BP-73244 Permit No. BP-73244 ProjectLocation: 9 BLUEBERRY LN
Commonwea " ter sachusetts
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PP � � , x� r ' o Phone#: _
' p� F 4(11 255-2246 5 . ' ,,- ?-e j„-r
MJS HOME' , '.- ( )
`gyp i64 • p ��
OWNER: ape a ° ��. .• �
PELLETIEItGAR° . �m�a�'n� ; - ,
Wirtµ
DATE ISSUED: C�
TO PERFORM THE FOLLOWING WORK:
Strip/re-roof residence
cement siding
DATE TIME TYPE OF INSPECTION &REMARKS I INITIAL
Permit No. BP-73244 BUIL'JJ # f "
GIS#: 3245.00 CoirtiGetnCend _ i abh Ink
Map 0066 .y s .W4 P't • 11404 E" 'p$�o '4..
mot 0002 40o brtoc,3tn 1t?tY 47%'
Sub Lot: "0028 - $ a:P"hon kso$ -_ 6 );91QR Pt841 s)
Category: RE-ROOF/SIDING - I°4i9, _ ,CV- s -s a
Project# 7S-2014-002442 PERMISSIONIVH$12E>r6RA DTO , �^ a
Est Cost: - $3500000 7 F "` �* s v Y k�'
Fee $75.00 Contractor: s a srurgtr hate"
441
Consf Class:- °` '- MARK SIL 4 i ,, , P v �� i 6 (s,,(4 5t 6
Use Group:"; R3; - Engineer. I a f L�` ° + t r ' t$ 'tij5,91, ranee#w
F Lot Size(sq.ft.). 45200 4, (A-t
Is. - - •:.' - is stf F„ a.
Ph .•
Aquifer Zone: - N/A MJS HOME 6 301\IENT L - r;,, !1),25'S011
6
mood Zone: ZONEX OWNER: s -)Fl . 1 {*3s4 49% ti
New Coast... 'N/A'
' PELLETIERG �64 �. e r ; 4 t+k�
Alt.Coast N/A:: : --• . 3. r g
Date Typed; 04-10-2014 PATE ISSUED: ' � f� k 's� p '4 a.8,7 A� :-
TO PERFORM THE FOLLOWING WORK:
Strip/re-roof residence/hardie cement sidings
Project Loco ' N
Approved/Issued By:
PAUL M.MUM' R SPECTION
MI work shall comply with 780 CMR 8111.Ed.(MGL Chap.143)and any other applicable Mass.Law r Codes and plans on file.
Schedule appropriate inspections as required. Upon completion of work,final inspection is required.
5111.8(NOT MORE THAN 3 EXTENSIONS WILL BE RANTED)OR ON ISSUANCE OF A REGULAR OCCUPANCY PERMIT.
I hereby certify that the proposed work is authorized b the owner of rec and I have been authorized by the owner to make this application as his agent
and to receive this permit, I further under t of r a a es may 'e reason t STOP WORK if items under their jurisdiction are not met; not
withstanding the issuance of this Buildin er
l
Signature of Owner/Agent:
Inspector of Inspector of D.P.W.Inspector Building Inspector Inspector of Gas Fire Department
Plumbing Wiring
Water Service#: Footings: Underground: Oil:
Underground: Service:
Foundation:
Rough: Smoke:
Rough: Rough: Sewer Service#: Rough Frame:
Insulation: Final:
Final: Final:
Cross Connection Final: Final:
Board of Health E-911
Additional Comments:
Planning Board
Prior to issuance of Certificate of Occupancy/Completion,this card must be returned to the Building Department with all necessary
inspections signed off. Department phone numbers are listed on the white"Required Inspections"document provided with the issuance of
the building permit.
POST CARD SO IT IS VISIBLE FROM THE STREET
• TOWN OF DARTMOUTH - BUILDING DEPARTMENT RECEIPT 732 2 4
]y p 1 PHONE: 508-910l-1820rn-i t,aFAX:l.5088-910.1838 �i /
Namel`2/.l J/ tLt re•...E.. L.v�x.?'yl�7.✓Irr p-eXty O %n .. '��/ SS U L.R.Date/_�//
A r .
