15 SUMNER RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
(I/1 One or Two Family Dwelling
This Section For Official Use Only'
Building Permit Number: Dat Applie
Building Offima not Name) :S' at a ate
TSECTION t:SITE INF Xl fro_perty Address: �QCde, 1.2 Assess ap&Parcel Numbers
55 rcumn�Ln. F ytis-M
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(it)
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❑
SECTION2,: PROPERTY OWNERSHIP'
2.1 Owner of Record:
�Ue,t� n Ctg �a
Name(PPrint)rint) y� City,State,ZI
x cl;1N�l� vw �* /�iiAn� xglt 197 MOIT
No.and Street Telephone Email Address
SECTION.3 DESCRIPTION OF PROPOSED WORW check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ® Specify:Insulation
Brief Description of Proposed Work': "— t
iX1 Y1rmYl. li.�a A nh
�
C SECTION 4:ESTIMATED CONSTRUCTIONOS,TS t;
Item
Estimated Costs: ,z
;l
Labor and Materials e'� �-,z Official Use Only
�'r
1.Building $ X (9, 3 j .(A? 1. Building Permit Fee.$ ` Indicate how fee is determined:
❑Standard City/Town Application Fee e `
2.Electrical $
❑Total Project Costa(Item 6)x multiplier' x.4
3.Plumbing $ 2. Other Fees $
4.Mechanical (HVAC) $
List:
"
5. Mechanical (Fire - ?
Suppression) $ Total All Fees.$
Check No Check Amount Cash Amount:
6.Total Project Cost: $ x t 3j�• (R 3 13 paid in Full '� .j`.11 Outstanding Balance Due -` t
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Ho der ,,t
List CSL Type(see below) �11{�p.1}( \C�2 d-
No.and St 1� �1111 kr,n c+
Typa —Descnption
reet
' + n 9�L MR- O�- R Unrestricted2 Family
(Buildings u el ing cu.ft.)
lAX L ' 1 1 R Restricted 1&2 Famil Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(�( 1 J:�>3 4r, jb g CAI 9 w7l n louil dli-\A 1 Insulation
Telephone Email address _ Demolition
5.2 Registered Home Improvement Contractor 1(jhtj l I 12
l �jC
Jose Santos- American Builder Technologies Hlelgiustration (n mber Expir tion Date
HIC Company Name or HIC Registrant Name
2Ne tune Rd #439 ibS-nuw,o.�, tu., huild,'3lta�
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.§ 25((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 .......... Q No...........Cl
'SECTION Tar OWNER AUTHORIZATION TO BECOMPLETED WHEN
OWNER'S AGENT OR.CONTRACTOR'APPLIES`FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Jose Santos - American Building Technologies
to act on my behalf,in all matters relative to work authorized by this building permit application.
X Danielle Cook 5I�� I I.3,
Print Owner's Name(Electronic Signature) Date
SECTION:7h: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.
_lose Santos
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
-I= NOTES: `;:J C
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
jyLv .mass.g_ov/oca Information on the Construction Supervisor License can be found at„ww.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
" Unrestricted ofan s Buildings y use group which
F'assac+ravoo,, roam nta
6aartl !@u�meny peg m u-s a e 4ta 7an+s contain less than 35,000 cubic feet(991 ro)of
t m S p r enclosed space.
cetisw:CS 101375 ,,,
0 1 -
JOSEASANTO�S wyj:
37 W MfLTON ST,711r3,."sy
F{YDE PARI�MA'02186 Pailure to possess a current edhion of-the Massachusetts.
!!mm
State Bulking Code is cause for revocation of this license.
gu,_AWW#'t yRir rion For OPSt Ih6lnfolre.ho isq: _ w.Mass.Gom/OPS
..esntsucser 1112712013.
Offtce'nf}°ndaneu," u,s use"', en�afonz' L¢ense or registration ralitl fur indmidul use only
'ik r HOME IMPROVEMENT CONTRACTOR -before the expiration dale. If fount)return W
'?x '` Registration: 163106 Type: Office of Consumer Affairs and Buvness Regu)nnon
`Expiredon: 5;112013 tLC 10 Park Plaza-Suite 5170 -
i`" Boston,MA 02116
FMERiCAN BUILDiNETEbHNOLOGIE S ...
JOSE ALVES-SANTOS. w r
i
2 NEPTUNE RD.SUITE 4J9.
BOSTON,MA 02126 — — d-
1 drseo-etvey Not vn lid widout signatu It
veAs
3 d
r
rr ,rWAP Work Order.WA-
r _ �
North Shore Community Action Programs,Inc .Job Number:�13043a ^� _
. Work Order Date 4/30/2013
98 Main Street
-� •ir Peabody,MA0196tl Ownership*
Phone:.978-531-8810
�---,? Auditor:Doug Cranford
AmerieanBuddingTee5nologtes s u # R
*� Etimi•dcranford nsca ar "
,... ., 263 Western Avenge ,,,;� , - s .xt �; P g 5
- Lynn MA 01904,'. ( a`'�'Ce�! 978 339-?154
7.
