16 RAYMOND RD - BUILDING INSPECTION The Commonwealth of Massachusetts FOR
Board o Regulations
f Building Rlations and Standar
�. MUNICIPALITY
Massachusetts State Building Code, 780 CMR, ed ion USE
qt Building Permit Application To Construct,Repair,Re r emolish a Revised January
One-or Two-Family Dwelling 1; 2008
This Section For Official Us O y
Building Permit Number: Date Applie 7 9 k .
Signature: i- AI L ! .
Building Commissioner/Inspector of dings Date
SECTION 1: SITE INFORMATION
1.1 Prope Addr 1.2 Assessors Map_&Parcel Numbers
1.1 a Is this an accepted s eet?yes no Map Number Parcel Number
-1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed lilse - '. Lot Area(sq ft) Frontage(fo
1.5 Building Setbacks(ft)
Front Yard Side Yards - - Rear Yard
Required Provided Required Provided Required Provided
L6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: Lis Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public El Private❑ Check if yes❑
SECTION 2: PROPERTY OVI'NERSHIP'
2.1 Owner'of Record: / N
� 2�- �
Name(Print) Address for Service:
C - 9-)k -z57 -S/ 71
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units ( Other ❑ Specify:
Brief Description of Proposed Work : o F uayr L
far co p1 l e s� A ff, 401
SECTION 4:ESTIMATED CONSTRUCTION COSTS -
Item Estimated Costs: Official Use Only
Labor and Materials '
1 Building $ 1. Building Permit Fee:$ _Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ -
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees:$
Suppression) _
00 Check No._Check Amount Cash Amount:_
6.Total Project Cost: $ �7J 60 . 0 Paid n Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
a
- License Number Expiration Date
Name of CSL-Holder 15FIV W.a
- List CSL Type(see below) 4
31�illt*��SV et
Address . .galem r�'U'1:01-970 ERC
Description
Unrestricted(u to 35.000 Cu.Ft.
Signature
Restricted 1&.2 FamilyDwelling
Mason"Onl
Residential Roofs CoverinTelephone Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
ly ;1oS �
HIC Company tLLU H Registration Number
Address 61 �g1 !'SFR AVr, Z?
Salem MA 01970 g 7 Y 7 Y t/-�,%Y 3 Expiration Date
Signature * Telephones.
1:5
SECTION 66: 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 Issuanc f the building permit. '
Signed Affidavit Attached? Yes ..........f< No ...... .... ❑ �\
SECTION?a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Q ro C btc>•I ! as Owner of the subject property hereby
authorize C (k l n to act on my behalf,in all matters
relative to work authorized by this building permit application.
�,... CMA kJISG // 3
Signature Owner - Date
/SECTION 7b: OWNERt ORAUTHORIZED AGENT DECLARATION
I, _ G/ . L �0. f --1 ,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.
Print Name
Signatureof Owneror Authorized Agent Date
(Signed under the ains and 2enalfies of e u
NOTES:
I. 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 Improvem ent Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.C.L.c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CNIR Regulations I I O.R6 and 1 I O.R5,respectively.
27 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 of Industrial Accidents
Office of Investigations
kv 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Atlantic Weatlierization,LLC
Address: Salem MA 01970
City/State/Zip: Phone #: ' 79— 7 jNVY-
Are you an employer?Check the appropriate box: Type of project(required):
1. am a employer with �7 5'- 4. ❑ I am a general contractor and I
employees(full and/or part-time).
have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner-. listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
❑ We are a corporation required.] 5. oration and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees, [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they me.doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContmctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must 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: r
Policy#or Self-ins.Lic.#: 5'6 2-? /]L ( Expiration Date:-
Job Site Address: A* �&VMo-� ^1 (� � City/State/Zip: 5_A Kam/ �t�
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: 7� �/�1� Date: YZa 6//
Phone#:
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. Electrical,Inspector 5.Plumbing Inspector
6.Other .
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hue,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,notthe.Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to rill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant ''should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel, #617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www,rnass,govldia
CONTRACT
'0 Prmhd: 4262013
T"'rA Work Onler Id: S93309P9699C299
:Contracto(Informatron- ;.:� .:Ctistomer/Srbe:Detarls r 1 �
Atlantic Weatherization Stefanie Crockett Phone(Eve): 978-257S172 -
61R Jefferson Ave 16 Raymond RE Phone(Day): 978-267S172
Salem,MA 01970 Salem,MA 01970-6325 Site 10: S00002093309
r TotaYdirstalled'Measdres -
Location Description Quantity Unit$ Total$
Attic 12"Mushroom Vent 3 $126.00 S378.00
Damming 78 $1.85 $144.30
Attic Vent bath fan to roof flapper 2 $118.00 $236.00
Halfway Atft Stair Cover Thermal Barrier with mrpentr 1 $237.65 $237.65
Door Sweep 2 $21.17 $42.34
Living Space - Alto Floor Open Blow Cellulose 8' 544 $1.46 $794.24
Living Space Perform Air Sealing at Estimated 62.5 CFM50 6 $77.00 $46200
6derior Door Weather Stripping 2 $26.20 $50.40 a
Installed Measures Total $2,344.93
. . .Y
Road Blacks.:;;t •., .
