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75 TREMONT ST - BUILDING INSPECTION (2)
The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR Revised MarALEM SdMar 2011 l V 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 Dat r SECTION 1: SITE INFORMATION NtO I A 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers � L 75 7rQrnort� S� 1.1a Is this an accepted street?yes_ no Map Number Parcel Number O N 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: l�Qlr2V\ b e5 rz).n k zr MA 6/976 Name(Print) City,State,ZIP 75 7-r--wl6v4 s-� ApJ sa zsi - -763-66?(, No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIW(check all that apply) Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ New Construction❑ Existing Building ( Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description of//Proposed Workz: ;d � /rl e-Us xAJ a4kc- CUY Sim,( . SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ �7,13 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ [I 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 $ Suppression) Total All Fees: $ �.� Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 6 I 0 Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor ynv�`isor License(CSL) -7 Z Z/6 G�l e 3 \C) License Number Expiration Date Name of CSL Holder 1 List CSL Type(see below) 5� d V Type Description No.and Stree t 1 / v, y /�//a 63�yZ U Unrestricted(Buildings u to 35,000 cu.ft.) -( R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding (963 -53 Z-(39q I Solid Fuel Burning Appliances Insulation Tele hone Email address D Demolition 5.2 Registered Home H/ome Improvement Contractor(HIC) /6/TQ to j6 � w (f— --, 6 40 HIC Registration Number Expirati n Date e or HIC C omarnZt-Im is Nameli � No.a2 / Email addressn / / 6,-N6Z 6of5 —/�Z— /3K CityJown, Stat ,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 .......... 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 G J¢.6 W 6 to act on my behalf,in all matters relative to work authorized by this building permit application. V-6Xe-vN � I S1 gl Print Owner's Name(Electronic Signature) Dine SECTION 7b: OWNEW 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. (,i.i-Z,� ak6 2 Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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" i CITY OF SALElm, ti'LxSSACHUSETTS • BETIDING DEP�R -MINT ' 130 WASHLNGTON STREET, 3w FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 KIJffiERL.EY DRISCOLL MAYOR THo&tAs ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMWSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c L 11, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) signature of permit applicant date Massachusetts-Department of Public Safety fetY Board of Building Regulations and Standards Construction Supervisor License: CS-072318 CALM AHO 'ro 482 JARMANY SHARON NH OtW. � - a n lxs Ex iration Commissioner 12M9/2015 �� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Co lti~�actor Registration Registration: 161406 X11^ TVPe: Individual �rW` Expiration: 1020/2016 Tra 258803 CALEB AHO �W CALEB AHO 482 JARMANY HILL RD. SHARON, NH 03458 Update Address and return card.Mark reason for change. ❑ Address Renewal nEmployment Lost Card SCA 1 O 20M-0 11 . C�Ixe i(�ananeonu�etsll�e a�0/Ifoawc%uanlld __,__._ _ ___ _. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: V egistration -:161406 Type: OLLee of Consumer Affairs and Business Regulation Expiration tOR02076 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 CALEBAHO 1, - CALEB AHO 482 JARMANY HILL RD. - n SHARON,NH 03458 - Undersecretary Not valid without signature r CITY OF S�ULEtii, NIASSACHLSETTS • BUDDING DEPARTMENT ' 120 WASHINGTON STREET,San FLOOR d TEL (978)745-9595 FAX(978)740-98" ICI,%BERLEY DRISCOLL MAYORTrtoMAS ST.P>FIeR13 DIRECTOR OF PUBLIC PROPERTY/BuI DLNG COMMSIONER Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbers Applicant Information Please PrintLeeibly c � / Name(BusinesworganizatioN/Individual): L l��Gl U J��G✓ G'!/Ia�YJ�S GL G Address: S i1Z rroI j I City/State/Zip: D 3 y5Z Phone #: 03 ' Sit-e 3�lp Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 5 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors; 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet �• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance S. ❑ We are a corporation and its ]0.❑ Electrical sus or additions required.] officers have exercised then 3.❑ 1 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 1 insurance required.]t employees. [No workers' 13.0 Other, comp. insurance required.] Any applicant that chuelts box at must also fill out the section below showing their worker'compensation policy infommion. 'l lonxowtwn who submit this affidavit indicating they me doing all wont and then hire omide onntretos must submit anew affidavit indicating such. :Cumrocnor that cheek this best must anached an additional sh n showing the name of Me cub-wntrcmr and their worker'comp,policy infamad=. I am an employer that Is providing workers'compensation Insuraneefor my emplayees. Below Is the policy and Job site information. Insurance Company dame: 1-1 A(4rn,,A V( JJ t5. 60 . Policy#or Self-ins.Lie.#: �a),2 JLAJG06a8371-6 Z Expiration Date- 469-z e/S / Job Site Address: 15 / <G/?'a?� Q �-4 Z City/State/Zip: c l�h (y � �5!1776 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration d"* 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 S 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 S250.00 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 vcrifrcation. I do hereby certify un e0 the pains d penal s o perjury that the isrformadon provided above Is i e"arnd carrect %etntum ' // [)are: I Z/ ale y phone!