0038 SALEM STREET- BPA j` The Commonwealth of Massachusetts
Department of Public Safety
\I,rs.achu.clt.tiLite Building C'ude(780C\IR)tievenlh Editio
City of Salem
Building Permit Application for any Building other than a I- or 2-Fn mij D e n
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block M and Lot 0 for locations for whic t of available)
ig S k w\ S 4)curl /!1 O l9 76
.No.and Street City /Town Zip Code Name wilding(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or constnation documents being supplied as part of this permit application? Yes ❑ No 0'
-Is an Independent Structural Engineering Peer Review required? 11 Yes ❑ No 2'
Brief Qescriptiun of Proposed Work: A: r S,c...� A }�,� C c-
lc�J/GwL -10,1 Aa>r �f
3.A1 Ju.l4-t'L f'r G4.1 (b'C�
c.f-(f4 loses aft
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): a YQ— 14 ; Proposed Use Group(s): >
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: t! Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 CI
1: Institutional 1-1 ❑ 1-2 O 1-3❑ 1-4❑ M:�Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ 11813 j IIIA ❑ IIIB ❑ 1 IV Cl I VA VBO
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public ❑ Chuck it outNide Flood Zone❑ InC110(e municipal ❑ A trench will not be Licensed Disposal Site❑
required ❑or trench or speci lc:
I'n cah•Cl or indcntil'v Zone: or on site s�strm ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \L\ I h,1,,nc( mmm-wn Hrcn„ forest
\ot \ppbadde ❑ I.SiructurC%r thin airport approach area' Is their recie,c completed.'
or C'msont to Budd enclosed ❑ I 1'Cs Cl or No❑ 1'es❑ \n ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
Fdnnm of C odC: L'sr(;rouplsl: rt pe of Construction: Occupant I ood per Flour:
I)ors the budding;contain an Sprinkler ticdcm': Speoal Stipulations
a
SECTION 9: PROPERTY OWNER AUTHORIZATION
:Vame,uid Address ul Properly Ownrr O/4 7d r
E�� ` E wS � � 3�f So_1 e ,.•-� Sf- S.e)e,�
Name(Print) tom_ Nu.end Street City/Town Lip
Property Ov,ner Conrad Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the pruperlp owner hereby authorizes
Name Street Address City/Town State Zip
to act on the +ro Verty owner's behalf, in all matters relative to work authorized by this buildin • permit a > >licatiun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(II buildin•is less than 35,Wo cu.ft.of onto d s+ace and/or nut under Construction Control then check here O and skip Section IU.0
10.1 Registered Professional Responsible for Construction Control
�l, 1"o ✓� 97 S -?Yq - W113 T Pa1.n') o l Q8�9
Name Telephon No. a-mail addre Registration Numb
eyy
( f /L �a /� `ice-✓l_� 7.}" ��n ,JAL
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cum any Name: ��77
e , � 1 r,, 1 7'7
Name of Peres ggrspunsible fur Cunstntction License No. and Type if Applicable
'S it Sr- � 0,97.0
Street Address City/Town State Zip
7% -1"- R//`/.3 1031 "T P C i C�Ca>r1C
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the iss ce of the building permit.
Is a signed Affidavit submitted with this application? Yee No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 'g.206. do (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
applicationnis'true and accurate to the be/stt tit my knowledge and understanding.
�r r 1"�Wl l�il ;'iL UUrly 1 01 JVy'- Flo
I'Ica.c pr nt am ign name Title Telephone No. Dale
street :Address Citc/Town State Zip
lfunicipal Inspector to fill out this section upon application approval:
Name Dale
AC,ORq CERTIFICATE OF LIABILITY INSURANCE 0ATE 3116/201Y
03/16/2011
PRODUCER 508.651.7700 FAX 508.655.8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC - Main ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
233 West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Natick, NA 01760
INSURERS AFFORDING COVERAGE NAIC#
INSURED Atlantic WBatheri48tiOn LLC INSURER A: Arbella Protection Ins. Co. 41360
61 Hear Jefferson Avenue INSURER B: Arbella Indemnity Ina Co. 10017
Salem, MA 01970 INSURER C: Chartis
INSURER D: Nautilus Insurance Company
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSRADD' POLICY EFPE POI EXPIR ION
L R TYPEOFR[SUFUNCE POLICY NUMBER PATE M6, E DATE MMIpD Y UMRS
OENEAAL LIABILITY 8500042816 03/20/2011 03/20/2012 EACH OCCURRENCE E 1 000 000
X COMMERCIAL GENERAL LIABILITY LU
