1 RIVERWAY RD - BUILDING INSPECTION G
The Commonwealth of Massachusetts
Q Board of Building Regulations and Standards FOR
m MUNICIPALITY
Massachusetts State Building Code,780 CMR, 7 edition USE
Building Permit Application To Contra air,Renovate Or Demolish a Revised January
One- or Two- amily Dw lung 1, 2008
This S tion For OffiI Us my
Building Permit Number ) Dat red:
Signature: Jd
Building Commissioner/Inspecto of Buildm Date
SECTION"r.SITE INFORMATION
1.1 Pyope Address: 1.2 Assessors Map&Parcel Numbers
X / 11621la
LIa Is this an accepted eet?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:
Zone: Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 /7 ,
X dea vt C'a��wi,er X 1 luk1
Name(Print,.. Address for Service:
X - X q n -7L/y
SignatukJ Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other WI Specify:
Brief Description of Proposed Work': Insulation - Walls R-14, Attic R-38
Door Weatherstripping other weatherization measures
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ X 1. Building Permit Feer$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
❑Total Protect Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) S List:
5.Mechanical (Fire $Suppression) Total All Fees:$
f,pp�� Cr-) heck No. Check Amount: Cash Amount:
6.Total Project Cost: S X 54, 1N:V r Q' 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 96385 10/08/2012
Romain Strecker License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) Unrestricted
10 Churchill Place Lynn MA 01902
Address Type Description -
�� U Unrestricted u to 35,000 Cu.Ft.
R Restricted l&2 Family Dwelling
Signature V M Masonry Only
781 7106637 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 169145
Romain Strecker _ Age
Building Technologies
HIC Company Name or HIC Re rs[mnt Name Registration Number
2 Neptune RD #439 O'Stor MA 02128 5/20/2013
Address
781 710 6637 Expiration Date
Signature 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 of the building permit.
Signed Affidavit Attached? Yes ..........WX No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�h ,n /� r
I, Xyab CAiras Owner of the subject property hereby
authorize Romain Strecker - American Building Technologies to act on my behalf,in all matters
relative to work authorized by this building permit application. G�
X ((7 , X
Signature caner ""'" Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, Romain Strecker - American Building Technologies,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.
Romain Strecker - American Building Technologies
Print Name
Signature of CVner or Authorized Agent Date
(Signed under the pains and penalties of a 'u
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 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'
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ai mlicant Information Please Print Legibly
Name(Business/aganimtion/Individual): Romain Strecker - American Building Technologies
Address: 2 Neptune RD #439
City/State/Zip: Boston MA 02128 Phone#: 781 710 6637
Are you sm employer?Check the appropriate box: Type of project(required):
I.M I oma employer with_7 4. ❑ I am ageneral contractor and t 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑.I am a sole proprietor or parmer- listed on the attached sheet.t 7. ❑.Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[Nonworkers'comp.insurance 5. ❑ We are a corporation and its I0:❑Electrical repairs or additions
required.] officers have exercised their -
3..❑ 1 am ahomeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers'comp. c.152,.§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.[No workers' 13 El Other -
comp.insurance required,]
•Any applicant That chmks box#1 must 21M fill can the section below showing thcv workers_compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mosrsubmii a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing die name of the subcontractors and their workers'comp.polity infcarra on.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Liberty Mutual Group
Policy#or Self-ins.Lie.#: WC231 5372122 Expimtion Date: 3/1%2���1
Job Site Address: X _� j/,Q.f(/L City/State/Zip: X c
Attach-e copyof the workers'compensation policy declaration page,(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25Aof MGL c. 152 can lead to the imposition ofcriminal 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 upto.$250.00 a.day against the violator.. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under a pains and penalties of pesjurythat Lire information provided abovvee is �je old
correct.
c ...,,u o. 7 Date: X
Phone# 781 71Y 6637
.Official use only. Do not write in this area,to be completed by city or town offretat
City or Town: Permit/License#-
Issuing Authority(circle one):
L.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
� �'I f � � � s �1t.i1\;li�t4t\E 91 iityl:ii 3(t}41LF as �3gti�lt'�'R��C'Cti•
surtler 1, f" "nets Zt! rs ri,
OtRcep ensnmot ars a smrss t¢uniwn 9 ituard a➢il3slidlnp!Rt uiJtitrl,mid wmi.trd!
r•- GNOME IMPROVEMENT CONTRACTOR ..+ Construction Supervisor License
Registration x169145 Type:
Expiration 5/2012019 LLC -License. GS 96365
AM CAN BUILDING TECHNOLOGIES.LLC..
x S
RQMAIN STRECKER -�
ROMA4N STREOKER't' i� 10 CHURCHILL PLACE }
u` 2 NEPTUNE RD'1W39 " ' _ ,,�- LYNN, MA 01902
z
" BOSTON.MA 02128 1 :Undersecretary
cxpirauon; 70/812012 -
4 aanuas6v4nP Tr�- 4344
American uildin Technolotes
f,.¢n.:x;p[:Gt�a:'lsnn;;l:iArts .
