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34 MOFFATT RD - BUILDING INSPECTION The Commonwealth of Massachusetts FOR Board of Building Regulations and Standardsth MUNICIPALITY ! Massachusetts State Building Code, 780 CMR T edI Qpi J USE 1 S� Building Permit Application To Construct,Repair,Renovate Or Dclntl[t`sh:a Revised January One-or Two-Family Dwelling 1,2008 This S ton F r Official Use 0 Building Permit Number: Date Appli I Signature: �/ N ild" or o Date CTIO ITE INFORMATION 1.1 Property Address: \ 1.2 AssessorsJl4ap&JPrcgl�IVlnml,ersili l,.ii„ - L1 a Is this an accepted street?yes_ Map Number Parcel 1V=bcr - 13 Zoning luformation: 1.4 Property Dimensions: Zoning Distdu Proposed Use Lot Area(sq ft) Frontage(11) 1.5 Building Setbacks(ft) - From Yard Side Yards Rear Yard Required Provided Required Pmvided Required Provided - 1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Cbeck ifyes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of R Jecord:�^ T ♦ enn f G.� V21o5� Name(Print) Address for Service: Signature 1 Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) El Addition ❑ - Demolition ❑ Accessory Bldg.❑ Number of Units_ Other pacify: -ki✓S Brief Description of Proposed Work': er. n Sim/` (Jo0 r 5 ! C C� i SECTION 4:ESTIMATED CONSTRUCTION COSTS - Item Estimated Costs: Official Use Only - Labor and Materials)-- I.Building - $ I_ Building Permit Fee:$ Indicate how fee is determined: ❑Standard Cityfrovvn Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier - - x 3.Plumbing $ 2. Other Fees: - 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ oppression) Check No. Check Amount: Cash Amount: 6.Total Projeet Cost: $ L 7�. Oa ❑Paid in Full ❑Outstanding Balance Due: a SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) Qr)97 ) 3 f y License Number Fa;piration Date Name of CSL-Holder 3,FlilbA Sheet List CSL Type(see below) Address _ Salem MA 01970 Type Description U Unrestricted(up to 35,0100 Cu.FL) R Restricted 1&2 FamilyDwelimp - Signature M masomy Only vv�" RC Residential Roofing Covering Telephone ry WS .Residential Window and Siding - - R-7 O` y y— b y� SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition- - 5.2 Registered Home Improvement Contractor(I11C) - / �r A It HIC Compan Registration Number fxl It TPfferscirT Alin,jeJJ Address Salem MA 01970 9,7fr 7q y-gT'f�j .Exp'. tion Date Signazure Telephone SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.§ 25C(6)) Workers Compensation lnsuiance 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, 6,i D e-S CO 5i C r 5 , as Owner of the subject property hereby authorize t, t_ /a 1 ,n.) to act on my behalf,in all matters relative to work authorized by this building permit application. - /1/,//3 Si n re of Owner Date SECTION 7b: OWNERr OR AUTHORIZED AGENT DECLARATION - asOwner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf." Print Name - Signature of OAmer or Authorized Agent - Date (Signed under the pains and penalties of - 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(MC)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 0.R6 and I I O.R5,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 ofhalf/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" - a CONTRACT y. Work Oreler Id: Printed. 122l2013 593627Pgggsgapg Atlantic Weatherization� Jennifer Destosiers CLC;� ". •� .�.