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68 DEARBORN STREET - BUILDING JACKET V-7- Certificate No: 345-11 Building Permit No.: 345-11 _= Commonwealth of Massachusetts City of Salem Building Electrical Mechanical permits This is to Certify that the RESIDENCE located at - --------------- Dwelling Type 68 DEARBORN STREETin the CITY OF SALEM --- ---- -- ----------------------- Address Town/Cit Narne IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY iE OCCUPANCY PERMIT ISSUED TO (68) DEARBORN STREET This permit is granted in,confornuty vrththe Statutes and ordinances relating thereto, and expires - - unless seonersuspended or revoked. - ----Expiration Date . _'"-'"-------'-----------------------------_ Issued On:Mon Mar 14, 2011 — - -- a /Jr� /. . GeoTMSEG 7-011 Des Lauriers Municipal Solutions,Inc. '- --- '— '-� IL-- `E'rra.i ---- --- ----- -------- �,�ONDtT � o YSOYE AO CITY OF SALEM BUILDING PERMIT 68 DEARBORN STREET 345-11 GIs#: " ,..x4184 " ' ° , . COMMONWEALTH OF MASSACHUSETTS Map: 36 a>; Block: CITY OF SALEM ;. Lot: 0487 Category: Il ALTERATIONSI L 6t Permit# 345-11 ,t' j@ BUILDING PERMIT Protect# JS-2011-000341 Est Cost 3" pPN $145,000.00 Fee Charged:', $1,020.00 . w Balance Due:ii $.00+' PERMISSION IS HEREBY GRANTED TO: Const.Class:; H, rf" J°" .; Contractor: License: Expires Use Group: '' :u Tom Tremblay STATE-072713 Lot Size(sq.ft.): 23399.9964 Zoning: ,}i„ �;; Rl ff� Owner: John Keenan Units Gained:,. % Applicant: Tom Tremblay Units Lost: t, :JA T. 68 DEARBORN STREET Dig Safe#: ISSUED ON. 19-Oct-2010 AMENDED ON: EXPIRES ON: 19-Mar-2011 TO PERFORM THE FOLLOWING WORK: ADD NEW SECOND LEVEL &MOVE 1ST.FLOOR BATH jbh POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground: Underground: Excavation: Service Meter: Footings: Rough: Rough: Rough: Foundation: Final: Final: Final: Rough Frame: Fireplace/Chimney: D.P.W. Fire Health Insulation: Meter: Oil: Final: House# Smoke: Treasury: Water: Alarm: Assessor Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: cwc ^-rkmo—unrl BUILDING REC-2011-000432 19-Oct-10 1789 $1,020.00 GeoTMS®2011 Des Lauriers Municipal Solutions,Inc. A. The Commonwealth of Massachusettst C Board of Building Regulations and Standards : P',W-T-��fS� �2 SALEM � F Massachusetts State Building Code,780 CMR Revised 2011 Building Permit Application To Construct,Repair,Renovate 01MALlral A 101, One-or Two-Family Dwelling 13utlding Peauit.N#mtbes ; Date Appliodl .. �aiidiug O, cart(Pro# ..'e) Sigaatme T- ate ,^,nnl , SEGTft1PI 1: T1PrO1tMA.TtON _ ! 1.1 P periy Address: 1.2 Assessors Map&Parcel Numbers Lla Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Ansa(sq ft) Frontage(ft) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yard Required Provided Required Provided Regmmd Provided 1.6 Water Supply: (M.G.L c:40,§54) 1.7 Flood Zone Information: 1,8 Sewage Disposal System: Public Private 13Zone: _ Outside Flood Zone? Mumcipal)K On site disposal system Q Check ifye SECTION2: PROIP=TYOWNERS1[IPt 2.1 Owner'of Record: S'ALM4, 6AA _Q to/ 70 ane(P4int) City,State,ZIP 7qy-71br (off � i.. 8y1- v�' �i''7✓'7s i 1Cx chu, � s�.ta-,..g��r_e v No.and Sheet Telepbcoe �--Email Address SEC'T'ION 3:DESCRIPTION OF PROPOSED WORKS(check alt that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) O 1 Alteration(s) Addition O IDamolition 13Accessory Bidg.❑ Number of Units_ Other D Specify: Brief Description of Proposed Work':zf i SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: only Item (Labor and Materials OlDete)Use 1.Building $ 2 qZ OD. .— 1. Fiailding Parmit Fee-$ Indicate how fee is determined: 2.Electrical $ M Cl Standard City/Town Application Fee Total Project Casts(Item 6)x multiplier x 3.Plumbing $ Sl 00- 2. Other Fees: $ 4.Mechanical (HVAC) $ Z-610- List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Beek No, Check Amount: Cash Amount: 6.Total Project Cost: $3J 9 ov. O Paid in Pkll f]outstanding 13aianoo Ane: TATart lot � tz-. ` Cu.� c777 C 60&} t SECTION 5: CONSTRUIC ROA SERVICES 5.1 Construction Supervisor License(CSL) rLi=—se © 3D�3�� A, �`6yIfs Number ' on DateName of CSL Holder t .Jt CSL Type(see below) (vim— >f�t,,,9wt c7 i Pt PC No.and Street 1�°° ,�..