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83 MOFFATT RD - BUILDING INSPECTION The C'ommmonw'e:dth of Massachusetts x, Board of Building Regulations and Standards Cfl'1 OF Massachusetts State Building Code, 780 CNIR S,\LG\I 'L,'•• Rrrised.I l,u _'llll Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Fuming Duelling This Section For Official Use Onl Building Permit Number: Date; pplicd: _ Budding 011imal(Print Nmne) . ignature 30 DJll` SECTION I:SITE INFORAIATION 1.1 Pyquerty pd e �D 1.2 Assessors Hap& Parcel Numbers L I a Isthis an acceptteci street9 yes no Map Number Purccl Numtkr I.J Zonlltg Information: 1.4 Property Dimensions: Zoning District Proposed Usc Lot Area(sq II) Fmnlage(Il) 1.5 Building Setbacks(D) Front Yard Side Yards Rear Yard Reyuircd Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if es❑ Municipal❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' 2. Own rl o cord: Name(Print) City.Slate,ZIP X) 3.0 MIM T7 /PU Nu.and Street Tele hone P Email Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied 17 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specily: Brief Description of Proposed Work r SECTION 4: ESTIDIATED CONSTRUCTION COSTS Item Estimated Costs: Labor and .\loteriaIS) Official Use Only 1. Building S3 , 2 I. Building Permit Fee: E Indicate how lee is determined: '. Electrical S ❑Standard City/Town Application Fee l ?. Plunihing S ❑Total Project Cost'(Item 6)x multiplier _ _.x ?. Other Fees: S J. .\lech:mical till':\('1 S List;_ _ __ ;. \Icchanical (Fire ------ -----.__.. ------ - ----Su t tression) S Total :\II—Fees: E -- o. Tidal Project Cust: J Q 1/ ('hak No. - --Check Amount: 0 ❑Paid in Full ClOutstanding Balvue Due: SECTION 5: ('ONSTRUCTION SERVICES 5.1 Cunstructiun Supervisor License(C'SI.) X ,_-- ._ {- _L� License Nun11 cr I'q) atioo I ate _ ---- N;uue of C.S1. I lulder List CSI.1)Ix:)sec helow) Type Description No Ind Slncl � / U I Inresiricicd(Building no to 35,0110 cu. 111 ��� .�_. _��� . ._ R Restricted IR'_ I anlil Dwelling Cnri full n,Stutc.LIP AI Nlasonry RC Roo in C'uverin —. A \Rindow and Siding SF Solid fuel Burning Appliances ��7�7 7 I emoliun 'felt hone Email address D Demolition 5.2 istered Ilomee rnpruvemerl{Contractor(HIC) —�~ J ZZ;op �] 4/44 a�'�yy/& ?,OAIa IIIC Registration unlbcr FspirnDale /`S I�R am egislr�u3t� e td�A �� Email address �� ti 4 Ci /Town,State,ZIP 'fete hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 152.1 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........... C3 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES/FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize�q, 46/ OR/l. to act on my behalf, in all matters relative to work authorized by this building permit application. PA�iz 7- tz Print Owner's Name(El Ltmnic Signature) Dakk SECTION 7b:OWNER( 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. Print t wner'i or:\uthorircd,\gene's Name(Electronic.Signature) Dut NOTES: I. An Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program),will! have access to the arbitration program or guaranty fund under NI.G.L.c. 1 a?A.Other important information on the HIC Program can be found at wlltl nll�.�n o, i Information on the Construction Supervisor License can be found at mos, go� dtis 2. \Then substantial lurk is planned, provide the information below: Total floor area I sy. R.1 1 including garage, finished basementanics,decks or pored Gross lining area(sq. it.) - Habitable room count Number of fireplaces Number of bedrooms Number of bathrounu Number of halt'huhs I\pe kit'healing s)seen, -- .-._ - _. .._ Number of decks, porches I\pc+lfi00111tgilstGm _ _ _ - 1,I1eowd _ _. .. - --011en . 