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18-19 WARD ST - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety Ulf Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling m'.('Fhi'sSection Fo'r Official.Use Only) Building Permit Number $' c Date Applied: r.O \ SSECTION 1:'LOcA_TI, di e ON(Please1nd6tte iBlock#and Lot#for locations for which a street address is'not available) 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 9 Existing Building❑ Repair q Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) n ,q Change of Use ❑ Change of Occupancy ❑ Other- ❑ Specify: J N Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No J Is an Independent Structural Engineering Peer Review required? Yes ❑ No, pa Brief Description of Proposed Work: -i SECTIONS:C_O_ MPLETE 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) O Existing Use Group(s): Proposed Use Group(s): SECTION 4:-BUILDING HEIGHT AND AREA. --' Existing V�Proposed No.of Floors/Stories-(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION SdTJSH GROUP(Check as applicable), A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 Cl H-4❑ H-5❑ 1: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 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 ❑ 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: Public Cl Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site ❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: - Hazards to Aix 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 ❑ •J,_.,._ „-`- �,�;:, SECTION 8:CONTENT OF CERTIPIGATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: r SECTION 9:'PROPERTY OWNER AUTHORIZATION _ Name and Addr s of Property Owner �� o� �\(2� \ ca xu �.\e (Print) No.and Street^ City/Town Zip Property veer Contact Information: �" Get Title j I Telephone No. (business) Telephone No. (cell) e-mail address- If applicable,the property owner hereby authorizes y? L��(1C1On17Qu(1 (kbm5��ac� �;a�1w _Qjn _�- Dame Street Address City/To State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building emdt application. s ,r SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix.2)° If buildixi is less than 35,000 cu.ft.of enclosed s ace and/or notunder Construction Control then check here❑and ski Section 10.1 10.11Registered Professional Responsible for Construction Control i.ct-1 Name(Regis t) Telephone No. e-mail address Registration Number a xm5 �lxcv�.,�Z 1�J t,t.�, '111) QAmy_3 a111- Street Address City/To vn State Zip Discipline Expiration Date �'1v0..2,General Contractor - - I�yan�aDa CompanymE — ent n 1 n A> ( �-, Q g Name of Person Responsible for Construction License No. and Type if Applicable y� \\Oune QA �R � ma L� Street Address - City/Town State Zip - �� y� 1s�1 1�13 Telephone No. (business) Telephone No. cell e-mail adAless SECTION 11:WORKERS'CONMFNSATION INSURANCE'AFFIDAVIT .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' ante of the building permit Is a signed Affidavit submitted with this application? YesJ3' No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor _ and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ ` Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ '�\� - (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 contaaimed in is application is-true and`accurate to the best o my knowledge and ((understanding. l Pleas rint and sign n e /� Title Telep o Date - \,_Ant iA Street Address City/ wn Stag Zip 1 Mumcxpal Inspector to fill out this section upon application approval i .,14�,.,, e,,` Name ,,,aM Date David Frankel Assistant Project Manager GOADVANTAGE ®®WEATHERIZATION I NCORP DRAT ED Two Adams Place Main(666)50B-OB66 Suite 100 Cell(61 7)921-7030 Ouincy,MA 02169 Fax(61 7]64B-3774 ��. tlfrankel®advancageweacherizecion.com 1 t CITY OF S�A'LEitil, XL-�SSACHUSETTS $i:II.Do.fG DEP ARTJIENT \ 120 WASHINGTON STREET, 3' FLOOR TEL. (978) 745-9595 Fn x(978) 740-9846 KI-,IBERIBY DRISCOLL MAYOR T HoMAs ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUUZLNG CONMaSSIONER 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 