�� T)w . ,,yvtA D 1��L2 ::1JRC Restrictedted l&2 FU Unrestricted ahtildings up to Cityown,State,ZIP masamly Roofin CoverinS Window and SiiAge- Solid Fuel Burning Appliances `77,6 7 yi/t/9�i 5i�r7/i� cSzl/Us 2!// Gherniation Tel hone Email address Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Exp' on Date Company Name or HIC Registrant Name ///, i ams �1v-T co No.and Street ' Email address T--Ivy ✓ /9Fi� 40(0,a 9jB74!_ /lZ�4E Ci /I•own State ZIP Telephone SECTION&WORIMRS''COMM &ATION PMRANCE AFFMAVIT(ALG.- c.152.4 2500) 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:O"RR RIZk TO M Co hOLMD WMN OWNER'S AG :NT R OR: 1F RIIMWWGrERMr 1,as Owner of the subject property,hereby authorize �e ,'� to act on my b alf,in all matters relative to work authorized by this building permit application. Q / 50&7 2�6Ei canter's 14ame(Electronic Signature) / _ Date SECTION 7b:6,,VMW OR AUTHORIZED AGENT MCL41AT1014 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. �G� � %9,e� 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 Mvw.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.fl.) (including garage,finished basement/attics,decks or porch) ) Gross living area(sq.it.) 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" A : 0, I 04ST 132-6$4 r �ti I aM 01 I � C i uQrT {.o hTt9 1 WIND* u M`I�kG{6F{ C I til Plr waLV. KNNin�N� VD&ATcnu P-- ST .: _�...--•+_r_..r.. r-^s-l.-.ram-•. v---. r .0 P `Y k � I n 1 ( d A' � e+ J...� } b �' .'r � -� ��I i q! r �� • 4 C a3 � ,. r '. 1 , ?,yam i .Jd* 4.— ' c. � 4 I t p f� r ti�f � } �, , r ro� `e t f ♦r s 4� IY 'f � f n Y r'-•✓- ' � ^1j Y .r •{ Fv.,_� / ,.w e i pT e F I fr �,. r,} . � Y _°r ^x d'T , '"n �� �i B� y Vy,< �' ,`� 'r m �� •v .� � � ',r Tom'• a.,� •y,;,: .��� '+. i d,t. � t �'. "d r" �« Tfit thmonwerlth af,M sso�liUsctt# �. s ' a 14 - � y`1w� I n Y 1u �Qb�rt(o�yltldlrt� Reg�tbtrort)and�SlaAdafbs� � .�a lop' r�N,t S�ch`ua 11 •JI v'694ildir? 10 7c e, 7 0GA 1 . edtpQtt ; �, AO Buddi„U Ixatmi�ADl�cxtl4„To•Sstnsjtvl�t; p�ir,.Rh�tnvpt2Or Derkiol)sh a. '•w 1 t �+i � �� 7 t�ItR�f�/'�1{I0`I�1�Rtt�i LIZ, r , . �, >P li S2�h8n F r,L)Iliciii€U!e Onl w` ' " ' ate Applied ins Pot it y � I ��s Dut t �1♦ Ins;C0mmso'l Oer Inlpecta/ot`BpIIdlEya r { , + -EcT10'N i SM'1'fE "^•. ���� '� r ° E�kAlfxl+�ri l�t�p df���irl�Rl AlumbRrl• f • I" ., P �,1. C-dtfc�r>ui R , Tlo -b,''X"'• t' , �areet NNmber ).!x la tlrirr -co pled Street, y ` ' `AJ:i' aptity Dltre4a16 ![n ,� 061 r � r _ Ares 1 �) Fronuro 1 R)' ;aE1nx D"rtnot •.. P�>� ti :. ' tpt `1 S�9rilldin{, ..Ibeetix,�h). '' �' ''• r '� aF/oelcY ,° , .'•' . o-5lddYwdl ,. � r: . ,.''. koxrYarA, '• k �� 6 'jj�� Providfd " J 4 itagmrcd �° . _ .•� Ir SR►�«w.DbpOldlrRYdoitst ti WxOr Supptj�t(gtj t."c 4D p4) )y7 Flopd�orE It�fni�mltlfotit x Flood Zeilal� �Ittielpdq•*(31tadlap(gea)vY nJ ,ry '`PybtiC �� ° , , ,• .o .;*' L • �_CT1bM s"'PB�P��'1"Y f1WNtr)tS)iCP ti ' •• _ y Na 10, 91) I:r:r b4l '� $ •4 s n Z a/,'/rJ� 'Y l-;'Ir .�Sit{n if 0 OF PR(�p0$;Dr Obit(c6eekiU fhrf;rpplr) si�c1�i1 ' r nauprt x. ` ` w d" ,G* bvi?rjel acCuprad O, { 2pill e) Qf '�►Itgf Utioti(a) iQ 6ddihar q ' Now oosauctio �lla6Is ftrrr< p o 4 • i(kmolifieil`' 0= �Aecdfaoky�ld(1�'aQ �N�,fis�'o[UpIi1 '�` " 01h `"" rSp�lf�r�:` . '•9 AW f L' ;'arief De e f i f f Proposed Wdrk � 'Oft d, s,f .r.Fa''h)eM y.� a A x> •� �W.. L• ✓.. 6 i 1' w %'� � _ 1 , ' .�;yb � s` n V•J:. !r r1a' _ f X ., t N .JI � w:.{i kY r [ a _•� �( y d�yyee ((�� 1/�NGO'�T� Tfl�f'A`Gtsb 1�� 0OCT Y ", l ' `.,F,lt4TCd1C0lt 'y 4u w w "r•°'n dme�� O�I`y °l�Em �$ - Libor a d`�Matenr'tb Y ' •. "� " �Fee f a . , , 1n�tci hor4'f'e�dxi ngined `� 1,�Uoddtdk °, I qut14[h{P�rtri a, ''h-- �"I O Stxp4tl► Clrylwd AppIIC}ll Fett; q - 'f � `O�otxl�Pto,��Ct'Cosl (It e�t6 :ate Itli^plier %_ a '•-r.,.,,--.. �,; ` 14nibl,x t ESIh tTitd1 �' '`..; x k .: ♦ r c P Y I y. cchant,Fq! Mlle, ; h ! �" fOgi Atil F,�'t1 ! ✓ ~'u {t�olr ... t + + " " Ct!sll':Am01tn1 _ h ck Ybo c tno- o h� Ir A� unl x ra aN. ji nce Our h' 1I oral Prb►xEt dolt , S ° 1 « . 't]paldtxU O Outs nB U '' �aflt7l •rt{p5 ICI fj •. � ', yy d j�+n� e o rY�� S 4� ar l d% a , '&'tfrya 1 k _•_ Y' + „e1 I� '- '.nY a .Y b di C... I M i1.