_ PREMISES Ea o¢unenw E 50,00
CLAIMS MADE O OCCUR MED UP(Any one eerwn) E 5,000
A PERSONAL B ADV INJURY E 1,000,00C
GENERAL AGGREGATE $ 2,000 000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E 2 000 000
POLICY X JEC LOC
AUTOMOSIM UABRITY 93827400003 03/20/2011 03/20/2012 COMBINED SINGLE LIMB
ANY AUTO (Ea a Bern) E 1,000,000
ALL OW NED AUTOS
X SCHEDULED AUTOS OILY INJURY E
B ( personl
X HIRED AUTOS
RY
X NON-OWNED AUTOS (Per le IdLY e t) $
PROPERTY DAMAGE E
(Per aodtlent)
[GARAGE LIABILITY AUTO ONLY-EA ACCIDENT E
ANY AUTO
OTHG ONLY: EA AGO E
AUTO ONLY: AGO E
EXCESSIUMBRELLAUAWLTTY 4600047820 03/20/2011 03/20/2012 EACH OCCURRENCE _ E 1,000,000
X OCCUR CIAIMS MADE AGGREGATE E 1,000,00 0
A
E
DEDUCTIBLE
E
RETENTION E wo E ,
RKERscoMPENSAnox WC1616071 03/20/2011 03/20/2012 X AND EMPLOYERS'UABILTTY LA
LIMITS ER
-
ANY OFFICERa1EMBPROPRIETER EXCLUDED ECUTIVE JOTH
� E.L.EACH ACCIDENT E Soo 000
(MaMd..rI NH) LJ E.L DISEASE-EA EMPLOYEE E 500 00C
It Ir.atory In antler
SPECIAL PROVISIONS Wow E.L DISEASE-POLICY LIMIT S 500,000
OTHER CPLO152189210 10/01/2010 10/01/2011 General Aggregate - $1,000,000
POLLUTION LAxaxLxTY
D Each Pollution Condition -
nON OESCRIP OF OPERATIONS/LOCATIONS(VEHICLES/IXCLUSIONS ADOEO BY ENDORSEMENT/SPECIAL PROVI SIONS $1,000,000
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR UABILTrY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
CITY OF SALEN REPRESENTATWES
93 WASHINGTON STREET AUTHOR�DREPgFSEMATWE ���
SALEM, MA 01970 Rosemary Fulham/PMA
ACORD 25(2009/01) W 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Department of Industrial Accidents
Office of.Inveogations
600 Washington Street
Boston,MA 02111
www.mass.gov7d1a
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information: Z+lease Print Legibly
Name (Business/Organization/Individual): A ° Wc '�s��1: ! �< 7 tirR
W
•Address:
/City/Statezip: /I- 01q?v - Phone#: 9
Are youuA°employer? Check the appropriate boa: Type of project(required):
1.&I am a employer with 4. 0 I am a general contractor and I
�P Y � 6. ❑ New construction
cmployees(full and/or part-time).' have hired the sab-conuacoors
2.C] I am a sole proprietor or parmer-: listed on-the attached sheet.t y RemPdelmg
ship and have no employees These sub-contracum have 8. []Demolition
working for me in any capacity. workers' comp.insurance. 9. C].Buiiding addition
sur
(No workers' comp. inance 5. C1 We are a corporation and its 10.❑ Electrical repairs or additions
required] officers have exercised their
3.Cl I am a homeowner doing all work right of exemption per IVIGL I I.[: Fltmtbing repairs or additions
myself.(No workers' comp. c. 152,$1(4),and we liave no 12.0 Roof repairs
insurance required.] t. employees.(No workers' 13.0 Other
comp. insurance required.]
•Any applicant that checks box kl must also till out the section below showing their workers'compensation policy infotmatlon
t Homeowners who submit ails affidavit indicating they are doing all wmk and then hire outside comultm must submit a now affidavit indicating such.
,Convectors that check this box must aneehed.a s additional:sheet showing Use nanteofthe sub•eomractors and their workers'comp.policy Wotmstion..
I am an employer that Is providing workers'compensadon imurance for my employees.::.$elow Is the polity and Jpb Are
Information. /
insurance Company Name:
✓Policy#or Self-ins.Lie. #: y 0 1 Expiration Date:
Job.Sim Address:_S� 5� City/Statetzip: 5-41-� �l/f
Attach a copy of the workers' compensstiou policy declaration page(showing the policy number and expiration date).
Failure to secur.e coverage as required under Section 25A of MGL c..152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisoagnent,as well as civil penalties is the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the,violator. Be advised that a copy of this statement may be fotwarded.to the Office of
investigations of the DIA for insurance coverage verification.
1 do hereby cerdfy under the pains and penalties of perjury that the Inform,don provided above is true and correct
Z.
✓c am,,r,• ?/j �/y �-' Date: //2 // 2-
/.Phone# �7 �' — ) VV- /Y"?
Official!use only. Do not writs in this area,to be completed by city or town otlteial.
City'or Town: Permit/f:lceuse#
Issuing Authority (circle one).