Type Status Notes
Asbestos UNKNOWN steam heat
INoikOrder
i
Paymerts _
Incentive Payments '
Air Sealing Incentive $792.39
Weal Incentivione
Incentive $1,156.40
79 —�--�-
ToFal Incentive Payments $1,956.79 Omer
Customer Share - Atlantic
Letet Customer Share $ . h�
Less Deposit OF $143143.2222
Customer Share Salence(Due Contractor) $244.92
v�
j�
-. Conservation Services Group-50 Washington Street Suite 3000-Westborough,MA 01581-(508)636-9500
AAC" CERTIFICATE OF LIABILITY INSURANCE 3iiii ol�)
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 N ACT-Construction
Eastern Insurance Group LLC PHONE (508)651-7700 FAX
c I
233 West Central Street
INSURERS AFFORDING COVERAGE NAICO
Natick MA 01760 INSURER A:Arbella Protection Ins. Co. 41360
INSURED INSURER a Arbella Indemnitty Ins Co. 10017
Atlantic Weatherization INSURER CNautilus Insurance Co
61 Rear Jefferson Avenue INSURER D:
NSURER E
Salem MA 01970 INSURER F:
COVERAGES CERTIFICATE NUMBERMASTER 2013 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.
ILTR N SR ADDITYPE OF INSURANCE POLICY NUMBER SUBR PWDPIYYYYI YEFF MWDDFYYYYI OLICYEXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,005
X COMMERCIAL GENERAL LIABILITY PREMISES Ea octane S 50,000
A CLAIMS-MADE FXI OCCUR 8500042816 /20/2013 /20/2014 MED EXP Any one person) E 5,000
PERSONAL S AOV INJURY E 1,000,000
GENERAIAGGREGAITEE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLES PER: PRODUCP AGO S 2,000,000
POLICY X PRO- LOC E
AUTOMOBILE LIABILITY COMBINED
e aBttI NOIMIT 1 000 000
B ANY AUTO BODILY Ierson) E
Au OOWNED X SSCHEDULED 020015871 /20/2013 /20/2014 BODILY Icdeen0 ENON-OWNED PROPERAUTOS
X HIRED AUTOS X AUTOS P accid $
PIP-Basic $
X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LAB CLAIMS-MADE AGGREGATE E 1,000,000
DED RETENTIONS 600047820 /20/2013 /20/2014 E
WORKERS COMPENSATION I WC STA U- OTH-
AND EMPLOYERS'LIABILITY Y I N ITO
ANY PROPRIETORIPARTNER/ ECUTNE❑ NIA E.L.EACH ACCIDENT E
OPPICERNEMBER EXCLUDED?
(MandaWry In NH) E.L DISEASE-EA EMPLOYEE E
U yes,describe under
As.
OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E
C POLLUTION LIABILITY PL2003786001 O/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AHacN ACORD 101,Additional Remmks SOWule,I1 mr,apace Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF BALM ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET
SALEM, MA 01970 AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PMA
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved._
IN5025 norms,m Th.Ar.nPn na,eo and Innn aro ron:afa.ad marks nP Af:rTRn
Rightfax C3-2 3/11/2013 4 : 45 : 54 AM PAGE 2/,002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATEfMM/DD/YYYY)
T IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OL R. HIS
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 and endorsement. A statement on this certificate does not confer rights to
the certificate holder In lieu of such endorsements .
PRODUCER CONTACT
NAME:
EASTERN INS GROUP LLC PHONE FAX
233 WEST CENTRAL ST (A/C,No,Ext): (A/C.No):
E-MAIL
NATICK,MA 01760 ADDRESS:
22MLW INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURERA: AMERICAN ZURICH INSURANCE COMPANY
ATLANTIC WEATHERIZATION LLC INSURER B:
INSURER C:
INSURER D:
61 REAR JEFFERSON AVE INSURER E:
SALEM,MA 01970
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
HISS TO CERTIFY E ISO INSURANCE IS ED BELOW HAVESESN ISSUEDTO THEINSURED NAMED ABOVE FOR THEPOLICY 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. THEINSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMITSSHOWNMAY
HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MmomyYYY) (MWDD\YYYY) LIMITS
GENERAL LIABILITY =ACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
CLAIMS MADE =OCCUR. IREMISES(Ea occurrence)
ED EXP(Arty one person) $
ERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER:
ENERAL AGGREGATE $
POLICY =PROJECT LOG RODUCTS-COMP/OP AGO $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY S
NON-OWNED AUTOS (Per accident)
PROPERTYDAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACHOCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKER'S COMPENSATION AND X We STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-5B270121.13 03202013 03/202014 LIMITS
ANY PROPERITORIPARTNER/EXECUTNE NIA E.L.EACH ACCIDENT S 500,000
OFFICER/MEMBER EXCLUDED?
(MenCetoryin NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,eesoibe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED
93 WASHINTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPR
SALEM,MA 01970
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 19t$8-2010 ACOR )CORPORATION. All rights reserved.
Unrestricted-Buildings of any use group which ? Massachusetts-Uepartmant of Public S maz
contain less than 35,000 cubic feet(991m)of 'P Board of Sui!ding Recula?icns and Standard's
enclosed Space. Ct License:
CS-0
S S08. 79 7i7 `I .
.��.� tits t
ERIC W PAL*' r
3 HII TON ST '
SALIiM MA-01970 � =.
l
Failure to possess a current edition of the Massachusetts - -
state Building Code is cause for revocation of this license. .-
v
For nPs licensing information ve:it• www.Mass.Gov1DP5 CGTTi55FOrier n.
0412=014
License or registration valid for individul use only � �� P � •`y
✓ Tiorxrr rveac o ✓
Office o nsomer owes •�
before the expiration date. lif found return to: - HOME IMPROVEMENT CONTRACTOR
Office of Consumer Affairs and Business Regulation -
_ RegLstrahon ,1420B9 T 3
IOParltPhr�-Suite5170 LtdUabi Co or i
Boston,MA 02116 - Expiration: 3/122014 Ny 1,
A C WEATHERMAT10N_LLC. �?
00*7 ERIC PALM {
t 61RJEFFERSONAVE
Not valid i ff 0 signs a SALEM,MA 01970 Underseeretar9