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7 READ ST - BUILDING INSPECTION � 11 - ► L4 The Commonwealth of Massachusetts �1g Board of Building Regulations and Standards FOR Massachusetts State Building Code, 780 CNM 7`s edition MUNICIPALITY USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January One-or Two-Family Dwelling 1, 2008 This Section For Official Use Only Building Permit Number: )j Date Applied: I p Signature: V"" �iYS<• /.�/f all 3 Building Commissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Addre u �• 1.2 Assessors Map&Parcel Numbers 7 P a S�J —1.Is 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(it) 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? Cbeck if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owneri of Record: ThM et-- 9 7 dead Sf . Su�e� 1y14 Name(Print Address for Service: 5418-72 90 sO Signature Telephone SECTION 3,DESCRIPTION OF PROPOSED WORK'(check allthat apply) New Construction❑ Existing Building Owner-Occupied, ] Repairs(s) ❑ Altemtion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ I Number of Units_ Other Specify:_ Brief Descripti of Proposed work on 7,f.Prni r�/wofe— rhicu c� `p>,i SECTION 4:ESTIMATED CONSTRUCTION, COSTS Item Estimated Costs: Official Use Only (Labor and Materials y 1.Building $ 6 3 , (91 1. Building Permit Fee:$ Indicate how fee�is.determined: 2. Electrical $ 0 Standard City/Town Application Fee Total Project-Costa(Item,:6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 7 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $A70 3 0 Paid in Full 1 Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 7�7 23 Z -Eric W. Palm License Number Expiration ate Name of CSL-Holder 5 l- ltdft -e SaleM MA0070 List CSL Type(see below)T _ Address Type Description U Unrestricted(up to 35,000 Cu.Ft. Signature R Restricted 1&2 Family Dwelling M Maso Only Telephone RC Residential RoofingCovcrm WS Residential Window and Siding SF Residential Solid Fuel Bumin Appliance Installation Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) 1 ,a HIC Company Name or t ame Registration Nu er 1 ef 'erson Avenue m Address Salem MA 01970 r - / �` 7 t(ll•�/f —* iration Date Signature iiJ, /J_ 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 I WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUH.DING PERMIT I, &e m G as Owner of the subject property hereby authorize R I v✓1 to act on my behalf,in all matters relative t wor an o e y this building permit application. \ /� 1 Si ature of Owner Date U`l l/l /SECTION 7b: OWNEW OR.AUTHORIZED AGENT DECLARATION I, . ,' r �_ Ir .N� ,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. 1 Print Name Signature of Own �AllthOn2 "Agent � � Date LSigued under the pains and penalties of au 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 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IAR6 and 110.R5,respectively. 2. 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" - r °i WAP Work Order North Shore Community Action Programs,Inc. Job Number:Plasencio-Gas 98 Main Street Work Order Date:9/2/2013 Peabody,MA 01960 Ownership:Renter Phone:978-531-8810 Atlantic Weatherization Auditor:Brandon Dorrington 61R Jefferson Avenue - Email:bdorrington@nscap.org Salem MA 01970 Cell:781-540-8569 Email:tpalm01@comcast.net Phone:978-531-0767 x121 Phone:978-744-8143 Ilsa Plasencio NGRID Gas $2,703.88 7 Read St Total $2,703.88 Salem MA 01970 Landlord Name:Therese Palm - Landlord Phone:508-726-9050 - Safety Issue(s):Knob&Tube Wiring/Mold Present - ` Authorized Actual:". Measi re Description - Comments r ' Price :Total' Qty .Total - Basement-Insulation-W •. ,' <; ' , .: "`ax -".. - Sill two-part foam w/fiberglass halt 130 $2.20 $286.00 130 $286.00 unfaced 1 v - Doors'-„ Repair/Refit Door 2 $52.00 $104.00 2 $104.00 j Health&Safety Clothes dryer vent including - 1 $89.00 $89.00 1 1 $89.00 - Exhaust Duct' _.�M-I c Insulation:. 