5 UGO RD - BUILDING INSPECTION (3) 2s GK -7 �95
I , The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR S
_ ReviseddMar Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
V) This Section For Official Use Only
0Building Permit Number: Date Applied:
^ ,
1 Building Official(Print Name) Signature Date
_I—Q SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
5 Rd
l.l a Is 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:
Public D/ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ann Marie Welch Salem MA 01970
Name(Print) City,State,ZIP
) I1 . 0 t2 99 R-u4Nda✓nwOc-h l��grti9uf �• n'J
No.and Str t 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_ I Other specify: Insulation
Brief Description of Proposed Work2:Install 3 door sweeps and weatherstrip, air seal 8 hours, instal attic stair cove
with carpentry, install 38 [in feet of damming install 51 propavents, insulate open attic floor bringing to
approx R38.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 2959.25 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑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: $2959.25 ❑Paid in Full ❑Outstanding Balance Due:
PAI-NtLt=p TO c,00 31IS
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CSSL 100454 6/13/17
%I Glenn Alexander License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) I
25 Bond Street
No.and Street Type Description
Reading MA 01867 U Unrestricted(Buildings u to 35,000 cu.ft.
g R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
781.397.9909 gja0613@gmaii.com 1 I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 188085 1/23/17
Alexander Insulation LLC HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
25 Bond St gja06l3@gmail.com
No.and Street Email address
Reading MA 01867 781.397.9909
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 .......... ® 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 Glenn Alexander
to act on my behalf,in all matters relative to work authorized by this building permit application.
3/10/16
Print Owner's Name(Electronic Signature) Date
SECTION 7b: 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 and accurate to the best of my knowledge and understanding.
tru
Glenn Alexander Fitt`. 3/10/16
Print Owner's or Authorized Agent's Name(Ele tronic Si ature) 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.eov/oca Information on the Construction Supervisor License can be found at www mass.g_ov/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"
/-ILL fD z5 70VO eoobnJ4
GCONTRACT FOR -
conser atlon PRODUCTS / SERVICE WORK
Services Group
This service is brought to you through support from your local utility
This Agreement is made by and among
and
Ann Marie Welch Conservation Services Group(CSG)
5 Ugo Rd Attn:RCS
Salem,NIAA 01970-1039 60 Washington Street,Suite3000
Site ID:S00050135889 Westborough,MA 01581
Pmjcct ID:P00050155019 Reg. No. 173484
Customer to:C0005 0 13 69 86 FederallD No.222457170
Contract ID:20151207_ASEA.L (NtJlcompleted comrtcuo midressabove)
I. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or curse to be performed the following work on these"Premises"in a professional manner and in accordance with the terms of
this Contract,including the attached recommendations/work order describing the work In detail(the"Work')which are incorporated herein by reference:
Description Quantity Location
Perform Air Sealing at Estimated 62.5 CFM50 Per Hour a Living Spars S674.56
Attk Stair Cover Thermal Bander with carpentry 1 Living Space S260.23
Door Sweep 3 N/A $69.54
Exterior Dow Weather Strippirut 3 N/A S82 77
Sub Total: S1,087.10
Utility Incentive Share S1,087.10
Customer Contribution S0.00
For office use only Printed:121712015 Page 1 of 2
If. PAYMENT
Customer agrees to pay Contactor for the Work,the Customer Share of the Contract Price as follows:Payment pl:S as a Deposit
payable to CSG upon signing the Contract(not to exceed ISgf the total retail costs).Naii check K contract to CSG,Attu:RCS,50 Wmitinbmon St,Ste.
3000,Westbomun,raw 01581.FSnal Paytuenc S_(/ as the final pnyrnem for the Work shall be payable to the Independent Installation
Contractor("IIC")upon satisfactory co Ietion of the Work Customer ndersds that he/she Dill not be required to pay die Utility Incentive'Share orthe
ContractpricetittheamountofS JORIA.,1 u am
0 Charges to individual line items anfor previous incentives may increase or decrease the size of the Utility Incentive
Share.