Job Location: If al.: -6 Map: � CI'''. Lot: ='f -✓> i(
Description General Ledger #'s Ref # Amount
Building &Building Misc. 01000-44105 Sdl{/fr/I gn A 737( r)
Electrical 01000-44106
Plumbing & Gas 01000-44107 �� OF DA3
d\c MJS
Trench Safety 01000-44129
Other Department Revenue 01000-42420 4 Atil I'0 NM
l '&
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department\`. Rec
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRI , L RING OR GAS
RESIDENTIAL ❑ Phased Approval.(RIO&'3.3)
$25.00 APPLICATION FEE IS NON RE-FUNDABLE & NON-TRANSFERABLE
I J rH yq DATERECEIVED
DARTMOUTH BUILDING DEPARTMENT
Jo
ni 400 Slocum Road
to
Dartmouth, MA 02747
*'(... 0%YTi Phone: 508-910-1820 Fax: 508-910-1838
Ifi LJ .
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
4 THIS SECTION FOR OFFICIAL USErONLY
RECEIVED BY: BUILDING PERMIT NUMBER: <4i
DATE ISSUED:
SIGNATURE: " DATE
Building Commissioner/Inspector of Buildings
Zoning District: Proposed Use: Zone: 0 X O°B 0 A 0 V Aquifer Zone:
THE FOLLOWING AGENCIES SHOULD BE NOTIFIED: DPW
•
Boardbf 0-Board of q, Cons. r 0 Planning • 0 Address P 0 Engineering r-,d. Cross
1- Appeals Health Commission Card Connection -
❑Fire 0 Gas - 0 Electric 0 Other 0 Water.Card 0 Sewer Card
Chief Cut Off Cut Off CutlOff Cut Off
ti
DEPARTMENTAL APPROVAL(S)
Board of Health: Signature: Date:
Conservation Commission: Signature: Date:
D.P.W.: Signature: Date:
Fire Chief: Signature: Date:
Other: Signature: Date:
Brief description of work being performed: _ - / 7
SSECTIONI -SITE INFORMATION
1.1 Property Address: 9 1J\Oc° Cy La-ht 1.2 Assessors Map&Lot Number:
Contact Person: itl"\(4se SL T �'r�c�tC� Map GG Lot 0 - c9�
Phone Number: Lib( ass 3a`{(0
1.3 Historical Districtp }'❑ Yes No
1.4 Water Supply(MGL c40 s54): 1.5 Sewage Disposal System:
Year Built (` 9-3 tt
❑ Municipal 0 Municipal ❑Altering more than 25% per side of building
0 Private Well ❑ On Site Disposal System Has application been submitted to the Historic Commission?
❑Yes ❑ No Date:
Revised 5/13
❑ CONSTRUCTION PLANS ❑ SITE PLAN ❑ ENERGY REPORT
RESIDENTIAL
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT _
2.1 Owner Record:
C,�.(' Re`�c c cc 9 3ii rr.f �c 508958r 95Y
Name(print) Contact Address Phone Number
2.2 Authorized Agent:. , l
MACAZ SiL .c ! mOUJ .Util 6L 4Akeolle ��, Woi as 5aave
Name(print) Contact Address Phone Number
• * SECTION 3'-CONSTRUCTION''SER ICES *
3.1 Licensed Construction Supervisor/Specialty License: C5 License Number: /0 Sd.
e/ 7
Company Name/Contractor Name: Y J 7-7 pP i rnnQvt4 .`/'gym Q(i 3 Vreb/Cc
Address: 4 Piaui S( Expiration Date:
Signature: daL- Telephone: it/ aj3 .?2`((.e 08-43 /co /
3.2 HomeoWnet Exemption &Two Family Only Section 110.R5.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section;provides that if a Homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor.
