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150 MARLBOROUGH RD - BUILDING INSPECTION (3)
The C'onmwnw'ealth of Massachusetts Board of Building Regulations and Standards Cl I')'OF Massachusetts State Building Cute, 730 CNIR SALE\I Relived l tits•_'ill/ Building Permit Application 'ro Construct, Repair, Renovate Or Demolish a One-or rnw-Fumilt Di elling This Section For Ot'ricial Use Onl Building Permit Number: Dat Applied: _ Building 011ieial(Print Nmne) Signature puce SECTION I:SITE INFORMATION L I Property Address: J 1.2 Assessors.Nap& Parcel Numbers i S D M 21/Jose ,9 I.la Is this an accepted street?yes V no Map Numhcr Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions. Zuning District I'r p..c—tie Lot Area(sq 11) Frontage(II) 1.5 Building Setbacks(R) Front Yard Side Yards Rcar Yard Required Provided Required Provided Required Provided 1.6 Witter Supply:(M.G.I.c.aa,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Munici al❑ On site Jis Check iP 'es❑ P pusal system ❑ SECTION2: PROPERTY OWNERSHIPI 2.1 Owner.of Record: L{*A VJLLSo SAti 1 Nalne(Print) / ,� City.State.ZIP ILZ Nu.onJ Street Telephone Email Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Buildin Owner•Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: Grief Description of Proposed 1Vork=: t t�SUI XkfIA SECTION a: ESTIMATED CONSTRUCTION COSTS Ilan Estimated Costs: (Laburand Materials) Official Use Only I. Building S I. Building Permit Fee: S Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier _ _ .x j ?. PIumM°g S '. Other Fens: S — - ...----- a. Mcch;lnic,ll III\'.\('I S List: �. \Ieeh:mieal Wire Suitressioni S Total \11 Fees: S Check No. _('heck Anwunt: (',uh \iuounl: n. Total Project Cost: 5 `�G�®• 0 P,tid in Full ❑Outstandin _ y Balance Doc: SECTION St ('ONS"I'RUC'f10N SERVICES 5.1 ('unstruction Supervisor License(C'SL) N:une oI CSL ll,,l��nld.__craa J __ .--_—_-- License Numhcr I ist 01. I)Pe Isec heloa 1 — No. .mJSlrcel ------_. --- ------------ .I.>Pe Description U I inrestricicd(Buildings tio to 3$,000 cu. 11.) f _ram t • .. 1�b R Rc.oicted IA? Famil Y Dttdlin l'itsi loan.Stoic.LlP N1 Masonry RC Riioling C,%erin ...—. W'S W'indo%vwd.Sidin SF .Solid Fuel Burning Appliances I Insulation 'I'elc hone Email address D Demolition 5.2,/Registered Home �Improvement Contractor(HIC) f*S3 I IIC Registruiun Ntunlwr Lspir,tiun Dale I IIC C'un any Nani�or I IIC'I(e istmm Numu _ /f'1N's WX�t (6utCcSJ.�t+P7� No.jgld$Inyt& !�' ©1116 V Y--1YY-?y 7� Email aJJress City/Town.S//TownY.State,ZIP rT rcie hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152. 4 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this atfdavit will result in the denial of the Is I uance of the building permit. Signed Affidavit Attached? Yes ........ _ No...........O SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize M*5"3 W ()-� to act on my behalf,in all matters relative to work authorized by this building permit application. s1.C� J A)10blV _ v 2-I 3 Print Owner's Nmne(Electronic Signature) Dui 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 and accurate to the best of my knowledge and understanding. ro zy � Prim Osuicr's ur:\uthariicJ.\yen '.Name I Electronic.Sign rare) ale NOTES: I. 