III. DISPUTE RESOLUTION '
The IIC and Crrstouter hereby numnal(y agree it,advance flea,in We event rhu We IIC has n dispute concerning this Contract,the IIC cony subndt stair dispute to a private arbitration
service which has bec,t approved by tieolfke orCmmnner Affairs ail Business Regulation and 0stomer shall be required to submit to sucharbimimm provided in ht.W1 cWA
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
— 3n LLLAL.tt.3 WX-Lel. 14-7. r 14.I.tnr�r�Sd lc,-+t zn L e 1,[-;i--j 40
cusl2w6limpature ,�D��1at))e'�'�,�a� IIndd�te/yourseletted IIC h"ere,if applicable t Rl InitiN here if you wtmt
/- l/Cf�7+4.c ���/ �,�U.Z Pa Program to:stricta
C ignature Date Name ooff UGC Representative(Printed) Participating Contractor
776R11t9 AND CONDITIONS BAR ON Y"REVERSE. N14
CONTRACT FOR
Conner atlon PRODUCTS / SERVICE WORK
Services Group This service is brought to you through support from your local utility This Agreement is made by and among
and
Ann Marie Welch Conservation Services Group(CSG)
5 Ugo Rd Attn: RCS
Salcm,MA 01970.1039 50 Washington Street,Suite 3000
Site ID:S00050135889 Westborough,MA01581
Project ID: P00050155019 Reg. No. 173484
Customer ID:C00050136986 FederalID No.222457170
" Contract 10:20151207 WORK (hlailcompleted contmcttoaddressabove)
1. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be perforated the following work on these"Premises"in a professional manner and in accordance with the terms of
this Contract,including the attached recommendationsrwork order describing the work in detail(tbe"Work•)which are incorporated herein by reference:
Description Quantity Location
Alto Floor open Blow Cellulose 9' 960 Living Son= S1,593.60
Pro veld 7 or 4' 51 Attic $195.33
Damming 38 NIA S83.22
Sub Total: S1,872.15
Utility Incentive Share 51,404.11
Customer Contribution S468.04
0Wa
For ofOc,use only Printed:I V?12015 Page 2 of 2
It. PAYMENT
Ctstomer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Pnyment pt:ti a Deposit
payable to CSG upon signing the Contract(tot to exceed JM of thCe tP sl,moil costs).Moil check&contract to CSG,Attn:RCS,SO Washington St,Ste.
3000,Westborough,MA 01581.FinaPPaymenc$__i/ V as the(Ina]payinent for the Work shall be pa)able to the Independent Installation
Contmctor("IIC'7 upon satisfa�tory c�t p' tion of the Work Customer understatids that he,%he will not be required to pay the Utility Incentive Shoe of the
Contract price in the.amounl or$L O r .Changes to indiAdual line items and/or prellous incentives may increase or decrease the size of the Utility Incentive
Sham.
III. DISPUTE RESOLUTION '
Tile IIC and Customer hereby mutually,alpee In nd ytce Lim in the Meta Out the IIC lets a dispute coa centbtg this Contract,the RC pay submit such d'gmle to a pri xAc a titmtimt
service which has bttst approved by the Office of Corstater Affairs and Business Regadation and Quaciner sisal be mlluired to submit to such addmdion as pmrided in aLG.L c-142A
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery;not later than midnight of the third
business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
'Sig avert Uate ,C Indicate our selectedIIC here,if applicable R) Initial here ifyo0 want
!1/Jl[J �1GCSA1 L-. /l(��U� the Program In assign a
Signature Dale Name of CS eprescoultivve(printnntte't,)a',t P.'trucipating Contractor
TEEMS AND CONDITIONS APPEARI kE�V6R5s. �y� X14
CERTIFICATE OF LIABILITY INSURANCE `1
ouo3/2o16
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: H 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 endomeme s.
ACT
PRODUCER IME: Mark S. Rowe,CIC
Michaud,Rowe And Ruscak Ins. PxoeN e,U,978 688 8829 Fax xe• 978 557 2130
P.O.Box Ise
North Andover,MA 01845 ADDRESS:
Mark S.Rowe,CIC INS S AFFORDING COVERAGE NAICa
MSURERA:Arbella Protection Ins.Co. 41360
INSURED Alexander Insulation LLC INSUREIRB:SafetY Insurance Company 12808
Glenn Alexander INSURER C:Am Trust North America INC
25 Bond Street
Reading, MA 01867 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 POLILh'NOMBFR POLICYEFF LIMITS .