For,the purposes of this section only,a"Homeowner"is defined as follows: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which
there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
SECTION 4-;WORKER'S COMPENSATION INSURANCEAFFIDAVIT(MGL c 152§25)
Worker's 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: gYes 0 No
SECTION=5-DESCRIPTION OF PROPOSED WORK(Check all applicable) '
0 Deck 0 Pool ❑ Repairs 0 Alteration 0 Chimney/Fireplace 0 Woodstove/Pellet Stove
i4T❑ New Construction* 0 Accessory Bldg. *Addition oo_fiSiding 0 Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) ' No.of windows Doors
0 DEMOLITION (specify): aid skin i
Location of debris removal (per MGL C.40 Sec(1 54): ❑Dumpster on site 0 Dumpster On Street
Facility Name: / ' 114 t- Lof k(__ Location:
*If new construction, please complete the following:
Single Family: No. of Bedrooms C?" No. of Baths D'
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑Furnace(hot air)-fuel gas(natural or propane),fuel oil,electricity,other(specify):
❑ Boiler(heating)-fuel gas(natural or propane),fuel oil,electricity,other(specify):
❑ HVAC(combined unit)-primary fuel,natural gas,propane,electricity,other(specify):
❑Air conditioning-(separate unit)
❑None of the above to be provided
0 Hot Water: Gas Electric Fuel Oil Other
A < SECTJON 8-ESTIMATED CONSTRUCTION COST
Item Estimated Cost($)to be completed by permit applicant
1. Building 06 cot.,
2. Electrical
3. Plumbing
4. Mechanical(HVAC)
5. Total =(1 +2+3+4)
SECTION7A-OWNER AUTHORI ,AfION
Ito be completed-when owner's agent,pr contractor applies for budding permit) + xi
(Please Print) `
I, (3 / Re%FL// L12 , as Owner of the subject property hereby authorize jfjr{, k c�,
to act on my Id half, in all mat re tive to work authorized by this building permit application.
��f//6/
Signature of Ow er Date
, SECTION 7,B OWNER/AUTMORI2ED AGENT bEELARATION
17/4Q,t;3 S,Lo c , as Owner/Authorized Agent hereby declare that the statements and information
on the foregoing application are true and accurate,to the best of my knowledge and belief.
Signed under the painjL
es of perjury.
��/
Sig t reof Or Auized Agent Dat
SECTION 8 R OFFICEIINSPECTOR'S NOTES
Less Application Fee: $25.00 Remaining Balance: $
Total Permit Fee: $
Other$Amount$
Gross Area-New Construction total sq.ft.
Gross Area-Alteration total sq.
///ft.. �J
Permit Issued to: oC..i//'/ (57 //1�/��- 1/(4 / �(
" f a SECTION 9-DESCRIPTION OF WORK BEING,PERFORMED
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Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supers isor
License: CS-104268
-ll . 43
MARK JSILVIA, -
4 MOULTON STREE
LAKEVILLE Mg 0 m
Jam.,, I "` Expiration
Commissioner 08/13/2015
s
•
IVUIIVOtIVII IIIO4i011l,O UUO'UOU-/a IU p. I
OP ID:JEC I
ACO O" DATEL1IIDDr VY)
�� CERTIFICATE OF LIABILITY INSURANCE I ry
01/01/13
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 CR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE 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 farms 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 endorsement(s).
PRODUCER CONTACT
Foundation Insurance Agcy.LLC Nyqa1m�e FAX
800 Davol St 1st Floor tNt No Fzit I INC.No):
Fall River,MA 02720 OMAN
ADDRESS:
Foundation Ins Agency,LLC PRODUCER MJSHO.1
CUSTONFRIDS:
INSURERS)AFFORDING COVERAGE NAILS
INSURED MIS Home Improvement LLC INSURER A:National Grange Mutual 14788
4 Moulton St INSURER B:National Grange Mutual 14788
Lakeville,MA 02347 INSURER c:Continental Casualty Co. _
INSURER 0:
INSURER E:
_ENSURER F-
COVERAGES CERTFICATE 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 WT H 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.LRA S SHOWN MAY HAVE BEEN REDUCED BY PAID MAIMS.
