4 N PINE ST - BUILDING INSPECTION �6U
The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code, 780 CMR, o editignoaf ?il`; 1
1 Building Permit Application To Construct, Repair,Renovate OrDetndlji"sh'.a 1Zevised January
p wo-Family Dwelling 1 , . 1, 2008
This ection For Official Use Only
Building Penn it Num ate Applied:
Signature:
Building Commissi ne spec dings Dare
ON 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map�&ParcTI lVupobersilii+l,i
e S
1.1 a Is this an accepted street?yes_ no Map Number .. Parcel Number .
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use - Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Requied Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 ' N Owo;rRecosrd: zo l� J
Name(Print) �� Address for Service:
&69 — Y( 7
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction CI Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ElAddition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': U low C l� (n r,:�e/f S C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4. Mechanical (HVAC) $ List
5.Mechanical (Fire $ Total All Fees:$
Suppression) Check No. Check Amount: Cash Amount
6.Total Project Cost: 70 - ElPaid in Full ❑ Outstanding Balance Due:
�7�P— 7f 31 c4W
r
=H�older �-
IECTION 5: CONSTRUCTION SERVICES -
isor(CSL) 9-r) T / ! b3
lfl
iI License Number ! Expiration Date
11 treet List CSL Type(see below)
Address SalelilA 01970 Type Descri lion
U Unrestricted(up to 35,000 Cu.Ft.)
Signature R Restricted 1&2 F araily Dwellin
M Masonry Only
RC Residential Roofing Covering -
Telephone r/ WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)HIC Companl Registration Number
f1"t PffPrgD�AYeraue �
Address Salem MA 01970 Q ZSj 7y y$(Y3 Expi ation ate
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. g 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 ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, L"r 20 I( , as Owner of the subject property hereby
authorize F. � a / e:ob to act on my behalf, in all matters
relative to work authorized by this building permit application.
Si nahme of Owner Date
/ SECTION 7b: OWNER' 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 Odmer or Authorized Agent Date
(Signed under the pairs and penalties of perjury)
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 Home Improvement Contractor(HIC)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 110.R6 and 1I0.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 of half/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"
RightFax C2-2 3/26/2012 7 : 26 : 52 AM PAGE 6/027 Fax Server
ISSUE DATE
=6al)12
...... .....
THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE D DES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
LOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETNAMEN THE ISSUING INSURER(S),AUTHORMED
PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:if the certificate holder is an ABOITIO14AL INSURED,the poft3i,(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 endorse ent(s).
PRODUCER CONTACT
EASTERN INS GROUP LLC NAIAE:
PHONE FAX
233"7%T CEIATRALST (Alq N..Ed rAr~N.
HATIC Y,MA 01760 E-MAIL
ADDRESS:
PRODUCER
CUSTOUER ION:
INSURED INSURER(S)AFFORDING COVERAGE NAIC#
ATLANTIC WFATHERIZATION LLC INSURER A AAMUCAN ZUPJCH INSURANCE C ONEPANY
61 REAR JEFFERSON AVE. INSURER B
SALEIVI,IAA 01970 INSURER C
INSURER D
INSURER
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER
THIS IS TO ERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED HAZAM) ABOVE FOR THE PERIOD P' U Y"CY OL 0
INDICATED ITOT\VITHSTAHDINU ANY REQUIRM43U7T,TERM OR CONDITION OF ANY CONTRACT OF OTHER DOCUMEIIT'WITH RESPECT P�TOWHIC'��THIS
T TERMS,
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCREBID HEREIN IS SUBIMCT TO ALL THE TERMS,
=LUSIONS AIM CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SIJBR POLICY NUMBER POLICY EFF POLICY EXP LriUTS
LTR GENERAL LIABILITY INSR—--'U1VD (L=SD D
PfYYY) (M1&DrrfYY)
F 11
0 acvl- $
ssea
niNRy_
0 $
GnVL
OPOLICY
AUTOMOBILE LIABILITY
❑ ParvPmo $
0 e.rDwIiIEDP.UIOS DDLILYDIATICY $
❑ xmmvLEDhVTOS PLOPFILIYDP.LTAGF II
$
0 ITON-ON=AU109
0
DF
U DEDUCTIBLE:
0 n1MT1=$ $
WORFMRS' COJ.TPENSATION wC
A AM EhIPLOYERS LIABILITY
YIN T 1LIIJ$
N $500,000
ExFr'oinmNIA 7PJUB-5B270121 03t2W12 03720113
RXOL� E
(s TORY W Nu)
$500000
Id" DEXLEPTIOIZ CUT HL.M�M-YCLICY
= " 17-0-0"000�
OPELktuk� T I
PTJOX amTIPLCATZIHUTDTO THE C OZIEP C OV Gr
F., �iG?kTl .. ...... ...
