22 SILVER ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
W
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CUR RevisedMar2011
ll
A� Building Permit Application To Construct,Repair,Renovate Or Demolish a T UUU One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Num er: Da Appfie
IL r/ 7L2' � tu$�Gc �
Building Official(Print Name) Signat°�e
SECTION 1:SITE INFO TI
1.I Property Address: 1.2 Assessors Map&Parcel Numbers
`Sa %0q!5 Parcel Number
Lla Is this an accepted street?yes no
Map Number
13 Zoning Information: 1.4 Property Dimensions:
Pro ed Use Lot Area(sq ft) Frontage(ft)
Zoning Distrito Pm
1.5 Building Setbacks(ft)
Front Yard
Side Yards Rear Yard
Required Provided Required
Provided Pcquired Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSIUP'
2.1 OvVn er'of Record:
`� ,�m )� )Gt 7
O0.h � t S W2.t:t1Q � ' v /,�
Name(Print) I City,State,ZIP S r '
� < �r St , �' 8�1'1 ,W ee�silAddtess
No.and Street Telephone
SECTION 3:.DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied 14- Repairs(s) 10 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg,❑ Number of Units__ Other ❑ Specify:
Brief Description of Proposed Wodtz:
SECTION 4r ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (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
J
3.Plumbing $ 2. Other fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $ Total All Fees:$
Suppression) Check No Check Amount Cash Amount:
6.Total Project Cost: $ /� �. ❑Paidin Full ❑Outstanding Balance Due:
SECTION St CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
`7p,MgL& License Number Expuraton ate
Name of CSL Holder
A) AAL List CSL Type(see below) .
No.and Street -_Type 'Description
�J / . / w &? t U Unrestricted(Buildings u el ing cu.R
a� l /f//n/� U R Restricted 1&2 Family Dwelling
Cityrrown,S IP M Masonry
RC Roofing Covering
WS Window and Siding
C' SF Solid Fuel Burning Appliances
9�0 ?pp
1496 I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) �Cr
V-4 -5 _ i�rlN - .�/
HIC Registmton Number Expi ion Date
HIComkt Natty orb J Registrant Name
No and Street
•CA, O� 9�6-99�-0690 Email address
CityfTown,S ZIP 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 Issu of the building permit
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[,as Owner of the subject property,hereby authorize ��-AAy!LS �6 /N
to act on my behalf in all matters relative to work authorized by this building permit applicationINNA
Print Owher7s Name(Electronic Signature) l Date
SECTION 7b:OWNER!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.
// /� Z
'nt er's or Amho Agent's Name(Electronic Signature) ate
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 I{�jo have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass.-govtdos
2. When substantial work is planned,provide the information below:
Total floor area(sq.fl.) (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"
02- 7ffice of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
` Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 166640
Type: LLC
Expiration: 3MG12014 Trlt 222331
AIR-TIGHT LLC. WEATHERAZATION --
JAMES FORTIN -
10 PINE KNOLL DR. ;, _
BEVERLY, MA 01915 A."',
Update Address and return card.Mark reason for cbeuge.
—_ Address —_ Renewal - Employment r-1 Lost Card
opa.GM $ S i+:iOi.CaiCi216
✓be f eneurcnrtal!/e n�, l[ax rrctFu elC License or registration valid for individul use only
office of Commuor A6Lim Boslnas RegWaHov
c HOME
IMPROVEMENT CONTRACTOR obeforeoffice
of Consumer
Affaire.s.
and BIffou d return to:
•-_y,� Office of Consumer A,ffairs.and Business Regulation
Regiahation: ie5s4o TYPa•
ExphatIon: 3115/2014 LLC 30 Park Plaza-Suite 5170
Boston,MA 02116
AIR-TIGHT LLC.WEATHERAZAT ON
JAMES FORTIN
10 PINE , OLL MA DR
BEVERLY td 01915. Undersecretary Not valid without signature
�[rssachusetts Deparrmen, of.Public S ift.t., .
