1 MOONEY AVE - BUILDING INSPECTION \
1 �
� ll ,!` The Cbmmunwralih uP Mnssachusetts
� � 3uard uf B�ils�ing:Rngulatiuns and Slnndnrds ��TY
s . _,
,6 OF SALEM
U' f ' �I� ' Massachusetts State Building C�xle, 780 CMR Z ,f���on
Q , �;, �:; E RrvisrJJu�ruur�•
13uilJing Permit Application To Cunstrucl, RC 91f. Reno��Ry�r� ,�mulish a /. ?O/hY
Onr-ur T�vo-Fumr w lling. ,. ,A , ,
This 5 ion r OITic' 1 Use Onl ' ' ' `
� � BuilJing Peirnit Number. Date lie
Signa�urr.� - � .
� . HuilJin�Cummissia�edlnspectw Buildi y� f�te .
SECTION 1:SI E INFORMATION
1.1 Properry Addna: 1.]A�aa�on Map d� Parcel Numben ,
I Moonc `�/ A1l-C- • � � .;,r:K.:',-.d)t,.;�di' f;,r:,:=�;•
I.I a Is this an acce ted slrcet?yns no Map Number � � �._ ;P ` �! mben,�,..
1.3 ZoalnQleformalbn: 1.�1 ProperlyDlmemldqs�i;. �..q,� r;,;:.�,;,•'.
Zuning,Dis�rict� Propoxd Use . . � Lol Ared(sq 11) � �Frontage(flI
I.S BuIlding8et6aclu(R) � :. ._._. . _
. . � Front YorGy. . .. , .... :Si�ls Yardf � . Rear Yerd
Requircd Provided -RequireJ � . Provided - Required Provided �
1.6 Water Supply:(M.G.L c.40,§54) 'IJ Flood Zooe tatorm�tlon: 1.8 Sew�Ye DVpoul Sy�tem:
��.Zone: �� � OWideFloodZone7
� Publie O Private O� � � - Checkif esO Munieipal O On siledisposal system ❑
SECTION 2: PROPERTY OWNERSHIP�
2:1/O'�wner'ot Record• �/� I ' r�� 1�.p
_} /): I P P c� �� - .I � i l O�I�� Y -.i`f"V l
Nume(Prinl) —r— � AAdmsf for Service:
' ' e:�-v�-��� R�� � :.YS - S�Y7/
s��m rai�Pn�
SECI'ION 3: DESCRIPTtON OF PROPOSED WORIC°(ctieck;rll t6�t apply)
�New�Constructioa0 �.�ExistingBuilding�0 Owner-Occupied O Repairs(s) D �� Alteration(s) �❑ �Addition O
Demolition O, Accessory Btdg.O Number of Units_ Qther •O?5peciryr �
Brief Description of Proposed Work': ;� L
S�/S1o..11 �l_o,l:�.: . . ce.l lu i e so'.:. � (.( S - :: � -3
a Qoe.,c ct1u��� ' ` ';
SECTION 4: ESTIMi�TED CQNSTRUCTION COSTS
EstimateJ Cosf's:
Item -0fllctal UaaOnly
LnborandMateiials �. .
I. DuilJing S - � � I.�.��uilding Pertnil�^Fee T - '� �Indicate'how.fee is Jetertnined:
. .OStandard CiryR`ownApplication:Ftt�� �
2.Electrical S �
O Total Projec�Cost;(Item 6).�-multiplier x
l. Plumbing S 2. Other Fees: 5
�. Mechanical (HVACI S GisG -
5. Mechanical IFirc 5
Su ression Tu�al All Fees:f
Check No. Check Amounr. Cuh Amount:
6. Tota1 Projcet Coet: S L� �aa, p a O Paid in Full O Outstanding Balance Due:
Ii ��`� � C�,����
SECTIONS: CONSTRUCTION SERVICES
[155.1 Licensed Construction Supervbor(CSL) 'g-)9 7 L Z
E�L,re I.icensrNumber Expiration Date
Name ufC'S1.-IluWer Sidi - List CSL Type(seebelow)
.Address. .. *Wxwv T Description
,000 ion
_ U 'In It u to 35,000 Cu.Fc
R Restricted 1B2 Family Owellin
Signawrc45e, M Only .
