18 PARLEE ST - BUILDING INSPECTION (2) z $ asi
RECEIVED
The Commonwealth of Massachusetts
(y Board of Building Regulations and Standards FOR
�y* Massachusetts State Building Code,780 CMR, 7`s editil$Ib JAN 12 , USITY
TBuilding Permit Application To Construct,Repair,Renovate Or Demolish a Revised January
..(1 One-or Two-Family Dwelling 1,2008
This Section For Official Use Only
t Building Permit Number: n Date Applied:
Signature:
1 Building Commissioner/Inspec or of Buildings Date
p qp tyty SECTION 1:SITE INFORMATION
1*,
8r l'arle A Salem MA 1.2 Assessors Map&Parcel Numbers
L1a Is this an accepted street?yes XX no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,g 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
.yy Zone: _ Outside Flood Zone?
Public Lf Private❑ Check if es❑ Municipal EX On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.6 Ow er'nfRecord: 18 Parlee St Salem MA
aroiyn Liering
Name(Print) Address for Service:
617.331.7637
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ 1 Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ Altemtion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other [ Specify: Insu atlOn
Brief Description of Proposed Workz: WeaulOrstrip 2 Cours ana InS a oar sweeps, IrIbLU11 thermal
barrier w/carpentry to attics air, air Seal 6 hrs es Whole house fan box wit
therm I barrier install 22 fin ft of damming, cut sheathing access, insulate attic fl w/blown i
ce u use o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building S 2,176.91 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cose(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ �� x
4.Mechanical (HVAC) $ List: CJ
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 2,176.91 ❑Paid in Full ❑Outstanding Balance Due:
M n.t t_tio 1 �,13 l l,b
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CSSI-100454 6/13/17
Glenn Alexander License Number Expiration Date
Name �O dH�t leading MA 01867 List CSL Type(see below)
,1 Type Description
A�dr U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Si ature M Mason Only
�81.397.9909 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 180885
Alexander Insulation LLC/ Glenn Alexander
HIC Co pany N or HICC Registrant Name Registration Number
256 St ieaNg MA 1/23/15
Ad ss
81/397.9909 Expiration Date
tgnature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 ..........12X No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 Carolyn Ziering as Owner of the subject property hereby
authorize Glenn Alexander to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER`OR AUTHORIZED AGENT DECLARATION
I Glenn Alexander as Owner 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.
Glenn Alexander
Print Name 11/3/15
Signatirre of Owner o ut r n Date
s(SignedAa under the ai 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(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 l IO.R6 and 110.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"
\ The Commonwealth of Massachusetts
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
wwwmass gov/dia
U,krkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FD.ED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name(]3winess/Orgmintionnndividml): Alexander Insulation LLC/Glenn Alexander
Address: 25 Bond Street
City/State/Zip:Reading MA 01867 Phone M 781.397.9909
Are you an employer?Check the appropriate box: Type of project(required):
1.01 am a employer with 3 , employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8, ❑Remodeling
any capacity.[No workers'camp.insurance required.]
3.01 am a homeowner doing all work myself.[No workers'wrap.insurance required.]t 9. El Demolition
4.❑I an,a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5.M I am a general contractor and I have hired the subcontractors listed on the attached sheet 13.E]Roof repairs
These subcontractors have employees and have workers comp.insurance t
14.®other Insulation
6.❑We are a corporation and its officer,have exercised Weir right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp.insurance required]
'Any applicant that checks box#1 most 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 Wen hive outside contractors most submit a new affidavit indicating such.
tConmactors that check this box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most 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:AmTrust North America INC
Policy#or Self-ins.Lic.#:TWC3356650 Expiration Date:4/7116
Job Site Address: City/State/Zip:
18 Parlee St Salem MA 01970
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 a/n�dppen/allies ofpedury that the information provided above is true and correct
Signature /J� c/ LG &&4 Date: 1/12/16
phone#:
781.397.9909
OKIcial 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):
t.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person' Phone M
tii NWSETTS
CITY OF S.-1LE, , SACH 'L
• BU PIING DEPARTMENT
130 WASHL%IGTON STREET, 3a FLOOR
°f TEL. (978) 745-9595
FAx(978) 740-9846
KLNfBERLEY DRISCOLL
MAYOR T HontAs ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUn DING CONMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
Glug 4ft!A0 Kckr
(name of hauler) /,-, /
The debris will be disposed of in : ✓
9
-�10s �
(narqjof facility)
(address of facili
signature o permit a plicant
ate
dcbrivtrd,x:
OWN&
PARMIPATING
ITass save^ COUTRACIGR
sa%-Wb -
PERMIT AUTHORIZATION FORM
I, Carolyn Ziering owner of the property located at:
(Owner's Name,printed)
18 Parlee St Salem
(Property Street Address) (city)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor
listed below to act on my behalf and obtain a building permit to perform insulation and/or
weatherization work on my property.
Owner's Signature
C)Liy/is
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
■ fJ ■
E,
for Once Use Only
Rev. 12132011
t
i
CONTRACT FOR
Conner atlon PRODUCTS / SERVICE WORK
Services Group This service is brought to you through support from your local utility
tFiis Agreement Is made>a d among
' and.
