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2D SPRUANCE WAY - BUILDING INSPECTION (2) The Commonwealth of Massachusetts ctDepartment of Public Safety i- J. � \husathust•tIs SLUG Building Qair(7811 C\IR) Building Permit Application for any Building other than a One-or Tsvo-Family Dwelli g (Phis SCclion For Official Use Only) Building Permit Number: _ Date Applied: . _ Building Official: SECTION 1:LOCATION(Please indicate Block k and Lot N for locations for which a street address i t available) No.and Street City/ own----------/ip Codc Name of 1iuildinl (u h}hplicable) SECTION 2:11110POSED WORK _ FJilion of NIA Stale Code used—_ If New Construction check here❑or click all that apph, in the two rotes below Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change-oPUse ❑ Cil,utgCof000upanCV ❑ Other ❑ Specify: _ Arc building plans and/or construction dtwumenls being supplied as part of this permit application? Y'es ❑ No (U/! --__- Is an Independent Structural Engineering Peer R ww rct sired? J ' ' Yes ❑ No m/ Brief D• cription of Proposed 11'ork;___ SECTION J:COMPLETE rills SECTION IF EXISTING BUILDI G UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here Lin Existing Building Investigation and Evaluation is enclosed (See 780 CMR 14) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Fluor(sit. ft.) Told Area(sq. ft.)and Total Fleight'(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A•'_❑ Nightclub ❑ A-1 ❑ A-i❑ A•5❑ 0: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ ❑ 1- Ili h Inxad H-1 ❑ H-2❑ I1-3 ❑ 11-a❑ Ii-5❑ ca 7—Residential R-I❑ t2❑ R•1❑ R- ❑I: Institutional I-1 ❑ 1-2❑ 1.1 tile❑S: Storage Sl ❑ 5.2❑ U: Utility❑ Special Use❑and please describe below: Special Use SECTION 6:CONSTRUCrION 7-YPE(Check as a licable) IA ❑ Itl ❑ IIA ❑ 11B ❑ ILIA ❑ 111B ❑ IV ❑ VA ❑ VIS ❑ SECTION 7:SITE INFORNIA'FION(refer to 780 C-MI(111.0 for details on each item) Water Supply; Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Mood Zone❑ Ioditale municipal❑ A trench will not be Licensed Disposal Situ❑ required ❑or trench or specify:... ._ I'rivalc❑ or indentify Zane: or on site vystCnh ❑ permit is enclosed ❑ _ Railroad right-of-way: Ilizards to Air Navigation: •i ' ' , , . ,1.,l., Nol:\ppli,,ible❑ Is Struclu re within airport approac It.I rea? Is their r,•v ietr crnnplclyd' or C,m,ant to Blold Cnclo,etl ❑ 1 es❑ or.No❑ I 1','s❑ N'o ❑ SEC'nON 8:CON IFNT OF(TR I IFICA 11;Of OCCUPANCY I Jilinn A Cade: .... - -_ C'so Gras pp): - ... . . I\pe of Coomrmnoll: U„up,uht load par liner I hoe, t he building wtoom,m Sprinkler S\ wtn' tipec iol Shpul,dions: _ SECTION v: I'It011l:li'IY O1VNIilt AU'I'IRLIt[ZA"[ION N.uur nd Address ul Prol,rrh'OMIL,r u Name(Print) No.and Street City 'Tuwtu Zip Properly Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) a-mail address If opplicable, the property owner hereby authorizes Nance Street Address City/Town Stale Zip to act on the property owner's behalf, mall mutters relative to work authorized by this bLJildillg iermit,r , licalion. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2). If buildin t is Inns than 35,000 cu.ft.of enclowd.s rose and or not under Construction Control then check hem O and.ski Section 10.1) 10.1 Registered Professional Responsible for Construction Control Name(Rc,istmot) "rcic hone Nu. c-mailaddress Registration Numbs Sheet Address City/Town State Zip Discipline ExpiraA 10.2 General Contractor rt� 1�9v � (� _ 3 Name r- _ ,f Person Res onsi" ICunstruc ion License No and Ty{x if cabl Slrcet Address ity/Town State Zip Telephone No. business Telephone No. cell a-mail address SECTION 11:,wir'KI1,:, r, ,xlrr���::�rlt�Nl•��,ur.\.Vt.'i'.\IrmaAMl M.G.L.c.152. 