3 PETER RD - BUILDING INSPECTION The Commonwealth of Massachusetts
\ Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. ate Applied:
,�� 010
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION -
1.1 Prope Address: 1.2 Assessors Map&Parcel Numbers
�ir ��
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
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'
��••1, Owner'of Record•
!rt/It71 >F1 to d C) Iq-+ b
Name(Print) CiTy,State,ZIP
2 Ip£i Eue \42cQ
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Exisfing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other Specify: I XAG( p ATKn A
Brief Description of Proposed Work': L
i
SECTION 4:.ESTIMATED CONSTRUCTION COSTS'
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 2 egg B 3 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee _ -
❑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: $ 2—43 9 -8_2� 1 ❑Paid in Full ❑Outstanding.Balance.Due:
ht l 4,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) OB11S 4 3 __ _ 0 )�
Lice umber T Expiration Date
Name of CSL Holder -
/J 1n, List CSL Type(see below)— U ,
80 &7'nI iP AIZ LL
No.and Street Type Description
a Unrestricted(Buildings up to 35,000 cu.ft.
I�� 1�7,a1n�IfirQ Restricted 1&2 Family Dwelling
Citylrown,state,ZIP M Masonry
RC Routing Covering
FF C� WS Window and Siding
SF Solid Fuel Burning Appliances
918 3t4 - --�2 I 1 Insulation
Tel hone Email address D Demolition
5.2�Re/giistered Home Improvement Contractor(HIC) t,b I q DIE
l I yG 4 A A Twl ( 1XI C HIC Registration Number ExpirationDate
HIC 8o Comtp-rancyt M H ICZtram Name
�v an Street Email address
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 f 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
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
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 a plic tior and accurate to the best of my knowledge and understanding.
ki-
Print Owner's or Authorized Agent's litime(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 mass. og v/oca Information on the Construction Supervisor License can be found at www mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
furor sap*Sr
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mass save CONTRAPCTOR
5im,t$.s thr9ty4t rrnrT'=.lfcivric;
PERMIT AUTHORIZATION FORM
I, Kenneth Velardi owner of the property located at:
(Owner's Name,printed)
3 Peter Rd 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
06/26/13
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
Rev.12132011
1
f col
G1�SCONTRACT FOR nationalgrid
�Conser atlOny • RODUCTS / SERVICE WORK HEREWITH YOU.HERE FOR YOU.
Services Group This service is brought to you through support from your local utility
This Agreement is made by and among
and
{Conservation Services Group(CSG)
("Attn:RCS_ _
Kenneth Velardi C5O Washington Street,Suite 3000
3 Peter Rd Westborough,MA-01581
Salem,MA 019704237 Reg. No. 173484
Project ID:P00000150554 Contract ID:20130626-1 WORK Federal ID No. 222457170
Site ID:S00002146027 (6fail completed contract to address above)
I. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be perforated the fo0owing work on these"Premises"in a professional manner and in accordance with the terms of
this Contract,including the attached reconm endationsilwork order describing the work in detail(the"York")which are mcory mated herein by reference:
Description Quantity Location
Altic Floor Open Blow Cellulose 9'__^. _ 1,359 Living Space _ $2,065.68_
Damming .. 60 N/A $711_00
Vent bath fan to roof Dapper 2 Atlic ____ $236.00
__. _ - _ —_ - ---_.. __ Sub Total. ____ . $2,412.68
Utility Incentive Share S1,809.51
Customer Contribution 5663.17-1
.. �V�_/•ll�l"G1��Orr 0'n �VI
Printed:612612013 Page 1 of 1
it. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1 r$ f7 'I d L� az a D "
to CSG upon signing the Contract(not to exceed IM of the total retail costs or actual c of;p clot idche ers,wver is greater):hra8 check&contract to CSG,�.
#Attri:RCS,60 Washington St.,Ste.3000,Westborough,IttA 01581.Fired Paynhenh Srt C as the Mal payment for the Work shall be tie and
ipayable to the Independent Installation Contractor("IIC")upon attlafactory completto f 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 S 190�,;;I .The Utility Incentive Share is dependent upon the package purchased and/or
prior incentive util-mL on.Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share.
Ill. DISPUTE RESOLUTION
The BC and Customuliemby mutually agtm bn adrmtm twt In the event that the RC has a dispute concerting Otis Contract,the BC may submit such dispute to a private arbitration
samcewhielt Imbect pmnred by the OHlreofConsufm/er/—AJ6nusandrhe" ess Regulation and Customersha0 be required to submit to such arbitration m provided in htG.L c 412A
Customer. F %-c==�' i�----""�" Contractor.