. Romain Strecker
Rsnainu#x51.w_n:."fAu.N�ctazgL=eia:o?o$z�cem
06/06/2011 21:11 17815955820 AMBROSE INSURANCE PAGE 01/01
qcc�� CERTIFICATE OF LIABILITY INSURANCE 6/7/2011 Y.YI
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 pollcy(les) most be endorsed. If SUBROGATION 19 WAIVED,subject to
the Lerma and conditions of the policy,certain policies may require an endorsement A statement on this Certificate dean not confer rights to the
certificate holder In lieu of such andomement(s).
'RODUCER
Ambrose Insurance Agency, Inc. PnDrvE 781-592-8200 un Na 781-595-5820
56 Central Ave.
Lynn, MA 01901 AM to a
boM RIDa
INSUBEINS) APPOROINO COVERAGE NAICM
JSURED American Building Technologies LLC INSURER A:Atlantic Casualty
INSURER B:Arbella Protection
2 Neptune Rd. , #439 INSURERc:Liberty Mutual
Boston, MA 02128 INsuEg.B National Union of Pittsburgh
INSURER E;
INSURER F!
:OVERAGES 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.
I;y EFF POLICY EAP
Le TYPE OF INSURANCE, AUM Ixea me POLICY NUMBER MMNUM'YY MWVDLIMITS
GENERAL LIABILITY - EACH OCCURRENCE s 1,000,000
X COMMERCIAL.GENERAL LIABILITY PREMISES Me occurrence) S 50,000 _
CIA1M&MADE LKODCCUR MED EXP IAry me Perron) ; 5,000
A L035-008370 10/17/10 100-1/7.1 PeASONAL I AM INJURY s 1,000,000
GENERAL AGGREGATE 7-2-700
GEN1L AGGREGATE LIMIT APPLIES PER; PRODUCTS•OOMPIOP AOG S 11000,000
POLICY P LDC ;
AUTOMOBILE LIABILITY CO(ED BINEDi)INGLE LIMIT 5 1,000,000
ANYAUrD BODILY INJURY(Par Parson) S
ALL OWNER AUTOS BODILY INJURY(Per weldenp $
B X SCHEDULED AUTOS 90593400003 3/9/11 3/9/12 PROPERTY DAMAGE s
HIRED AUTOS (Fer..Wnt)
NON-OWNED AUTOS S
;
UMBRELLA LIAROCCUR EACH OCCURRENCE 111,000,000
D g EXCESS LIAR CILVMS•MADE AGGREGATE f 1,000,000
DEDUCTIBLE, $Bu401458042 10/17/10 10/17/11 ;
RETENTION $ ;
WORKERS COMPENSATION I WRSi�T
AND EMPLOYERS'LIABILITY
•• ANh' PROPPRTGRPARTNERIIXCGUTNE Y� NIA WC23IS372122 3/10/11 3/10/12 E.L.EACH AC $ 11 00,000
DFFICEanau,R R BXCG10eDr 1,000,000
pl.."n In JIM E.L.DISEAS E-CA CMPLOYEE ;
1I 06,f109flib0 untlnr
DPSCRIPTION OF OPERATIONS belwv E.L.DISEASE•POLICY LIMrf 8 1/-00010 0
PPSCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 1011 AddelWal RemarkS Schedule,lI men spnca In mqulmd)
arpentry & Insulation
ERTIFICATE HOLDER CANCELLATION
Conservation Services Group SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
40 Washington St. , Ste. 300 THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
Westborough, MA 01551 ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENT '
I Z000�
1 88-2009 ACORD CORPORATION. All rights resorvad.
CORD25(2009109) The ACORD name and logo are registered marks Of ACORD
ACTION, INC
47 Washington Street
Gloucester, MA 01930
Agency =' NSCAP NGRID Application#:
- PROGRAM. _ AARAWAP 0
JOB NUMBER:
DOE.Work Order#1 0 E.S.C.performed? N-0-
Work;Order Date: _ 07/07/11
Primary Contractor. .:` American Building Technologies
-= Other Coiltractori '' '�Cliffo_rd,Beckford i `#Bulbsinstalled _ '-$0.00
Cost of Bulbs $0.00
- - Client: Jean Cormier - - Inspt$175.00 Max - $0.00
1. _-_- Street: :1 Riverway Road, ". Other 7n Kind - 50,00
- _ City; State Zip: Salem,Ma. _ "-- 01970 Electrical Work $GAO
Telephone 978-744-5907 . ;. $.Amount KeySpaq $0;00 `
Amount,National Grid $0.00-.