� yF -'.. °. K - ° •� ( `, p � tier < 510 y, •'h tom, y ,, �( �F q, a� y y •Q ( � e1 n it p 6 r+J•I' M.. I b J T 2 r.': F rt. �'r ♦ r. � '.Y rY a;:f.' f w 1, cM�atls�Y a w rt-lit 1. vk'ko� ♦ a!I .y �'� �: .. .. - •ram----�--^^ - —. --� -.. r , to n ` SECfIt7N;i3, COh$TRUCTION'$�g+ICES ' y ensedCon if 0Vt`Superaas t IGSLR, p ; / Lkr6W,Nnlnbar'� `Eapir�l�o DilO j1 N+lae of>t SL" .lyl ` r Lht r 5L Tip,,e lsca Mitowj • r hQ ', " Des to loon rT. I U` cUn►eYtnated'u 'to-)i°OOOt?u d' P' a L)i2 fitnif,Dyellin R' Rirtrlct' �ilruwre ''��J w�c�� J. ', a N' ' fawn:�l)nl `-• RC _ Rcl denuJl Roo h'nCoverm fitlelp ' WS Re`ltJenFl`aUfffidow,Md 5101n ., ,- -. r •,, y Sf Renden6al;Sohd Filet'Bturitrt ^ lianee Irt mrahon D ReiideniiarDemolinon' S,2 R�Iltefed H g J pr' vompol,Copoitir 1 IC) i, y ' �• HIC[ � N! 1 of Il ' eglslrLt f9 egul►aii' gNum4�e A 91� 7ys=�f�� Eapiraion Datd. F M a hor11 ... hire r SECTION bt WOR1tERSCIMPENSTION'i1NSWRANCE AFF111AVIT tl1QCi.L.t 1!1 1 3iiCpS)). Fr ., ' Wolkela.C`omplgnsatiort lntilirap4e ttfiida'v1t mu�t;lfe¢bmpltgied acid submitted with Ikia apphiCanom'Frtilure to provide this afOdlldit wilf.resuli in'the denial of the laivanCA".of ilding priimii . Yea "Si,plaiAmdltvit;A,nao�r SECTION 7a:OWNER AUTHORIZATIOM TORE.COMPLETED'WHEN OWNER'S•AGENT OR CONTRACTOR.�APimis dIt'BUIIi1�INC'P.ERMI ,was Amer oI iltb subjccrproplsy'hlrcby auQionie i to`acton my behalf,In,all mattes 1 y► e relative+ Work a}Itfton `by;ihla building permit'apPllcatlDtl i afOwnar •.'. '' ` SECTIOi�;7b'"pWNERI OR AUTHORIZED AGENT DE RAT dN = 4 Le Owner or`Authonf-od Aged hereby,declatb That tlk'stltemenla and mfpri{fonon on°the ior'joinB,apphcation are(rue apd aeeuiate,Eq the,best ofyny'know(pdSe and - i Ohl Nam tii x fir? sae P x f�t tx /• $ignapw df Ownar or Aulhor4cd'Agen w 7 s 4 r, DPI t iledUnder the sinrand hsaiis of r' '. 2 •NOTES• l: AmO.wllet w,ho obtalAa.+b° tog rfn!)do do iyhef gwl�wark oran ownrM'r4ho hirc�ad UrJregtatered'codiractor i (nQ(rt gstered'ill.lht Honielmptovement Cd�itia4itir I SIC)Progr>tm) well have acce{!id lhe-arbitrrlrpn prograin'or'g1oaratnty fiend ynd's?M ,i yc 142A Other inrpo- and Inforttla(itlA on the lijCProgram and _; �onllrutli411 Of 'i ot"LiclnstryS(CSL)kanjboJ1d'rrdii�r78bCMk_R�guhlVdna IJOR6uid.il;0°R3 re:peailvely 1 WhcrowA 1anoal 06tit iti planned pfo'h&th0 mfottndfloY�l�belerr ?o14i"can area(Sgr.Ft) I x a Ilnc;ludrng' arag4 idish'4basemenVattics,dccks or'po0h) x� Gross lieipq HARM,icbmlount ' tiumbel.pf lireplice! _,_ '� k umber of beJlOQrhsN vumberol�hllfbalh! Number of galhfooln! H ti } �4pe or mg cyslettY' Numtierof Jecky portheli ii{ 1, Tonl,Proli t A'yuare'Fuolage May her`uh.utui0 for i,Tuial Prolccl Co.t' The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR S Revisedd Mar Mar 20/1 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 plied• uilding Official(Print Name/ Sign re Date SECTION 1: SITE INF ATION 1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers 6 � 4�,x� St— ?4- 6gJV7-- - 1.1 a Is this an accepted street?yes Co , no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions:..... 537 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 yesO SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Tott.. /G-cc-dta.-, <A!-&7'1n rKr4 Illy-in Name(Print) City,State,ZIP (9Y Oe->4t[bYt-h/ S+ 9-11(-74u-70Y 404 w►aF�✓�l+l..v@CIn ••cily�. 7t No.and Street Telephone Emai Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other Er!�pecify: ~.AolAr— B,riieef Description of Proposed Work : 7CtlJY- ✓t'1 n�//!'�f c� L4ftAtl 1't P/0 1^✓ Si)kta- sy S Aew7 SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ Xx 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 (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ �Cj -1�f7 — ❑Paid in Full ❑Outstanding Balance Due: o��i�cJ�oil r161(17- SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) .SY14o � l ZIn f W Ut le!a9-nj License Number Expiration ate Name of CSL Holder -?:I ��� ^2 List CSL Type(see below) No.and Street 9�/ Type Description �t U Unrestricted(Buildings u to 35,000 cu.ft. /tiAl or S?{ -5 R Restricted 1&2 Family Dwelling City/Town,Stale,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances SUI'-8�y'9�°►s /Io Jfkko.,(T&O 4&logit I Insulation Telephone Email address lo►y. D Demolition 5.2 Registered Home Improvement Contractor(HIC) . Lt'ney, rl4,,, s IAti. Se t✓/LeS HIC Registration Number xpiration Date HIC Comp7 Name or HIC Rgiant Name No.and ,b� Email address Q'Ir.