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25 PICKMAN RD - BUILDING INSPECTION The Commonwealth ofMassachusetts Board ofBuildmg Regulations and Standards R E C E `, FOR Massachusetts State Building Code,780 CMR INSPECTION ! I %• t s , Building Permit Application TO Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling '70I5 JUN I t P 3- 01 \ This Section For Official a Only bo Building PemitNumber Date A lied Budding Official(PrmtName) - - Sigaaome. �i^ SECTION 1:SITE INFORMATION - 1.1 Property A ress: 1,2 Assessors Map&Parcel Numbers , � 'Lia Is this an accepted street2 yes no Map Number • Parcel Number 13 Zoning Information: 1.4 Property Diniensious Zoning Dlstdct Proposed Use Lot Area(sg 8) 'Frontage(ft) 1.5 Building Setbacks(ft) Front Yard 7 I Side Yards .. .-. Rear Yard .. Requied Provided Required Provided Requaed . Provided 1.6 Water Supply:(M O L¢40,§54) )[J,Food Zone Information; .1,8 Sewage D)sposal System: Public❑ Private❑ - Zone: _ OntsideFloodZone2 �ma al Chc&Kyeg MiPO On site disposal system ❑ [TON 2: PROPERTYOWNMMHIP' 2.1 0 cof-ReeoterM�icrr7 /21y7 f�l� Name(Pant) Cdy,State ZIP a,t T/o�chu-, t2�if- (vl7-�,753(. �3 No.and Street "Telephone '-' Email Address - SECTION&DESCRIPTION OF PROPOSED WOIW(check ail that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 0 LAfteration(s) ❑ Addition ❑ Demolition . E3 Accessory Bldg.❑ Number ofUnits- I Otirer CeSpeclfy BriefDescriptionofProposed o SECTION 4:ESTIMATED CONSTRUCTION COSTS . Item Estimated Costs: abor and Materials Official Use Only 1.Building $ 0V. .. 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard`Citylrown Application Fee ❑Total Project Cost'(Item 6)x multiplier x 1 Plumbing $ 2. OtherFees: $ 4.Mechanical (HVAC) .$ List_ 5.Mechanical (Fire Su ression $ Total All Fees$ 6.Total Project Cost: $ Check No. Check Amount Cash Amount /�` O Paid inFnil ❑OutstandingBalanceDue: SECTION Sc CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) _I. 7 ! 7—7 .�j• � ' License Number F.xpirationDate Name of M Holder List CSL see below -,Eric W.Palm 1Yne( ) No.and Sheet 3 Hlltoll Stmet t Type Desmpnon U umesasaed(Buildirum up to 35,000 ca It Salem MA R Reshicfedl&2F DwelFm Cdy/fown,State,ZIP M Masom RC Rooting Covering WS wmdowand Siding SF SolidFudBmmngAppliances huvletioa Telerhouc - limem7addiess .. D ... Demolition 5.2 Registered Home Improvement Contractor(RIC) j a 0 `3 Z & Atlantic WeatlicrILALluiy L,�. ffiCRegIstranon ®ber EspbatlonDate MC Company Name or H[Me#sMMMM t'�^V7entle No.and Street Email address atytroya state,zip . Tel bone SECTION 6-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M GY c,152.§25C(6)) Work=Compensation hissmance affidavit must6 completed and submitted with this application. Failure toprovide this affidavit will result in the denial-oftltehrstmancepEielmildingpermiL Si ed AffidavitAttached. Yes t" No:.......„.