1. ''Fowl Proicet Square Fotnl,gC nha) he substituted ltlr-I'UI;11 Project Cost- GCONTRACTOR WORK ORDER Conser4ation Services Group so Washington St.suite 3000 Westborough,MA 01581 Printed: 511812012 Work Order Id: S26922P29886C200 io nt ......... Vr: r, A&M General Contracting Inc Paul Segal Phone(Eve): 781-258-0002 119R Foster Street 83 Moffatt Rd Phone(Day): 781-258-0002 Peabody,MA 01960 Salem, MA 01970-4356 Site ID: S00002026922 Location Description Quantity Unit$ Total$ Blowdr Door Test Only 1 $60.00 $60.00 Living Space Insulate Multiple Siding Wall With 4"Dense Pa 1,085 $2.40 $2.604.00 Living Space Perform Air Sealing at Estimated 62.5 CFM50 14 $75.25 $1,053.50 Living Space Dense Pack 19'Cellulose In Overhang 42 $2.35 $98.70 Installed Measures Total $3,816.20 -g s Incentive Payments Air Sealing Incentive $1,053.50 Weatherization Incentive $2,000.00 Total Incentive Payments $3,063.50 Customer Share Total Customer Share $762.70 Less Deposit Of $283-83 Customer Share Balance(Due Contractor) $478.87 Conservation Services Group-50 Washington Street Suite 3000-Westborough,MA 01581 -(508) 836-9500 G Gonser atio Services Group CERTIFICATE OF COMPLETION 50 Washington St.Suite 3000 Westborough,MA 07581 Paul Segal Phone(Eve): 781-258-0002 83 Moffatt Rd Phone(pay): 781-258-0002 Salem,MA 01970-4356 E-Mail: SitelD: $00002026922 Contract ID: 20111215 WORK Company: A& M General Contracting Inc Sub-contractor Work Order* S26922P29886C200 Blower Door Test Only 1 Living Space Insulate Multiple Siding Wall With 4"Dense Pack Cellulose 1,085 Living Space Perform Air Sealing at Estimated 62.5 CFM50 Per Hour 14 Living Space Dense Ppck 10 Cellulose In Overhang 42 PRE- COMBUSTION SAFET TEST ✓; ?IPL E T E D POST- YES NO NOTCER IFIED PLEASE NOTE:The Inspection of the house is for the purpose of finding CUSTOMER AUTHORIZATION OF CERTIFIED WORK out whether the Contractor completed the work. 1 confirm that the measures listed above have been completer) to my CUSTOMER SHOULD NOT RELY ON THE INSPECTION FOR satisfaction. I have received a copy of the Certificate of Completion and ASSURANCE THAT THE CONTRACTOR'S WORK NECESSARILY hereby authorize the release of any final payments to the Contractor. I COMPLIES WITH ALL LAWS AND STANDARDS RELATED TO understand that this Authorization of Completed Work does not in any SAFETY. manner void any warranties provided to me by the Contractor. It was the Contractors sole responsbiltyto assure that the measures were installed properly and safely. In addition, this Post-Installation Inspection does not replace inspections by licensed inspectors where required by state or local law. It is the duty of the Customer to obtain such required inspections. Contractor's Signature Customer's Signature Date Date Conservation Services Group-50 Washington Street Suite 3000-Westborough,MA 01681 -(508)836-9500 CITY OF SALEM9 `ti kss kCFjUsETTS 9L1tOLVG DEP.IRT\tF.\T 120 W.1S'f4GTON SMITr YA Ftccit h?L. (978) 745-9599 KIJ(HFRt ISY DAMOLL FNc(978) 740.9844 MAYOR THO-%I"StPMRtts D'"CrOQ Of PLSLlC PROPUTY/aLMOLNG cmal1SSIONE)t Construction Debris Disposal Aftldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section I l I.S Debris, and the provisions of MCL a 40, S 34; Building Permit 4 is issued with the condition that the debris resulting from Ibis work shall be disposed of in"­a properly licensed I 11. S 130A. waste disposal facility as defined by MCL c The debris will be Vans rtcd by: (name of hauler) �" 'w Z The debris will be disposed of in : (namaoYfacility) ORII2 144e'llwy (iddresa of ruili�y) �>q�olo l tj� 0 nan,re ofper ipphcanr l�ta The Commonwealth of Massachusetts Department of Industrial Accidents (' Office of Investigations _ 600 Washington Street Boston, MA 02111 Cyst www.n ass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): o Address: Jam. City/State/Zip: 6 Phone #: Ar ou an employer?Check the appropriate box: Type of project(required): 1.Y3 I am a employer with_,,9-6 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition workingfor me in an capacity. employees and have workers' Y p ty• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.