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) Sig ture of p mit applicant - date - Jc6ristfi:Jnc - I NOTICE TO PROCEED Action for Boston Community Development(ABCD),administrator of the DOE Expiring Use energy efficiency program for low-income multifamily properties, is hereby autho rized to have its contractors,employees, and other representatives access the property and perform the work contained in the attached Work Order, including final inspections.A copy of this document shall be carried by ABCD's contractors,employees, or representatives and presented upon request. By signing this Notice to Proceed,the applicant acknowledges that the benefits to the clients will be delivered as stated in the attached document. Applicant Information II n Site Name: Or4�, 6 (� c hC 4vi `/ 0 im Street,City/Town, Zip: b 2. 1 Contact Name&Phone at Site: �G�� -M — -IL(s S U9- Signature: Printed Name: ' R k C ko N o f-A(n o k Title: lam. Organization: ogr4L SA1nf- Date• _ 3.1- 1 Acknowledeed by ABCD's representative: John Wells,Vice President for Real Estate and Energy Services,ABCD Please sign and date two originals. Retain one for your records and return the other to: Grace Park ABCD 178 Tremont St Boston,MA 02111 fax:617-357-4661 Qark(r)bostonabcd.ore Two Adams Place G®ADVAN 1 AGE Suite 100 N'" ('1I®®1 "0It11Al Quincy, MA 02169 4 : l- V-11 ' = „ 7%28%2011$ - , m _ Date: AGENCY: Action for Boston Community Development, Inc. ABCD 178 Tremont St. Boston, MA 02111 HOMEOWNER: TOTAL Salem Street Properties WORK ORDER $17,113 18-19 Ward St Salem MA Date of walk-tIfiOughs 4/20/11 Job'Cos#g14037 DESCRIPTION QTY. I UNIT UNITPRICE TOTAL PRICE DOORS Weatherstrip w/Q-Ion or equal 24 ea $43.00 $1,032 Automatic Sweep 24 ea $22.00 $528 MISC. MEASURES Basement air sealing 28 man/hr $75.00 $2,100 Building Permit 1 LS $318 $318 BASEMENT INSULATION Basement overhead insulation (Dense pack-9.5" - R32) 3,360 sq.ft. $3.75 $12,600 Strapping/ Sheet Rock,taped &coat-for holes in ceiling 96 32 $5.28 $507 Page 1 of 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 Washington Street Boston,MA 02111 ww%mass,gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Businessorganintion/individual); City/State/Zip: rn�. C \ Phone.#; 5 1" ()3-) Are you an employer?Check the appropriate box: Type of project(required)':, 1.r[c�I I am a ero t er with 10 4. ❑ I am a general contractor and I tFr.. Po Y 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. 7. ❑Remodeling ship and have no employees These sub-contractors have 8, ❑Demolition workingfor me in an capacity. .. employees and have workers'__-, _ , Y P co insurance.t' 9;'�-Q Building addition req workers comp,insurance e a _. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL - 12.❑Roof repairs insurance required.]t o. 152, §1(4),and we have no employees, [No workers' 13.❑ Other comp,insurance required;) *Any applicant that checks box#1 must also fill out the section below showing their workm'compmsation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. , (Contractors that check this box must attached an additional sheet showing the name of the sub-eohtractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp,policy number. I am an ernployer'that is providing workers'compensation insurance for my employees. Below is the policy and job site information.\ Insurance Company Name: Policy#or Self-ins. Liicc.#: /C�bl p�} _,�1� Expiration Date: ClQ. ZOO p`101"3, _ Sob Site Address: \'�(�— �"\ �` 11lMa_ City/State/Zip: �13 \ 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 fire tip 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 maybe forwarded to the Office of Investigations of the DM for insurance coverage verification. I do hereby certify under the pains"and penahies�paf erj that the information provided above is true and correct. Signature; ` . Date: �\ _ Phone t,n a, \ \ i06 i [6. fficial use only. Do not write in thr a ea, to be completed by city or town official ity or Town: Permit/License# suing Authority(circle one): Board of Health 2.Building Department 