You may cancel this agreemerif if it has been signed by i party there to at a place other than an address of the seller,
which may be his main office or a branch there of, provided you notify the seller in writing at his main office or branch
by ordinary mail posted,by telegram sent or by delivery, not later than midnight of the third business day following the
signing of this ogre meat. DO JOT SIGN THIS ON RACT IF THERE ARE ANY BLANK SPADES.
Caton r ignatun to Indicate yoYrseiected�Il)C Isere,if applicable(OR) initral here if you want
7j 4._�3,� •'1�.lC. cr TT the Program to assign a
CSG Signature
Date Name of CSG Representative led) . Participating Contractor
TER6IB AND CONDMONS APPEAR ON THE REVERSE.
CONTRACT FOR nationalgrid
Conser atlon PRODUCTS I SERVICE WORK HEREWITH YOU.HERE FOR YOU.
Services Group This service is brought to you through support from your local utility
This Agreement is made by and among .
and
Consetvauon S_erv_fees Group(CSG)
Attn:RCS
.:-
Kenneth Velardi 60 Washington Stree[;$bite 3000
3 Peter Rd Westborough,MA 581 01
Salem,MA 01970-4237 Reg. No. 173484
Project ID:POODO0150554 Contract ID:20130626_ASEAL Federal ID No.222457170
Site ID:S00002146027 (Alai completed contract to address above)
I. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be perforated the following work on these"Premises"in a professional manner and in accordance with We terms of
this Contract,including the attached recommendations/work order describing the work in detail(One"Work")which me incorporated herein by reference:
Description Quantity Location
_Whole House Fan Box,Thermal Barrier Polyiso 2'(Attic)_ __ .I_ .Living Spacer _ . _ _$154.32 _
Perform Air Sealing al Eslimated 62.5 CFM50 Per Hour_- .. .10 Living Spare $770.00 _
` Sub Total_ $924.32
Utility Incentive Share $924.32
Customer Contribution
Printed:612 612 01 3 Page 2 of 2
If. PAYMENT
Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment 81:$ as a Deposit payable
to CSG upon slgning the Contract(not to exceed U3 of the total retail costs or actual costs of al orders,whichever is' titer).hfall check&contract to CSG,
Attn:RCS,6o Washington St.,Ste.3000,Westborough,hIA 01581.Final Payment:$ `' '.r- as the final payment for the Work shall be due and
payable to the Independent Installation Contractor(0611C")upon sails etory compleeo of the Work.Customer understands timt he/she will not he required
to The Utgi Incentive Share is dependent upon the package purchased andfor
priorce Utilityhnc bone Shares the Contract price r theamountvi 3 ty P P p e
prior incentive utilization.Changes[o individual line ilerns and/or previous incentives may increase or decrease the size of[lie Utility Incentive Share.
III. DISPUTE RESOLUTION
The RC and Customerhereby mutually agree in advance that in the event that the RC has a dispute concerning this Conhact,the RC may submit such dispute to aprivate albitration
servicewldrhlimbeenappmvedhytheeOOfgm ofcomumer 's audit es Regulation mid Customersh/��11 be�nY*edttomtbnutiosucharbihafionmp�'idmlinhLG.Lcl42A
Customer.f - �,..-.- 6 �; Contractor. / ✓ V �.�
01
You may cancel this agreement if it has been signed by a party there to at a place other than-an address of the seller,
which may be his main office or a branch there of, provided you notify the seller in writing at his main office or branch
by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the
s1 ran of this agree eni_u NOT SIGN THIS �Oi A rn THERE ARE ANY BLANK SPACES. Program g c
2+�
the
Participatin
Custou er, naHIT - ate bmicate y ur selected IC here,da licable Initial tem tf ouwant
rl�� assign a
CSG Si nature
Date Name of CSG Representative ruded) Contractor
TERMS AND CONDTPIONS APPEAR ON THE REVERSE. 1/13
The Commonwealth of Massachusetts
Department ofbtdustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.tnass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Oiganizationtlndividual): "
Address- v7Y�tt_ Vdt
City/State/Zip: ml- kLmyW,, 't U&Mhone.#: c1-16 al
Are yi an employer? Check the appropriate box: " "Type of project(required):,
1.LvjI am a employer with. 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. El New construction
2.❑I am a sole proprietor or par trier- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub-contractors have S, ❑Demolition
working for me in any capacity. - employees and have workers'
[No workers'comp.insurance comp.insurance.t 9. ❑Building addition
required.] - 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeownerofficers have exercised thew doing all work 11.❑Plumbing repairs or additions
myself. [No workers'comp_ right of exemption per MGL
insurance required.]t e. 152,§1(4),and we have no 12.❑ of repairs
employees.[No workers' 13. Other AASt Il /rrs lm A
comp.insurance required.] ji "
-Any applicant that checks box N most also fill out the section below showing their workers'compensation polity information.
t tionmowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
tconuactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those mtitics have
cmployces. If the sub-contactors have employees,they most provide their workers'corrip.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: - �n`
',Policy#or Self-ins.Lie.M .Gros ucwb 2 - Expiration Date:
fi p� 12- 01 - 20 )3
Job Site Address: i City/State/Zip:
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 rip 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 certify under th pains allies ofperjuty that the information provided above is true
/and correct.
Signature, Date 7,
Phone#:
Ojilcial use only. Do not write in this area,to be completed by city or town offciaL
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#:
#_Massachusetts_Department o;?uoi:c safe:..Board of Building Regulations and g;
Con+tru-. anoarcis
umn Supcn i,or
License:CS4L57754
8�BD IM
NANDOTrI#MA 01045 71
=
' Commissioner
03f04=14
Office of�nsnmq Adsirs Bc Baswess � ... :. _. .. .. _. .. .._..__
ME Regntatioo License or registration valid for individul use only
PROVE.MENTCONTRACTOR before the expiration date. if found return to:
n: ;101730 Type: Office of Consumer Affairs and Business R
it0tion: -_8/2820;g= I'dvate Cotpotalicr, 10 Park Plaza-Suite 5170 Regulation
HRH CONSTRUC-n& INC_ - Boston,MA 02116 -
William Hope
80 CAMPBELL RD
L
NORTH ANDOVER,MA 01845 —Undersecretary Not valid withouut si
ature
s
A�" CERTIFICATE.OF LIABILITY INSURANCE DATE(MO°NY'
013
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(tes)must be endorsed. If SUBROGATION IS WAIVED,subject to the
terns 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 N2Ww cr Michael Emond
Emond&Associates PNONE FAX
Ac Ne:
857 Turnpike Street Lnrike_ p'
Suite 133 INSURER(S)AFFORDING COVERAGE NAICE
North Andover MA 01845 wsURERA: Farm Family Casualty Insurance Company
INSURED HRH Construction INSURER B:
80 Campbell Road wsuItER C:
• wsuRERD:
North Andover MA 01845 wsURER 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 ADO BR POUCYEFF. POLIcYE%P
LTR T'PE OF INSURANCE POLICYNUMBER MMm WDD LUSTS
GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000
X COMMERCIPLGENERAL UA91tt1Y PREMISES Es ecOa . $5().()00
IM CLAS-MADE F—x]OCCUR F77, MED EXP An are
A 2001XO726 11/20/2012 11/20/2013 PERSONAL&ADv INJuRV $ Included
GENERAL AGGREGATE $2, 000,000
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AEG $20 000
X POLICY PRO LOC $
ROAMUTODO'Sm
—ILITY ��r' COMBINED 1 SINGLE UNIT 00 0
00
ANY AUTO BODILY INIURY(Per Person) $
ALL WNED X S�HOESDULED BODILY INJURY(Per actitleM) $
ANDN-OWNED 2001C4287�3A 03Ii6/2013 03/16Yt014 PROPERTY DAMAGE
HIRED AUTOS X[I AUTOS Per acddent S
$
X UMBRELLA UAIB X OCCUR F� EACH OCCURRENCE $ 1,000,000
A IXCESS LUIB CLAIMs.MADE 2001E1169 12/14/2012 12I412013 AGGREGATE $ 1,000.000
DIED I X I RETENTIONS $
WOR10FRS COMPENSATION I WCSTATIA OTH-
AND EMPLOYERS'LIABILITY
A ANY PROPWETORIPARTNERIEXECUTIVE YIN E.L.EACH ACGDENT $5000 0
OFRCEIMEMBER EXCLUDEDT NIA� 2005W6827 12/07/2012 12/07/2013
(Ma Um,in" E.L.DISEASE-EA EMPLOYEE $500000
If yes.describe under
r r E.L.DISEASE-POUCY LIMIT $500,000
I ;I .
DESCMMONOFOPERATONSILO nONS/VEHICLE$(Atlaeh ACORD teI,AddXbnal Remadm Schedule,I/moM spa�eb requbed)
Operations by named insured
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 PUIJCY.7tOVISIONS.
AUIHOR�D REP A
O 1588-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
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