.............. ........
CITY OF SALENI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
93 WASHINGTON ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
S'ALEJ%,I,NIA 31970 IN ACCORDANCE WITH THE POLICY PROVISIONS.
AVTBUM=i^'� rA1I�
a-UMD.q) :x:
CERTIFICATE OF LIABILITY INSURANCE 3/19/2012
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; 11 the4����dficate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and coritflu`(iIla 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 Construction
NAME: _
Eastern Insurance Group LLC PHONE . (508) 651-7700 FAX No: _
233 West Central Street ADDRESS:
PRODUCER 00024397
Natick MA 01760 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A.Arbella Protection Ins. Co. 41360
INSURERB:Arhella Indemnity IRS CO. 10017
Atlantic Weatherization INSURER.C:Zurich—American Group
61 Rear Jefferson Avenue INSURERDBeacon Hill Associates Inc
INSURER E:
Salem MA 01970 INSURER F:
COVERAGES CERTI6rGATENUMBERNASTER'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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE D S POUCYNUMBER UEUR MM/DCDNYYYl YEFF MMLIDYEXP. LIMITS
LTR
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES REe occurrence $ 50,000
A CLAIMS-MADE ❑X OCCUR B500042816 /20/2012 /20/2013 MED EXP(Any oneperson) $ 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
G 1 AGGREGATE LIMIT APPLIES PER: _ PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY X PRO-JECT LOC E
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E 1,000,000
(Ea accident)
ANY AUTO
$ ALL OWNED AUTOS
938274*00003 /20/2012 3/20/2013 BODILY INJURY(Per person) $
BODILY INJURY(Per accident) E
X SCHEDULED AUTOS "' PROPERTY DAMAGE
X 0 $
HIRED AUTOS (Peracciden
X NON-OWNED AUTOS Uninsured motorist BI split limit $
Undennsured motorist BI split $
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000
DEDUCTIBLE - $
A RETENTION $ 4600047820 /20/2012 /20/2013 $
L. WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY - LIMITS ER
MY PROPRIETORIPARTNER ECUTIVE Y[ E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
IMandatery In NH) CERTIFICATES TO BE ISSUED E.L.DISEASE-EA EMPLOYE $
If as,describe under DIRECTLY BY CARRIER E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS below
D POLLUTION LIABILITY CPL200378600 0/1/2011 0/1/2012 GENERAL AGGREGATE $1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS. -
CITY OF SALEM
93 WASHINGTON STREET AUTHORIZED REPRESENTATIVE
SALEM, MA 01970
Rosemary Fulham/PMA
ACORD.25(2009/09) - - 01988-2009 ACORD CORPORATION. All rights reserved.
INS025(2W909) The ACORD name and logo are registered marks of ACORD
The Commonwealth ofMassaehusells
Department of Industrial Accidents
Of we ofinvestigations
600 Washington Street
Boston,MA 02111
www.massgop/dia
Workers' Compensation Insurance Affidavit:Builders/ContractorsMeetricians/Plnwbers
Applicant Information Please Print Leltibly
Name(Business/Ofgan dionlbdividasl): A&n&Wce&MzWonJIC
k Jeff Ave�fe
Salon hftM970
Address: 01
City/State/Zip: Phone#: `12$ 7
A 6an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 1. 5 4. ❑ I am a general contractor and 1 6. 0 New construction
employees(&U and/or part-time)s have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t- �. ]remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity workers'comp.insurance. 9r El Bmlding addition
[No workers'comp.insurance 5. We are a corporation audits 10.E]Electrical repairs or additions
required.] officers have exercised their
3 I am a homeowner doing all work right of exemption per MQ 11.�Plumbing repairs or additions
myself[No workers'comp- c.152,$1(4),and we have no 12.[1 Roof repairs
insurance required.]t employees. [No workers'' ME1 Other
o0dop_insurance required.]
