15 STORY ST - BUILDING INSPECTION (2) y
The Commonwealth of Massachusetts
#'' d Department of Public Safety Nib DEC -1 P 1: 38
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION!:LOCATION(Please indicate Block#and Let#for locations for which a street address is not available)
i 15 Story St Salem 01970
No.and Street City/Town Zip Code Name of Building(if applicable)
ISECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
` Existing Building❑ Repair❑ Alterafion ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other to Specify: Insulation
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Basement insulation Door swee2sr weatherstrips Air sealing
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
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 Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ I Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench ors specify:-
or P f3
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazazds to Air Navigation: MA His'tori<Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkfer System?: Special Stipulations:
i r e 'M-T
ti
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Linda Tardiff 15 Story St Salem 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Linda Tardiff 978 741.7636
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
lose Santos 263 Western Ave Lynn MA 01904
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Jose Santos 781- 598-7125 lobs@abtisulation.com 101378
Name(Registrant) Telephone No. e-mail address Registration Number
37 W Milton St Ant 1 Hyde Park MA (1� 1117712017
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
American Building Technologies
Company Name
lose Santos 163106- HIC
Name of Person Responsible for Construction License No. and Type if Applicable
2 Neptune Rd.Ste 439 Boston MA 02128
Street Address City/Town State Zip
781-598 7125 617 -233 -8704 jobs@abtinsulation.com
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'CObIPENSA' ION 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes® No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $2 229.60 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 $ 2,229.60 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By enterfn m ame below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
applicaf, is a an'Accurate to the best of my knowledge and understanding.
lose Santos Owner,ABT 781-598 -7125 12/6/16
Pleas ' d sign me Title Telephone No. Date
263 st Ave Lynn MA 01904
Street ddr City/Town Statee � Zip pJ
Municipal Inspector to fill out this section upon application approval: N
Name Da
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block #and Lot#for locations for which a street address is not
available)
15 Story Street Salem 01970
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107.The
checklist below is a compilation of the documents that may be required for this.The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Buildin Surve Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zi
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Ulf www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business Organizationnndividuap: American Building Technologies Inc - Jose Santos
Address: 2 Neptune Rd.Ste 439
City/State/Zip: Boston MA 02128 Phone#:(617) 233-8704/ (781) 598-7125
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with 5 4. [11 am a general contractor and 1 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. r ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. Building addition
tNo workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
I0.❑ 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'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.] 13.®Other Insulation
'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such,
tContraelors that check this box must attached an additional sheet showing the name of the sub-contractors 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.
Insurance Company Name: Ace American Insurance
Policy#or Self ins. Lie.#: 2E918445 _ Expiration Date: 10/20/2017
Job Site Address: 15 5 &.A L7i City/State/Zip: �m t (j�� 0
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 a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify ad rh pui s a d penalties of perjury that the information provided above is true and correct
St nature: Date:
Phone#: (617) 3- 04/ ( 1) 598-7125
Official use only. Do not write in this area,to be completed by city or town official
City or Town: 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#:
ArAEff@
(617) 7521570
Contract for Products/Service Work
This Agreement is made by and among
Linda Tardiff
15 Story St
Salem, MA 01970
American Building Technologies(ABT)
2 Neptune Rd, Suite 439
Boston, MA 02128
DESCRIPTION OF WORK TO BE PERFORMED
1- Basement insulation
2- Door sweeps
3-Weatherstrips
4-Air Sealing
Total: $2,229.60
Customer Signature: Ij
Customer Name: Date:0
0,Contractor Signature:
Contractor Name: Date: 1 (�
� Jewaironmen/(�nj
Office of Consumer ARaira&Bus[de Rcgajgdpnl`
OME IMPROVEMENT CONTRACTOR
Registration: 163106
Expiration ,5 11 112 0 1 7 Co Type: -
rporation -'
r AMERICAN BUILDING{fCHNOLOGIES,INC.
License or registration valid for individual use only
JOSE SANTOS ') t - before the expiration date. If found return to:
NEPTUNE RD.SUITE'439 °{ Office of Consumer Affairs and Business Regulation
2
2 '"h_'`�-- ` 10 Park Plaza-Suite 5170
TON,MA D.SUITE
Boston,MA'02116
Undersecretary i
Not 'dw ou ignature
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-101378
Construction Supervisor
. Construction Supervisor
- 1: Restricted to:
JOSE A SANTOS of
37 W.MILTON STREET APT 1 less t Unrestricted 35-Buildings feet
use group Which contain
less ihan.35,000 cubic feet(991 cubic meters)of
HYDE PARK MA 02138 ." f Y enclosed space.
Expiration:
Commissioner 11127t2017
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
DPS Licensing information visit:W W W MASS.GOVIDPS
A� i
®�
ABT
American Building Technologies
Energy Savings Is Our Specialty
263 Western Avenue-Lynn-MA 01904
Phone-781-598-7125/Fax-781-479-0727
www.americanbuildingtechnologies.com
Authorization Letter
I,Jose Santos,HIC 163106 and CS-101378 holder hereby give my authorization to Andre Aguiar
to act on my behalf regarding the Building Permit Application
15 Story St. Salem, MA 01970
tos
1Is
016