't ="v. Domestic water pipe wrap 6 $2.63 $15.78 6 $15.78 Steampipe insulation to 1.5-2 in. 120 $6.35 $762.00 120 $762.00 iron pipe R-5 Steampipe insulation up to 1.25 in. 140 $5.51 $771.40 140 $771.40 ` iron pipe R-5 _ Date:9/2/2013 Page I A WAP Work Order: Job Number: Plasencio-Gas Misc Measures, - - F Basement sealing with two-part 3 $75 00 $225.00 3 $225.00 foam Permit Building Permit 1 $100.00 $100.00 1 $100.00 ;r} Wall Insulation -• _• x , h - .,a... Drill finish patch plaster(dense 153 $1.90 $290.70. 153 S290.70 pack) Test drill 4 sides 1 $60.00 $60.00 1 $60.00 Total $2,703.88 $2,703.88 Contractor Instructions: Before Starting the Job: During the Job: - 1.Please notify us 24 hours before starting or scheduling a job. 1.Incorporate lead safe practices as applicable. 2.Obtain required building permit. - 2.Total for Heath&Safety and Repairs cannot exceed$2500.00. 3.Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH-347. Additional Contractor Instructions: Certificate of Insulation posted? Yes No (Circle One) Attic Inspection form attached? Yes N/A (Circle One) Where Posted: - Contractor: - Date: WAP Auditor: - - Date: Energy Director: Date: Fiscal Officer: Date: Date:9/2/2013 Page 2 y .. l WAP Work Order: Job Number: Plasencio-Gas FOR AGENCY USE ONLY Pre Post Language Other than English needed? Yes No (Circle One) Dryer CO 0.000 If Yes,indicate language: Stove CO 0.000 Occupany change in last 18 months? Yes No (Circle One) H2O Tank CO 1.000 Comments: - -- Heating System CO 0.000 Number of windows_ Ambient CO 0.000 Number of rooms_ - - Blowerpoor 0.00 Date:9/2/2013 Page 3 The Cominonivealth ofillfassachuselts Deptartinelit of Industrial/I cci(lentv Office of Invewfigations 600 I-Vashin-ton Street X Boston, ATA 02111 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name (BLISille.,Silor,-,,Illizatioll,'Iiidi%idual): Mnntin,W-0th-6zallion,LLC Address: 61 R Jefferson Avenue aem Citv/Slate/Zip: Phone #: 97$-7qq- E-A/ 3 Are an employer'' Check the appropriate box: I.Y3, 4. ❑ 1 am a general Type of project(required): I am a employer with -al contractor and I employees(full and/lai pirt-tiine).* have hired the sub-contractors 6. E] New construction 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. E] Rernodelinp 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.= 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.[] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised then I LE] PhImbura repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E] R�Xirepairs insurance required.] c. 152 §1(4)- and we have no employees. [No workers' 13.2`6tbel comp. insurance required.] I I :Aan.arl that checks box 41 Mail also ril out the section beio,, slho,iae their\,orkers compensation police inforniatio, 110111CO0TerS1010 submit this affidmi indicative they are doing all ork and then hire onside conirac(ors toast submit ane,k affidavit indicating such. Contractors that check this box must attached all addit-ionai sheet silo,ille the zilille Grille sub-contractors aad state hetheror not those entities have employees. If the sub-contractors have employees.they must provide their 1%orkers-conip policy nuniber. I am on emplo,,),ertlititi.vproi,iiiiiigivorAer.v'coiiil)eits(itioiiiiisiii-(IllcefoI.itl-llei?iplal?ees. Behau,is the policy undjob site information. Insurance Company Name: 1 2(4 ri-cl 411 Policy or Self-ins. Lic. 4: Expiration Date: 31.2 / Job Site Address:- 7 g 66 2701.2, 1 7 e,J S+. City.!State/Zip:�/Ch? 611'?70 Attach a copy of the workers' compensation police declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section ?5A of MGL c. 1752 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 Lip to S250.00 a day against the violator. Be advised that a copy of this statement inay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the plains and penalties qfperjwy that the information provider/above is In and correct. Signature: Date- 1OW7, 3 Phone -7 Of.ficial use only. Do noi write in/his area, to be completed bY Cifl,or lown qfficiat Cite or Town: Permit/License 9 Issuing Authorit'N,(circle one): 1. Board of Health 2. Building Department 