36 MARLBOROUGH RD - BUILDING INSPECTION (3) fl
The Commonwcallh of Massachusetts Town of
Board of Budding Regulations and Standards
1 Massachusens State Budding Cale, 780 Ch1R, T"edition Budding Dept
�\t Building Perron Application To Construct. Repair, Renovate Or Demolish a
�I One. or Tiro•Fwrulr Du rlling
This ction F ORcul Use Onl
Building Permit Number Date Applied:
Signature: -�
Bwldin issioner/In t uddmp Datt
SECTION 1:SITE INFORMATION
11 t.l perry Address: �Q 1.2 Assessors Map& Parcel Numbers
r-).Qtx-o
M Number Parcel Number
I.la Is this an acce led street'!yes no ap
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning District ProposedUse
Ld Ana(sq n) Froniage In)
1.5 Building Setbacks(11)
Front Yard Side Yards Rear Yard
Required Provided Required Provitltd Required Provided
1.6 Water Supply:(M.G.L e.a0.Isa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public D Private O Cheek if vesill
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 3` ✓t c�� a 2ri�
e' -YFP Address f
or Soviet:
Name lPrinq
Signature telephone
SECTION l:DESCRIPTION OF PROPOSED WORK'(cheek aB that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) O 1 Alterstion(s) 0 Addition O
Demolition O Accessory Bldg.O Number of Units_ 10ther O Speeiry:
Brief Description of Proposed Works: n Q-T`A Y. 3g QT`>
0
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Omclal Use Only
lit m Labor and Marterials _
L Building f 00'i ' 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
1 Electrical f O Total Project Cost'(Item 6)x multiplier x
Plumbing f 2. Other Fees: 11
a. Mechanical IHVAC) f
List:
S Mechanical tFire f Total All Fees. f
Su ression
Check No. _Check Amount: Cash Amount:-
6 Total Project Cost S 0 Paid in Full 0 Outstanding Balance Due
CONSTRUCTION SERVICES
r
SECTIONS: CO
9.1 Licensed Construction Super isor(CSL) (� e, e 1
�(OS� 4\[�rR+h�•�"�-�j� 1. L .cn.�mbcr E.puar�on Date
N.yar'it Csl HpWer � T� Lr.r CSL Type(.v lwluw)
a 2* A 1J Cyi T
A s oats-I--- T Description
2yt U I Unrestricted(up to 35.000 Cu Ft
R Restricted Id2 FamilyDrelLn _
Si tore .N I Masonryonly
RC Residential Roofing Covering
- Telephone WS Residential Window and Siding _
SF I Residential Solid Fuel Burning Appliance Installation
D 1 Residential Derr arlito
5.2 Registered Home Improvement Cogtrsitor(HIC) b
HIC Comp my-Name or HIC Registrant Name Registration Number
p c
.A �! a3o 3S Expiration Date� �f a
Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2.12SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this andavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes.......... No...........13
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize rk uthorized to act on my behalf,in all matters
rcla6ve to v�o a by tht mg permit application.
SitinsiturotOwner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
t t the acements and information on the foregoing application are true and accurate,to the best of my knowledge and
0
isnarujit of Owner or Authorized Agent Dan
11isionell under the pains and penalties ofperjury)
NOTES:
(.-An Owner who obtains a building permit to do hither own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor)HIC)Program),will iM have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.RJ, 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 ISq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
.Number of bathrooms Number of half.baths
Tvpe of heating vystern Number of decks/porches
Typeofcooling vyuem Enclosed ._Open
t Total Project Square Footage"may he.uh,muied for 'Total Project Co%C
CITY OF SM.E.`[, UxSSACHUSETTS
BU DL%JG DEPARTMENT
ti 120
WAS INGTON STREET, 3w FLOOR
TEL (978) 74S-959S
FAX(978) 740-98"
KI�BERIEY DR)SCOLL —
�SAYOIR TiOMAs ST.PMRAA
DIRECTOR OF PL BLIC PROPERTY/lIU DCIG CO.%L%ilSSIONER
Workers' Compensation Insurance Aliidavit: Builders/Contractors/ElectriciansiPlumbers
Allfillcant InformallOn Please Printe
VatTt tBusirwasOrganuariorolnshvtthtal):_�r�y I��VW VcIDu-Q
—y
Address: a(cwc.M S 7
City/StateiZip: fit �y la ,e (lam Phone M: 61 ? 2 Z o 6S'_�
, you an employer?Cheek Rho appropriate boa:
4 ❑ I am s � Type of project(requtred):
I. I am a employee with general contractor and 1 6. ❑New construction
employees(cull and/or part-time).• have hired the subcontractors
2.❑ I am a soft proprietor or partner- listed on the attached sheet : 7. O Remodeling
:hip and have no employees Thee subcontractors have 8. El Demolition
working for me in an capacity. worker'comp.insurance
g Y P tY• 9. 0 Building;addition
required.)