LTR
A X COMMERCUU.GENERAL LIASIJTY EACH OCCURRENCE It 1,000,
CLAMS-MADE �OCCUR 8500060511 03M2/2015 03/12/2016 PREMISES EaaPcrurenm S 100,
MED EXP one Person) S 6,000,
PERSONAL SAW INJURY $ - 1,000,
GENL AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $ 2,000,00
POLICY❑jE7 LOC, PRODUCTS-COMPIOP AEG S 2,000,00
S
OTHER:
AUTOMOBILE LIABILITY (EONIDINEDISINGLE LIMIT S 1,000,00
B ANY AUTO 104342 02011/2016 02/01/2017 BODILY INJURY(Pw Person) S
ALL OWNED X SCHEDULED BODILY INJURY(Per emtlal) S
AUTOS AUTOS
NON-OWNED PROPERTY E S
X HIREDAUTOS X AUTOS PerrcCilenl
$
I( UYIRELLA LUUr X OCCUR EACH OCCURRENCE S 1,000,
A ExcEssuAe CLgH45-MADE 00052AIS 0311=015 03112=16 AGGREGATE $ 11000100(
DELI I X I RETENnONS 10000 $
WORIDERSCOMPENSATNAI TUTE =0
AND EMPLOYERS'LIABILITY -
C ANY PROPMErORmARTNERAD(ECUrIVE YIN - C3157346 07/29/2015 07/29/2016 ELEACHACCIOENT $ 1,000,0
OF ICERIMEMBER EXCLUDED? El NIA 1,000,
(Mandatoryy 1n NN) EL DISEASE-EA EMPLOYEEE
DESCRIa PION OF OPERATIONS below 00(
Under - EL DISEASE-POLICY LIMIT $ 1i000,
llix
DESCISPTION OF OPERATIONS I LOCATIONSI VEH=LES (ACORD IM,Addinc l Remarts SchMY4 nmy W aWthed R o spaze M regWreJ)
CERTIFICATE HOLDER CANCELLATION
GLENALE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Alexander Insulation LLC. ACCORDANCE WITH THE POLICY PROVISIONS.
Glenn
25 Bond Street AUTHORIZED REPRESENTATIVE
�Reading,MA01867
(a 1929-201A ACORD CORPORATION. All dahls reserved.
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Orgmimtion/Individuat): Alexander Insulation LLC/Glenn Alexander
Address:25 Bond Street
City/State/Zip: Reading MA 01867 Phone#: 781.397.9909
Are you an employer?Check the appropriate box: Type of project(required):
1.2]1 am a employer with 3 employees(full and/or part-time).* 7. ❑New construction
2.r_1 I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling
any capacity.[No workers'comp,insurance required.]
9. ❑Demolition
IF�I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I IQ Electrical repairs or additions
proprietors with no employees.
12.[]Plumbing repairs or additions
5 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These subcontractors have employees and have workers'comp.insurance? 13.❑Roof repairs
6.r-J We are a corporation and its officers have exercised their right of exemption per MGL c.
14.R Other Insulation
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box 41 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 most submit a new affidavit indicating such.
:Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
AmTrust North America INC
Insurance Company Name:
Policy#or Self-ins.Lic.#:W WC3157346 Expiration Date:7/29/16
Job Site Address:5 Ugo Rd City/State/Zip:Salem MA 01970
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerh under thepains;annd�p�e�nalties ofperjury that the information provided above is true and correct.
Signature. (�� V "Y( `~� Date:3/10/16
Phone#:781.397.9909
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#:
1 ORce�f�`omer`nAtts�rs arrB sines"- amn
HOME IMPROVEMENT CONTRACTOR
Registration A180885 Type:
' Expiration: 123/2017 LLC
A NOER INSULATION LLC.'(n
'ra
GLENN ALEXANDER.
25 BOND ST , ._
` READING,MA 0180 Undenecretary
eF
L e
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
CnnsLicens :CSS isor Srecinl.
License:CSSL-100454
Lim
GLENN J ALF.XA11 �"
25 BOND STREEY' R P
Reading Mn 018d7
J.�.• S )1110� Expiration
Commissioner
06/13/2017
Permit Authorization
VW r1r=
mass Save Form
9. �t,.to a pr.ns er coffmcm
Site ID: S00050135889 Customer: Ann Marie Welch
I, Ann Marie Welch owner of the property located at:
(Owner's Name,printed)
5 Ugo Rd 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 permitto perform insulation and/or
weatherization work on my property.
Owner'sSignatureL (/�y )yja, ni (.JJ.
Date: fa • 7•d e tip^
••�ee��e�4r�e����e�ee���e�ee�4r�rl4r�4r�e��e�ee�4re�e�4ree�4re�ee��eee��eeee•
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
U C,
Participating Contractor Date
ot�o
conservation Semcrz Group • SO Washington Street,Suite 3000 • Westborough,MA 01581 • 1800-480-7472 ❑rr
li
rw offte usecinty
Rev. 102015