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 Hume Improvement Contractor(HIC) Program).will M) have access to the arbitration program or guaranty fund under M.G.L.c. 1 42A.Other important information on the HIC Program can be found at „wts m t,, ,, ,�,,i Information on the Construction Supervisor License can be found at%%%s,,.ni.n:�:�� Ill, \Tlien substantial%wrk is planned, provide the information below: roiai flour area[sq. R.) _ I including garage, finished basemenCmtics,decks or porch) (truss Iic ing area(sq. 11.) _-__ _ __. - _- Habitable room count I \umber of fireplaces __. Number of bednwoti Number of hathrounis Number of liall h;uhs I)lie of heating s)stem Number ofdecks, porches i I*)pcofo,olingi)item 1`11closcd Open 1. "Total Project Square Footage-map he sulisiitutcd fir"lolal Project Cost. The 4=ommonwealth of Massachusetts Department of Industrial Accidents f Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): t✓j O W X Address:3 O(;W lk-"!i q City/State/Zip: SkAm NA- Phone#: ZLI-/---?V Are you an employer?Check the appropriate box: Type of project(required): 1�'I am a employer with�_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working forme in any capacity. employees and have workers' 9. Building addition [No workers'comp.insurance comp.insurance.t ❑ g required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself„[No workers,comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13Other \ employees. [No workers, 5U(�fAxIGJ comp.insurance required] 'My applicant that checks box#I 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. iContractors 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: Policy#or Self-ins.Lic.#: Ur l- 1 Expiration Date: 04 Job Site Address: Um M0a l YJ®I(PiUQg / City/State/Zip: tv c rvs'1 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 unprisonment,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 certify under the pain nd penalties of perjury that the information provided abo e i'sstr wand correct C � Signature: q Q y Date ? ) Phone#: 1 0' 7gL39 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/Liceuse# 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 bum 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 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia eel �i//,� �((�r., Office of Consumer Affairs&Business Regulation ..Isr� ,F�OME IMPROVEMENT CONTRACTOR Type: e g i st rati o n: 111617 xpiration: 1/12/2015 Private Corporati< RICHARD LAMBY 3 OCEAN AVE -- SALEM, MA 01970 Undersecretary l 8r arcl of ml !inU (i lainn i '(`��mtrurti�ut Super.ianr Spceioln ,^;7,5. CSSL-102293 RIC'HARD LAMBY 3 6cEAN AVENUE SALEM MA 01970 - y- �,. . . . . 05/03/2014 CONTRACTOR WORK ORCEI Printed: 10127/201 50 Washington St.Suite 3000 Work Order Id'. 526759P30974C79 Westborough,MA 01581 Contractor information Custo_rnerlSite Detaiis Mass Weatherization]tic Kenneth Wilson --^- — _--' Phone(Eve). 781-241.2354 3 Ocean Ave 160 Marlborough Rd Phone(Day): 781-241.2354 Salem, MA 01170 Salem,MA 119,70.1052 Site ID: S00002126759 - - L—. .._.-..... ....... Total Installed Measures Location Description Quantity Unit$ Total $ Blower Door Test Only 1 $60.00 $60.00 Living Space Insulate Vinyl Sided Well With 4"Dense Pack 684 $2.20 $1,504.80 Door Sweep 4 $21.17 $84.68 Living Space Perform Air Sealing at Estimated 62.5 CFM50 8 $77.00 $616.00 Exterior Door Weather Stripping 4 $25.20 $100.80 Living Space Attic Stair Cover Thermal Barrier with carpentry 1 $237.65 _. $237,65 Installed Measures Total $2,603,93 WorkOrder Notes ------- Payments _._._ '.. incentive Payments Air Sealing Incentive $1,039.13 Weatherization Incentive _ $1,173.60 Total incentive Payments $2,212.73 Customer Share Total Customer Share $391.20 Less Deposit Of $130A0 Customer Share Balance(Due Contractor) $260.80 Conservation Services Group-50 Washington Street