21 WARREN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
' Board of Building Regulations and Standards CITY OF
Massachusetts State BuildingCode 780 CMR SALEM
, Revised Mar 2011
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 Ap ' d:
Building Official(Print Name) Signature V '-Date m
1 SECTION 1: SITE INFORMATION z'
--4
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers N
Namen 51jC SQlem MR 0I970 J D
1.1 a Is this an accepted street?yes no Map Number Parcel Number rr
D cn
( <
1.3 Zoning Information: 1.4 Property Dimensions: to <
N n
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) O I,,
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L a 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'
2.1Owner'of Record:
/tC - Iel , kourion s Ifrn A on-40
Name(Print) City,State,ZIP
11 Warms +. q18745.-(JM5
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other bb Specify:
Brief Description of Proposed Work 2: Aj(i(, ln'N1104AQ]Cx C'IOCr SU=C4
Stela i na
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1. Building $ �� 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 (BVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) L61379 11 1
.bk Santa License Number Expirati n Date
Name of CSL Holder
M
List CSL Type(see below)
w. �; � .
No. and Street Type Description
(�,,
U Unrestricted(Buildings u to 35,000 cu.ft.
H"+i--A-11-I - R Restricted l&2 Family Dwelling
City/Town.State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(pl 233 �7G�1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
A etri a I'ti,�1 IInc,T , teS C23 �—
�'� HIC Registration Number E pvation Date
HIC Company Name or HIC R.e�i qrant Name
Rd. � '�9 ��W a"I>�fA'tlnn. 1"M11
No.and Street Email address
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 ..........IP1 No........... ❑
SECTION 7a`. OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize_Ayy- . i can &;AdilrA Tec"-dc�jZ
to act on my behalf, in all matters relative to work authorized by this building permit pplication.
Ch WAot "u r j o n 512(0115
Print Owner's Name(Electronic Signature) ate
SECTION 7b: OWNER[OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
s K1k ,�rylas 512to p
Print Owner's or Authorized Agent's Name(Electronic Signature) Dat—�
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. ovioca Information on the Construction Supervisor License can be found at www.mass.�ov� i
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"
Fr_t�T
eiABT
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
21 Warren Street Salem, MA 01970
Jole 4ntos
5/26/15
.,! o d CERTIFICATE OF LIABILITY INSURANCE 10/2e 2014 ,
THIS CERTIFICATE M 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 POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE fSSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the cartlBcrto holder Is an ADDITIONAL INSURED,the policy(ias)must be endorsed. If SUBROGATION 18 WAIVED,sublod to
the terms and condi8ons of the Policy,cartaln Policies may require sn Bndorsemeat. A statement on this ceteacab does not carder rights to the
carmkate holder R1 New of such endonsme s.
PRODUCER NAME;
Ambrose Insurance Agency, Inc. NE . 701-592-8200 781-595-5820
56 Central Ave. (ucNa1
L Mil 01901 A»oRE s.
Lynn, erumrri AFwImINo wveeAos xuce
INSURER A:Atlantic Casualt
INSURED American Building Technologies Inc INSURER 8:Torus
Specialty
INSURER C:Hartford
2 Neptune Rd. , #439 INSURER o:
Boston, MA 02129 INSURERE:
...
S RER 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.