Conservation Services roup, (CSG)
Carolyn uertpg Attnr�RCS
IS Par lee St 50 Washiftgton Street Suite 3000
Salem,MA 01970.1947
westborough,NiAolssl •;
Site[Dc S00002080884 - Reg.'No. 173484
Project AID:P00W0083968
Cuatomw ID:C00000090909 ` Federal ID No.222457170
Co it ID:20150.914_WORK-' (Mail completed contract to address above)
I I. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be performed the following work on these"Premises"in a professional maarer and in accordance with the terms of
this Contract,including the attached recommendationstwork order describing the work in detail(the"Work')which are incorporated herein by reference:
Description Quantity Location
AtligFlaor Open Blow Cellulose 4 _ _ ...788 Living Space $1,055.92
Damming ....... 22 .... N/A _. S48.18....
..... . _. ...... ..... _. .._.. _.. ._.._ _ .._
>1 Sheathing Access 1 NIA
Sub Total: $1,140.24
Utility Incentive Share $855.18
Customer Contribution $285.06
i
l
it For office use only Printed:9114/2015 Page 2 of 2
.., H. PAYMENT Q
Customer agrees to pay Contractor for the Work the Customer Share of the Contact Price as follows:Payment ftl:$ / r UU as a Deposit
payable to CSG upon signing the Contract(not to ex O of the total retail costs).Mail check&contract to CSG,Attn:RCS,60 Washinglon St,Ste.
3000,Westborough,MA 01581.hint Payment$ 1 Z O r $ as the final payment for the Work shall be payable to the Independent Installation
_ Contractor("IIC")upon sattef c I on
of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the
Contract price in the amount of$ .Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive
Share.
III. DISPUTE RESOLUTION
The IIC and Customer herebymumally agree in advance that in the event that the IIC has a dispute concerning this Contact the RC may submitsuch dispute to apuvate arbitration
service which has been approved by the Office of ConsumerAffaus andlkskress Regulation and Customer shall be required to submitto suchadettvdon aspravided in RG.L c 142A
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT
IF THERE ARE ANY BLANK SPACES.
l/�r y ( 90 i5 I t�. applicable
T/Orr .
Cpgt�y��r S. ate inydiratee your sellected 11C here,of applicable IoR) Initial here if you want
y11./�3' 7a- 4 r -IL Ile 3c)A the Program to assign a
Participating Connector
Signature Date Name of CSG Rep�(r[/e/fsentltiv
e kYrinteG)
ND TERMS A CONDMONSA�VON THE REVERSE. a/14
i
CONTRACT FOR
Conser atlon PRODUCTS / SERVICE WORK
Services Group This service is brought to you through support from your local utility
-7fi/s Agreeine is mare 6y afsdamony
anal
Conservation Services Group(CSG)
Carolyn Ziernlg Attu;RCS
iBParleeSt 5Q Washington Street Suite300D
Salem,MA 01970-1947 Westborough,Mr101681
Site m:500602080884 '$eg No. 173484
Project;lD:P00000083968 Federal ID No.222457170'
Customer)D:Cbo000090909 (Mail completed contract to address above) �i
Contract ID:20150914 ASIiALi .. ---
ri _. ..
I. DESCRIPTION OF WORK TO BE PERFORMED
.'I Contractor will perform or cause to be performed the following work on these"Premises'in a professional manner and in accordance with the terms of
this Contract,including the attached recammendationshvork order describing the work in detail(the"Work")which are incorporated herein by reference:
Description Quantity Location
Perform Air Sealing.at Estimated 62.5 CFM50 Per Hour 6 Livia Space. $505.92
.._. 9 Pa .. ......
_- .. . .._ 26023
Attic Start Cover Thermal Barrier with carpentry_ ......, , 1__ Living Space
whole - -- $168.98
: Whole House Faq Box ThermaLBarner Polyiso 2'.(Athc) 1 Lnnng Space ._-. .. ,.. __-
Cj Door Sweep 2 N/A
j Exterior Door Weather Stripping___ ... 2 NIA..-.........
_._.
"- Sub Total: $1,036.67 -
[<� - - Utility Incentive Share $1,036.67
>d Customer Contribution $0.00
j
i
I
Of`0
Printed:911412015 Page 1 of 2
For office use only
PAYMENT
Customer agrees to pay Contractor for the Work,Ore Customer Share of the Contract Price as follows:Payment tit:$ C7 r G y as a Deposit
payable to CSG upon signing the Contract(not to exceed U3 of the total retail costs).Mail check&contract to CSG,Attn:RCS,50 WaehingWn St.,Ste.
3000,Westborough,MA 01581.Final Payment:$ / O as the final payment for the Work shall be payable to the Independent Installation
Contractor("IIC")upon satisfacto eoJ� letion of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the
Contract price in the amount of$ �.Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility incentive
Share.
III. DISPUTE RESOLUTION
'Rue IIC and CustomerhembymutualLy t>0ee in advance that in the eves that the IIC has a dispute concerning this Conimet,due RC may submit such dispute to aprivate azbihation
_ ThenCandCstoueirlimben oved by the Oflire of ConsurnerArg ins and Business Regulation and Customer strait be requhedtosrbmttservice which has to such arbitration as provided inM.G.4e142A
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
I`,lltks l&Kunr�
dr �
C w,t�*Si ore—''�/ rhrt Indicate your selecchted nu here,a appbcable ( R) initial here R'You want
the Program to assign a
Participating Contractor
Signature Date ame of CS/G/ Repres tati a(Pr led)
TERMB AND CONDTTlON9 APPEAR oNC�E. 3/14