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30 PERKINS ST - BUILDING INSPECTION �2� � czzy ;t , The Commonwealth of Massachusetts C f1 ,11ALCXpgiCES Board of Building Regulations and Standards SALEM \ f/ Massachusetts State Building Code, 780 CMR ZOf6 :N�R -*visAV Al�v I (4) Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only 1 Building Permit Number: Date plied: Building Official(Print Name) Signature Date n� SECTION 1: SITE INFORMATION ry ' 1.1 Property Address: 3 Perkins St 1.2 Assessors Map& Parcel Numbers I.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 R) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required 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: Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Julia Medina Salem, MA 01970 Name(Print) City,State,ZIP 30 Perkins St 978-741-7505 juliamedina@msn.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ® Specify: Insulation/Weatherization Brief Description of Proposed Work': Air sealing weather stripping and door sweeps SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1. Building $ 2,474.88 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cos[ (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ l 4. Mechanical (HVAC) $ List: z��1�) 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 2,474.88 ❑Paid in Full ❑Outstanding Balance Due: �.. Nl P, SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) _ CS-052576 10/03/2017 James Fortin License Number Expiration Date Name of CSL Holder U 50 Rundlett Way List CSL"type(see below) No.and Street Type Description Middleton, MA 01949 U Unrestricted(Buildings up to 35,000 cu. ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-998-4684 phil@air-tightweatherization.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 165640 3/15/2016 Air-Tight Weatherization,LLC James Fortin HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 50 Rundlett Way phi]@air-tightweatherization.com No.and Street Email address Middleton, MA 01949 978-998-4684 City/Town, State,ZIP 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 .......... EX No ........... ❑ 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 James Fortin to act on my behalf, in all matters relative to work authorized by this building permit application. v�Q wed% Mar 3 2016 Julia Medina �uamea„fl�Ma,s 201G1 Print Owner's Name(Electronic Signature) Date 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. James Fortin �" `� -- 3/3/2016 Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 can be found at www.ntass._ov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned, provide the information below: Total floor 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" Work Order North Shore Community Action Programs,Inc. Job Number: Perkins 119 Rear Foster Street,Building 13 Work Order Date: 2/4/2016 Peabody,MA 01960 Ownership: Renter Phone: 978-531-0767 Air-Tight Weatherization Auditor:Marc Lorah 9 Story Avenue Email: mlorah@nscap.org Beverly MA 01915 Cell: 978-587-5104 Email: inbox@air-tightweatherization.com Phone: 978-531-0767 x777 Phone: 978-998-4684 Julia Medina NGRID Gas $1,594.88 30 Perkins St Total $1,594.88 Salem Ma 01970-5514 978-697-0219 Safety Issue(s):Lead Paint Possible Authorized Actual „ Measure Description Qty price Total Qty Total Comments Basement Insulation Sill two-part foam w/fiberglass batt 128 $2.46 $314.88 128 $314.88 Doors Automatic Sweep 3 $26.00 $78.00 3 $78.00 Front& Back door to apt and bulkhead Site Built Basement Door 1 $489.00 $489.00 1 $489.00 Weatherstrip s/Q-Ion or equal 3 $51.00 $153.00 3 $153.00 Health&Safety Clothes dryer vent including 1 $100.00 $100.00 1 $100.00 Exhaust Duct Misc Measures Attic/basement sealing with two- 2 $84.00 $168.00 2 $168.00 seal joist pans return and supply part foam Seal ducts with mastic or butyl 4 $73.00 $292.00 4 $292.00 sell all ducts in Basement backed tape Total $1,594.88 $1,594.88 Date: 2/4/2016 1 1 1 1 1 1 Page I Work Order North Shore Community Action Programs,Inc. Job Number:20287 119 Rear Foster Street,Building 13 Work Order Date: 2/4/2016 Peabody,MA 01960 Ownership: Renter Phone:978-531-0767 Air-Tight Weatherization Auditor: Marc Lorah 9 Story Avenue Email: mlorah@nscap.org Beverly MA 01915 Cell: 978-587-5104 Email: inbox@air-tightweatherization.com Phone: 978-531-0767 x777 Phone:978-998-4684 Ana Pimentel NGRID Gas $880.00 30 Perkins St Apt 2 Total $880.00 Salem Ma 01970-5514 978-825-0243 Landlord Name:Julia D.Medina Landlord Phone: 978-741-7505 Safety Issue(s): Lead Paint Possible Authorized Actual Measure Description Qty Price Total Qty Total Comments Doors Automatic Sweep 2 $26.00 $52.00 2 $52.00 Front and back door to apt Weatherstrip s/Q-lon or equal 2 $51.00 $102.00 2 $102.00 III Misc Measures Seal ducts with mastic or butyl 2 $73.00 $146.00 2 $146.00 backed tape r Other f , repair ,. 