reA TYPE OF INSURANCENPPL Wuer� POLICY NUMBER M LIMITS
a
GENERAL LIABILITY EACH OCCURRENCE S 1,000 000
X COMMERCIAL GENERA-LIABILRY PREMISES Ea caueaa9 S 100,000
CAMS-FADE 7XI OCCUR SED EXP I"Orr Perm) a 5,000
A L035-011680 10/17/1410/17/15 PERSONAL&ADVINJLRiY & 1,000,000
GENERAL AGGREGATE S 2,000,000
GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AOG $ 1,000,000
POLICY PRO-ACT LOC $
COMBINED SINGLE LM17 —
AUTOMOBILE L.wa&Iry fE.K -s
ANYAUTO BODILY INJURY(Per POrom) $
HALL OWNED SCHEDULED BODILY IMURY(PWOOCklOrk) S
AUTOS AUTOS
HIRED AUTOS A L'�
NON-OWNED Per Br &
UMBRELLA LIAR OCCUR EACH OCCURRENCE a 1,000,000
�8331OH141AL 10/17/14 10/17/1s
B X EXCESS lIAB CLAIMS4ADE j AGGREGATE & 1,000,000
DED RETENTION& S
WORKERS COMPENSATION X
AND EMPLOYERS'LABILITY
C. AN YINNT S 1 000 000
NrA E.L.EACH ACCIDE
j iNmemyln Mp 6SO2483-5-14 5/29/145/29/1 EL DISEASE-FA EMPLOYE S 1,000,000
Syyea,duorlM UMa
DESCRIPTION OF OPERATIONS PORN, E.L.DISEASE-POLICY LIMB I s 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Atlarh ACORD 101.Additional Remake Schedule,S more eeacs a mgdmd)
Insulation Contractor
Community Teamwork, Inc. , NGrid Corporate Services, LLC, dba National Grid, dba
Boston Gas Co. , dba Colonial Gas Co. , dba Essex Gas Co. , Action, Inc. , NStar, and
ABCD, Inc. as additional insured general liability, excess liability, auto liability
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
NBC" THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
98 Main St. ACCORDANCE WITH THE POLICY PROVISIONS.
Peabody, MA 01960
Fax: 978-531-1012 AUTHOm2ED RE ESENryrNE�C
01988-2010ACORD CORPORATION. Alirightsmserued.
ACORD25(2010/05) The ACORD name and logo am registered marks of ACORD
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction supemkor
License:CS-101378
JOSE A SANTOS
-37 W.
Mig"I's Hyde ParkMWZt06
Expiration i
Commissioner IM12015
Office of&nsurotr Affairs&Bosinvs$RC90lAton Lirense or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
ogistration: 163106 Type:
Office of Consumer Affairs and Business Regulation
,t
�Elxplration: 5111120,15, LLC 10 Park Plaza-Suitt 5170
Boston,14A 02116
AMERICAN BUILDING TECHNOLOGIES
JOSE ALVES-SANTOS
2 NEPTUNE RD,SUITE•4351
Z A0�_ ------
BOSTON,MA 02128 Undmccrtrary N4-ot#afid ithout signature
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Registration 163106 ;.1�..
#f
Registrant AMERICAN BUILDING TECHNOLOGIES Hain Imorovemant Contractor Reostation
Home fss re
Name .LOSE ALVES-SANTOS
Address 2 NEPTUNE RD.SUITE 439
City, State BOSTON,MA 02128
Zip
Expiration MI112017
Date
Complaints Details
.NO complaints fawn for this registrant.
You can also view arbitration and Guaranty Fund history.
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02012 Cam to ealth of Massachusetts. Site Policies Contactus
Mass.CovO is a regir tei ed service mark of the Commor-wealth of Massachusets.
c
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(Basinss/organizationnndividnal): 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 box: Type of project(required):
1. 1 am a employer with 5 4. ❑1 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 9. ❑Remodeling
ship an no d have employees These sub-contractors have 8. ❑Demolition
mP
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 homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. a 152,§1(4),and we have no 12.❑Roof repairs
insurance required.) employees.[No workers' 13.[D Otherinsulafion
comp.insurance required.]
•Any applicau tbst checks box p I must also fill out the when below showing their workers comy recomon policy information.
t Hemeowrms who submit this affidavit indicating they are doing all work and than hire outside contractor most submit a new affidavit indicating such.
�Cunvamms that check this box must attached an additional sheet showing the name of the sub<ommcton amt their workers'camp.polity information.