-5 Rclo-,'e 00i+ 187t>a- S'1b-�rJ-y�;PO Ci /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 Gl ox(r J4[.Aec &—,o to act on my behalf,in all matters relative to work authorizedby this building permit application. t 63 uLi a_r��3 Printlet's Name(Electronic Signature) Date 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. 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. oe v/oca Information on the Construction Supervisor License can be found at www.mass.eov/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" ASA Engineering Shrewsbury, Ma .Tune 22,2013 To. John Pitcavage Endless Mountains Solar Services Re: Solar Array installation No.65 Raedborn Street Salem,MA Per your request,I have evaluated the information provided for the existing roof structures and framing system, at the above referenced project, This evaluation was conducted to determine if the existing roof structural framing system has the load carrying capacity to support the additional proposed loading for the solar array system., Based on the information provided,the roof framing consist of 2xI0 @ 16"O.C. with a span of 14 ft.,with 2x6 collar ties at 32 in O.C. Based on my best professional opinion,the existing roof system have adequate load-carrying capacity to accept additional loading due to the solar panels, without any modifications. Please note that this review is intended solely for analyzing the structural capacity of the.roof framing system due to the additional loading of the solar panels and it is not intended as a complete structural analysis or code compliance review of the entire building or its framing system. The roof connection system for the solar panel shall be in conformance with the system installation manual,in order to resist the uplift forces due to basic wind speed as determined by the current building code. I also recommend staggering the attachment of the rail to the roof at alternating roof rafters between the upper and lower rail, to avoid concentrating loads on a single rafter. Each lag screw must also be centered on and fully penetrate the rafters(min 2" embedment). In particular the installation is designed to confirm with ASCE-70 wind limitations and Endless Mountains Solar Services shall confirm that the system designed will be installed accordingly. Please contact me at 978-377-5084 if you have further question regarding this report. Sincere`l zlzi,P.E. _ ^i �tx OP yen hW�W-/O-�,OD- ny� Oi war., N atata SroxAL E� ` SYSTEM SPECIF[ACRONS Endless Mountains KWDQ 6.75 ENPHASE M215-60-240V LINE DIAGRAM SOLAR SERVICES KWAC 5.375 AC VOLTAGE*240 AC AMPR28.125 AC DISCONNECT SIZE:30 MODULESIQTY:SOLAR WORLD 2700 ENPHASE CABLE BLACK-LI RED-1-2 WHITE-NEUTRAL GREEN-GROUND JUNCTION BOX ti 2 POLE 20 AMP Egl CIRCUIT BREAKER PER BRANCH CIRCUIT F— r,OAWG rwc...T B AWG WIRE (FROM COMBINER TO IRE(FROM SOLAR ARRAY TO COMBINER) ���� INTERCONNECTION) IPANo TwccONBurt P[dUBYG1IEU V V 6AW VG 6AWG MTP TERMINATOR CAP —'^` 1^wc coxoulT INSTALLED ON END OF CABLE TO METER OR AC DISTRIBUT ION UP TO 17 M215s PANEL PER BRANCH CIRCUIT REC METER B m 8 AWG WIRE 1-2 POLE 40AMP AC DISCONNECT (FROM COMBINER TO CIRCUIT BREAKER NONFUSED INTERCONNECTION) To¢NSTAUEO BIMEST DO1"WCCONWT ETHERNET CONNECTION AWAY fgOM MAN OPGRFP ENVOY COMMUNICATIONS GATEWAY ./ TO BROADBAND ROUTER -I j'ejenphase COMPANY:ENDLESS MOUNTAINS SOLAR SERVICES NEUtRAE cRouNO 120 Vac POWER CABLE 288 KIDDER ST AC OORSVB-MNPANEL 6AWG WILKES BARRE PA 18702 (570)820-5990 ON U00A MURRY 200 AMP DRAWN BY:JAMES LASKOWSKI CUSTOMER: JOHN KEENAN 68 DEARBORN ST SALEM MA 01970 978-744-7168 6126113 30 DECREES 3 MODULES LANDSCAPE 0 2 MODULES LANDSCAPE O 11 MODULES 0 O 9 MOOUUE3 n COMPANY:ENDLESS MOUNTAINS SOLAR SERVICES SOUTH 150 288 KIDDER ST WILKES BARRE PA 18702 SYSTEM SPECIRCAT10NS J DRAWN BY:JAMES LASKOWSKI 7D CUSTOMER:JOHN KEENAN SIZE' 6.75 65 RAEDBORN ST MODULES SALE M MA 01970 TYPE SOLAR WORLD 270 AMOUNT:25 � , � � fhe Cummumvr•rlth of Mrssachuxt2,s . UoarJ ul'BuilJing Rrgul•ruuns anJ StanJar�s CITY ' !� Massachusr�u State BuiWing Cude, 780 CMR, 1'"cJilion ��F SALkM i Rrrurd Jwruurr IluilJing Prrmi� Applicatiun To Cunstrucl, Repair, Rrnurate Ur Demulish a /. :aAv y Onr-or TrvwFurnilv Owrlfing ��[, Ir This Scction Fw OlTicid Use Onl J BuilJing Permi� Num Dale Applied: d � s������.