1,Blowerpoor.Test - Yes - - - - Other Utility $0 oo
- Inspect Knob_&Tube. No -- - -
Date Job Completed:. Estimated Repair Total. $400.00
Actual Repair Total $0.00
Weatheriz_atimi Est - Act Cost Est Cost Act Cost
Door Kit. 3 $43.00 $129.00
Regular,Door Swee -- : - 3 - $15':00- -`' $45100 - -
Automatic Door Sweep- $22.00
Air Sealing-2-part Foam(per hour).. 3 -$75.00 -$225.00
Ai "AuS�i�g2-p.F..(per .,) 2 $75.00, $150.00
Weatherstrip Window(per side) 8 - $5.00 _$40.00
Sea]Ducts-Mastic - $62.00
W/S-&Insulate Attic Hatch R30 1 $30.00 1 .$30.00
- $0.00 - ..
$0.00 -
$0.00
$0.00 _
- $0.00
$0.00
WeatherizationTotals: $619.00 $0.00
Insulation Est Act Cost Est Cost - Act Cost
Attic
FlatR38open,
- 1158 $1.40. $1,62L20.
Attic=FlatR30.o n = - - - $1.30
Attic Flat/Slop6s R30 restricted - $1.41
Attic-Flat/Slopes R20 restricted -$1.35
Attic Kneewal:Rl3 FG-. $1.25
Attic Kneewall-RI5 Cell w/Membraner $1.65.
Attic KdeewallFlour R30 restncted $1.41-- -
InsulateAttic-Stairs,&'Walls - - $130.00
Sidewalk.-Vin 1R15 DP- _ - 908 - $7:70; x $1,543.60 _ -
InieriorWall.-Plaster-R15'DP ' 210 $1-.81 $380.10_
1"Rigid Foam Board- $1.85 -
Duct insulation k5&SealSeams $2.95
Aydronic Pipe Insui to I"R5 . - $3.25
Steam Pi a lnsul to 1.25"RS $5.25
DHW Pi lnsuation R5-- _ 6 $2.50 $15.00 _
Insulate.Door w/FB(I"min) 1 $44.
Sill 2-part Foam w/FG Batt R19 148 $2.00 _ $296.00
Insulation Totals: $3,899.90 $0.00
Jean Cormiei."- - - - Page-2- _- -- DOE - - -0 -
.Other Measures Est- -- - Act Cost;".- - Est Cost Act Cost --
RoofVenf sma0' - - j $75.00- -
GableVint-rectanlar 2 $88.00 $176.00
Recessed Can Cover $30.00
Cut/Fimsh-Attic/KneewalPAmess $100-.00
Test Drill:Sidewalls7-4'sides' _ $60:00
Blower-DoorTest e - 1 - $45.00 $45.00
Vinyl Replacement Mindow.- l0lut ->:• - $350.00.- - - - - -
Steel Pre-hun- Door w/Lite - - $610.00 - -
SolidCore-Door w/Hardware $350.00 _
Faucet Aerator. - $15.00
Low Flow-Showerhead - $25.00 - -
- $0.00 - -
"- -$0.00 .
-- - - $100.00
Other Totals. �- F _ _ $221.00
Energy Conservation`, - - - Est Cost Act Cost
Totals:(Max$10,000700)- $4,739.90 $0.00
Repairs - .Est. Act _ Cost Est Cost Act Cost -
Re air/Refif Door -2 $50.00 $100:00
Clean-Gutter-sGutt&-s(pir hr) 2 $60.00 $120:00.
Be air OutterBhead Door- '- I $40.00' - $40.00 .
$25.00
Slide Bolt--z n. - 2 - $20.00 $40.00
Sash Lock $9.25
Glass Replacement-to 64 ui 1 $42.00
Sit>Wm ter.Bulkhoa Doo,w/Jmb, $415.00 -
BuildingPermitFee - - 1 - $]00-00 --$100,00- _ -- -
$0.0.0-
Health&.Safe
VentClothes Dryer,to Exterior $85.00 -
vent Bath Extiaust Pan to Exterior - $85.00
Replace Dryer Hose - $38.00
Knob&Tubc-lns ction - $175.00
Bathroom-Exhaust Fan - $500.00 -
$0.00 -
Re air Tot:{(Max$2500.00) $400.00 $0.00
"-"Work`Order Sub Total: $5,139.90 $0.00
Measures" • °' - Est - - Act '- Cost Est Cost�- Act Cost:
Other-: $0.00
Other - - $0.00
!*Heating System Repair I $0.00 I I $0.00
•"Action approval only - - - - -
Estimated Job Total: $5,139.90
Job cannot exceed$10;000.00
Job minimum $500:00 Job Grand Total: $0.00
r AUDITOR: Doug Cranford