,Board of Buildin r-Re-al riom and Standards-—;
Construatibn Supervisor License
license: CS 52,575 - - - -
JAMES E FORTIN
10 PINEMOLL DR
BEVERLY,`AM 01015 t `
Expiration: I(IG 013
Commivirmer Tr,— am - -
A1RTI-1 OP 1D: KZ
Ai.:OKO DATE(uwvDlYYYY)
CERTIFICATE OF LIABILITY INSURANCE 02/27/12
:REPRESENTATIVE
CERTIFICATE IS.ISSUED�:,3 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
W.. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pOlicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement($).
PRODUCER 781-9f4-1000 °ONracT
7GA Cross Insurance,Inc. NAME:
401 Edgewater Place,Suite 220 PHONE FA)--------
Wakefield,MA01880
John Scanlon 400E-MAIL
RESS:
INSURER(SIAFFORDING COVERAGE NAICk
---"—=---------. ---_---_—.___.__..--____..wlysuREaA:Arbella Protection Ins. Co. _ '.41360
INSURED Air-Tight Weatheriza0on,-IC - —"--'- ---- ----- -- -------
9 Story Ave. —_-- rb 117_0_0_0_
,.,+NsuRERe:Arbella Mutual Ins. Co.
--------------Beverly, ----------------
MA 01915 INSURER C: --
INSURER O:
INSURER E
INSURER F
COVERAGES 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 VVITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND BE
OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED 8Y PAID CLAIMS.
LTR TYPE OF INSURANCE --- -AOD13Uetf -,___ LILT EFf POLICY EI(P
POLICY NUMBER MMIDDlYWY MM)DD/YYYY LIMITS
GENERAL LUIBIUTY _
_EACH OCCURRENCE '> 1,000,00
L,AUTOM,,,L,.,,..
COMMERCIAL GENERAL LlaeiuTY .8500046432 03/08/12 03/08/13 D"FAGE RENTED— ---"'
PREm15ESLa occ;nrcnrzt _5 1)( 00
RASAIADE X OCCUR --M,ED EXP(Arry or,4 person) $ 5,Go.__ PERSONAL Z AOV INJURY S 1000__.-. GENERALAGGREGATEATE UWT APPLIES PER: PRODUCTS COMPiOA ACG 2,000,ODPRO- -LOC - _ .. "__ Emp Ben. : $ 1,000,00WBiUTY , COA981NEC SINGLE LIMIT
iiaa.. mi _ S 1,000,00_
A. _ _ANY AUTO _ 27088400004 03/08/12 03/08N3 BODILYIN!URY(perperso 1 $
ALL OWNED SCHEDULED _ _
_ AUTOS _X,AUTOS BODILY INIURY IP r acc:dam),5 — -- — -
X !HIRED AUTOS X_; NON-OAUTOS INNED - 7 PROPERTY DAMAGE--
. lPar amaemL
FEXCESS
SRELLA UABOCCUR _ EACHOCCURRENCE__ 5 1000,00CESS UAB _CLAMS-MAD_ _ '4600052930 03108112 03/08113 :acGREGarED X :RETENTION$RS COMPENSATIONPLOYERS'LIABIUTV L^tC STATU- OiH-
YIN - - —AR_ LIIr]
OPRIETORIPARTNERRXECUTIVE,,—e:14VABEREACWOEDI I /'NIA _. - ELEA:H ACCIDENT :S
ary in NH)n."coueL DISEASE-EA EMPLOYEEIPTION OF OPERATIONS tame EL DISEASE-POUCYLIfvIIT;S ~—
DESCRIPTION OF OPERATIONS:LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required)
CERTIFICATE HOLDER CANCELLATION
MOYNIHA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIESBE CANCELLED BEFORE
E82RiverStreet
n Lumber CO. 7
THE EXPIRATION DATE THEREOF,. NOTICE WILL 'BE DELIVERED 1N
ACCORDANCE WITH THE POLICY PROVISIONS.