{: Cob —J �Z —6, V(e Official use only. Do not write in this area,to he completed by city or town oJJlcial, City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: A�® CERTIFICATE OF LIABILITY INSURANCE DADD/YYYY) 1z/8/2a/zo14 THIS CERTIFICATE IS 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), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT rari Reeves NAME: FIAI/Cross Insurance PHONE CINC.No Est, ( ) Noll(603)645-4331 1100 Elm Street E-MAIL ADDRESS:kreeves@crossa4 y'enc com INSURERS AFFORDING COVERAGE NAIL p Manchester NH 03101 INSURERA:West American Insurance CO. INSURED INSURERB:Oh10 Security Insurance Company ESE Insulation, Inc. INSURERC:Ohi-O Casualty Ins Co Energy Saver Enablers IINSURERDAmerican Alternative Insurance 52 Fitzgerald Drive INSURER E: Jaffrey NH 03452 INSURER FF COVERAGES CERTIFICATE NUMBER:14-15 All lines REVISION NUMBER: THIS IS TO CERTIFY 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 CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER MM/LDDY� MM/DDY EXP LIMITS LTR GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISESE.occurrence $ 300,000 A CLAIMS-MADE OCCUR 55684497 /31/2014 /31/2015 MED EXP(Any one person) $ 15,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY Eae�tleDt IN L $ 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 55684497 /31/2014 /31/2015 BODILY INJURY(Peracadent) $ AUTOS AUTOS NON-OMED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Peraccident Uninsured motorist combined S 1,000,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS Me CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTIONS 10,00C PS055684497 /31/2014 /31/2015 $ D WORKERS COMPENSATION F3a.) WC0000371-02 X WCSTATU- DTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NK 6 NA EL EACH ACCIDENT $ 500 000 OFFICER/MEMBER EXCLUDED? N/A(Mandatory In NH) o£ficera included /8/2014 /8/2015 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Salem, MA ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington Street 3rd floor AUTHORIZED REPRESENTATIVE Salem, MA 01970 Laura Perrin/JSC ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025,7ntnmi n1 Th.A(.nPn namn and Innn am r.nic,fc r.,l mark.of Anr1Rn CONTRACTOR WORK ORDER conser ak Services Group 50 Washington St.Suite 3000 Printed: 11/21/2014 Westborough,MA 01581 Work Order Id: S74953P80738C332 Contractor Information Customer/Site Details Energy Saver Enablers LLC Karen Desrocher Email: 52 Fitzgerald Dr 75 Tremont St Apt S2 Phone(Eve): 251-753-0586 Phone(Day): 251-753-0586 Jaffrey,NH 03452 Salem, MA 01970-1543 Site ID: S00002274953 Total Installed Measures Location Description Quantity Unit $ Total $ Living Space Perform Air Sealing at Estimated 62.5 CFM50 4 $84.32 $337.28 Living Space Insulate Vinyl Sided Wall With 4" Dense Pack C 696 $2.41 $1,677.36 65.7065.70 Blower Door Test Only 1 $ $ Living Space Insulate 3rd FL Vinyl Sided Wall With 4"Dense 584 $2.57 $1,500.88 Living Space Attic Slope Enclosed Cellulose Dense Pack 6" 476 $2.57 $1,223.32 Installed Measures Total $4,804.54 WorkOrder Notes i p(c.l�2l�►f ', — Incentive Payments Air Sealing Incentive $337.28 Weatherization Incentive $2,000.00 Total Incentive Payments $2,337.28 Customer Share Total Customer Share $2,467.26 Less Deposit Of $822.00 Customer Share Balance(Due Contractor) $1,645.26 Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 CONTRACTOR WORK ORDER Conser a Services Group 50 Washington St.Suite 3000 Printed: 11/21/2014 Westborough,MA 01581 Work Order Id: S74965P80750C332 Contractor Information Customer/Site Details Energy Saver Enablers LLC Gas Ann Wallace Email: 52 Fitzgerald Dr 75 Tremont St Apt S1 Phone(Eve): 251-753-0586 Phone(Day): 251-753-0586 Jaffrey,NH 03452 Salem,MA 01 9 70-1 543 Site ID: S00002274965 E Total Installed Measures Location Description Quantity Unit $ Total $ Door Sweep 3 $23.18 $69.54 Exterior Door Weather Stripping 3 $27.59 $82.77 Living Space Perform Air Sealing at Estimated 62.5 CFM50 1 $84.32 $84.32 Living Space Insulate Vinyl Sided Wall With 4"Dense Pack C 696 $2.41 $1,677.36 Living Space Insulate Rim Joist With 2"Thermal Barrier Polyi 68 $4.40 $299.20 Installed Measures Total $2,213.19 WorkOrder Notes Payments Incentive Payments Air Sealing Incentive $236.63 Weatherization Incentive $1,482.42 Total Incentive Payments $1,719.05 Customer Share Total Customer Share $494.14 Less Deposit Of $164.00 Customer Share Balance(Due Contractor) $330.14 Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 Rim, mass save �, R s�dtndenewn«m rra9+ r lqmmmmlw► PERMIT AUTHORIZATION FORM I, Karen Desrocher owner of the'property located at: (owner's Name,primed) 75 tremont st Apt 2 Salem (Property Street Address) (city) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. X 1�1 �JJ4]► K�'lJ� ` owner's Signature /OI/O ' /t4 Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: G V1 L!Vl wVcd ��h,4Lvs L-L c J2I- Part(cip�t actor Date sur otrKe usa only Rev. 12132011 � - � j9WAG mass save PoR PERMIT AUTHORIZATION FORM 1, Karen Desrocher owner of the property located at: (Owner's Name,printed) 75 tremont st Apt 1 Salem (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. n '_ Owner's Signatur(� � tnl ,o ry Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating CWnfractor Date Of' W 01 �° Frx Office Use Only Rev. 12132011