❑ga � .. SECTION 7a:OWNERAUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACT ORAPPLIES FORBIJI DING PERMIT . I as Owner of the P subject ro hereby uthonzer G ♦�al fa'4 J PAY. Y a to act on my bebA in all matters relative to work authorized by this balding permit application. - Print Owner's Name PectrwileSignahme) J Date SECTION 7b.s OWNEW OR AUTHORIZED AGENT DECLARATION By entering-my name below,I hereby attestunderthepainsandpenalfiesofpesjurythatalloftheinfomiation . contained in apspli' a is _ �a`ccu_ratetothe best ofmy knowledge and understand'mg. Print Owner's or Authorized Agent's Name(Electronic Signature) -Date NOTES: _ 1. An Owner who obtains abuildingpermitto do his/her owawork,or an owner who hires anumegistered contractor (not registered in the Home improvement Contractor(MC)Program),will ofof have access to the arbitration program or guaranty fond underNML..a 142A.Other important information on the IIIC Program can be found at MMm mass. og v/oca Information on the Construction Supervisor Licemse can befouud atmmm mgg env/dos 2. When substantial work is planned,provide the information below. Total floor area(sq.fi.) (including garage,finished basement/attics,decks orpowh) Goss living am(sq.1) Habitable room count— Number offireplaces. Number of bedrooms " -Number-of-bathromas Number-of-haltlbaths Type of heating system Number ofdeeWporches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for`.Total Project Cosr. The Commonwealth ofmassaehusetts Department of IndusftW Accidents Office oflnvestrgations, Ulf 600 Washington Street Boston,MA 02111 tutmv mass govl dia Workers'Compensation Insurance Affidavit:Builders/ContractorsXlectricians/Plumbers Applicant Information 7 Please Print Lemb►v Dame(Busincsdorgani-rationlindividual): Aden&'w��fion,LLC Address: C Vl City/State/Zip: Phone#:_ al�-7y('- 9103 Are yo/urn emPloyer?Check the appropriate has. I.5 am a employer with—j< 4. Type of project(required): ❑ 1 am agents]contractor 1 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ I am a sole proprietor or partner_ listed on the attached sheet-t 7. ❑Remodeling ship and have no employees These sub-contractors have 9. (]Demolition working fbr me in any capacity, workers'comp,insurance. [No workers'c 9. El Building addition mrrP,insurance 5. ❑We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑Phmrbing repairs or additions myself.[No workers,comp. c.M,§1(4),and we have no )Z❑Rypf�repaas insurance required.]t employees.[No workers' �/ comp.insurance required.] 13. Other l�sl UI i�•rn..,, *Any Hemeo lieant that checks box is gi musl also fill out the section brow showing their WorkW,,,mpeasa6on polity infarmarion Homeowners who submit his affidavit out they arc doing all work and then Aire omsideconnecton,must submit a new affidavit ivdteubs such roomucmrs that cheek this box must numbed bed on additional sheet showing the nameof the subcontracmm.,d their wurkcm'comp,policy information, I urn an employer ll,X lspmsvding workers'compensadon ulmmnce for my employees Rdow is thepoliry and job site information Insurance Company Name: t Policy#or Self ins.Liic..#: J 1�7 �/z J - - - Expiration Date:""++ 03 fob SiteAddrass: 25 City/State2ip:__.ZG Ar1.7-t Attach a copy of the workers'eompersation 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 S 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 tray be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do.hereby certify under the and�penalti4s fP01 rl'a , P�� s o u that the ittfonaation pmvlded above is��+++e and correct Si¢natitre• '�r : t ,_., eat L Date.