25C6 A Workers'Compensation Insurance Affidavit from the NIA Department of Industrial Accidents must be cmnpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this a lication? Yes O No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor �Z n ©® and Materials) Total Construction Cult(from Item 6)=S G.JCJ I. Building $ Building Permit Fee-Total Construction Cost x—(Insert here 2. Electrical S appropriate municipal factor) =5 3. Plumbing �. \Icvhanir 11 (HVAC) S Note: Mininnun fee-$ (contact municipality) 5. .Mechanical Other) S F.nduse check pocuhle to b, Total Cult ti (contact nwnicipality)and write rhak nunilx•r here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Itv entering my name below, 1 hereby altest under the pains.uul penalties of perjury that all of the information Cont,1incd in this o ,p l icdtion is true and accurate to the best of my knuw Ictige,u1LI understanding, I'lease print mnl sign n,un• I'ttle 1clephnoe No. hate I City/Town Stale Zi <trret Address p Municipal Inspector to fill out this section upon application approval: __"-___-_-__ Name 17,ne CITY OF &U.E11, %L1SSACHUSEM r 13uiLDING DEP.i RTNIE\T 120 1' ASHINGTON STREET, 3aa FLOOR � �aeLrn TEL (978) 745-9595 F.A_X(978) 740-9846 Kl_\IBERLEY DRISCOLL .VLiYOR THo%w ST.PtERu DIRECTOR OF PUBLIC PROPERTY/BUII.DI\G CONMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Muni: Organiraliun;Individual); ' Q.{� � Address: n CitY P�_/State/Zi Are you an employer?Check the appropriate box: Type of project(required): 1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. 0 New construction ntployces(full and/or part-time).* have hired the sub-contractors 2. i am a sole proprietor or partner- listed on the attached sheet. I 7• ❑Remodeling ship and have no employees These sub-contractors have S. C] 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 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.(No workers'cramp. C. 152,§I(a),and we have no 12.0 Roof repairs insurance required.) f employees. [No workers' comp. insurance rcquirod.J 13.0 Other •Nry eppticsnl dw chwks boa si mart also fill oul the wctioo below showing their waken'compenud nn un poucy inli, ation. s I haneuwners who suhnsil this utidavil indieasing they am doing all work and then him outside contractors most submit a new amdsvlt indicting aeh. :C,mtmctura that chick this box mud anachud an additiurad shmi showing the nwne of the subaontra nom and their workers'rump.policy infiurnnion. l um an employer that!s pruviding worker'cumprusatlun insurance for my eanp/uyees. Below Is the policy and Jab site information. Insurance Company Policy 4 or Sclf-ins. Lie, d: Expiration Date: Job Sim Address: City/State/Zip: Attacb a copy of the workers'compensatlon pulley declaration page(showing the policy number and expiration date). Failure:to secure coverage as required under Section23A of NfGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,100.00 and/or one-year imprisnnmcriL as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S230.00 a day against the violator. lit advised that a copy of this statement may lx:forwarded to the Offico of Invesligaiions ofthe DIA for insurance coverage verification. I do hereby cetrlf r rs (er the pains mad prn�ulrlr�s of perjary that Nu iajunnuNmr provide)above i/.r ague nnJ eurrrrt � •' I J / `(C 11� pats: __1_(s�_ i 011k iul arse wdy. Do our write in tlriv area,ra be completed by city ur town ajjiciuL City nr 1'uwn: - -.� - __ Pcrmitfl.lccnae k � fss ui rig Aral hori I (circle one): L lioord of Ilealth 2. Building 'Deparhnent 3.Cilyi town L'Idrk J. Electrical Ltryscctor 5. Plumbing; fuspector 6.Other Contact Person: Phone B: ( Information and Instructions .,lassachusetts 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 hire, 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 ajoint 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-contractors)nume(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, not the 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 OfTlcials 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 fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to till in the permitilicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense 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"ail 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 i-877-MASSAFE Fax#617-727-7749 