15 1/2 WILLIAMS STREET - BPA-14-1261 l�
i The Commonwealth of Massachusetts RE EVOeTP5
' Board of Building Regulations and Standards �NSPECTi NAtSMassachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or De?o�qli a�
One- or Two-Family Dwelling August I5, 2013
This Section For Official Use Only
Building Permit Number: Date Applied:
/� /
Signature: 7,rw 3
Building Commissioner/Inspector of Buildi gs Date
SECTION 1: SITE INFORMATION
1.1 Property Address: V 3 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes —Irno 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 Requred 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 Rego :
N e(Print) Addresstfor Service:
1l S 8 ery --zo 7 s —
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied, Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other Specify:
Brief Description of Proposed Work':
rt!A TV&AA70
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials 1
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (RVAC) $ List:
5. Mechanical (Fire $ V
Su ression Total All Fees: $
9 8G Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ - 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Li , nsed.Construction Supervisor(CSL)
License Number Exp rat Ion Date
Nan of CSL�Hol ,er
_
List CSL Type(see below)
Ad ess Type Description
U Unrestricted(up to 35,000 Cu.Ft.
- R Restricted 1&2 Family Dwelling
Signature -ff- 7 Y/� V7/ M Mason Only
7 0 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registere Home nt"Improvem Contractor(HIC)
//t�1erS� GJ �
III omp�ny I�{am HIC R is rant Name Registration ut er
]�(V�(:F`i% G�
�G Ex ira ion 15ate
Signature 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 CONTRA TOR APPLIES FOR BUILDING PERMIT
I, ,, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Wder Date
" SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
I, �G as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name (/
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
1G CONTRACTOR WORK ORDER
�
col-1s Cl"�at101-1
50 Washington St. Suite 3000 Printed: 7/29/2014
Westborough,MA 01581 Work Order Id: S37756P43270C199
Contractor Information Customer/Site Details
Mass Weatherization Inc Elysia Alleman Email: elysiaalleman@gmail.com
3 Ocean Ave 15 112 Williams St Apt S3 Phone(Eve): 413-884-2075Phone(Day): 413-884-2075
Salem, MA 01970 Salem, MA 01970- Site ID: S00002237756
Total Installed Measures
Location Description Quantity Unit$ Total $
Living Space Install 3" Fiberglass Batting In Open Kneewall 248 $1.70 $421,60
Living Space Insulate Vaulted Roof From Interior With 6" De 450 $2.57 $1,156.50
Blower Door Test Only 1 $65.70 $65.70
Temporary Access 4 $85.96 $343.84
Living Space Kneewall Floor Enclosed Cellulose Dense Pac 186 $2.27 $422.22
Installed Measures Total $2,409.86
- Road Blocks
Type Status Notes
Knob &Tube Wiring FIXED Rec'd Pre-wx&invoice. K&T has been cleared for exterior walls,
kneewall Floor and attic slopes. License#A17458 has been verified.
Cleared in Home. Ok to issue contracts
Payments
Incentive Payments
Weatherization Incentive $1,807,41
Total Incentive Payments $1,807.40
Customer Share
Total Customer Share $602.46
Less Deposit Of $179.15
Less Pre-Weatherization Incentive $65.00
Customer Share Balance (Due Contractor) $358.31
Conservation Services Group- 50 Washington Street Suite 3000-Westborough, MA 01581 - (508)836-9500
The Commonwealth of Massachusetts
Department of Industrial Accidents
—r = Office of Investigations
._.. ..,
600 Washington Street
=__ = Boston,MA 02I11
- www.maz.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print L,eaably
Naule (Business/Organization/Individual): MASS W ATHERIZATION 'Na
3 OCEAN AVE
Address:
City/State/Zip: 978-14bt4L4d#4.
Are on an employer?Check the appropriate box: Type of project(required):
1V1 am a em to er with 4. ❑ I am a general contractor and I -
ploy 6. ❑New construction
-t employees(full and/or p me).* 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 g, ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.#
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 11.❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no p
employees. [No workers' 13.KOther
comp.insurance required.]
'Any applicant that checks box#1 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 must submits new affidavit indicating such.
tContractors that check this box must 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.
1 am an employer that is providing workers'compensation insurance for my employees. Below is flee policy and job site
information. t^� 1n1n
Insurance Company Name: IDID `` NVd
ers
V Policy# or Self-ins. Lic.#: U 15 9 1 1 c l R !"I - 1 -3 Expiration Date: 3
Job Site Address: /S Z (JJ tl.(i!/N+ rJ` City/State/Zip:
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 certify under the pains and penalties ofperjury that the information provided above is true and correct.
Si ature: Date:
Phone#:
Of 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#:
rAfairs n//nlee. anon L�
r z� Office of Consumer Affairs&Bustbess Regulation
- OME IMPROVEMENT CONTRACTOR
egistration: 111617 Type:
xpiratlon: 1V1212015 Private Corporatic
i
s a.rtn.
MASSWEATHERIZATION, INC
RICHARD LAMBY
3 OCEAN AVEc�>,^ a
SALEM, MA 01970 Undersecretary
t
)at Massachusetts - Department of Public Safety
�WJ Board of Building Regulations and Standards
Qunctruction Supett isor Specialtc
License CSSL-102293
RICHARD LAMBY.
3 OCEAN AVENUE
SALEM MA 019�0 ;
1
Expiration
Commissioner 0 510 312 01 6
e