- /(,J/ Phone#: q7 S{• 7ulA— Ff l(7 official use only. Do not Wile in this area,to he completed by city or town gamut City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityfTown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: - AC<>9bP CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDA'YYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 2015 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES the BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. theIMPORTANT: If the certificate holder is an ADDRIONAL INSURED, the poficy(Jes)must be endorsed. R SUBROGATION IS WAIVED,subject to certificate terms and Conn lieu of the policy,certain Policies may require an endorsemen4 A statement on this certificate does not center rghts t0 the certificate holder in lieu of such endorseTneM(s). , PRODUCER CONTACT COIISLrpCtiOII Eastern Insurance Group LLC NAME PHONE (800)333-7234 Fax 233 west Central St E-MAIL D R Natick t+fA 01760 INSU S AFFORDING COVERAGE NAIC0 INSURED INSURER AArbella Protection ins. Co. 1360 Atlantic Weatherization INSURERB:L'TautiluS Insurance Co 61 Rear Jefferson Avenue NsuRERc: INSURER D: Salem MA 01970 INSURER E: COVERAGES INSURER F: CERTIFICATE NUMBE111 1 11BR 2015 REVISION NUMBER: NHD TIFICAATED E MAY BE ISSUED G ANY POLICIES PER I NT. TERM OR CON ITION OF ANY CONTRACT OR OTHER DOCCUHE INSURED MENT WITH RESPECT TOEFA�VE FOR THE LIWHICHR DD 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 LTR TYPE OF INSURANCE MPMLICY EFF PM/OCY EXP GENERAL LIABILITY POLICY NUMBER 10 OMnS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ® /20/2016 pCCUR 500042816 /20/2015 PREMISE Ea $ 50,000 MED EXP(Any one penmen) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY X PRO- LOC PRODUCTS-COMP/OP ADD $ 2,000,000 AUTOMOBILE LIABILITY $ ANY AUTO EaMaUe0n1 IN LE UMIT A ALL OWNED SCHEDULED BODILY INJURY(Per person) $ 1 000 000 AUTOS X AUTOS 020015B71 /20/2015 /20/2016 X HIRED AUTOS X pUfO-0SWNED BODILY INJURY(Peracddenn $ PROP�ERd�OAMAGE $ X UMBRELLA DAB X OCCUR PIPAasr< $ A EXCESS UAB CLAIMI EACH OCCURRENCE S 1,000,000 DED RETENTIONS 600058654 AGGREGATE $ 1,000,000 WORKERS COMPENSATION /20/2015 /20/2016 AND EMPLOYERS'LIABILITY $ ANY PR OPRIET NH)pRIPARTNERIIXECUTIYE Y/N WC STATLI- DTH- OFFIC In ERAA XCLUOEDt O NIA E.L EACH ACCIDENT I If9 deeunder DESLIRIPTION OF OPERATIONS below EL DISEASE-EA EMPLOYE S B POLLUTION LTABILITY E.L DISEASE-POLICY UMR S PL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AHeeh AOORD toT Atltli0o11al Ranlazks Schedule,Hmore space is required) :ERTIFICA I F HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SALEM _ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED' IN ACCORDANCE WITH THE POLICY PROVISIONS. 93 GI4SHINGTON STREET SALEM, LEA 01970 AUTHORQEp REPRESENTATIVE CORD 26(2010/06) 'TOE ltoegel/PMA �-' �y�r� iS02.5/2mmslDT The Ar!nRn name and Innn aro rani-f—d madre nF ArnwnORD CORPORATION. All rights reserved. L UGl VCl ♦ .:.::1j..`y?y."'.:<::`1:::.