1 man employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name. Hartford
Policy#or Self-ins.Lic.#: 6BO2483-5-13 Expiration Date: 5/29/15
Job Site Address: 21 WQA'YY.Y1 s}. City/State/Zip:kdem "K 0mo
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 die 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 afore
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 ce u thKW*ns and penalties ofperjury that the information provided above is true and correct
Signature: U, Date:
Phone#: 64A 23 7
63
Official use only. Do not write in this area,to be completed by tiny or town offrclat
City or Town: PermidLlcease#
Issuing Authority(circle am):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Work Order
North Shore Community Action Programs,Inc. Job Number:20698
119 Rear Foster Street,Building 13 Work Order Date:4/23/2015
Peabody,MA 01960 Ownership: Owner
Phone:978-531-0767
American Building Technologies Auditor:Brandon Dorrington
263 Western Avenue Email: bdorrington��a}nsca or8
Lynn MA 01904 Cell:781-540. gto P
Email:retieCana69
,americanbuildingtechnologies.com Phone:978-531-0767 x12I
Phone:781-598-7125
Charlene Laurion NGRID Gas $1,686.11
21 Warren St Total
Salem MA 01970 $1,686.11
978-745-0585
Safety Issue(s):Lead Paint Possible
p 3M
1oi ah a.ikge � p * y iF
,: 4n�sB t Cy i
i - iti't.;' h"CgtiBlh ,.'ft � h a s. tya a. F �3,{ x i a , un
°� ya
R-1I FGB in open rafters/walls/ 15 $1.47 $22.05 15 S22.05 where missing
kneewalls
R-18-20 unrestricted-settled 451 $1.44 S649.44 451 $649.44 flat
cellulose
v r,
Automatic Sweep 1 $26.00 $26.00 1 $26.00
Fixed Sweep 3 $17.64 $52.92 3 $52.92
R-5 Duct-wrap or R-max on door 1 $57.00 $57.00 1 $57.00
Repair/Refit Door 1 S58.00 S58.00 '1 $58.00
Weatherstrip s/Q-Ion or equal 4 $51.00 $204.00 4 $204. 00
ryes s q,y r
Vent kit/bath fan 1 $100.00 $10000 1 MUM
- .arhl'i 's,',:��P�F'—�`� ,,,. +u ips+<v. � a,•r*:':- s�"�"4 3.' tl�" _:�+�,s., .z. a _.�., d_...�
.. 5 !?5?... . ,.. .. • N!�a( ..' ..-15w.. e' ndh ... F1nl�ix , iGY'F X+S�tpt$'."+y:J{U
Domestic water pipe wrap 6 $17.70 6 $17.70
Date:4/23/2015
Page I
• Work Order: Job Number: 20698
IA'?} xiY(T$CC8S re3�(4�°,i,!Ft ar:yt "Jv`j �,{vx t {.y. g` a3 a:µuspy,
�lk&YFf]' 34JtMairo,ad'3434?$� Hf��YyN,�t+Y�`iGYo-FIr h' `�d`�s°4,va`'�� ��'YR:celirs � �. 't �«{p
Basement sealing with two-part 3 $84.00 $252.00 3 $252.00
foam
Blower door set-up with pre&post 1 $45.00 $45.00 1 $45.00
tests
Weatherstrip(Q-lon or equal)attic 1 $35.00 $35.00 1 $35.00
hatch
itHi1','- t "5` "� f `''+: .dvN$
.._ t
Building Permit 1 $100.00 $100.00 1 $100.00
_iltpt415 .
4 web,, M x,A"»�* ''... 4 u�p I'° *11 sir.
Test drill sides 1 $67.00 $67.00 1 $67.00
Total $1,686.11 $1,686.11
Contractor Instructions:
Before Martin the a Job: During the Jobs
I.Please notify us 24 hours before starting or scheduling ajob. I.This residence was built before 1978.Lead safe practices are
2.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,
Additional Contractor Instructions:
Certificate of Insulation posted? Yes No (circle One) Attic Inspection form attached? YesA ire ene)
American Building Technologies hereby certifies that thisjob was supervised and completed in compliance with all Department
Io-fnLabor Standards and Lead RRP regulations.
ore.
n5ature: Date: RRP License N:
Page 2
a
Contract for Products/Service Work
This Agreement is made by and among
Charlene Laurion
21 Warren St.
Salem, MA 01970
American Building Technologies(ABT)
2 Neptune Rd, Suite 439
Boston, MA 02128
I. DESCRIPTION OF WORK TO BE PERFORMED
1- Insulate attic R20
2- Door Sweeps
3-Venting
4- Basement sealing
Total: $1,686.11
Customer Signature: Lj�aJ� �,�Q �rf /01 1A�n1
Customer Name: "1wfFA)E (_,yUa+ Dater/J
Contractor Signature:
Contractor Name: Date: 5 27— )S