11 STORY ST - BUILDING INSPECTION (3) 1 The Commonwealth of Massachusetts
CITY OF
Board of Building Regulations and Standards
Boa
SALEM
Massachusetts State Building Code, 780 CMR
/I Revised Mar 2011
(I� Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
�Building Permit Number: �> Date Applied:
1�'1 LtiLAwii� VTI�"/ K�f+yS'�
Building Official(Print Name)f Sign e Date
z� ,; SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
11 Story Street, Salem, MA
l.la 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(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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2 PROPERTY OWNERSHIP'
2.1 Owner of Record:
arnin Salem MA
ame(Print) City,State,ZIP
11 4tnrn Straat 978 998 2109
No.and Str a Telephone Email Address
;`, , ,", SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ® Specify:Tnculation
Brief Description of Proposed work': Walls R15 -Attic R38 -Air-sealing-Weatherstripping
and oTier weatherization measures
;a "SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 4499.57 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ '❑Total Project Costa(Item 6)x multiplier x'
3.Plumbing $ 2. OtherFees: $
4.Mechanical (HVAC) $ .List
5.Mechanical (Fire Suppression)
$ Total All Fees: $
4499.57 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
[� Cl1c„�elLf- nh
SECTION S:,CONSTRUCTION-SERVICES
5.1 Construction Supervisor License(CSL)
96385 10/08/2012
Romain Strecker License Number Expiration Date
Name of CSL Holder
Lis[CSL Type(see below)
10 Churchill Plarp Type Description
No.and Street '
U Unrestricted(Buildings up to 35,000 cu.ft.
_Lynn MA 01902 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7R1 710 6637 rostrecker@ ail.com I Insulation
Telephone mail address F D Demolition
5.2 Registered Home Improvement Contractor(HIC) 169145 5/20/2013
Romain Strecker- American Building Technologies HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
2 Neptune Rd #439 rostrecker@gmail.com
No.and Street Email address
Boston, MA 02128 781 710 6637
City/Town,State,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 Issuance of the building permit.
Signed Affidavit Attached? Yes ..........CI No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Romain Streck r-Am rican Building T hnolo i s
to act on my behalf,in all matters relative to work authorized by this building permit application.
Jason BENTAMIN T 05n7n7
Print Owner's Name(Electronic Signature) 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 orate to the best of my knowledge and understanding.
Romain Strecker 05/17/12
Print Owner's or Authorized Agent's Nam (Electronic Signature) Date
r ._ :�.i;. 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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor 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
Anlrlicant Information Please Print Legibly
name(auainessrorsanimtionnndividuaq: Romain Strecker - American Building Technologies
Address: 2 Neptune RD #439
City/State/Zip: Boston MA 02128 Phone#: 781 710 6637
Are ybu an.employer?Check the.appropriate box: Type of project(required):
1.M.lama employer witb . Q lam a general contractor and l
'� 4
—. 6. 'Q-New construction
employees(full and/or part-time)." have hired the sub-contractors
2..❑Tama.sole proprietor or partner•
listed on the attached sheet.t ❑Remodeling
ship and,have.no employees These sub-contractors have 8. ❑Demolition
working for,me,in any capacity. workers'comp..insurance. 9. Q Building addition.
[No workers'comp.insurance 5.-❑ We are a corporation and its 10.Q Electrical repairs or additions
required.] officers have exercised their
3.01 am a homeowner doing all work right of exemption per 11.❑Plumbing repairs or additions
myself.[No workers'-comp. c.152,§1(4),and we have no 12.Q Roof repairs
insurance required.]t employees.[No workers' 0.0 Other
comp.insurance required:]
•Any appbesnt thit checks box#1 must also fill out the secaonbelow drawing their workers'compensanonrpolicy information.
t Homeowners who submit this affidavit indicating they are doing an work and then him outside contractors.must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
l am an.emplayer that is providing workers'eompensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Liberty Mutual Group
Policy#or Self-ins:Lic.#: WC231 -S372122 Expiration Date: 3/10/13
Job Site Address:I l Story Street City/State/Zip:Salem,MA
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 c. 152 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 copy of this statement may be forwarded to the Office of
investigations:of the DIA:for insurance coverage verification.