�l"/� RC Residential
sidemial Roulin Covering
rdephone WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Applianc.c Installation
'1 D I-Residential Demolition
5.2 Re istered Home Improvement Contractor(HIC) yl xo
Hie Com y[�f _C��V c tslmt ame egistmtion Nute- 152.
°'�'dddress 1A81970 ` q- y t/-F1/V�j Erpiralion DSignature Telephone i2SC(6j))SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L
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..........o No...........O
SECTION 7a:OWNER�AUTHORIZATION,TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. e%✓1 /�!5 w f/1 as(honer of the subject property hereby
authorize r /a f s to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
�^
SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the,statements and information on the'foregoing application are we andaccuratc.,to the best of my knowledge and
behalf.
Prim Name
re
Signature of owner"Authorized,A%gent --
Dat
70wner
the ainsand; naitics of- 'u
NOTES:
er who obtairis a building permit to do his/hercwnwork,or an owner who hires an unregistered contractor
istered in he Home Improvement Contractor(141C)Progtam),will-W have access to the arbitration
or.guaranty fund under M.G:L.c. La2A.Other important-information on the HIC Program and
ction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
bstantial work is planned,provide the information below:
rca(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross Iivingprea(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system - Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
¢'! Print Form
The Commonwealth of Massachusetts �__._
Department of Industrial Accidents
_ a Office of Investigations
' l Congress Street, Suite 100
Boston, MA 02114-2017
J
14zi fi= www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): Atlantic Weatherization, LLC
Address:61 R Jefferson Ave
City/State/Zip:Salem, MA 01970 Phone #:978-744-8143
Are you an employer? Check the appropriate box: Type of project(required):
1,21 1 am a employer with 26 4. ❑ I am a general contractor-and L -.. . -- _..
employees(full and/or part-time).* have hired the sub-contractors 6: _❑New construction
1 ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. '❑Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P >y� 9. EJ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
3.❑ 1 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.] ' c. 152. §1(4), and we have no
employees. [No workers' 13.0 Other
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.
: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: Chartis
Policy#or Self-ins. Lic. #: WC1616071 Expiration Date:3/20/2012
Job Site Address: I /Yl oo-,i City/State/Zip: ���>;i 1011�7
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 DTA for insurance coverage verification.
Ido hereby certi under the pains and enalties of erj=that the in ormation provided above is true and correct.
Signature• Dated C/
Phone#:978-744-8143
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#:
ACORQ , CERTIFICATE OF LIABILITY INSURANCE DATE(MMMDIYVYY)
03/16/2011
PRODUCER 508.651.7700 FAX 508.655.8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC - Main ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
233 West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Natick, MA 01760
INSURERS AFFORDING COVERAGE NAIC#
INSURED Atlantic Weatherization LLC INSURERA: Arbella Protection Ina. Co. 41360
61 Rear Jefferson Avenue INSURER B: Arbella Indemnity Ina Co. 10017
Salem, MA 01970 INSURERC: Chartis
INSURERC: Nautilus Insurance Company
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.jNTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND COTIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTA Op TYPE OF INSURANCE POLICY NUMBER pATEC Dru O DATE MWDDm�N LIMIT
GENERALUABDfTY 8500042816 .03/20/2011 03/20/2012 EACH OCCURRENCE 1 000 000
X COMMERCIAL LIABILITY PREMISES Ee omunenw 50,000C1A1MS MADE ❑X OCCUR MED EXP(My we person) 5,000
A PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000.