�: //� /� rr� Nw J'n Cwnmisaioned In�pec�or uf Buildinrs (}a�e SECTION I:SITE INFORMATION 1.1 Properry Addna: 1.2 Aaeaon Map d� Parcel Numben ��'� ,��,�fYl �S•�6iP�.L I.la If�hi�an acce ted stree�?yts ✓no Map Numbn Po�cel Num6er t..I Zoolo�In(ormalbo: 1.4 Properry Dlmeoslow: Zunin�{Di�tric� PropoxJ Ux Ld Area(sq Il) � Fromage pT) 1.3 Bulldlo�Selb�eks�1t) Fronl Yord SiJe Yardf Re�t Yvd Rryuircd PruviJed Requind Provided ReQui/ed Provided � � V lJ�d� 3V /(�.f 1.6 W�ter Supply:(M.G.L c.d0,§34) 1.7 aod Zoae lo(ormatloa: 1.8 Sew�Qa Dbpos�l Syifem: Public O Prirae O Z�' — ����F����� Munieipd D On�it¢disposd system O Cheek if es0 SECTION 2: PROPERTY OWN6RSHIP� 2,..1��oer�of Record: �p YVnn a.� �n 0.6E ��i�r.✓1 LdL����C'}�'�I b� -o- =-�---�— Nome IPrinl) Add�ssf�'�rJ ice� — / � , �yjv �/ �3 sfgnwure re�epnw�e SECTION J: DESCRIPTION OR PROPOSED WORK�(e6eck�U tA�t apply) New Conftruction O Eaisting Building O Owner-Occupied O Repein(s) 0 Alteration(s) O Addilion O Demolition ❑ Acceswry Bldg.O Number of UniU Other O Speciry: � Brief Description of Proposed Work': � %� /�" ��L�/L �s/ /-�9'c/.�� S/'�LGi n> >1a- '�'/on2 �/ �-G2u�NS / /Ia�,s� ?w/ k� b � � SECTtON 4: ESTIMATED CONSTRUCTI N COSTS ���m Estimated Cosb: 011lclal Uae Onlr Labot and Ma�erial� 1. DuiWing S �,2 � � �� Ouilding Pertni�Fee:S Indicale how ke if Jatermined: �. Elec�rical S � UU �Standard Citylrown Applicalion Fee ' O Total Projat Co�� (I�em 6)�t multiplia x ). Plumbing 5 �� �ij 1, O�her Fm: S �� /�� �,� 1 1. Mechanical INVACI S Lish � / VU S. M.thanical �Fire S Su «�sion Tu�al All Fees:S Check No. Check Amounc Cash Amounc 6. Totrl Projecf Cwf: S ,�S�v� O Paid in Full �Outs�onJing Balanee Due: ' Q U j �ll`(�1E=G'W�� �,� r , tiECT10N S: CONSTRUCTION JERVICES S.1/LlStnaed Con�trucilan 5upsrvbor ICSL) ����3 ' �( � I.ireroe Number L. pim�iun 1 ��e an l�D,;� — N:une ul l'�I IulJer /�,� � �,/� `(,� I.i9 CSL�f>pe 1�bslowl �- �hC �LY11�' FX'Sri't'l�!'��V7� Ikacri ion � u U llnns�rKteJ �u JS.00O Cu.Fi. � / R Res�ricted Id3 Famil lhvel�in tiiyiu�urc � M M lhJ �i/�/1 ���"y�.i� RC Re�iJrntial Rwlin ('overin I'.I.phixie WS RsaiJmlial WinJowanJSiJin tiF ReeiJenlid Sulid Fuel Bumin A lianco Immlla�iun D RaiJemid Demoli�ion S.��t re Hame Improvemeet Coslnelor(HIC) � Z�g fc Z_ I11 Cwn y ams w kl C �{is�r�m • e Reyis ra�im Numbet � � L � .Y� .. �/�� nJd y7�+/L���-`/ls7� v�r+�on oau tiiyn:uure � � 'fciephune SEGTIOIV 6: WORKERS'COMPEN9ATION INSURANCE AFFIDAVIT(M.G.L.a 132. f ?SC(6)) Worken CompmLtion Inswence alTidavit mus�be completed and submined wi�h this application. Faiturc to provide thia�fTidavit will rcault in the denial of the Isawnce of building permit. Signed AlTidavit Altachedl Yea .......... No...........O SECTIOIV 7a:OWNER AUTNORIZATION TO B6 COMPLBTED WHEN OWN6R'9 AGENT OR CONTRAROR APPLIES FOR BUILDING PERMIT � , a�Owner of the eubject property hercby authoriu to act on my behalf,in all matten rela�ive to work amhorized by tAis building permit appliulion. . i Si ureofOwner pote 3ECTION 7A:OWNER�OR AUTHOIIIZED AGBIVT DECWRATION I. ��� /„J-•7 .as Owneror Authorized Agent hercby declare that Ihe statemenp and information n the forcgoing application arc we end accurate,to the bat of my knowledge and behdf.� . . . '. n� K �\i�,. h(n -i Print Name ��^ � / i�/�� , b�'c � Signalure of<hv�er or Aulhorized Agenl �«� I Si unJer the aine and naltip of 'u ' NOTES: � I. An Owner who ublains o building pertnil lo do hie/her owo work,or an owna who him an ueregistercd cuntroctw - � (nd rcgistercd in�he Home Improvemmt ConUxla IHIC)Progrnm),will�have access�o the arbitrmion . program or guaranty fund under M.G.L.c. I J2A.Otha importanl informa�ion on�he HIC Program and j Conslruction Supervisor Liceneing(CSl)can be found in 7A0 CMR Regula�ions I IO.R6 and I IO.RS,rnp�a�ively. � �. When substanlial work is planneJ,provide the informalion below: �� Tu�al Noan arca(Sq.FI.) /yGs/ (including�rage,finished basemenVatticf,deckf ur porch) i Gros�living arn(Sq.FI.) Habimble room coum Number of fircplxn 6 Number ol'bedrooms � li Numberofba�hrwm� / NumberoFhalt%bath� J' Type uf he�ing sysiem (�5 z�A"'"� Number of deck�/porche�� Type uf couling sys�em .