3.City/Town Clerk 4,Electrical Inspector 5.Plumbing Inspector Other ontact Person: Phone#: F—CrA A CERTIFICATE OF LIABILITY INSURANCE a6/0120E'mmlooWYY) 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 Diane Shaw Fred C.Church,Inc. NAME: 41 Wellman Street PHONE 9783227272 FAX (9?8)454-1865 Lowell,MA 01851 AIC N EA I: AIC NO (800)2251865 E-MAIL dshawQfredcchumh.com - ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# INSURERA: Citation Insurance Company 40274 INSURED INSURER B: National Union Fire Insurance Company of Pittsburgh,PA 19445 Advantage Weathedzalicn,Inc. 4230] INSURER C: Navigators Insurance Company Two Adams Place,Suite 100 Gemini Insurance Company - 10833 Quincy,MA 02169 INSURER D: INSURER E Start Indemnity&Liability Company 38318 INSURER F: COVERAGES CERTIFICATE NUMBER: 18541 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 I TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/O�YIYYYY MMgDD//YY Y LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1.000,000 X A G O NTEO 100,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE FTI OCCUR MED EXP(Any one person) $ 5,000 D VUMAOOOO890 412/2011 41V2012 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 POLICY X JE CT LOC $ AUTOMOBILE LIABILITY COMBINED SINGL'denESINGLE LIMIT $ 1.000,000 Ea ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED BBNT98 4/2R011 4/2f2012 BODILY INJURY(Per accident) $ AUTOS AUTOG X HIREDAUTOS X AUTO OWNED Pena cdenOPERTY DAMAGE $ $ X MBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 U E EXCESS LIAB CLAIMS-MADE BINDER 6/20/2011 6/20/2012 AGGREGATE $ Sp00,DO DED X RETENTION$0 $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN T RV LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? NIA 006430048 6/20/2011 6/20/2012 (Myandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 IDESC describe under RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 $10,000,000 x of a5,090,000 C Umbrella I NYIIEXC]111931V 612=011 6/20/2012 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remark.Schedule,if more syace is required) As required by Contract,Action,Inc.Keyspan Energy Deliveries and it's subsidiaries,National End USA and it's subsidiaries and NSTAR are included as Additional Insureds with respect to general liability only. Weatherization Projects. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE h 4)tZA � � � Client# til4bI Mat# Cert Holder# 26872 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The,ACORD name and logo are registered marks of ACORD -: • }3 ,nac4xx 6td. 1)r�i ratrttx nt rYFesb#r. a.n,as ' . t 1.t• rry r,t ttnt3tlrn #2t vt atrra9>and 1t xr€4 sri,e. - Resme BRIAN MACHADO ;�,:: �. 47 MALBONE ROAD te? ASSONET iMA 02702 Expaat�r 5/261201.3 x.,s£inei+=i:•ttrr 7nsG 102976 I: i i Office of Consumer Affairs&Business Regulation License or registration valid for individul use only 'HOME IMPROVEMENT CONTRACTOR. - before the expiration date. If found return to: ( r - Office of Consumer Affairs and Business Regulation E i ' Registration 166075 Type: 10 Park Plaza-Suite 5170 Expiration. W2112012 Supplement Card Boston,MA 02116 ADVANTAGE WEATHERIZATIQN INC. - BRIAN MACHADO TWO ADAMS PLACE - QUINCY, MA 02169 "` ....., Undersecretary Not valid without signature _............ _. —. v!s+s+cbu+ratp-4eparcrnx'tst iaf PaaLttt a,.,gin I B,m•d of Bti0di4-_ Rt uialiitn<and, iianu'dr'tl' � LU.erStTUCt}CFl.Su(h,. 'f Sesr LtGCnS£ ,_ Uoeose; CS 1029713 Restricted W. 00 'BRIAN MACHADO 07 MALBONE ROAD``' iASSONET„MA 02702 Expiraion 5+2672013 i namr*vLner Tr#: t02978. j I ' I I CI, �1ee Vr amrmsosu�aa.�.dre o��naoa✓euvelld @I�:Office of Consumer Affairs&Business Regulation License or registration valid for individul use only kOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: r Office of Consumer Affairs and Business Regulation ?' Registration. 166'075 Type: 10 Park Plaza- Snite 5170 Expiration q�-2{jy412 Supplement Card Boston,MA 02116 ADVANTAGE WEATF1E�iTION,`INCBRIA . - - TWO MACHA TWO (7O ADAMS PLACE QUINCY, MA 02169 Undersecretary Not valid without signature