12 $40.00 $480.00 12 $480.00 adjust windows and re caulk windows(jamb set screws) Permit Building Permit 1 $100.00 $100.00 1 $100.00 Total $880.00 $880.00 Date: 2/4/2016 Page I Work Order: Job Numbers: Perkins and 20287 Air-Tight Weatherization . fflffi I t 50 Rundlett Way Middleton, MA 01949 978.998.4684 CONTRACT AGREEMENT /OWNER AUTHORIZATION FOR CONTRACTOR TO PERFORM WORK I as owner/authorized agent of the subject property, hereby authorize James Fortin to act on my behalf, in all matters relative to work authorized by the building permit. Owner/Authorized Agent(Print Julia Medina: Date: Mar 3, 2016 vGa �eoC..,a. Owner/Authorized Agent Signature:yn� eam rd,A,s.zo, Contractor Signature: Contractor:James Fortin Construction Supervisor License: CS-052576 Exp: 10/03/2017 Date: 2/4/2016 Page 2 . .. ",\ - n��<� (Torir-iirairir�c<il/� r./��7<i.I,��i<•�i�.1<�//.1 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165640 Type: LLC Expiration: 311512016 Trp 248557 AIR - TIGHT LLC. WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR. BEVERLY, MA 01915 Update Address and return card,Mark reason for change. $CA 1 o PaMAM n Address Renewal Employmcnl Lost Card Ogee of Coma mer Again& Rusiness Regal nion License or registration valid for individul use only TOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ogtstration: 155640 Typo: Office of Consumer Affairs and Business Regulation Expiraton: 3/1512016 LLC 10 Park Plaza-Suite 5170 Boston.,NIA 02116 AIR-TIGHT LLC.WEATHERAZATION JAMES FORTIKNOLL 10 PINE KNOLL DR. BEVERLY,MA 01915 Uedene<retnn' Net va id without signature z Massachusetts Department of Public Safety : Board of Building Regulations and Standards License: CS-052576 Construction Supervisor JAMES E FORTIN`� '.�,.'� -Ill 60 RUNDLETT WAVE 'A, MIDDLETON MA,:01 ` Expiration: Commissioner 1010312017 � J Al CERTIFICATE OF LIABILITY INSURANCE °A07nv2015YY' 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 CONTACT Elaine Zolotas MassPay Insurance Seruces,LLC NME PHONE FAX 27 Garden Street,Unit 18 a INC,No): Danvers,MA 01923 ADDRESS: Elaine@philrichardinsurance.com INSURER(S)AFFORDING COVERAGE NNC p INSURER A: AmCUARD Insurance Company 42390 INSURED Air-Tight Weatherization,LLC INSURER B: 50 Rundlett Way INSURER C: Middleton,MA 01949 INSURER D: INSURER E: INSURER 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 TYPE OF INSURANCE INSIR AWL WU POLICY NUMBER MMItDOIYYYY MMt/DOMIYY LIMITS LTR GENERAUUABULITY EACH OCCURRENCE $ AEM ET =Ir COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE E OCCUR MED EXP(Any one person) $ PERSONAL SADV IMURY $ GENERAL AGGREGATE $ GEHL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ POLICY FRO LOG S AUTOMOBILE UAB WTY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OVMIED SCHEDULED GODLY INJURY(Per amident) $ AUTOS AUTOS HIRED AUTOS AAUTOS�D (Perac PROPERTY $ UMBRELU1 LIAs OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AIM693663 07/01/2015 07/01/2016 J NC STATI} OTK AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNEWIE4ECU➢VE _N NIA E.L.EACHACCIDENT $ 1,000,000 OFRCERIMEMBER EYCLUD=M (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1.000,000 IT yes desenoe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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 Cltyof Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120W3shington St 3rd Floor ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA01970 AUTHORIMD REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD _A`�o�® CERTIFICATE OF LIABILITY INSURANCE s%siaois�) 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(les) 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 endorsements . PRODUCER NAONTACT Jill DeHetre TGA Cross Insurance, Inc. PHONE (T81) 914-1000 FAX I.,.