I do;hereby certify under 'epains and penalfies ofperjury that the information provided above.�iiss aannd curled
nature .1—� Date: . 1 C-.-
Phone#• 7il-7-9 6637 t
Offwhil.ase only;.Do not write in this area,to be completed by city or town offciaL
City or Towns Permit/License#
Issuing Authority(circle one):
1.Board of.Health 2,Building Department 3,..City/Town;Clerk 4,Electrical Inspector 5.Plumbing Inspector
6.Other.;... ..
Contact Person: Phone.#:
I
.� OI'1"ic<o nnaumer i�(o s li F'accs f`egu aiian �„ l3i=�f`d ni 13141di" Itc=!ui rti �+ roil �t lt}tl;a
m
r�•y �' HOME IMPROVEMENT CONTRACTOR 1 :�. Construction Supervisor Lrmense
=u Registration .169145 _ `TYPer
01 Expiration W912013 LLC 4. Liceo} e� CS 96335
r A RICAN BUILDING TECHNOLOGIES LLC.
ROMAIN STRECKIER • `'
. :ROMAiN STREGKER" 10 CHURCNILL PLACE 9
2 NEPTUNE RD#439` LYNN, MA 01902 ;,
BOSTON,MA 02128 'Undersecretary e
n ^
Tir_ 4344
American Buildin Tes Fssso{o i
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ACoJR CERTIFICATE OF LIABILITY INSURANCE DATE(MMDDNYYY)
PRODUCER z7/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Ambrose Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Lynn,
n, MA 0 A01 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lynn, MA 01901
781-592-8200 INSURERS AFFORDING COVERAGE NAIL#
INSURED American Building Technologies, INSURER A: Atlantic Casualt
LLC INSURER S: Arbella Protection
2 Neptune Rd. , #439 INSURER C! Libert Mu ua1
Boston, MA 02128 INSURER D: Nation Union of HitLEtLi h
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,
1 R
LTR xeoIYL P pDFECTNE LIC�XPIRgT70fl LIMITS
RO POLICY NUMBER
GENERAL LIABILITY EACH OCCURRENCE 4••,1,000 000
COMMERCIAL GENERAL LIABILITY PREMISES E-( s ecc�Wpal S 30.0.0.0
CLASASMADE OCCUR MED EXP(ArD'Om patA ) A 5.000
A L035-009067 10/17/11 10/17/12 PERSONAL&ADV INJURY a 1 .000.000
GENERAL AGGREGATE S 2 000 OQQ
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO S 1 COO OP-0
17 POLICY PRO-' LOC
AUTOMOBILE LIABILITY ••
ANYAUTO ((EaMP clowt)SINGLE LIMIT S 1,000,000
ALL OWNED AUTOS
BODILY INJURY $
R SCHEDULED AUTOS (Par pnrForl)
B HIRED AUTOS 90593400003 3/9/12 3/9/13
BODILY INJURY $
NON-OWNED AUTOS (Par BccHenq _
PROPERTY DAMAGE P
(PerA Id no
OARAGE LIASILTIY AUTO ONLY-EA ACCIDENT S
ANYAUTO
omemmAN FA ACC B
AUTO ONLY: AGO S
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE S 1 000 r 000
R OCCUR M CLAIMSMADE AGGREGATE S 1,000,000
S
D DEDUCTIBLE EBU-019084283 10/17/11 10/17/12 S
RETENTION 8 S
WORKERS COMPENSATION G W bLIMR r "L
AND EMPLOYERS'LIABILITY YIN
ANY PRCIHDBTOR1PARTMVIJ ECU"M EL.EACH ACCIDENT $ 500.000
OFFICS"131DCR MLUOFI"
C wane wMmnI WC2319372122 3/10/12 3/10/13 E.LDISEASE-EAEJMPLOYEE s 500 000
ifg a0cdibR under