� ' Ili T IFICATE IS ISSUED AS A MA1TERq OFFINFORMATIONOONL`Y LIABILITY S NOSURANIS U�CE E CERTIFICATE HOLDER T ";8�n CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED gY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE THE ISSUING INSURER AUTHORIZED REPRESENTATIVE C p C O IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(Ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and I:Dn er I millions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemen s. PRODUCER CONTACT EASTERN INS GROUP LLC NAME. 233 W CENTRAL STREET PHONE FAX (A/C,No,EIq: (A/C,No): - NATICK.MA 017(p EMNL 22MLW ADDRESS: INSURED INSURER(S)AFFORDING COVERAGE NAIL# ATLANTTC WEATTHERIZATION LLC INSURER A: tCAN ZURICH INSURANCE COMPANY. INSURER B: INSURER C: - 61 REAR JEFFERSON AVE INSURER D: SALEM,MA 01970 INSURER E: COVERAGES INSURER P: CERTIFICATE NUMBER-FY TH4T THE POLICESO NSURANCe LISTep eELp REVISION NUMBER: WYFEOUIFEMENf,TERM OR VEB ENISSUEDTO THE NSUREII NAMED 4BOVE FORTHE POLICY. NDICAlE0. NOTWRXSTANDNG AFFOFOEp BY THE POLICIES DESODR BE XHEERONIS$ug,IR pADLLTMTME��N IXSAND ENT CONDRWNT IS 6Up1ICATE MAY BE O BROWN N4Y XAYTARL THE INSURANCE PAD CLAIMS. RESPECT TO WXICH THIS CERTIFICATE MAY BE OWED OF MAY PERTAN.THE NSURANCE UCEDBY NSF LTF TYPE OF INSURANCE ADD EDB POLICY EFF DATE POLICY EXP DATE L R POLICY NUMBER (AMADMYVYY) (MMDOWYYV) GENERAL LIABILITYLDdR3 COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE $ CLAIMS MADE MOMUR. AMAGE TO RENTED REMISES ME mmmence) $ ED EXP(Any onepwsmi $ GENL AGGREGATE LIMIT APPLIES PER: _ ERSONAL&ADV-JURY $ POLICY PROJECT❑LOC ENERAL AGGREGATE $ AUTOMOBILE LIABILITY RODUCTS-COMP/OP AGG $ ANY AUTO COMBINED SINGLE ALL OWNED AUTOS LIMIT(Ea accidere) $ ' SCHEDULE AUTOS BODILY INJURY $ HIRED AUTOS (Per person) NON-OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTYDAMAGE $ (Par accident) UMBRELLA LIAR OCCUR EXCESS UAS CLAIMSi♦MDE EACH OCCURRENCE $ DEDUCTIBLE AGGREGATE $ RETENTION $ $ A WORKERS COMPENSATION AND $ EMPLOYER'S LIABILITY YIN U"B270121-15 WCSTATUTORY ' OTHER ANY PROPERITOFIPARTNEF/EXECUTIVE 03Y102015 03/20/2016 X UMRS OFPCER/MEMBER EXCLUDED? ©WA (MrneMwy I,NH) E.L EACH ACCIDEM S 500,D00 yes,#esa@e E.L.DISEASE-EA EMPLOYEE OESCRIPn OF OPERATIONS OF OPERATIONS below $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONSIVEMCLESIRESTRICTONS/SPECIALITEMS E.L.DISEASE-POLICY LIMIT $ 500,000 THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORRIERS COI COVERAGE. CERTIFICATE HOLDER CITY OF SALEM - CANCELLATION 93 WASHINGCONST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. SALEM,MA 01970 AUTHORIZEDA_ 'E >. `:.:. : ACORD 25(2010/OS) The ACORD name and logo are registered marks of ACORD 1986='2p10 ACORDCOpppppT)ON. All rights reaeroed. tit Massachusetts -Departmentaf Public Safety Board of Building Regulations and Standards ConstructionSupenhor —� License CS-087977 FAIC W PALM , Salem MA 01970 Ilit Expiration .. Commissioner 04/2312016 CF11e e.Mmoerrmallll ry/C-'il�m;ac�ruel6 Ot<ce ofConsumer Affairs&Busiaess Regulation eME IMPROVEMENT CONTRACTOR gistration: 142089 Type: phation: :3/102016. Ltd Liability Corpo-.'". z ATLANTIC WEATHERIZATION L.L.C. 3' ERIC PALM 61RJEFFERSONAVE Q �_ SALEM,MA 01970. Undersecretary i itris iam saHinsalt - �dPFffiri` I B4BPGimaa-gInns � Qfl'itMeEC m rc°ns m'er �aa �ZMMSRW ip caa ptfg-a>!awat:•�.Pll-= 00ew pa B aurim ravamtss6o13ameoSFttel7O0" dFa2vd7=1-8@QctorIntbrtt sa�rnddtesja s erw I �% 'aP@Om'ecBm,+.dd¢g� •A - Cir,.rarm �C°map�tglespeamr L aJ Saeyn�C� 01970 &14ins Adaret;roEremt 1� 3 ��7ltorw Fuse TiPCm .. Iliuov�F°oQ - ��a'amass h�a }ha Coam.Gora° r �naossi" I(/J� in�j "�' / a: mdoth craIIoxioggthe8o m//\nPl`�/�sS�:°'�€ing'yeaR araaxcmm"Der. 