INSR TYPE OF INSURANCE J1y,Ag SUBSO POLCY NUMBER IMMIDONYM1 EFF M IM(On YMI UNITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
A X COMMERCIAL GENERAL LIABILITY MPF1681Y 04/12/13 04/12/15 pREM6E5(EaoNlbUrenea) $ ��,I' 1
CLAIMS-MADE ( OCCUR MED EXP(Any one xenon) $ 10,000
— PERSONAL a ADV INJURY S 1,000,000
_ GENERAL AGGREGATE
GREE $ 2,000,000
Cart AGGREGATE LIMIT APPLESI 0
PER: PRODUCTS-COMP/OP AGE $ 2,000,00
G LE
7 POLICY I7,,, 1 I LOC $
AUTOMOBILE I,etUTY COMBINED SINGLE LIMIT s 1,000,000
A ANY AUTC M1F16BIY 11/29/13 11/29/14 (Eaaaiden) _
BODILY INJURY(Per parson) S
X ALL OWNED AUTOS BODILY INJURY(Per accident) $
SCHEDULED AUTOS— PROPERTY DAMAGE
A X HIRED ALTOS M1F1681Y 11/29/13 11/29/14 IPe-accident/ $
A X NON-OWNED AUTOS M1F1081Y 11/29113 11/29/14 S
UMBRELLA LIAR I X OCCUR EACH OCCURRENCE $ 9,000,000
—
EXCESS LIA9 CLAIMS-MADE AGGREGATE S 5,000,000
A MB1681Y 04/12/13 04/1211S
DEDUCIBLE S
RETENTION S $
_
WORKERS COMPENSATION we STATU- OTH-
ANDEMPLOYERS'UABILRY ITORY MIFFSX FR
C ANYPROPRIETORIPARTNEIVEXECUTIVE YIN 0764079 07/14/13 07/14/14 EL.EACH ACCIDENT $ 1,000,000
OF-ICE3GIEMBER EXLL110ED7 NIA
(Mandatary In NH) E.L.DISEASE-EA EMPLOYEES 1,000,00t
IESCRIPPTd10 OF OPERATIONS below EL DISEASE-POLICY LIMIT $ t,000,00(
DESCRIPTION OFOPERATIORS/LOCATIONS I VEHICLES(Much ACORD 1DI,Additional Remarks Schedule,Ames space le required)
job location : 9 Blueberry Lane, Dartmouth, HA 02747
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN
Town of Dartmouth ACCORDANCE WITHTHEPOLICY PROVISIONS.
400 Slocum Rd
Dartmouth,MA 02747 AUTNDRInDREMIESENTATWE
Foundation Ins Agency,LLC
I
ED 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
. e� The Commonwealth of Massachusetts
f x " Department of Industrial Accidents
:- - ,,fir' Office of Investigations
1 Congress Street, Suite 100
4, ! Boston, MA 02114-2017
•�: -- �yj
k.:E1+=` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): c \V 3 �pf� Co_ ce� ��� �
tr - t,
Address: t-{ MO -\-n g4, AA
City/State/Zip: : - ` . in QZ3y3- Phone #: Q / ZSS 49a414°
Are you an employer? Check t e appropriate box:
I am a general contractor and I Type of project(required):
4.
1.� 1 am a employer with ❑
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance. 9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11.❑ Plumbing repairs or additions 3.El I am a homeowner doing all work
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.� Other S 'I(1c1(}rt�CZYS-
_ comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state 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: On 70 l
Policy#or Self-ins/Lic.##: t- 6709
1/U /I Expiration Date:
Job Site Address: l� I.*) 1( be, -,( 1 anP_ City/State/Zip tAlvico-k PAi ,
Attach 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 of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
_..
I do hereby ce , nd th pain nd penalties of perjury that the information provided above is true and correct
Signature. . 'I/, Date:@ t t t1 /l9 c)O _y
f
Phone#: 47/'�/, SJ ,9,9 `f6
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: 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 their certificate(s)of
insurance. Limited Liability Companies(LLC)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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 7-2010 Fax# 617-727-7749
www.mass.gov/dia