women'comp. insurance S. We are a have
exercised
and its 10.❑Electrical repairs or additions
required.) OfIICGx have Gxerelaed their
).❑ I am a homeowner doing all work right of exemption per MOL I I.Q Plumbing repairs or additional
myself.(No workers'comp. C. 152.f 1(4),and we have no 12E'D oaf repairs
insurance required.]t employes.(No workers' 13.�-OthrYrlr�r
comp. insurance required.] �---
-Any 4ppiicam that chMM boa Of must alwr fin out the minis ticlwr showing their working,compon"dtw,policy infimmancia,
'1 hmteuwtnas who aubod this atTtavn indication they r doing all worn and thin him outside contracpn mom"limit anew amdsvii indiotimi ruck
T.wtna•1on that cMek this box mud aeaehsd an additiwul short showing tla,use dlha aWawmracrom aid thick workers•ramp.policy informatim
l am as employer that&Providing workers'compenradon laasaroaet for my etmployttes. Belrew le/ice PW&7 and feel sip
in/ormadote.
Insurance Company rq6
Policy 4 or Self-ins.Lic. H:—� C� f)o F S—h 7 00 Expiration Date: k q ( It,
Job Sire Address: L(a wwr W,0 rrz`6zs City/Statrizip: r,,�t= u
,%ttach a copy of 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 ors
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a titre
of up to S250.00 a day against the violator. Ile advi.%W that a copy of this statement maybe rorwurded to the oface of
Invcatigationa dl'Ure DIA for insurance coverage veritieotion.
l da her i nder the pains and penatles of perjury that aka brjormodon provided ubp4ir is tare and tarred
,;I�tantre'
Pho r:� -alb ,
O/Jleial use dnly. Do not write in this oree,to be rorrrpleid by Lily or rows olfti el
City or ruwn: Yrrmit/LlccnseM__.
Nsuing Authuriiy (circle une):
I. Ituard of IleAlh 2. 9uiiding Department J. Cityfrown Clerk 4. Electrical inspector 5. Plumbing Inrpeetor
6.Other
Contact Person: _ _ __. __ Phone e•
Oaani -
yCO!'TF'ACTOn.
�
T:e 25 rE7C-
�Airtio..
T:Pe'
,:BA
V.s k
' " 1U-SE FI! f r JrrbiCl _
:Massachusetts- Department of Public Safetca
Board of Buildiru, Re'_ul: tiuns and Standrds
Construction Supervisor License
License: CS 87 573
Restricted to: 00
JOSEPH E BARAN "
OWSKI -
58 ALMONT ST "e
WINTHROP, MA 02152
of-,L. �•
Ex iration: 9/30f201 1
('ounni....i.wr Tr#: 8014
,
I
-� n7
11 WORKERS' COMPENSATION AN ;EMPLOYER'S4LIABILITY�IN*SURANCE POL`
>j wlriformat�on Pager E " µxaNC oo.Qi
Atlantic Charter Insurance Company VDAC
NCCI Co.No.:29211 Policy Number: WCV00850700
1. INSURED: Prior Policy Number: New
csech Baranowski
Producer:
58 Aimont St. R. M. Cataldo
t^rrthrop, MA 02152 Federal ID Number.141680119 557 Broadway
Risk ID Number: Revere, MA 02151
Business Type: Individual
SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS
Other Named Insured: See WCE106 Other Work Places: See WCE107
2. POLICY PERIOD: The Policy Period Is From: 7/29/2009 To 7/29/2010 12:01 A.M. Standard Time
at The Insured Mailing Address
3. COVERAGES:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states liste
here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our
liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insured: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
All states except Monopolistic State Fund States
D. This policy includes these endorsements and schedules:
9
See WCE105
4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates &
Rating Plans. All information required below is subject to verification and change by audit.
Code Premium Basis Total Rate Per Estimated
Classifications No Estimated Annual $100 of Annual
Remuneration Remuneration Premium
See WC 00 00 01
Minimum Premium: Deposit Premium:
,S500 $704
Interim Adjustment: Annually
Servicing Office:
Total Estimated Premium $677 25 New Chardon Street Surcharge(s) 27
Boston, MA 02114-4721
Total Premium and Sur harge(s) $704
issue Date 08/04/2009 Countersigned By: Date AUG Q 4
?ghi.1987 National Council on Compensation Insurance - Forr
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tic A'.\it it, i ll^7 l NrL'T 5.\I P\t,St.Ni.\( i It iI 1 1,
I'rt:WV-'45.9595 .1:%s:979-740-984e
Construction Debris Disposal Af idavit
(required lour all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
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 he disposed of in a properly licensed waste disposal Facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
prams ut ha Itr) �—
The debris will be disposed of in
(name ul a,; ity)
plddress of Facilityl
.ignaiure of permit applicant
d
(late
-.Ichi n,ll,h,