POLICYX JECTT LOC
AUTOMOBILE LIABILITY 93827400003 03/20/2011 03/20/2012 COMBINED SINGLE LIMIT
ANY AUTO (Ee acckent) E 1,000,000
ALL OW NED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per Parson) $
A
B
X HIREDAUTOS BODILY INJURY $
X NON-OWNED AUTOS (Per ecueem)
PROPERTY DAMAGE $
(PeraccMant)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
AUTO ONLY: PGG $
EXCESSIUMBREUALIABILRY 4600047820 03/20/2011 03/20/2012 EACH OCCURRENCE $ 1,000,000
X OCCUR F—I CLAIMS MADE AGGREGATE $ 1,000,00
A E
DEDUCTIBLE
RETENTION $ $
WORKERS COMPENSATIONAND WC2616071 03/20/2011 03/20/2012 X
WORKERS COMP NSATILUMITY YIN TORY LIMITS ER
APROPRIETOR/PARTNER/EXECUTIVE
OPRR EMBE
IETRIPARTNEXECUTIVE❑ E.L.EACH ACCIDENT $ 500000
C OFFICEFFICEREXCLUDEDEDT
(Iftnft ny In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
SyyeCIALPaoe ISIO E.L DISEASE-POLICY LIMIT $ 500,00
SPECUk PROVISIONS Mflow
OTHER C 1.0152189210 10/01/2010 10/01/2011 General
OLLUTION LAIBILITY Aggregate - $1,000,000
D Each Pollution Condition -
$1,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF ME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,RS AGENTS OR
CITY OF SALEM REPRESENTATIVE&
93 WASHINGTON STREET AUTHORIZED REPRESENTATIVE /�11
SALEM, MA 01970 Rosemar Fulham/PMA
ACORD 25(2009101) ®1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Jun 07 2011 10: 34 HP LASERJET FAX page 3
CONTRACT
_ Printed: 6 011
Contractor Information Customer/Site Details _
Eric Palm CATHLEEN CUTTER Phone (eve): (978)745-8471
Atlantic Weathenzalion 1 MOONEY AVE Phone (day)'.
61 R Jefferson Ave
Salem, Ma 01970IMA A 01970 1519 () Site ID: S10000824374
-------A�pointment',Details -- - ---
Completion Deadline: -
Location Desai tion Quantity Unit $ Total$ Notes/Revis ns
Work Order: ATLANTIC-20,11060
ASL Attic Slope Dense Pack 6" 128 2.02 258.56
AFL Attic Floor 6.25' Fiberglass Batting 49 1.40 68.60
AFL Densepack Cellulose-7" 212 1.94 411.28
AFL Open Attic 8"Cellulose 251 1.23 308.73
RMJOIST Rim Joist 6.25' Fiberglass Batting 104 1.80 187.20
EXTERIOR Wall Ins. Multilayer Siding 4" Cellulose 1094 2.24 2450.56
OVERALL 8" Roof Vent 2 83.00 166.00
OVERALL Air Sealing-Hours 4 70.00 280.00
HALLWAY Therma-Dome w carpentry sponsored 1 135.00 135.00
Total for Work Order ATLANTIC-2011060: $4,265.93
Grand Total: $4,265.93
Road Blocks
Combustion Safety Faded Revisit Passed
3-12-11 GOLDSMITH:HOLE IN CHIMNEY IN ATTIC. EVERYTHING ELSE PASSED AT SCREENING. 5/11/11 rtl 130:
chimney sealed, cust sent picture to r6130. CST passed.
OW A
Adan is Weat4err*014 LLC
61 Tt Jed MA0 Avenue
Saleth MA 01970
Conservation Services Group -40 Washington Street Westborough, MA 01581 - 800-480-7472
^Restricted to: 00
., Alussachusetts- Department of Public Safet% 00- Unrestricted
Board of Building Regulations and Standards IG-1 2 Family Homes
Construction Supervisor License .
License: CS 87977
Restricted to: 00 r Failure to possess a current edition of the
ERIC W 'PALM as,$s. Massachusetts State Building Code
is cause for revocation of this license.
3 HILTON ST
SALEM, MA 01970 Refer to: WWW.Mass.Gov/DPS `
Expiration: 4/2312012
('omini ionrr Tr#: 22214
9,4 &—�—ld License or registration valid for individul use only
before the expiration date. If found return to:
OBice of Consumer Affairs&Business Regulation Office of Consumer Affairs and Business Regulation
HOME IMPROVEMENT CONTRACTOR 10 Park Plaza-Suite 5170
Registration:y..142089 Boston,MA 02116
Expiration. 3I12f2012 Trill 292174
Type: Ltd Liability Corpor
ATLANTIC WEATHERIZATION L.L.C.
ERIC PALM I
li 61R JEFFERSON AVE' g`�"'o Not valid without signature
e�'$ALEM•MA 019710 "` ' Undersecretary
Atlantic Weatherization, LLC
6 1 R Jefferson Avenue
Salem MA 01970
To Whom It May Concern,
1, Eric Palm, owner of Atlantic Weatherization, LLC authorize my employee,'
to pull permits for my Company.
Sincerely,
Eric Palm
Atlantic Weatherization, LLC
Subscribed and sworn to before me
This—f-- day of "k4 2010.
1
Notary Pbblic
_M_y Commission Expires: r 4a(j0