A 01915
AUTHORM:ED REPRESENTATIVE
_ ID1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
— � ine-commonweturnoJinassacnusetrs
Department of lndustrial,Aceidents
Office of Investigations
600 Washington Street
Boston,MA 02111
up www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual): (�li(RTyC-.a•;� w .ATf�'�J`i7L��o�
Address: 02 A
City/State/Zip: 61 ZLS�— Phone#: ?7$- 9�c4— 4�68 r
Are you an employer? Check the appropriate box: Type of project(required).
1.ID( I am a cinployer with_ _ 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet I I- Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required-] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner 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 12.0Roof repairs
insurance required.]t employees. [No workers' 13.0 Odter
comp, insurance required.]
Any applicant that checks box#1 must also fill out the section below sbowing their workers'compensation policy information:
t nomeowners who submit this affidavit indicating they are doing all wark and then lme outside conhactors must submit a new affidavit indicating such
!Contractors that check this box must attached an additional sheet showing the name of the subwatractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. n
Insurance Company Name: Na G� an ( t) 2Y/�
Policy It or Self-ins.Lic. A i W 1 Z�)S.5- Expiration Date: .& ,445
Job Site Address: - 2 s/l t.�,_ ✓� CiCity/State/zip: 7:3A��tt t /(M OPM
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 e.452 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$250.00 a day against the violator. Be advised that a copy of.this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify an sins and penalties ofperiury that the information provided above is true and correct
Si ature: �7 Q Date:
Phone#: Y66V
Official use only. Do not write in this area,to be completed by city or town offWal.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Totvn Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I
MOYNIHAN LUMBER OF BEVERLY, INC.
"QUALITY BACKED BYA DESIRE TO PLEASE"
82 River Street P.O. Box 509 FEIN:04-2261995
Beverly, MA 01 91 5-0509 004AA Contractor Reg No.:
978-927-0032 96 Exp. Date:
Salesperson(s):
HOMEOWNER INFORMATION
Name / Daytime Phone
Street Address(Not P.O.Box) Evening Phone,��/�
01,970
City/Town State Zip Code Mailing Address(d different from Street Address)
WORK TO BE PERFORMED AND MATERIALS TO BE USED
Moynihan Lumber of Beverly, Inc.agrees to perform the work set forth in Exhibit A for Homeowner and to
use such materials in connection therewith as set forth also in Exhibit A, attached hereto and made a part
hereof.
The following schedule shall be adhered to unless umstances arise beyond Moynihan Lumber of
Beverly, Inc.'s control:Work scheduled to b n: _/ / Expected date of completion _/_/—
Ma be u namva/of 'al order material
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
Moynihan Lumber of Beverly, Inc. agrees to erfo t work, and furnish the material and labor set forth in
Exhibit A for the Total Contract Price of:$ (which amount includes all finance charges).
Paymentsss,�halo%e made by Homeowner according to the following payment schedule:
$ Ff00. Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of
one-third(1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom
Ord rs as s f forth below).
$ by_LLor upon completion of delivery of materials
$ by_/_/_or upon completion of install
$ upon completion of the Contract
In order to meet the comple ' schedule set forth above,the following materials/equipme ust be special
ordered before the Contra work begins,for a Total Cost of Special/Custom Orders of
$ to be aid for building permit
$ to a paid for
$ be paid for
DO NOT SIGN THIS CONTRACTIF THERE ARE ANY BLANK SPACES
Q6ies )I I I�II`1 Moynihan Lumber of Bevet Inc. // �� �z
Home er's Signature 1 Date T� Contnictor �f/�D toe
ByZ
Homeowner's Name(Printed) Nam9(printed)and Ti le of Signatory
You may cancel this Contract If it has been signed by a party thereto at a place other than an address of
Contractor,which may be its main office or branch thereof,provided you notify Contractor in writing at
Its main office or branch by ordinary mail posted,by telegram sent or by delivery,no later than midnight
of the third business day following the signing of this Contract See attached notice of cancellation for
an explanation of this right.
1057-ecv 4/09 whhe-o five Yolk..-:,alas rar.iaa Pir.::-C y:O.T.cr Pe^^1 of 5 .