- Emallt rostrecker gmail.com ` "` Phone 978 531-0767 x135, ,'�
Phoned 781-598-7125 '
.-
2 `r Y ° ,✓
n ~r" _ NGRID Eiectric f xY -r$6,317.63
Danielle Cauk " .
_ �; _z
15 Sumner Rd ' ,,.^* - Total v$fi,_417.63
' Salem MA 01970,e
978-745 1698
Safety Issue(s):Lead Paint Possble
_ ��
'a t01 n.
oT£ 9 s
n
Kneewalis R-12 cellulose behind_ "` 60 x $1.73 , $103.80 60 $103 80 r y
petmeablemembrane
R 30 restricted-elopes/floored fill=� 301 $1.48 $578,68 391 $578.68 - ,1V
R-38unrestricte unrestricted 13G $lA7 5199.92 136 $199.42
Reinforced polv112-30 cellulose open 493 $2.05 $1,010.65 - 493 51,010,65
rafters
r F
y u_r
#v+1t1 fntCnn. ..
°
Sill two
foam w/fiberglass butt 134. $2.20 $294.90 134 $294 80
�a�ue .,E'S33.'NR n In a#bn_. +'. '
Fixed Sweep 4" $15.75,: $63.00 . " 4 ' 563.00
R-S.Quctwrap or�R max on door, r 1 : 51.00^, $51.00' 1 e $51.00
A c
RepairlRefitDoor ` 1 = ' $52.00 $52.00 1 $52i00
Weatherstrip st lon or equal .a 4 v $45.50 $182.00 �`'. 4 $182 00 ,
`Date:460Pd0I3
i ��.. �_ ��w.�,n..,�.—,��,..,..«•-...w �=.es�am- .-= c.t> ..S�..a«rs *. .ee+a?^ zw s _ »^_ ;a�rtn=
N df
` t `
WAP Work:
Or'der Job Number: 13Q435
s ,
�f
a -
r.
d: Vent kit/bath fad I $89 00 ' $89 00 Y $89.00
. t 4�.a'Iaiva�gW4t=id091k ri...
Domestic water pipe wrap `.u 6 $2 63",' 515.78 6 $15.78
Hydrobic pipe insulation 1.25;-151 130� : $3,68 $47&40 130 $478.40
popper gape R-5 _ k
Aydronic pipe insulation to 1 in 50 _` $3.41 5170,50 : 50 $17tt.50 t
?. copper pipe R-5
Attic seating with twa-part Inam; 3 S75.00 $2215.00 •` 3 ' $225m t ,
Basement sealing with two-part', , 3 ,-. $75.00 $225.00 3 $225.00
foam
Blower door set-up with pre&post 1 '..: $45.00 $45.00 , : 1 S45,00 r.
, -
tests
Clean Gutters �. 1' $90.00 t $90.00 1 "0.00 a *'
Cube lose attic-kneewall access''= 1' $78.75 S78.75 - 1 $78.75
IP
y
_ r
yf
- BuiidingPermit ', �, 1 : $100.00 $100.00 ,; 1 $106.00 ,
�.
. v 9
P � ,� ,
a ,�•, ��rig; s —eat
}� ' '• .`'.� ar ?ar nx.. 3: `. ;a, '. y
" Wood or r` 1265 $1.79= $2264.35 ;1265 $2,26435
"f, v1nyI(dense pack)
N.
w
Total �, $6,317 63 x: S6,317 63
e
` Contractor lnstrucLons
. Befdre Startin¢the Iob. - " . " Auring t ie Job�;,�s .. Al
i-Please notify as 24 hours before starting or scheduling alob - ._1.This residence was built before 1978`�kllla c`a fe nractroes are
2 Obtein required building pallid r ' required. x a a
2:.Total for Reath&Safety=and Raga oannbt e3toeed-.$2500 g0
-`` ' - �, 3:bavis Bacon time sheetsrequrred for Al2RA wozk on US
Department of Labor Certified Payroll Depart Form W11 347 . -
Date.A 30t2013 ._. t, -� x ,� ,, „ e #s, Page 2
''5r
The Commonwealth of
Department of Industrial Accidents
'Off1ce of Investigations
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
Applicant Information Please Print Leeibly
Name(Bnainessiftaniution,mdi�id.1): Jose Dos Santos - American Building Technologies
Address: 2 Neptune RD #439
City/state/Zip: Boston MA 02128_ Phone,#: 617 233 8704
Are you an employer?Check thc:appropriate boa: Type of project(required):
1.M I am a employer with 5 4. [1 1 contractor am a general conro 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.-S []Remodeling:
ship and have no employees These sins-contractors have. 8. [3 Demolition
working.for me in any capacity.. workers'comp.insurance. 9: ❑Building addition
(No workers'comp.insurance S. ❑We are a corporation and its 10.❑Electrical repairs or additions
.required) officers Have exercised their
3.(] I am a hi ineowner 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.❑Roof repairs
insurance required.)t employees [No workers' 13.®OtherinauJatLQn
comp.insurance required.]