�� 61R Jefferson Ave _ 32 Moffatt Rd ,- ` jf, SHIM,MA 01970 Salem,MA o1s7o 43z6 Phone(Day?e s78 ssrr32s6 SitelD: 500002093627 Location r � x ems. . Description O Lmng Space Insulate Aluminum Sided Wall With 0 Dense p �� Unit$ Total$ 84 $2.55 $1,999.20 Installed Measures Total $1,989.20 ,�. v ti Incentive Payments Weathenzation Incentive $1.499-40 Total Incentive Payments $1,499,40 Customer Share Total Customer Share $499.80 Less Deposit Of $166.60 Customer Share Balance(]Due Contractor) $333.20 Conservation SeMCes Group-50 Washington Street Suite 3000-Westborough.MA 015f31 -(508)WB_W00 CONTRACT' - _ Printer: 1f2=13 Work Order ld, S936311396857C299 Atlantic Weatherization Donna Gaito Phone(Ew;_,978-678�8564 i 61R Jefferson Ave 34 Moffett Rd Phone(Day): 978-9963286 Salem,MA 01970 Salem,MA 019/(¢7a}00--,9328 Site ID: S00002093631 Lotion Description Quantity a Unit$ Total$ EJderior Door Weather Stripping 6 M20 $15120 Living Space Install 3'Fiberglass Betting In Open Kneewall 84 $1.46 $122.64 Living Space Perform Air Sealing at Estimated 62.5 CFM50 6 $77.00 $462.00 DoorSweep 6 $21.17 $127.02 Living Space Attic Floor Open Blow Cellulose 6' 598 $1.34 $801.32 Living Space Kneewall Floor Enclosed Cellulose Dense Pac 84 $2.07 $173.88 Damming 18 $1.85 $33.30 Attic 12'Mushroom Vent 2 $126.00 $252.00 Living Space Door.Thermal Barrier Polyiso 20(Attic) 1 $74.31 $7431 Living Space Door.Thermal Barrier Polyiso 2'(Attic) 1 $74,31 . $74.31 Living Space Insulate Aluminum Sided Wall With 4'Dense P 784 $255 $1,99920 Installed Measures Total $4,271.18 OLj^mil Incentive Payments Air Sealing Incentive $740.22 Weatherization Incentive $2,000.00 Total Incentive Payments $2,740.22 Guatomer Share Total Customer Share $1,630.96 Less Deposit Of $510.32 Customer Share Balance(Due Contractor) S1,020.64 �'� Conservation Services Group-50 Washington Street Suite 30M-Westborough,MA 01581 -(508)836-9500 RightFax C2-2 3/26/2012 7 : 26 : 52 AM PAGE 6/027 Fax Server ISSUE DATE :i-�i i:� m::� 3n612012 SMANO THIS CERTIFICATE IS ISSUED AS A hTATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETNITEN THE ISSUING INSURER(S),AUTHOIUMFD A THIS EN 0�N�R SETNITATC�T OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy,(ics)must be endorsed.if SUBROGATION IS WAIVED,subject to the terms 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 EASTERN INS GROUP LLC NAME: PHONE '33 W CENTRAL ST (AC Na,E.t) FIAAIL HATICY,MA 01760 ADDRESS PRODUCER CUSTOFAER ION INSURED INSURER(S)AFFORDING COVERAGE NAIL 4 ATI-kNTIC WRATHER12ATION UC INSURER AMERICAN ZURICH INSURANCE COMPANY III REAR JEFFERSON AVE INSURER SALEM,MA 01970 INSURER C INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER RFVISION NUMBER: � THIS IS TO CERTIIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ITA=ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO N171ECH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HER=IS SUBJECT TO ALL THE TERMS, 12-0CLUSIOMI AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAWS INSK TYPE OF INSURANCE AJML SUB R POLICY NUMBER POLICY EFF POLICY EXP L31TITS LTR INSR XVVD— (L=D1YYY70 _M0&DD/YYM GENERAL LIABILITY EACH CcaUBSENCE $ DP EIOE LM $ 0 CEASES �Sa $0 $ 0 DnUE.y GMrl,hG:PEoklB T"ey hPPLIEg IM PEOWCILCOIdPAJY $ 0P=y 0I'PJ�EC1 01m: P.C{: AUTOMOBILE LIABILITY acnaB12TED BDBGIX T n]Il EUL D=f�-y ❑ �rvpxro (Fn.Pus EODILyo=y 0 2EED818DXul0f 0 M"nhuzo$ 0 IMIT-Ow UrDA1709 0 �Xll CICIMILIOWE I] Ma2MULD13 0LXCOo4 I 0 E.WESSLD3 13 CLAMbw= 0 DmwlI 0 MNw1ICQ;S $ %VO RS' COI,IFENSATION 2 ITh" .rurClKy A AND EhIPLOYERS LIABILITY 'eolt Y/N N NIA 7PJUB-5132'10121 33!20�12 03t2WI3gELI. $500,000 ff=LU ( MTORY 0 IfO) $500,000 OF PL.IHBFA BF POi.ICY $500,000 ISLHI 5.C=�CATE ISSUED TO TH1 CMTD`ICATE 110�� CC-%'N�C I�C 17GE == . ........... CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBEO POLICIES BE CANCELLED Q-.:WASHIKGTON ST BEFORE THE EXPIRATION LATE THEREOF, t40TICE WILL BE DELIVERED SALEM,IVIA 01970 IN ACCORDAIJCE WITH THE POLICY PROVISIONS A CERTIFICATE OF LIABILITY INSURANCE 3/19/20 2""' 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 OR 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: lithe Icate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condinrrof 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 Construction NAME: Eastern Insurance Group LLC PHONE Exit- (508)651-7700 we No): _ 233 West Central Street ADDAIL RESS: PRODUCERCUSTOMER ID 00024397 Natick MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Arbella Protection Ins. Co. 41360 