2cvi;cd 5-26-05 www.mass.govldia CITY OF S.VZNf, atiLkSS.1Cf-I[.'SETI'S JULOLNG DEP.tATILNr 120 W.ksmC4GTON SrXMM, jw FtOOE rEL (978) 743-9595 KIMBEK.EY DBLSCO[L FAX(978) 740.9946 ,NEAYOIt IkO.0 tf StPtEtns DIAECTOt OP PLBLlC PII0Pf?1k7Y/9CM,00VG Co. 011SSiONEIt Construction Debris Disposal At'ttdavit (required for all demolition and rcnavation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.3 Debris, and the provisions of MCL a 40, S 54; Building permit p is issued with the condltion that the debris resulting from S I JOA. INS work shall be disposed of in a properly licensed waste disposal facility as dcfincd by,bICL c 111, The debris will be transported by: (name of hoular)�"—' The debris will be disposed or in l i (Malme of f cdiry / (� dreaorru+hry) + ynarure ofpermit�pphant ��z z Llfa nit„d L. J hOY'J-GL1C rx:co rrtur ... .�•-.• •-• __ American Properties Teem, Inc. I TO: 2D Spnran►e Way ' FROM: Jennifer Pappas.Property Manager i RE: Window Replacement DATE: January 9, 2012 ttwMOYMilwttf0ii�yi0��0��A�0Ae+Mi009�tf�fM�A9i�90t0i�it�A�iOA•fiOWr�rY►• - Please be advised that the Board of Trustees for Pickman►Park has approved replacement windows fbr the above referenced unit. This approval is contingent upon them mathhing the existing windows and that they fit In the existing opening Imtellation must be completed from the Interior of the unit and they must be the some in appearance from the exterior. Should the installation be completed from the exterior of the trait,you will be responsible for a4y damage that your contractor might cause(this includes painting). The Board will not allow windows with grids,crank out&.etc. Should you contractor find any rot or damage during the window installation,please make sure that it is reported to my office Immediately- We also require that permits be pulled in advance(regardless of what your contractor may tell you).and then a copy of the final approved permit one completed must be sent to APT for the unit file as well. We Woo recommend that owners obtain a certificate of insurance t Om the licensed contractor. You wig need to bring a copy of this letter to the Salern Building Department in or4er to receive your permit. j Should you hav¢any questions or require additional information, please feel free to call me directly at(781)569-2675. �i cc: Unit File I i Y n 600 WMGUD MM*FAnx•3Une6060.WMRM•4A-QUU-M-0389733-FAX 70L435409 lic ,a \lassachuscW4 �c11 jaGuns:mdlStandards Board d Bu'Idtn ervisor Specialty License Construction-Sup License: CS St. 101217`.. 'w4'... to: RFAS ... ➢,',, Restricted f. '+ IALBERT'BARTON 6 54 BURNSNH 0307 PELMAM, Expiration: 6123/2012 101217 ullltuin < Office of Consumer Affuns O T Business HOME IMPROVEMENT CONTRA Type: Registration 114423 Individual s Expiration 911712019 ar,J ALB RT T.BARTON JR�jjkz = ALBERT BARTON?JR €v� ✓ moo_ - 54 BURNS RD .,..�,}`,x'�, Undersecretary NH 03076 Aco CERTIFICATE OF LIABILITY INSURANCE DATE(MM OD/Y2 1/iz/aolz THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE IJOES 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 endorsements . PRODUCER CONTACT Terri Truhn, CISR ACSR NAME: Foy Insurance - Salem PHONE (603)898-6320 FAX,No:(603)898-8269 ADDREic_130 Main St - Suite 103 WC SS:terri.truhn@foyinsurance.coal PRODUCER 00021077 Salem NH 03079 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Main Street America Assurance 29939 INSURER B: BARTCO INSTALLATION 6 SERVICE INSURERC: 54 BURNS RD INSURER D: INSURER E: PELRAM NH 03076-3100 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1211209413 REVISION NUMBER: THIS IS TO CERTIFY THAI THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A13OVE 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. INSH ADDL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DDNYY MM/DDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,000 DAMAGE TO RENTE X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence $ 500,000 A CLAIMS-MADE 1XI OCCUR MPP85056 10/20/201110/20/2012 MED EXP(Any we person) $ 