3. GiN/To,au Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other LC 0 iltact Pcrson: Phone ni�nzxax l'3—L 3/11/2013 4 : 45 : 54 AM PAGE 2/002 Fax Server Ae 4� b CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) T IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS II PON THE CERTIFICATHOLDER. T IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE CONTRACT BETWEEN THE ISS AFFORDED BY THE POLICIES BELOW. LING COVERAGE AGE AUTHORIZED REPRESENTATNE 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 233 WEST CENTRAL ST FAX (A/C,No,Ext): WC,No): NATICK,MA 01760 E-MAIL ADDRESS: 22ML W INSURER(S)AFFORDING COVERAGE NAIC# FNED INSURERA: AMERICAN ZURICH INSURANCE COMPANY ANTIC WEATHEMZATION LLC INSURER B:INSURER C: EAR JEFFERSON AVE INSURER D: EM,MA M970 INSURER E: INSURER F: AGES CERTIFICATE NUMBER: REVISION NUMBER: HI I C I E ESO INSURANCE LISTED BELOWA SS D TO THEINSURED NAMEDABOVEFOR THE POLICY PERIOD INDICATED. NOT WITHSTANDING pNY 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MnODIYYYY) (MWDDIYYYY) LIMITS GENERAL LIABILITY $ COMMERCIAL GENERAL LIABILITY ACH OCCURRENCE CLAIMS MADE r7 OCCUR, DAMAGE TO RENTED S EMISES(Ea occurrence) ED EXP(Arty one person) $ GEN'L AGGREGATE LIMIT APPLIES PER ERSONAL 8 ADV INJURY $ POLICY a PROJECT �LOC ENERAL AGGREGATE g ODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE $ LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY S SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY g NON-OWNED AUTOS Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAS OCCUR EACHOCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S DEDUCTIBLE S RETENTION $ S A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY X LIMITS ORv OTHER YIN UB-56270171-13 03202013 03202014 LIMITS ANY CERIME BEREXCLUDED? CVrNE M N/A OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $ 500,000 u yess,.des yaibto e antler (Me NH) E.L.DISEASE-EA EMPLOYEE S 500,000 es DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 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 BEFORETHE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. SALEM,MA 01970 AUTHORIZED REPR 7E Ar7 7 a.%'�..,..w ..., ACORD 25(2010I05) The ACORD name and logo are registered marks of ACORD . IUUU-2010 ACORD CORPORATION. All rights reserved. I CITE' OF 5.11.E JUASSACHUSETTS ©t:ILDLNG DEP.IRTJ(ENT R4 120 WASHNGTON S TtiEET, 3AO Roott TVL (978) 745-9595 1Q1[0ERLEY 0RISCOLL FIL<(978) 7-W-9344 `�UYolt -I�to�c�ST.PiEajts D(tECTOR OF PCOLIC PROPERTY/BCILOLYG C0WUSSIONER Construction Debris Disposal AttTdavit (required for all demolition tuld renovation work) In accordance with the sixth edition of the State Building Coda, 730 ChIR section l t L5 Debris, and the provisions of MOL c 40, S 54; Building Permit is issued with the condition that the debris resulting from this work shall be disposed of­Tinaerly licensed waste disposal facility as defined by,YIGL c l It, S 150A. The debris will be transported by; LV0-4kS r (name ul'haul�r) The debris will be disposed ()fin ( ddres.t of twitily) riynanua ofpermit applicant 9 masszchusr is-Depmment of public sa-._:�4. Bawd of BuAding neg,dabons anJ Standards - - llmi:rurtion Unrestricted-Buildings of any use group which L.censaa:CS-0e7977 contain less than 35,000 cubic feet(99 im')of Mai enclosed space. ERYC W PAL.,I!1f'� 3RILTONSL I SALBMMA-01976, rF FailuretopossessacurrenteditionoftheMassachusetts - eommissioner 04/23/2014` - State Building Code is cause for revocation of this license. - For DPSLicenslnginfamationv6lr. w .Mass.Gov/DP5' a� Othec Vf C mmee'r'd�f{'etrsc °ro`d`Regn'fat * —HOME IMPROVEMENT CONTRACTOR `License or registration valid for individul use only Registration 142069 Type: - S before the expiration date. If found return to: F ; 3/1212014 Ltd tiablity" Coryor 4)Expiration: .. ORice of Consumer Affairs and Business Regulation AT'C'�4F7rICWEATHERtZATION.L).:C. f 10ParkPlaza-Suite5170 i Boston,DL4 02116 ERIC PALM , 61P.JEFFERSON AVE. - 1 - SALEM MA 01970 - Undersecretary Not valid without signature 4