49 SUMMER ST - BUILDING INSPECTION (2) l
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The Commonwealth of Massachusetts
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ALEM
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SdMar
Revised Mar 201
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 pplied:
Building Official(Print Name) Signature Date
' SECTION 1: SITE INFORMATION
1.1 Property Address: 49 Summer Street 1.2 Assessors Map& Parcel Numbers
I.I a 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:
Zone: _ Outside Flood Zone?
Public❑ Private ❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Frank Camarda Salem,MA 01970
Name(Print) City,State,ZIP
49 Summer St (978)888-5515 pmarehand79 a gmail.com
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other M Specify: Insulation/Weatherization
Brief Description of Proposed Work': Blown in cellulose to exterior walls,air sealing
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 6,209.10 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
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: $ 6,209.10 ❑Paid in Full ❑ Outstanding Balance Due:
M0-1l_E.D 3ILA
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS-052576 10/03/2017
James Fortin License Number Expiration Date
Name of CSL Holder U
50 Rundlett Way List CSL Type(see below)
No. and Street Type Description
Middleton, MA 01949 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
� � 5: ;.• RC Roofing Covering
WS Window and Siding
• SF Solid Fuel Burning Appliances
978-998-4684 phi]@air-tightweatherization.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 165640 3/15/2016
Air-Tight Weatherization, LLC James Fortin
HIC Registration Number Expiration Dale
HIC Company Name or HIC Registrant Name
50 gun Jett
Way phi]@air-tightweatherization.com
No. and Street Email address
Middleton, MA O1949 978-998-4684
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 .......... EX 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 James Fortin
to act on my behalf, in all matters relative to work authorized by this building permit application.
Frank Camarda fe 1, CA..a.e"(a. Feb 25, 2016
Rank eanmma(Feb 25,2016)
Print Owner's Name(Electronic Signature) Date
SECTION 711b: 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.
James Fortin 6—� s-�^ 2/26/2016
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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" maybe substituted for"Total Project Cost"
The Commonwealth of Massaehusetts
- > Departmeut of lurlustrialAcehleuts
a 1 Congress Street, Suite 100
13ostou, MA 02114-2017
t yt wmj1.Drass.gov/(pia
Workers' Compensation Insurance Afficlavit: General Businesses.
1.0 BC WILED WITII TIIE PERMITTING AU'I 1IORITY.
ADDIic•uit Information Please Print Leiibly
13usiness/Organization Name: Air-Tight Weatherization, LLC
Address:50 Rundlett Way
City/State/Zip: Middleton MA 01949 Phone Jt: 978-998-4684
Are you an employer? Check the appropriate box: Business Type(required):
I.Q 1 ana a employer with 30 employees(full and/ 5. ❑Rctail
or part-time).* 6.6. ❑Restaurant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Off ice and/or Sales(incl. real estate, auto, etc.)
employees working forme in any capacity.
[No workers' cop. insurance required] t3. Non-profit
m
3.❑ Noe are it corporation and its officers have exercised 9. ❑ 1-:11lertainment
their right ol'excmption per c. 152. §1(4),and we have 1011 Manulacttlring
no employees. [No workers' comp. insurance rC(]Liiredl*l I I.❑ I-Icalth Care
4.❑ We arc a non-profit organiz<Ition• staffed by volunteers,
with no employees. [No workers' comp. insurance req.:1 12.0 Other Insulation/Electrical _
'Any a pplieam that checks bum 81 must also fill out the scetinn below showing their workers'compen,adiau policY in fivmnl ion.
" u the cxlwnlle ul'I leers haec exempted Ih<nl5elves.Fm the<nrpor alien has other employees.a worker, compensation pnlicy is 1u,Jmted anti such all
mrganinliun should chuck bos NI.
1 ore an enrp/nrer I/ol ix providing wnrkerc'cnrapensnlion insurance tiff mp enrp/gyees. /feGnv is Ilse patio,irr fnnnnlinn.
Insurance Company Name: Guard Ins. Co.
Insurer's Address: P.O. Box AH / 16 S River Street
City/State/Zip: Wilkes Barre PA 18703
130licv it a'Self-ills I..ic. H AIWC 693663 Expiration Date:7/1/2016
Attach a copy of the workers' compensation policy declaration page(sbowing the policy number and expiration dale).
Failure to secure coverage as required under Section 25A of MGI. c. 152 can lead to the imposition of criminal penalties of a
line up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDI?R and it line
of up to$250-00 a clay against the violator. Be advised that it copy of this statement may be 1'01-vaided to the Office of
Investigations of the DIA to- insurance coverage verification.
l do hcrehv cerfiff,, under the pohm tit emi ies iof perjury float rite in(nrrnnriun provided above is true mrl a correct.
Sss�nnuue' C►-^-�^fitDate: —
Phone If- 978-998-4684
Ofrciol u.se onto. Do not write in this area, to he completed hp city or town official.
City or Town: Permit/License tt _
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Licensing Board 5.Selectntcu's Office
6. Ofhcr . -_—
Contact Person: Phone t/:
www,mtassguv/dia
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165640
Type: LLC
Expiration: 311512016 Tr# 248557
AIR - TIGHT LLC. WEATHERAZATION
JAMES FORTIN
10 PINE KNOLL DR.
BEVERLY, MA 01915
Update Address and return card.Mork reason for change.
sCA i 4 :4EIMv Address Renctral Employment Lost Card
Orpce or Consumenlffairs A Businesx RcCulaiion License or registration slid for individul use only
iHOME IMPROVEMENT CONTRACTOR before the expira/ion date. If found return to:
2 ttIOM trIMPR 1MENT Typo: Office of Consumer Affairs and Business Regulation
y`Expiration: 3I7512016 LLC IO Park Pinza-Suitc 5170
�"-F' Boston.,NIA 02116
AIR-TIGHT LLC.WEATHERAZATION
FORTIN 10 PIN \\
f0 PINE KNOLL OR, d"�_ v ��•
BEVERLY.MA 01915 Undersecreian' Not ca id without 5ignnta re
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-052576
Construction Supervisor
JAMES E FORTIN.�
60 RUNDLETT WAY w
> ,
MIDDLETON MA-01i
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Expiration:
Commissioner 10103/2017
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