��� Encloxd Open ). "Tuial Projecl Syuare Fuo�age"mny Ae wbs�itumJ for'?o�al Pmjrct Cux�" ��,;; lJC1 Y ur �N���v� y '?;• I�LIBLIC PRc�PRERTY ,:,,. ��y �.': �"�' � �_�'-� DE1'.�lt"I'�[ENT � � �,N�.!"' _ ' i ` ',�� �.. �.. 11 I:. \� r.11l\�..��•.11 ll I f � \.\I I \I. \�.\.�N . .. I . � _I'� . I I I 'I'3.'li.�l:4G � � \C: 'i'9.'J:.'�dl�� ('��nstructiun Dcbris Uisposul ,affidavit (rc��uirc� liir �II �anulitiim auJ rcnuva�iun �wrk) In ;iccurdancr ��itl� thc sixth rdition uf thc Jlatc Duilding Codc, 7S0 CMR scctiun I I I.� Dcbris. and thc provisiuns uF �iGL c -10, S 54; QuilJing Permi� h is issucJ with �ht couditiun that Uu dcbris resulling tiom ihis �vurk sh:ill bc di,poscd ut in a properly IiccnscJ wa.re�lisposal I'acility �s Jcfincd by �1GL c I t l. S I51)A. Thc dchris will bc U'ansportcJ by: ��r{'l� c5i��r ��`-� 1 n�mc ot haultr) . I hc Jrbris will be Jisposed ut'in : �u�a.��� � �� ���:,��r ��i �����y� O��Z�,/-��STl�-Ca�ki•�- t �:�JJres�ul�I�cililyl . I I ( . . .i¢ualwc nl'prnnrt apphcant - ✓ � o �� l l �i�c� �,�,,..,....... ���s s�� ja y Information and Instructions \I�5i:il'IIUiCIIS GCfICf:�I L�\VS l'I7J�[C� I�� rcyuirrs�II einployers to provide w,uckers' compensation tix thcir cmployees. Punu:uu w this�iaw�e, an rmplu�•rr is definod as "...every person in the scrvice uf anuther unJer any connact uf hire, CY�f25)Jf Ifi1�I1CtI. Jf:II or written." \n�,npiny�r is detin�d as"an individual,purtnership,:�ssociatiuu,corporation ur oeher Icgal entiry, or any two or mure �d ihc fomgoing engagcd in a joint enterprise,�nd including the legal rapresentatives of a dece�srd employcr,ur the fCCCtVCf Jf INJICC UI aIl IIIdIVI(IUBI,pwmenhip,;usocia[iou or other legal endry,cmpluying�mployees. Noweve�the uwner of a dwelling howe having not more than three apartrnents an1 who�resides cherein,or the occupant uf the JweUing huusa af�norher whu employs persons to do m�int�nance,cunwuction or repu'u wuck un wch Jwelliag hou,e or on rhr grounds or building appucten:urt therem shall not becaust of such tmployment!x; deemed tu be an employer." `1GL chopear 152, �+?SC(6)also sta[a�thue"every st�te or locnl licensing •rRency shal! N•itbhold the issuance or _ rene�val of u license or permit tu uperafe n business or ro construct buildings in Ihe communwealt6 for any :ipplicant who has not producnd :+ccepfable evidence uf cumpll•rnce wi[h 1he insurance coveru�e requlred:' Ad�itiunalty, �IGL chapter l�?, �25C(7)srates"Neither the commonwcalth nor any of its political wbelivisions shall . encer inro;uiy cuntr�et Cor[ha perfomiance ul'public work until accepta6le evidence ol con�pliance wi[h the insur�nct reyuiramcnts of ihi�chup�ar have been presen[ed tu the contracting authority." ApVlicants Plense fill out the workcrs' cumpe�uation aNidnvit completely,by checking ehe 6oxcs that apply tu yuur situation and, if necessury,wpply sub-contractor(s)name(s),address(es):u�d phona numbar(s)along with their certificate(s�)uf insw-rnce. Limiced Liabiliry Companies(LLC)or Limieed Liability Partnerships(LLP)with no employ��es uther�han the members or pariners, are nut required ro carry workers' compensa[ion i�uuranca If an LLC or LLP does have employaes,u policy is roquired. Be advised that this atFdavit m•ry be sub�nitted to the Depurtment of Industrial �lccidants f'or contimiation of insurance coverage. Also be sure tu sign unJ dute the •rl'lidavit. The aftidavit should bc rcturned tu die ciry or town that the applicadon for che pennit or lictnse is bcing requzsced, not the Department of Indus[rial Accidant�. Should you I�ao�e uny yuastiuns rtgarding the law or if yuu�rn ceyuirzd to obtain� workers' cumpen,ation policy, please call the Dep•rrtrnent at ehe mm�ber IisteJ bclow. Self-insund cwnpanies should enrer their � sctf-insurance license number on the appropriate linc. City or"fown Oft7clab Plcnse be sure that the affidavit is completc anJ printed Iegibly. The Department has provided u spacr at the butWm of cha alfidavit for you tu fill out in the cvent the Oftice uf Investigations has to conlac[you regarding the applicant. Pl,ax be sure to till in the permiblicense nwnbor which will ba usad as a reference number. In additiun,an applicant tha[must subinit multiple penniVlice�vtie applications in any given year,need only submit one ;iftidavi[ indicacing cuerent policy information lif