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5 RAVENNA AVE - BUILDING INSPECTION (2) 1 The Commonwealth of Massachusetts RECEIVED Board of Building Regulations and Standards INSPECTION L SE MM Massachusetts State Building Code, 780 CMR SALEM Revised—mar.2Oil Building Permit Application To Construct, Repair, Renovate Or D"li� I' 44 One-or Two-Family Dwelling + This Section For Official Use Only Building Permit Number: Date Applied: -4 In Building Official(Print Name) Sig tur Date SECTION 1:SITE INFORMATION 1.1 Propert�y7 Address: 1.2 Assessors Map& Parcel Numbers a>La� �hY�U. 11Vti 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 B) Frontage(fit) 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: \"1i�r\� S o \ Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction El [Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) [90 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work: - \ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ b1 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 $ r6,uTotal ression Total All Fees: $ Check No. Check Amount: Cash Amount: Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: The Commonwealth of Massachusetts 1 Department oflndustrialAccidents 1 Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 " www mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information \' Please Print Legibly Business/Organization Nam \- e: .i ,:\ — 1CCLV Address:_ C� City/State/Zip: `Jvvll Phone#: C--J s qq&- V L(jC < f , Are you an employer? Check the appropriate box: Business Type(required): -- --1.� I am a employer with�employees (full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]** 11.❑Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp.insurance req.] I 12.❑ Other *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#l. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Cal ^E�j'( `_W. LG Insurer's Address: ' City/State/Zip: �v'L\y-os Policy#or Self-ins. Lic.# OX. X 5-7U� L(I D Expiration Date: �I I J ZC�[� 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 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. 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 the pains and penalties ofperjury that the information provided above is true and correct. Signature: Ca„�r C c ( Date: Phone#: I — (C L�(.0&,..Li- Official 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): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Office of Consumer Affairs and Business Regulation J �i 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165640 a� Type: LLC Expiration: 3/15/2016 TrN 248557 AIR — TIGHT LLC. WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR. BEVERLY, MA 01915 Update Address and return card. Mark reason for change. SCA i 0 20M-05/n - � Address [] Renewal Ej Employment D Lost Card � ���oo�<rnnoaruen�o�6��n'mtaefierae7l� .. lvw^� Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistratlon 165640 Type: Office of Consumer Affairs and Business Regulation � xpiration 3/15/2016! LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 AIR-TIGHT LLC.WEATHERA' iON 10 PINE KNOLL DR BEVERLY, MA 01915 Undersecretary Not va id without signature 1 Massachusetts - Depc+rCn��e nt of Public Sae�Cy Board of Building ReGulotiooc avid Stanorrds fnnuiunion aopciNimr Licenso: CS-052576 10 q 14,. < E .IAMF,S E HOR 1'il)F It)PINCKNOL:L DR Beverly MA 0190 10/03/2015 �'OnRYp39OOfH t The Commonwealth of Massachusetts i Board of Building Regulations and Standards CITY OF 4 / Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application 'Po Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 5 PAv( M!4 I.la 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 11) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yads Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c. 00,§5.1) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private Cl Zone: — Outside Flood Zone?Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.11�O,w��nerl o�f Fteecord: ` g�,� p p•� N.m-1Y.b�l't_�t�uty 1G---aO -<A AA ©1 1 /6 (Po City,Statc,ZIP No.and Street "Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) <1 Alteration(s) Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specilj•: Brief Description of Proposed Work'': e...e !• -Jh1=tc�:v. SECTION 4: ES'rh,Nl.4 rED CONSTRUCTION COSTS Item Estimated Costs: Labor and MaterialO Official Use Only I. Building $ I. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard Cityfrown Application Fee ❑"total Project Cost'(Item 6)x multiplier x_ 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (IIVAC) $ List: 5. Mechanical (Fire Su ression) $ Total All Fees: $_ V o� Check No. Check Amount Cash Amount: 6. 'total Project Cost: $ ❑ Paid in Full 11 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL.Type(see below) No.and Street 'type Description U Unrestricted(Buildings up to 35.000 cu. ft.) R Restricted 1&2 Family Dwcllin CityfFown,State,ZIP M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Tele hone Ernail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Dale IIIC Company Name or IIIC Registrant Name No.and Street Email address City/Town,State,ZIP 'telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(IDLG.L.c. 152.1 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 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 71b: OWNEW 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. Prml Owner's ur Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/lier own work,or an owner who hires an unregistered contractor (not registered in the Horne Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at www.niass eov/oca Information on the Construction Supervisor License can be found at www.nwss.gov/dps 2. When substantial work is planned,provide the information below: Total Boor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. R_) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms _ Number of half/baths Type of heating system Number of decks/porches_ "fypcofcoolingsystcm -- Enclosed --open, _- 3. `Total Project Square Footage"may be substituted for"Total Project cost- Commonwealth of Massachusetts A `b n City of Salem n .o 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 Return card to Building Division for Certificate of Occupancy Permit No. B-14-1189 FEE PAID: $42.00 PERF0. 1"T TO BUILD DATE ISSUED: 7/16/2014 This certifies that SHUTE PAMELA has permission to erect, alter, or demolish a building 5 RAVENNA AVENUE Map/Lot: 30012-0 as follows: Insulation INSTALL CELLULOSE IN WALLS;&ATTIC. r« l Contractor Name: Air Tight Weatherazatlon LLC/James Fortin `_ t" DBA: -4 F yL Contractor License No: 52576 d � �{ p 1 F�4f a � l F, 7/16/2014 E "Building Officlalk+ g1 Date r.xy Ef IE ifik,�r 1 707, x This permit shall be deemed abandoned and invalid unless.the work authorized by this permit is commenced within six months after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request""µ� r �iMk3 S All work authorized by this permit shall conform to the app��r{o{wed application and the approved construction documents for whichthis permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. -qd - The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on thiiss permit. r! az "a,K,!!P H I C#: 165640 Persons contracting with unregistered contractors do not have access to the guaranty fund"(asset forth in MGL c.142A). ' �i IQ. ;.C{{ E'..-9 iy,� r I Restrictions: i f ;tile e �'1`l a... a', I�� W'Fi N.rr T ' , { MM f Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER.