52 TREMONT ST - BUILDING INSPECTION a»
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The Commonwealth of MUSOM & SERVICES
® Department of Public Safety
`n Massachusetts State Building Code(7 �
Y Building Permit Application for any Building other than n r T o y Melling
1`n (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official: 7
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
52 Trrn»xY+ IS1 '%1 r rn clq-4-O
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
1 Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
{`-- Change of Use ❑ Change of Occupancy ❑ 1 Other Specify: 1 r1SU 1C'k:"C'T!l
Are building plans and/or construction documents being supplied as part of this permit application? Yes 1A No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:C(�1r } tiyCl1� elll�l+lCYl r�f'YJC1'k'1 dOCvf
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 ❑ A4❑ 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❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit,. Debris Removal:
A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal El required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic 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 Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
n2 Tfr tic 8V. aAC c\
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
AOT - AOSe SCOOS XA YZSkrn AU-r- MA 61d r'w
Name Street Address C ty/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❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Name e ant) Telephone No. e-mail address MA�� Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Company Name
tk�, ftes-Santm I tP 31 n t a kla H I G
Name of Person Responsible for Construction License No. and Type if Applicable
2 NPn4�ter, 12CI. ��r . 439 (rC > �Jj f\ CJZ i2.2�
Street��Apddress City/Town State Zip
ccyl
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION 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 $ 7. Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact
/muu�nniiici ty))
5.Mechanical Other $ Enclose check payable- to l -J1 r C.J V
6.Total Cost $ C) 1 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 accu to the be of my knowledge and understanding./1
N - A► -F aLL-Mg-71Zn
Please tint and sign name Title Telephone No. Date
LMnn
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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)
'D2 Trees S+- Sct.1 m G'1 G-4o
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 Building Sury /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 RegistrationfN�berStreet Address City/Town State ZipDiscipline Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State 1p
Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town/Town S Discipline Expiration Date
tate Zi
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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
52 Tremont St, Salem, MA 01970
Jos Santos
9/3/15
AE®
(617) 7521570
Contract for Products/Service Work
This Agreement is made by and among
)ulissa Garcia
52 Tremont St
Salem, MA 01970
American Building Technologies(ABT)
2 Neptune Rd, Suite 439
Boston, MA 02128
1. DESCRIPTION OF WORK TO BE PERFORMED
1-Attic Insulation
2- Door sweeps &weather strip
3-Wall Insulation
4-Venting
Total: $5,248.23
Customer Signature:
Customer Name: Al- A ( 1-ba Date: FCIW)
Contractor Signature:
Contractor Name: '--inhL Date:
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Orsanizationimdividuaq:American Building Technologies - Jose Santos
Address: 2 Neptune RD #439
City/State/Zip:Boston MA 02128 phone#: 617 233 8704
Are you an employer?Check the appropriate boa: Type of project(required):
1.[3 I am a employer with 5 4• 111 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.t 7- ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑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 ME]Electrical repairs or additions
3.❑ I am a homeowner 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' 13.13tOther linsulation
comp-insurance required]
•Any applicant that checks box#1 must also fill out the section blow slowing their workers'wmpmation policy information.
t Homeowners who submit this anidavil indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lConlracors that check this box must attached an additional sheet showing the name ofthe subcontractors 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: Hartford
Policy#or Self-ins.Lie.#: 6BO2483-5-13 Expiration Date: 5/2 9/17
Job Site Address: 17a City/State/Zip: c�C1]'C.v'v� ut� C'Sl9-:3,C
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.
I do hereby ceni der and penalties of perjury that the information provided above is true and correct
Signature, Date: P/_30,75
Phone#: 61kk3V8 4
Official use only. Do not write in this area,to be completed by city or town offkiaL
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#:
_ Work Orderr,t�%►e
North Shore Community Action Programs, Inc. Job Number: 150151
119 Rear Foster Street,Building 13 Work Order Date: 6/17/2015
Peabody,MA 01960 Ownership: Renter
Phone: 978-531-0767
American Building Technologies Auditor: Brandon Dorrington
263 Western Avenue Email: bdorrington@nscap.org
Lynn MA 01904 Cell: 781-540-8569
Email: rebeca@americanbuildingtechnologies.com Phone: 978-531-0767 xl21
Phone: 781-598-7125
Julisssa Garcia MAJOR REPAIR FUND- $750.00
52 Tremont St ELECTRIC $4,498.23
Apt. 3 NGRID Electric $5,248.23
Salem MA 01970 Total
646-338-9706
Landlord Name: Juan Thomas Pena
Landlord Phone: 978-594-5006
Safety Issue(s): Mold Present/Lead Paint Possible
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MeasnreDescn tlon ° * > t %Lom1lREnt3g " z '
gig, lt� ` eta '`stk ; tY ay�C4e'e.% nff. Total( t"Qt,}• * T6tali "eaa .>. a o ""��sat -S. .�P
'fit .o. ' �c, zh$5s k .�, �.�1^�. n} -� .�.- `�''f„Ew^r. t.��^"• aa»:� .,'ttb,'..�`+1� � .x4n,"`r �'M`�'��,. ��!{
A,
= 'Attrc In3ntettont z b
4, ev3>Y-.
8-20 restricted-slopes/floored 409 $1.55 $633.95 409 $633.95
w/cellulose
19 unrestricted-settled cellulose 715 $1.80 $1,287.00 715 $1,287.00
x
. rAttic vent7la ttnp a � '_ J
:tangular gable vent 2 $103.00 $206.00 2 $206.00
)f vent 865 9 ft N A s small 3 $90.00 $270.00 3 $270.00
( �
iA� r"� «e .. ✓ tWr �S'§ai "* W Wri S � „� s-'� &t �„*4�x.
ed Sweep 2 $17.64 $35.28 2 $35.28
atherstrip s/Q-Ion or equal 2 $51.00 $102.00 2 $102.00
J a Health&,.Safety kN vim* Z,
it kit/bath fan 1 i"01-00
$100.00 I 1 $100.00
te: 6/17/2015 Page 1
- Work Order: Job Number: 150151
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'� f F g.sn k �"Jn
CFM bath fan(new with switch) 1 $750.00 $750.00 1 $750.00 3rd fl.
tic sealing with two-part foam 3 $84.00 $252.00 3 $252.00
P_erwt
u �+
ilding Permit 1 $100.00 S100.00 I I S100.00
-x18uI1L41{lah0"'.c4 s._z"'^'` y ar'k1 -' sT xk o4-``, i .g �i & •s. :p §," a': E'• rd TF ,z.�..,, 4
rod clapboard/shakes/shings or 756 $2.00 $1,512.00 756 $1,512.00
iyl(dense pack)
tal $5,248.23 S5,248.23
itractor Instructions:
ire Starting the Job: During the Job:
lease notify us 24 hours before starting or scheduling ajob. 1. This residence was built before 1978. Lead safe practices are
obtain required building permit. required.
2. Total for Heath& Safety and Repairs cannot exceed$2500.00.
3. Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form WH-347.
litional Contractor Instructions:
Attic Inspection form attached? Yes N/A (Circe One)
tificate of Insulation posted? Yes No (Circle One)
erican Building Technologies hereby certifies that this job was supervised and completed in compliance with all Department
abor Standards and Lead RRP regulations.
itractor Signature: Date: RRP License#:hM -
-eby acknowlege that all work has been completed and inspected.
tomer Signature: Date:
te: 6/17/2015 Paae 2
Work Order:-Job Number: 150151
rgy Director: Date: Fiscal Officer: Date:
FOR AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
,er CO 0.000 If Yes,indicate language:
ve CO 50.000 Occupany change in last 18 months? Yes No (Circle One)
)Tank CO 17.000 Comments:
sting System CO 0.000 Number of windows
ibient CO 0.000 Number of rooms
-wer Door 0.00
:e: 6/17/2015 Page 3
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