* required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 PIu bing 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 13. Other`//,/���� employees. [No workers' yJ� comp. insurance required.] *Any applicant that checks box N 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. =Contractors 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: lfl, A Z&j, /,/�M /� I L/ Policy#or Self-ins. 2Lie.#: A It/ 3 7 `J Expiration Date: 7 Job Site Address: �3 31/JiPT City/State/Zi ,4l�/1/) p/�i{� /✓l�7q/0 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 certij der the pains and penalties of perjury that the information provided ais true m1 correct. Stenatu Date -5-7 Z Phone#: Official use only. Do not write in this area,to be completer/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#: ABMGE-1 OP ID:SM CERTIFICATE OF LIABILITY INSURANCE R DAT03/22 03/22NDI2 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: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies) 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 781-914-1000 CONTACT TGA Cross Insurance,Inc. NAME: FAX 401 Edgewater Place,Suite 220 ac°NNa EXt: AIC N Wakefield,MA 01880 E�IdAIL John Scanlon ADDRESS: INSURERS AFFORDING COVERAGE NAIC Y INSURER A:Peerless Insurance Co INSURED A&M General Contracting, Inc. INSURER B:Guard Insurance Group Norman Dube 119R Foster St. Bldg 14 1INSURER C: Peabody,MA 01960 INSURER D: - INSURE E INSURERR F: COVERAGES CERTIFICATE 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 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POUCY LTR TYPE OF INSURANCE POLICY NUMBER MM/DOS MMID FYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CBP8833284 03/20/12 03120/13 PREMISES Ea occurrence S_ 100,00 CLAIMS-MADE 7 OCCUR MED EXP(Any one person) $ 5,00 PERSONAL S ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2,000,00 POLICY PRO LOC $ AUTOMOBILE LABIUTY (Ea �BIO IISINGLE LIMIT $ 1,000,00 A ANY AUTO BAS762301 03/20/12 03/20/13 BODILY INJURY(Per person) S ALL OWNED XSCHEDULED AUTOS S BODILY INJURY(Per acdentI $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS LIAR CLAIMS-MADE CU8762501 03/20/12 03I20/13 AGGREGATE $ 1,OOB4O0 DED X RETENTION$ 10000 $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY 8 ANY PROPRIETOR/PARTNER/EXECUTIVE YIN MWC345622 03/20/12 03/20/13 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? ® NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,0B Myes,desodbe antler E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS below � DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (AKacb ACORD 101,Additional Remarks Schedule,If mom apace Is required) CERTIFICATE HOLDER CANCELLATION SALEM-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ty ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington St Salem,MA 01970 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD I DPS-CA1 O 50M-0QN-G10)215 1 T /v n//' e Vnr,ewrm->une.z�(� . �lsuar,�i<rlrllo -.. Office of Consumer Affairs R Bu4iness Regulation 9 UHOME IMPROVEMENT CONTRACTOR Registration: 141124 Type: Expiration: 1/12/2014 Supplement Card • A+M GENERAL CONTRACTING INC. MICHAEL FITZGERALD 5 SOUTH RIDGE CIRCLE ��^ •- LYNN,MA 01904 Undersecretary \1u..aihu.rN. - Department of Public 1a00n &,aril of Buildim_ Rc-ulalinn. Lind 't:1nd:11'11• Ccristruction Supe*visor Specialty License License: CS SL 99933 Restricted to: RF,WS,DM,IC MICHAEL FITZGERALD 9 WINCHEST COURT GLOUCESTER, MA 01930 cAptratlon. 6/19/2012 f numi•�inu.r Try- 99933