necrssary) :uid imder'7ob Site Address" thz upplicant,houW write"ull lucatiuns in (city ur «nvn)."A copy of�he aFtidavit�hat h�s baen officially sumpcd or marked by tha city or town m•ry be proviJed tu the applicant as proof diat a valid alfid�vit is on file for futurc permits or ticenses. A new affidssvit mu.t be filled out aach yt:ir. Whtre a hwne uwner or citizen is obtaining� licenx or pannit not related ro any business or commercial venture ti.e. u dug licanse or permit w burn Itavts etc.)said person is VOT required to completc this affidavit. l'hc OIIICI'OI II1V21(l;�:ll10f15 l4UUI(I IIRd IJ U1:IIlIC YOU IIl :1(IVelll'C fUC yUllf COOPtl(8[IUII JIl(I\IIUUIII y0U I7�YC:lfly yUCll1011i� . plea,e Ju nut hesieatt to give us a cail. ' fhc Ueparnncnt's addrass, telcphone and fax numbtr. � 'I'he Commonwenith of Massuchusztts Departrnent of Industrial Accidents O[ftce of[uvesUgadons 600 Washington Street Boston, MA 02l l I Tel, t� 617-727-4900 ext 406 or I-877-MASSAFE Fax #617-727-7749 �c:�;�.�d ;-�r,-os www.mass.gov/dia -��� CITY OF SALEM ' :�,,. ,#�:, ,, " PUBLIC 1'RUPRERTY � - ''`���� ' ' DEPARTiVIEl`�1T ' .y;, pr, ,,_�. .i�u:: NlfY:)MIiG4L � � �I�n,n 12�\Vn.r+�vi:i o�57'se�l' � S,ctli�l.M.�i�.u:i n si;n s^v197� . �R:�.:978-.'�li9i'>i � I'.�x:97%-N�UB�G � �Vorkers' Cumpensation Insurance :V'fiduvit: l3uilders/Contracturs/Electricians/Plumben � � ili�,�nt Infonnrtion Plcase Print Leeiblv V81TCllJusiotsslOr�anin�inNlndrviSu�l):� e•.y��IZ� ( / /h'/fLT�'� �`l /9�� . � />_ K O.�n�n ��rr:i/�/ dt'f�-, �/9�3 :1�idi'c�ti: J�' /c.f-�i �-ay.> .. Ciry;'S�:uc;"/.ip� I'hunei:.0 9�'� �"�l— �L�� I :�rc vuu •rn employcr? Chcck thc:ippropriute bu:: � '1'ype uf projcet(rcyuirrd): I 4. ❑ I um a gcnural coutractor and l (� T�w con,truction 1. ❑m a cmpluycr wiih ❑ employces(Cull and/ur p�rt-nnte).` have hirod ihc suh-cuntractors 7. ❑ Retnodeling 3.� 1 am a solc propriccor or partncr- listtd un rhe attachcd shcct. � . sl�ip and havc no empluyces . These sub-contracrors have K. ❑ Demolirion �vorking tiir me in •rny capacity. workzrs' comp. insurvnce. 9. � Duilding�dditiun �Ko workers'comp. insurancn 5. ❑ We are:�corporution�nd its �� ❑ E��etrical rtpairs ur additions rccpiircJ.� ofticcrs huvc csa'ascd ihcir ri�ht of cxcm tion �r MGL I 1.0 Plumbing ropain or additions 3.❑ i am a homcuwncr Joing all work b h P' inyselE �Ko ��;orkerx' cump. . c. 152, j l(41,and we have no 12.� RuuFrepairs _ . insuranm reyuited.J r anployccs. (To workars' 13.❑ Uther comp. in,urancc rcquircJ.J •.q�ry:,,plicaul�huc chccks bos 71 musl:Jsu lill out Ihc u<lion Ixluw slwwiny�hoir aurkul cumpenvuion puliry inlirtmvtiun - ' Ilumcuwnen whu au�mit Ihis a171Javi�indiwting thcy am duiny ull woh and Ihen him uWside eu�urxton mm�whmii a new al'f:Javi1 inJi�.l�ng aueh. -C.mirxiva ihul chcck this box m�wl alixhid,n addilianal..hesl shuwing Ilio nante of fM subronirxton and iheir a'urlcen'eanp.(rolicy inPormariun. /mu un r�iipl�yer!hu(is pruriJing workers'cuinpensnlinn inaurrtuee foi•ury enrp/opres. Belrnv is the puGcy und�ob.r�lr iufannufiun. /� Insurancc Cumpany Vame: ����-��Y(fI�L�'��_ _�-G�--'---- - 7I���T I� Pulicy #ur Sclf-ins. Lic.r: - .. ___- 2 Expirutwn Datn: I/ . _. . .. J�b Jit� :\il�lres�:� �-�'�y�Y� JJ"`� CityiStatd"Lip: '-7��'/ �''� �.� �/ �� .�ttach s�copy of Il�e workers' cumpcns•rtiun pulicy decl•rralion pa�;e(sl�owin�; the policy nmuber•rnd expiratiun d•rte). Pailure to+ccure co��erage as«quireJ under Scctiun?SA uC�IGL a I 52 can lead to the impusition of criminal pennities of a tina up to SL�(10.00 and/or une-year imprisumncnt, as wcll a.civil �n�mllics in ihe 1'urm uf a STOP �YURK URDE2 and a fine ot up co 5'_i0.00 a day uguinst the �ialacnr. 13c adviscd thut a copy uf ihi�,tutcmcnt muy be l'urwarJcd to �he 011ice uf IIt�'C>II��UnIli UI t11L• I)Ir\ (Of iiKuf:11:GC �OVCfa�C \YCitiCaL'Ull. /Ja hcrcby c�rNj uuJr�tde paias�u�J pri r�jury/!ml fhe iiijunnulJon pruvidcJ uGuve�s uue und cwrec�. ��,. ,;��,,,� � J -� ��,«. �o���/�a ���,,,�:�;�: � Y7 - �/�-13 . Q/jiciul i�st we/y. Do�mr rvrire in dii.r urea. m hr co�nplelyd by city or�arvn oJ'/iriu/. , � . � Ciiv or'fuwn: __ . . . Pcnnitll.icensc�.