 Waorongton St0reet, SteBlll INSURER D:
AttMA INSURER E
COVERAGES
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED 8.YTHE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONOMIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAYIHAVE BEEN REDUCED BY PAID CLAIMS.
LTA DRIMIC SR TYPEOFINSURANCE POLNCYNUMBER DATE MM/DD DATE MM/DD LIMTB
GENERAL LIABILITY - EACH OCCURRENCE $l DOO,000
A X X COMMERCIAL GENERAL LIABILITY CFtP9151210 10/02/09 10/02/10 PREMISESIEao Bnm 5100,000
CLAIMS MADE W OCCUR MED EXP(Any one penan) s 5,DDG
PERSONAL a ADV INJURY s 1,0OO,000
GENERAL AGGREGATE s 2 000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO s2,000,000
POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
(Es a dent)
X ANY AUTO
ALL OWIJED AUTOS BODILY INJURY s
A X SCHEDULED AUTOS MCA7014992 01/12/10 01/12/11 (Perparwn)
A X HIRED AUTOS BODILY INJURY 5
(Pere dent)
A X NON-OWNED AUTOS ,
PROPERTY DAMAGE $
(Per ac dant)
GARAGELUBILtY AUTO ONLY-EA ACCIDENT S
X ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: ADS 5
EXCESS I UMBRELLALJABILRY EACH OCCURRENCE S
X OCCUR CLAIMS MADE AGGREGATE S
5
DEDUCTIBLE $
RETENTION $ $
ERS COMPEN8I1D0 X TORY LIMITS ER
AND EMPLOYERS LIABILITY !YIN
B ANY OFFICER/MEMBER ARTNER0 FCUTIVC-{—� 6'li'liUB-4102P72-4 01/01/10 01/01/11 E.L.EACH ACCIDENT 5500,00D
OFFICER/MEMBER
E.L.DISEASE-EA EMPLOYE s500,000
(MuradMory In It Ye4 UaWee under E.L.DISEASE-POLICY LIMIT :50D 000
SPECIAL PROVISIONS Calm
OTHER
DESCROMON OF OPERATIONS I LOCAMON5/VEHICLES I EXCLUSIONS g00FD BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE I5SUIN3 INSURER WILL ENDFAVOR TO MAR 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,IT$AGENTS OR
REPRESENTATNES.
AU RRED REPRESENTATNE
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