+Any applicant that checks box#i must also na ad the section bdow slowing their workers'cnmpe+reation policy information.
t Xomeownos who submit this affidavit indicating they are doing all work and then hire outside commission must submit a new affidavit indicating sucit.
tcommoua au cheek this box mart am hed an additional sheet showing the name of the subcontractors and their workers'coup.policy information.
7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy anojob site
information.
Insurance Company Name: Liberty Mutual Group
Policy#or Setf-ins.L'ie...##: W C5-31 S-372122-023 Expiration Date{: 3/23/14
Job Site Address: fJ S O VYt i10 it rucl Cityistate/Zip:_\Wa n ' (�)]Gl�1 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 formal 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.
1 do hereby cery nder the and penalties of perjury that the information provided above is trod and eotrect
nature: Date: S 3
Phone#: 1 2 87
official ase-only. Do no write in this area,to be completed by city or town.o,fJiclat
City or Town: Permit/Llcense-#
Issuing Authority(circle one)
1.Board of Health 2..Building Department 3.CitytTown Clerk 4.Electrical Impactor 5.Plumbing Inspector
6.Other
Contact Person: Phone.#::
03/28/2013 23:05 17815955820 AMBROSE INSURANCE PAGE 08/09
AC'aR� . • CERTIFICATE OF LIABILITY INSURANCE 3%29%2o173
THIS CERTrMATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES 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), AUTHORRED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pellWes)must he enemsmI. B SUBROGATION 13 WAIVED,suhJact to
the terms and conditions of the policy,COMM Policies may esquire an andorsemant A statement on this eerDaeete does not confer right,to the
certificate holder In lieu Of such endamomend(s).
PRODUCER
Ambrose Insurance Agency, Inc. PHONE
781-592-8200 A/D .181-595-5820
56 Central Ave. L
I,y=, MA 01901 tlDRES
E ID
nlBUBeRIc) aWORDelP CavanAae NAtc/
INSURED American Building Technologies LLC INSURER A!Atlantic Casualt y
INSURES a:Safety
263 Western Ave. INauRE,:tber y Mutual
Lynn, MA 01904 man National Union of Pittsburg
INSURER E
NSUR ER F:
COVERAGES CERTIFICATE NUMBER: R0ASION NUMBER:
THIS IS TD CfiRYIFY 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 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 CLANS.
MR TYPE OF INSURANCE POLICY NUMBER M(D LIMITS
GENERN- Llq@ILiTy EACH OCCURRENCE b 1, ,DUG
X COMMERCUN.GENERAL LIABILITY OPERSOML&ADVINJURY
EGoo.) s SU UUU
CLAIMS-MADE OCCUR dme Waon). 1.. 5,000
A L035009905 10/17/1.2 10/17/13 s ,000,000
GGREGATE b 2. 00,000
OENL AGGREGATE LIMIT APPUES PER COMP/OP ADD 1 1,000,—OTT
POLICY PRO- LOC b
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANYAIJTo Me acddeN) $ 1,000,000
ALL OWNED AUTOS OOOgV hNJURY IPa Peres!) b
$ X SCHEDULED AUTOS
62221$3 3/9/13 3/9/14 BOmIV INJURY(Pa mowAm s
HIRED AVTDa PROPERTY DAMAGE 1
(Par nm'dwo
NON-OWNED AUTOS 1
a
UMBRELLA UAB OCCUR EACH OCCURRENCE 1 , OO,DOO
g EXCESS LIAR CLAIM"ADE 000 D DEDUCTISLE EBU018715159 10/17/12 10/17/13 AGGREGATE , ,
RETENTION b
WORKERS COMPENSATION fATU- OlH.
AND EMPLOYERS'LIABILITY LA1R X
C k IXAQ ,mom YIN NA Binder 3/23/13 3/23/14 E.L EnCH ACCIDENT b 1,000,00
ehMMwe m o
Myyrns dnearlbe anew EL.DISEASE-MEMPUTYEE3 1,000,000
DMdRiPTION OF OPERATIONS Eelev, E.L DtSFiASE-PtlItCY IJMR a 3.1 , 00
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(Attecn RCORD 10t,Addnicne)Ramdnp Schedule.If Marc @PACE le mAMmtl)
NGrid Corporate Services, LLC, d/b/a National Grid, d/b/a Boston Gas, d/b/a Colonial
3as Co. , d/b/a Essex Gas Co. , & Lowell Community Teamwork, Inc. , GLCAC,Inc. , Columbia
3as of Massachusetts & Action, Inc. are additional insureds, general liability only
CERTIFICATE HOLDER CANCELLATION
NSCAP
98 Main 3t. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Peabody, MA 01960 ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESEX
988-2609 ACORDt OFRP'ORATION. All rights reserved.
1CORD25(2009/09) The ACORD name and logo are registered marks OfACORD
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