('61)224-5777 401 Edgewater Place =L,,,.Jdehetre@tgacrose.com Suite 220 INSURERS AFFORDING COVERAGE NAIC0 Wakefield MA 01880 INSURER A Arbella Protection 41360 INSURED INSURER BArbella Mutual 17000 Air-Tight Weatherization, LLC INSURER C: 9 Story Ave. INSURER D: INSURER E BeverlyMA 01915 INsuseRF: COVERAGES CERTIFICATE NUMBER:CL153532018 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POUCYNUMBER D UNITS GENERAL LIABILITY EACH OCCURRENCE S 1_000,000 X COMMERCIAL GENERAL LIABILITY 3 100,000 A CLAIMS-MAOE a OCCUR 8500046432 /8/2015 /8/2016 MED EXP(Any oneperson) S 51000 PERSONAL S ADV INJURY S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEDTL AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGO $ 2,000,000 POLICY X PRO LOC S AUTOMOBILELIABILITY COMBINED SINGLE LIMIT 1 OOO OOO JECT A ANY AUTO BODILY INJURY(Per mrsonl $ ALLOWNED X SCHEDULED 020015286 /8/2015 /8/2016 BODILY INJURY(Per eccidenl) S X AUTOS X NO-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS fPoI Mon.w namem. 3 X I UMBRELLA LIAB OCCUR EACH OCCURRENCE S 4,000,000 B EXCESS LIAR X CLAIMS-MADE AGGREGATE S 4,000,000 DED X RETENTIONS 10.00 600052930 /5/2015 /5/2016 S WORKERS COMPENSATION WC STATU- OTR" AND EMPLOYERS'UABIUTY' YIN ANY PROPRIETOMPARTNEWEXECUTIVE❑ NIA E.L.EACH ACCIDENT S OFFICEWMEMBER EXCLUDED? (MArbdlory In NH) E.L.DISEASE-EA EMPLOYEE 3 II a.desa oe antler DESCRIPTION OF OPERATIONS W. E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AHech ACORD 101.AddRional Remoms Schedule,H more space Is nmulret) 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 44 Lafayette Street Salem, MA 01970 AUTHORIZED REPRESENTATIVE Thomas Gregory/JD2 � — ACORD 25(2010106) ©1988-2010 ACORD CORPORATION. All rights reserved. iNSO25tniom).o1 The ACORD name and logo are registered marks of ACORD i The Commonwealth of Massachusetts Departineut of hidnsb'ial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 �\�T�I Ivtvrtcmnss.gov/dirt Workers' Compensation Insurance Affidavit: General Businesses. To BE FILED\1'I1'11 T11E PERMITTING AUf110KITV. Applicant Information Please Print Legibly Business/Organization Name: Air-Tight Weatherization, LLC Address: 50 Rundlett Way _ _ City/State/Zip: Middleton MA 01949 Phone #:978-998-4684 Are you an employer'? Check the appropriate box: Business Type(required): I.Q I ant it employer with 30 _employees(full and/ 5. ❑ Retail or part-time)." 6. ❑Rcslau ran UBa rlEat ill'It Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. ❑011ice and/or Sales(fnc1, real estate, auto,etc.) employees working for me in any capacity. lNo workers' comp. insurance requircdJ R. ❑ Non-profit 3.❑ We are it corporation and its officers have exercised ',. ❑ I:'.ntertainnwnt their right ofexemption per c. 152, ti 1(4), and we have 10,❑ Manufacturing no employees. [No workers' comp. insurance requircdJ* I I,❑ 1-Icalth Care 4.❑ We are a non-profit organization,staffed by volunteers; Insulation/Electrical with no employees. (No workers' comp. insurance req.J 12.❑� Other 'Any applie:va tint checks box N I nmsudso lilt out the section bclnw showing their.vorkers amgtenzaliun pulley innvnwnon. "Irate corlxvatn olliecrs have ccanpled themselves•Nil the c,ltpmaliun Fax othu nuplay cc+,a%wrkca'compcnsmion policy tv regnirod mill euah all orgammi'uu vhnuld check Fox ill, !am an emplaper that is providing workers'c•ompehsalioa fasurancc%or n{p enhphirces. !te/olv is the prhlicv iu/nrnuniou. Insm;lnce Companv Nmnc: Guard Ins. Co_. Insurer's Address: P.O. Box AH / 16 S River Street _ City/Sfatc/`Lip: Wilkes Barre PA 18703 Policy a,or Self-ins. 1,ic. k AIWC 693663 Lxpiration Datc:7/1/2016 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration (late). Failure to secure coverage as required under Scction 25A of Ev1Gt., 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 limn of a STOP WORK ORDFA and it lino 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. !do herebt,cerriijj,, tinder the pains ar enalties hf perjury that the ihfnnnation provided above is trite and correct. siy,mtlurc' Date: -- phone N: 978-998-4684 O(licial use un(p. Do not write in this area, ro be cnrrrpleled!ry c•itp or tuuv a/ficiol. City or"Town: 1'crntit/License h Issuing Authority(circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6. 0ther Conutct Person: Phone H: ww•sv.nmse.gavlAia