1.Board of Renith 1.Building Department 3.C1tylTowu Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
Contact Person. Phone#t_
r' pt4 t tn'y21( 7z' L�tSCv$
�7, �- C�lt, h 5 f'(vw' T2. Cti Cr0�,44 a'fh c C-e.1 vt
yt-vve_
Action .Inc. ottv
47 Washington Street
Gloucester, MA 01930
Tax Exempt# 042-389-332
Agency: ACTION
PROGRAM: LIMF
JOB NUMBER: 1403584
Did ESC? No
Work Order# 1403584
Work Order Date: . 12/20/11 Enter information below:
Contractor: Atlantic Wx #Bulbs installed
Cost of Bulbs
Client: 38 Salem Yelsae Co K&T Inspt$125.00 Max $0.00
Street: 38 Salem St other In Kind
City; State; Zip: Salem, Ma 01970 Electrical Work
Telephone: 978-745-5892 $Amount KeySpan $0.00
$Amount National Grid $0.00
Blower Door Test: No Other utility $0.00
Inspect Knob &Tube: No
Date Job Completed: Estimated Repair Total $300.00
Actual Repair Total $0.00
Weatherization Est Act Cost I Est Cost Act Cost
Door kits 21 $43.00 $903.00
Door swee s 21 $15.00 $315.00
Auto Sweep $22.00
Caulking per tube $13.00
Air sealing two part foam 8 $75.00 $600.00
Weatherstrip Window/Side $4.25
Glazin Persash $10.00 t
Glaze cellar window $6.54;$-,,818
WeatherizationTotals: . 00
Insulation Est Act Cost Est Cost Act Cost
DHWT - $33.00
Hydro ic e up to 1" 15 $3.25 - $48.75
Attic flat R38 $1.40
Attic stairs per stair well $112.00
Attic sloe R20 $1.35
Attic Flat restr R-30 4000 $1.41 $5,640.00
Interior wall blow $1.34
Kneewall floor RW $2.00
Wall R14 wood sh /cla DP $1.70
h dronic Pipe 2" R-5 55 $6.05 $332.75
R-5 Ductwrap or R-max on door $36.50
Insulation Totals: $6,021.50 $0.00
0 Page 2 DOE 1403584
Other E.C. Measures Est Act Cost Est Cost Act Cost
Roof vent 1 sq ft Large $84.00
Roof vent.4 sq ft small $66.00
Close SxFopeninq to attic $175.00
Test drill 4 sides $53.00
Replace sash 74-83 ui $327.00
Replace sash 83-93 UI $368.00
Blower Door test $45.00
Other Totals: $0.00
Energy Conservation Est Cost Act Cost
Totals:(Max$4000.00) $7,839.50 $0.00
Repair. Est Act Cost Est Cost Act Cost
Repair/Refit Door $50.00
Door handle $6.00
To—uch-up paint on siding $75.00
Sash Lock top or side $7.75
Move items in kneewall area $52.00
Cut finish attic-kneewall access 2 $100.00 $200.00
Cut close attic-kneewall access $75.00
Health&Safety '
Permit 1 $100.00 $100.00
Vent bath/dryer $70.00
Repair Tot: Max$600.00 $300.00 $0.00
Work Order Sub Total: $8,139.50 $0.00
C` ,-4,� ,1,,
Measures Est Act Cost Est Cost Act Cast
Exterior Storm Windows
Heating S stem Repair $500.00 0 $0.00
Estimated Job Total: $8,139.50
Job Can not exceed: $4600.00
Minimum $200.00 for DOE credit Job Grand.Total: $0.00
... e, .+, . ..:.: .a +.✓`*�..��«. ., .ova„i.d . _. �.Ff�z�.i z.'^8. .. ..,...va..-. ..>ro�:�a r -:.,1+ ��.t ...., -.xY'���'.
Restricted to: 00
Massachusetts- Department of Public Safets 00- Unrestricted
Board of BuildingRegulations:mdStandards 1G-12 Family Homes
Construction Supervisor License _
License: CS 87977
Restricted to: 00
Failure to possess a current edition of the
ERIC W-PALM ; Massachusetts State Building Code
3 HILTON ST is cause for revocation of this license.
SALEM, MA 01970 s .
- I Refer to: WWW.Mass.Gov/DPS �,a
Expiration: 4r3M12
('omiuis>ioner Tr#: 22214
��e-t�omnxmuaealt/ ��t( r/u„> Q License or registration valid for individul use only
before the expiration date. If found return to:
„ Office of Consumer Affairs&Business Regulation before
of Consumer Affairs and Business Regulation
6 HOME IMPROVEMENT CONTRACTOR 10 Park Plaza-Suite 5170
Registration:_142089 Boston,MA 02116
Expiration: 3112/2012 Tr# 292174 1..
Type: Ltd Liability Corpor �J
ATLANTIC WEATHERIZATION L.L.C.
ERIC PALM e
61 R JEFFERSON AVE Not valid without signature -
+SALEM,MA 01970 - Undersecretary