*Any applieaattIatcbefix boat#1 must also hill outthe seetim belowshowmg theirwo irrW compensation policy inSotmativa
t Homeowners who submit this affidavit indicating they am doing allwmk and than him outside eontiaztosa must mdw*a vewaeidavit indicating sect.
tCuunac[oa that click this box most attached so additional abeetshowmg the name of the sub-contiaaors and thdrwodcas'map.policy infomstim.
jam an employer that is providing pvvrhers'compenwdom insurance for my employees. Below is the polfey said job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: !j/�� 2� 1 2 ( Expiration Date: �✓
Job Site Address: `>' l'ii+t 5f City/State/Zip: S�
Attach ar opy.of the workers'compensation policy declaration page(showing the policy number and ezpiraiion date)•
Failure tasecure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine tip to%1,500.0(1 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 cerlify under diepaba andppaxaMs oofperjmy that the frrformadon provided above Is
true and correct
Date: ldz--
Phone#. k- 7 y — S} /y
Of(kW use only. Do not write in this area,to be completed by dry or town off"rddi
Cityor Town• PermidUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Chyll'own Clerk 4.E.IectficalInspector 5.Plumbing Inspector
6.Other
Phone
Contact Person: #
Customer Name: Larry Zoll _
Contract
Address: 4 N Pine St Apt-2 --
Salem Roadblocks:
Ma,01970 None
Subcontractor Name: Atlantic Insulation
Site ID: S00002071427
NSL Work Order# OQOCOOOOOOOMBHiKAO
Billing Utility National Grid
IN'evasure* ,�t � y� ,quantityStoped t Quantrty1nstalled ,lJmt . „ - s Uq�tP,rice �Subtotal -�,_,
Blower door test 1 ' Test $54.00 a $54.00
Insulate Clapboard Sided Wall With 4"Dense Pack Cellulose 1089 x"i"'3s aj � � Square Ft. $1.76 $1,916.64
D r
* s e t ?k n "
s zd4 9M n4
..'mexwr r
Change Order Detail:
Original amount of scope
B P 51,970.64 -ENTER BAGS OF CEL1L LM
Change from scope revisions $0.00
Change from scope additions $0.00 "PLEASE ENTER A NEGATIVE,NUMBEIR OF BAGS
Final amount of scope $1,970.64
-USE ABOo ESECIfON'ONLVdF4AMICIPATiN61NAENEW
Total change order difference $0.00 90570N'INSULATION OflAWDOWAFPROGRAtvt:
j ,
"Change order math above will calculate if"Quantity Installed"filled Owner
out in Excel,otherwise ignore the above section
Atlantic
Please indicate any materials installed that were not on the original workscope below:
Product type ` Measure, quantrtyiostalleq Unit .- UnRPriee Subtotaf
FAX COVER SHEET
Atlantic Weatherizatioh, LLC
61RJefferson Avenue
Salem, MA 01970
Tel: 978-744-8143
Fax: 978-745-2200
Date:
# Of Pages Inc. Cover:
Sent To:
Sent By:
i
Massachusetts-Department of Public Safety -
Board of Building Regulations and Standards
Construttion Supen isgr r Unrestricted-Buildings of any use group which
License:CS-087971 contain less than 35,000 cubic feet(991m3)of
enclosed space.
FRIC W PALl1f� +A v t
3 HIL1'ON Sr-
SALEMMA-0t97,0 -
� o
re
Expiration. . Failure to possess a-current edition of the Massachusetts'.
Commissioner. . - _ 0412W2014 State Building Code is cause for revocation of this license.
_.. for OPS licensing iMarm don visit: vrv+w:Mass.Gov(DPS'
Office Arleme�ocr' ff 8dial-reguakaeolA „^+<._.,�..--•-- ......,.,...-»....-.,,�.....,.,.,.----�..w,
HOME IMPROVEMENTCONTRACTOR License or registration valid for individul use only ,f
Registration ,y742089. Type: i f before the expiration date. If found return to:..
Expiration. 3/ (2914- Ltd Liability Cotpor Ift {` Offce'of Consumer Affairs and Business Regulation ;
V'C
1.WEATNER1L'C. - % tO Park Plaza 5170
u 4 (( Boston,MA 02I16
r
ERIC PALM -
61R JEfFERSON
SALEM,MA 01970 ;yf;.,. <a Undersecretary
Not valid.without signs re - e
ATLANTIC WEATHERIZATION, LLC
61R JEFFERSON AVENUE
SALEM, MA 01970 Equality
FOREVER
Eric Palm
Atlantic Weatherization, LLC
61 Jefferson Avenue
Salem, MA 01970
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