INSURER B Arbella Indemnity IRS Co. 10017 Atlantic Weatherization INSURER :Zurich—American Group 61 Rear Jefferson Avenue INSURER Deacon Hill Associates Inc INSURER E: Salem MA 01970 INSURERF: COVERAGES CERTIFIC%ATE`NCJMBER38ASTER'2012 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 WITH 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, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE D S R - .POLICY EFF POLICY EXP. LTR POLICY NUMBER MMID MW LIMITS GENERAL LIABILITY - EACH OCCURRENCE S 1,000,000 ]{ COMMERCIAL GENERAL LIABILITY RENTED PREMISES OEa occu ence $ 50,000 A CLAIMS-MADE ❑X OCCUR B500042816 /20/2012 /20/2013 MED EXP(Any oneperson) $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEM,AGGREGATE LIMIT APPLIES PER: _ PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOCJECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO B ALL OWNED AUTOS 93827d00003 /20/2012 3/20/2013 BODILY INJURY(Per accede)BODILY INJURY(Per accident) $ X SCHEDULED AUTOS 4 PROPERTY DAMAGE X HIRED AUTOS - r (Per accident) $ X NON-0W ED AUTOS uninsured motorist BI split limit S Underinsured motorist BI split S X UMBRELUl LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 E%CESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DEDUCTIBLE S A RETENTION E 4600097820 /20/2012 /20/2013 E C WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'UABILITY - ANYPROPRIETOR/PARTNER/EXECUTIVE YIN N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED'! Li CERTIFICATES TO BE ISSUED (Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE E ❑yyee IPTIOeantler D ESCRIPTION OF OPERATIONS below IRECTLY BY CARRIER E.L.DISEASE-POLICY LIMIT $ D POLLUTION LIABILITY CPL200378600 10/1/2011 10/1/2012 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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. CITY OF SALEM 93 WASHINGTON STREET AUTHORIZED REPRESENTATIVE SALEM, MA 01970 Rosemary Fulham/PMA �— ACORD.25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations, 600 Washington Street Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Pledse Print Legibly Name (Business/Organization/individual): Address: 61 R JAwn Avetlue City/State/Zip: Phone #: 1 j y Are yoyt an employer?Check the appropriate boa: " Type of project(required): 1.21 am a employer with :;L _ 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ]0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §](4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other - comp. insurance required.] *Any applicant that checks box#t 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Z V, f A,'le_/;ca G Policy #or Self-ins.Lic. #: S a �,��t� �I" �— I Expiration Date: �j 7-o ///3 Job Site Address:_'.- L-3 �1/ T City/State/Zip: e�► � / 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: . Date: 4A, // 3 Phone#: i -7 Official use only. Do not write in this area,to be completed by city or town ojj9ciaL City or Town: Permit/License# Massachusetts-Department of Public Safety - Board of Building Regulations and Standards calstructiun Supcni.ur t" ,,a Unrestricted-Buildings of any use group which License: CS-087977 i contain less than 35,000 cubic feet(991m)of enclosed space. ERIC W PAL➢ + x. 3 HII.TON ST SALEM MA-01970. w k r J..C.—� si%:0 Expiration Failure to possess a-current edition of the Massachusetts - Commissioner 04/23/2014 - State Building Code is cause for revocation of this license. ' For OPS Licemingthfoimation visit: www.Mass.Gov/OPS Office At�me°"�rai Ad.utsrs�cgo°''� aT 6ou HOME IMPROVEMENT CONTRACTOR 1 t License or registration valid for individul we only W—N Registration t42089 TYPe before the expiration date. If found return.to:Expiration: 3;t?J2014 Ltd Uabihty Cotpor � .,Office of Consumer Affairs and Business Regulation t ATTIC WEATHERt7.ATLON-4,G:C. - ; 10 Park Pbaxa-Suite 5170 Boston,AIA.02116 - ERIC PALM t i 61R JEFFERSON SALEM.MA 01970 ; Undersecretary i - - -is . - Not valid-without st re a n .