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Homeowmersievosecutetheirmmbuiildingpermitsarearmmaticallye%ctndednomallGeaaatyFundprm4sion of the IiamelmprovzmentCo reonnemma9beeafitledtoothzrsoecificlePlrimthemntnctoas d inn timely and-,eodmmnlftm Hom for marenteesorpro ides anexyresivarraDtynorlmanshipormaterial5 Inadditionto�taranteesorrarranties omvidedbythamrdracm=ailgno�sold,nMasachaseascmryanimpttednvaaatrt9ofinetohanmbilit andn'mesfor a aaria3arouraosz Anaamneresuraofotherommitson-hichthehomeonlaerandcanuac[orlaivfidlyagze may addedmaratermsoEtheronsactasloinastheydooutma¢ictahomeoeneesbasiccuoinir rrlehts• Fo que:doos aboutyrourconsmnerllmmemvzwTnO s•ror�ra�the Consuraarhttovdation Hotline(listedbeloi+:). h-cecution of Contract Tile contreamust be executed in dunHeate andshould not be signedmrtil a copy ofall e�hr3its andraferenczd documemsli vebearindsched.parties am also advisednotmsignlhedr antmtilaDbhnl sections have-been filled in ormarimd asw4 deleted,or not applicable. One originalsigued copy elheconhaotivith atmchmerrts is m be giventotheon9uandtheodwIraptbythecontractor. modification to receivedafhll e�zrartedcopyoi� and amedtobybothvarties.Contracted eriodhaswotk May notbe in undl panics the contract:and tbelhmedayresoisionP Accelerated Paymens A contractormaytmt demand payments in advance ofthe datesspettified on ptvhere a sponoedmrdpM5 h®ber'elf homeonaer deems lumiheselftobefinenciallyitsecme.Hovvetw-mmstanaes mbefrtmnrdallyiaseeme drecmrtracmrmaytaco¢ethatthebalanceofinndsnotyat due beplacedinajoimescron` account as a prerequisitetocontmtflngtheronmacted,mdc r dramaloffmdsGomsaidatxmmhvonldtequirethe sima um ofboth paries. Additional lArmadOr' ContcactaLanorother ifyou have Fmeral questions or need add Ouaib1bratetioaabouttheHotaeTmpracemaat cpnsumarrip arifyonndshmobtainafrceropFof iiivlassaclmsearC m Guide to Rome ImprovemenF contact: Consumer Information Hotline Of=of Consumer AfiensandBovinesRM- lation 10 ParkPb¢e_Room5lia Bosmt4 MA M116 617AT�:8S8-38i-3i357orvisittheOCABR — —' Ifyaun2ntmverifythereeisL'adono;awnnactmorieI baveem Conhacmriam contact= rota F about the conttaictstr strationcompm!rotaftheHomelmpm Direct ra,Homelmp D%elneaComWor'Wsttafion office of Constmter Affabs and Bmittess Regulation 10ParkPlaaa.Room 5170,Bo3WE04A M116 617Ai3-B 78i,388-38^,-37ir orvisitrhe a C rveusltz az• Go radio to tijew the starter of aHmnelmvwvemeat ContracoesRe_nistradoin - 'a. -•�r�_-r,_usua•n�;rm�-ac men: Cans 'sLos- .. Forassistence ividr informal medtatioa ofdispmessarto 14ster•formal complaints against a busitras.call! ianiker Complaimsecdon ofce$ftbeAtmmey General a -7TT=840o .-MOR 3et�BusmessBrneam i08.6>'o=80Q708 T5�'t8 or#li T�43II4 ;.�3t-ttmnntp ! mass save �R PERMIT AUTHORIZATION FORM I, SCOT STERNBERG owner of the property located at: ' (Owner's Name,printed) I 25 PICKMAN 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. X Sti0wner' Signature. t 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 g a Force Use Oniy Rev. 12132011