SPECW PRO SONS Woo E,L.018PASE.POLICY LIMIT S 500.000
OTHER
ESCRIPTION OF OPERATIONS!LOCATONB/VENICLE81 EXCLUSIONS ADDED DY ENDORSEMENT I SPECIAL PROVISIONS
Carpentry & Insulation
National Grid Corporate Services, LLC d/b/a National Grid, d/b/a Massachusetts
Electric, d/b/a Boston Gas Co. , and Action, Inc. as addtional insured. NStar
and Action £or Boston Community Development, Inc, as additional insured
ERTIFICATE HOLDER CANCELLATION
Greater Lawrence Community Action BNOULO ANY OF THE ADM OESCRIDEO POLICIED 0E CANCEU.00 BEFORE THE EXPIRATION
Council, Inc. GATE THEREOF,Nt RIBLiIxP.INSURER VIRA,ENDEAVOR TO%mL 20 DAY,WRITTEN
305 Essex St. NOTICE TO THU MTIFIDAWI HOLDER NAMED YO THE LAP?,BUT FAILURE TO DO PO AHALL
.Lawrence, MA 01840 WOES NO OBLIQATICN OR 1JABILITY OF UPON THE INSURER,ns AD"OR
Fax: 978-681-4 980 REPREBeNrA
AUTHORV
:ORD25(R009101) - 009ACORDCORPORATION. All dghtsreserved.
The ACORD name and logo are registered marks of ACORD
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NSCAP
98 I%bin Street
Peabody,MA 01960
Tax Exempt#! 042-385-280
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339
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459 $f,42' $651.78
Aftfd flat(slope RID i6iffliffid --ig- $1.30,
2,39,
AftfdAdii�RWO—f ifflMn DP
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R If V
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7-":L. $4.007
.......% $92.00
Saffif.veilt
$1;95;it—d6lope tt3O iel[Hos6 Wdiibly
A %e RXM[Wose w6irfihiaiiil $05,
to rsdrula -Pbm am
I $89.00i Mtht drydr/6aw0004st fan,
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Single fiAMd"asbeatusliA haICR15 DP
- -
Doublenaitedaslstslsslalumindm R13J$2 31 r: -
R"ricklstucco
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lWrlor iviN.STow=. lasterRl$RP:
Cl-boar"d/woi)dshin "nIR15.DP 1716 -';'- = $1
cst $3,071,b4
Tdnll:4ssrdo :_-_. _;_-. . ...,
Sill 2 w/FG batt Rl9 ; ``- -
Sill'i65irfatiohRl9faccd =;_ -5158 - -
PffIii11¢[Qr Wlap'RSIa= �3_' . :�: '• - -=::' __� _ . ..:'Si'91 .;,,. - _
. $d5,50
Regu orsw $15?S : -
Autnmitio:doorswei :: == :_$23,00,
_:.
Airseoliri'+Zr' artfoiim= ''-:-' ,. _..
Sish9obk�;'r�i=.;, ::__,.; :,- -.:^_ ., •_�__._ .�y' $9r3o='t.•_=:_ -- - -
010s r' laceroent . .. : _$44.00
r _ - --
tnl -
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}Tiiritin stem IYleesnies _' '"
ISuot-inAnlatiori 8escul'sesms:(s .R. - _-- `?`$3.16' '•. '`": "
li drfiiic' i e.ini'ulatlontool.RS
Hydro*WilnsalAiion'1.254+R5. _'
Stiain `i'`e.insulationaol'.25":RS
.�;.
Stcani`' 6.insulation LT'=2''RS
BoilcrflGin9Core laeCmant -::: '..: so-do ..
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$ro ram re air $0.00'
naiwrrw.iaa �mm<weoi+rewKaramss. ...- I v,'499.57 F lEst-TrotT,
S0.00. Acf Toisl'•