Suite 3000-Westborough,MA 01581 - (508)836-9500 r; Tuc: UO:i CVtlti t,'iJI Cniv DATE IMWDDIYYYP) j CERTIFICAtE OF LIABILITY INSURANCE 9/4/2013 THIS CERTFCATECDO OR ESSNISSUED AS A OT UEDAFFIRMATIVELYER COR'NEGATVELYINFORMATION AMEND,EXTEND OR AND CONFERS AL EftTIHE COVERAGE AFFORGHTS UPON THE DED ABY TE HHOE POLICLDER HES IS C REPRESENTATIVE BELOW. THIS CERTIFICATE PCATE OF RODUCERINSUI ,AND THE CI RTES NOTE CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREII AUTHORIZED THIS IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the Polley(les) must to be endorsed. If SUBROGATION n WAIVED, subject he the terms and conditions of the Policy,certain Policies may require an endorsement. A statement on this Certificate does not confer rights to the certifi cute holder in lieu of such endorsements . ..CT Northborouch Select West PRODUCER PHONE (SOB)393-7744 Eastern Inaurance Group LLC E-MAIL 155B Otis Street NAIL e INSURERS AFFORDING'OVERAGE Northborough MA 01532 INSURER A:Wes tern World Insurance Co. I INSURERB:Harle sville Worcester Ina Co 6182 INSURED Mass Weatherization Inc INSURERC:BOOtt9 dB110 insurance COm an 9357 3 Ocean Avenue INsuaeno:Travelez8 IN6URER E: i I Salem MA 01970 IRauRER F: COVERAGES CERTIFICATE NUMBER:CL139422206 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW NAVE 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 L WHICH THIS CERTIFICATE MAY BE ISSUE' OR MAY PE RTAIN,I;THEI INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN RED uCED BY PAID POLICY EPS LIMITS TYPE OF INSURANCE VVLIUUU POLICY NUMBER I YY LTR 1,000,000 EACH OCCURRENCE 5 GENERAL UAINUTY ATE 100,000 PREMI ES Es o Ire I $ X COMMERCIAL GENERALLIABIUTY /20/2013 /2e/2014 5,ODD PP MI R FXP PERSONAL S ADV INJURY $(An one person S A CLAIMS-MADE O OCCUR 0115119 1,000,000 PERSON GENERALAGGREGATE S 2,0001000 PRODUCTS COMPIOP AGG $ 21000,000 GEN'L AGGREGATE LIMIT APPLIES PER: q, X POLICY PRO LOC M INS IN L L 1 000 000 AUTOMOBILE LIABILITY E9 Beel BODILY INJURY(Per person) S I B ANY AUTO ALL OWNED X SCHEDULED BA 00000024700P 10/4/2013 10/4/2D14 BODILY INJURY(P&eeeidenll S AUTOS AUTOS PROPEFTY DAMA'E $]000 000 X NON.OWNED Pvr occ,denl HIRED AUTOS X AUTOS S UASC X UMBRELLA UAB OCCUR EACH OCCURRENCE AGGREGATE S 1,000,OGD E%CE$$LIAO CIAIMSMADE $ _ C /28/2023 /20/2014 $ DEB RETENTIONS 9D03067D wC STATU- OTW ' rj WORKERS COMPENSATION AND EMPLOYERS LIABILITY YIN E.L.EACH ACCIDENT S 500000 ANY PROPRIETOWPARTNER,E ECUTIVE ❑ NIA OFFICER✓MEMBER EXCLUDED". 65B44939A13 /3/2013 /3/201A E.L.DISEASE EA EMPLOYE S 500000 (Memalory In NH It yyoi.doscriDD o�tlar E.L.DISEASEPOLICY LIMIT 5 5D0000 D65'RIPTIBN OF OPERATION$Dvlpw DESCRIPTION OF OPERAHON$(LOCATIONS/VEHICLES (Anazh ACORD 101,Addlllond Remake Schedule,R mere apace la"gWred) 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. AUTHORIUD PRESS ATTVE Debora Monac U / ACORD 25(2010/05) I 1 -2010 ACORD CORPORATION, All rights erved. INS025(201000)01 The ACORD name and logo are registered marks of ACORD I n. `P 0,Wur.(IV S"Px PARTICIPATING mass save, CONTI]ACYOR PERMIT AUTHORIZATION FORM kenneth Wilson owner of the property located at: Name,printed) 150 inarlborough rd saleril hereby wid-twize the Mass Save Home Energy Services Program assigned Participating Contractor Imed below to act on my behalf and obtain a 1)(111ding perinitto perform insulation and/or weathenzation work on my property. X Owner's Signature 03/26/13 Date FOR CSG OFFICE USE ONLY Conservation Services GrOL11)has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Rev. .12.132011