10,000 PERSONAL B ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 600,000 X POLICY PROjECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIREDAUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WCSTATU- OTH- ANDEIAPLOYERS'UABILITY YIN ANY PROPRIETOWPARTNEF/EXECUTIVE❑ N/A EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ Ii yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Karen Gouiello ACCORDANCE WITH THE POLICY PROVISIONS. Spruance Way Unit #20 Salem, MA AUTHORIZED REPRESENTATIVE T Truhn, CISR ACSR/SA ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. I NS025(200909) The ACORD name and logo are registered marks of ACORD Established in 1976 C & D REPLACEMENT WINDOW CO. ' Mail All Contracts Attention: BRUCE MCLEOD 8 Arnold Road, Peabody, MA 01960 Telephone & Fax (978) 531-0672 NEW WOOD - VINYL - ALUMINUM WINDOWS & DOORS Construction Supervisor PRICES GOOD WORK ORDER Specialty License#99193 FOR _DAYS Salesperson's Name ,LEI0,5;, Azano/' Date OWNER: Ik"Z ✓ COWe e) y 91� -Tyr/YYZ Address Phone Number WORK Z � f�i�VisNce; iwy -Q6,Ii Address - Phone Number HOUSE BUILT YR 90 { 0 DELIVER �21�1 �� { CuF S[iyc� dive !//yiYm' tJoOdG� A C INSTALL f7r/suGe1 P1fc /yC / GL.� �z s�.eed s f Lill tG/c .n Jlr.Ay- f�6G s'i" itsNB' /�6 /1 c..�l Y 1 �r TOTAL PRICE $ 1/3 TOTAL PRICE UPON SIGNING $ ?,G G[o BALANCE ON DELIVERY $ BALANCE ON 50% COMPLETION $ THE FINAL PAYMENT OF $ TO BE PAID UPON COMPLETION OF INSTALLATION. Nothing else to be done unless agreed upon in writing by both parties,barring delays caused by circumstances beyond C&D control.Material and labor to be supplied approxi- mately 3-5 weeks from measuring. WARRANTIES All installations done by any contractors who do work for customers of C&D Window Co.will have liability insurance and installation will be warranteed for 1 Year. All materials are guaranteed by manufacturer ONLY.NO OTHER WARRANTIES OR GUARANTIES,EXPRESS OR IMPLIED ARE AUTHORIZED UNLESS IN ACCORDANCE WITH A STANDARD WRITTEN WARRANTY HELD BY A PURCHASER.The materials and items listed above are to be built to order for the purchaser and therefore this agreement cannot be changed,varied,cancelled,modified or dischargeo or rescinded in whole or in pan by the purchaser except without express written consent of the seller.Seller does not guarantee performance in case of strikes,floods or other conditions beyond its control nor does any salesman or agent of the Seller have any authority to change,in any manner,any conditions of this agreement as herein stater) Not responsible for any pre-existing conditions in ooenincis where new windows are to be Installed,or any painting or conditions or circumstances beyond its control resulting rom of cue to pre-existing conditions. Buyer agrees to pay for any and all legal fees required for collection of non payment. DO NOT SIGN THIS Contractor's Signature- Date 1/4 / IF THERE ARE ANY BLANK SPACES Owner's Signature Date PC- �/_ 6 NOTICE OF CANCELLATION Date of Transaction To cancel this transaction,mail or deliver a signed and dated copy of this You may cancel this transaction,without any penalty or obligation cancellation notice or any other writeen notice,or send a telegram to: within three business days from the above date. C & D REPLACEMENT WINDOW CO. If you cancel any property traded in, any payments made by you under the contract or sale, and any negotiable instrument executed 8 Arnold Road, Peabody, MA 01960 by you will be returned within ten business days following receipt by the Seller of your cancellation notice, and any security interest not later than midnight of/ arising out of the transaction will be cancelled. Date I hereby cancel this transaction. Buyer's Signature Date The cancellation date filled in on this notice is three days after the date of the transaction.In figuring the cancellation date'.Sunday.New Year's Day,Washington's Birthday, Memorial Day,Independence Day,Labor Day,Columbus Day,Veterans Day,Thanksgiving Day and Christmas Day should not be counted.