------ - , . _ . . . . . Issuiny;:\wharily (circle onc): � I. Ilu�rJ uf Il.aldi 2. ITuildiu� Ucpar[mcut .L (:it��i fo��n Clcrk �. Llcctrical luspertor i. Plumbin�; Inspccror I G. O�ber --. - Cuutact Pcnou: __ . -- 1'honc tl: � �e 1 y - . REScheck Software Version 4.3.1 ' ' � Compliance Certificate �. ��coaa: zoos�Ecc �ocatlon: Salem,Massach� Co�wctlon Type: 81ngle Pamly P�o)ectType: AddHlonlAlteratlon Buildirg OrleMetion: Bldg.o�lenfatlOn unspecHled Heetlng�e9ree Days: 8266 Gimffie Zore: 5 Construction Site: OwneA/�ent Desi�er/Contrador: 68 Deerbom St Mtl.aughlin Keenan Residence Tom Tremday Salem.MA 01970 BB Dearbom St Trembay Generel Conhactlng.Inc. Selem,MA 01970 5 Ross Road Topafleld,MA 01�3 978-887-27� � tomhemdeygc�verizon.rret ��.r t:. • ::.. _...,f _ ... ✓'7 ' ' ..... ,.. . ..... _t...: � ,,.. . , Compllaxe:9.9X BelEar Than Code � Me�dmum UA 205 Your UA 197 Tne%aae.aworee m�com„a�bma iow ao�m���ew ro�e re mma m mae�an�e. n ooEs rar a��•�•m or�er�or�remwa m a�u��.�.<oaa�re. ... . . _ . . . _ . . , . . , , . r.sr+�c+Y . � . Ceflirq�2:Flet Celling or Sdssor Truss 2124 38.0 0.0 84 Wall 1:Wodf Frame,76'o.c. 1312 19.0 0.0 &5 Orlenfeslon:Unspedfied WirMow 1:Wood Frame:Double Pmre xAtli Low-E 225 0.300 � SHGC:0.00 Orlenls�bn:Unspedfied Compllance Statemenk The qoposed bWl�rg design tlesalbed hae Is ow�sistmit wIM the buiWhg plans,sped�etbns�mM dher calculatiw�s submitted wMh the permit epplkasion.The proposetl 6ullding has been desigr�l fn meet the 2008 IECC requGements In REScheck Ve�sbn 4.3.7 a1W to comply wIM the mandalay reqWremeMa Osled In Me RESMeck Irepedion Cl�eddist. Name-Title - S�naW�a Date i - -- ---- .. _----------..__...._.__ . _ _. .. . .. . . . ProJect Title: RepoR dete: 09/3W70 Dafe ftlename: UMitled.�dc ' . Page 1 of 4 � ' � 2009 IECC Energy � Ef�iciency C�r�i�icate � � # F^Y \ .`i.F'�.M1 - ' � ;."rSY.+ . _.. ... . _ Celling/Roof �� Wall 1&00 Floor/FoundeHon 0.00 Dudwodc(uncondMlonad spaees): - � f � . �:,,. . ,� ,., ,.., ... .._ YYlndaw .. 0.30 Door -��: Heatl�S�ratan: Cooll�SyeEsm: WaEer HmEer. Name: Date: - Comr�reMs: � I RES'check Software Version 4.3.1 ' ' Inspection Checklist ���o�: ❑ Ceiling 2:FIffi Ceiling or SGssor Tnrse.R-38.0 cevNy Ireulatlon Commenis: /4bove-GradelNalls: ❑Well 1:Wood F�arre,1G o.a.R-19.0 cavily hmulatla� Co�runneMs: Wlndows: ❑Window t:Wood Frem�Double Pare wNh Low-E.U-fador.0.3� Fo�wlndowa wMhout labeled LLfactas.desafbe fesWies: fiPanes—FrameType ihemialBieelO—Yes—No CommeMs: Alr Leakage: � JoiMs(Indudirg Am JolstJunctlons),aCic axeas openings,pene4atloim,and all other such openings In the buflding ernebpe Met a�e soiuces of air leakage ere sealed wllli eaWk gesketed�weelherstrlpped or otherwlse aealed wilh an alr bertier mate�ial,suMeble film or solld material. � Alr bartler arW sealhg e�ds�on common wells belween Awelling�mlls,m e�derbr walls behlnd tube/afawew.end In openings beMeen vNnawv/aoorJambs arw framing. � Recesaed Ilghffi In the bWkD�ttiertnal eNelape are 7)lype IC�end ASTM E283 lebeted anA 2)seeled wMh a gesket or eaulk belween C�e Irousing and the i�erlor wall or ce0h�g caveri�g. � Accesa doors sepa�atlng owiditloned hom uncandllbned apace are xreatl�er�trlpped arM I�ulatetl(wNlwut InsWatlon compresslon or demage)to at I�et the level of Insu�llon af the suimund6ig aurfaoas.Whe�e bose fill trisulatlon mdsts.a bal9e M retal1rer ie I�talled to maWaln Irmuletlon appOcation. � WaoGbumirg fl�ePlews have geslmteA doas and auOdoor oombustlon alr. Nr Sealing and Insulatlon: � Bullding ernelope air tlgMness arW InsulaRbn tr�sfellatlon canplles by elUrer 1)a po�iougfNn bbwer door taet�esWt of less then 7 ACH at 33.5 psf OR 2)the folbwirg Items have been setlsfled: (a)Alr baMe�s enA iheimel bertier.Ir��ed on oulside of etr�ertnesble Insulatlon anE breal�orJoiMs in Ure air barAer are filled a repelred. @)Cellhgladi¢Alr bmrier in a�ry dropped cellUg/softit Is subsfarAialy all�ed wIN Ireulatlon antl mry ga�ps are seeled. (c)Above�sde we�s:Irreul�lon�6refalled in subslenlial oon�d mW cmtlnuous alignrtierd wlMi tlie building ernelope alr bartler. (�Floois:Alr ber�fer k Inslelled et arry e�sed edge of Irreuletlan. (e)Plumbl�arW wi�ing:Inaulefbn is placed beNreen aAside arM pipea.BaY ir�suletlon Is cut to iN arow�d wMng arM Wumbin9.or BP�Y�bloem In�Aellon e#ends behind plping arM wlArg. (Q ComeB.heede,s.neirow haMrg Cevitles�aMl rim jolsls a�e Insuleted. (9)�ftW m e�de�br xrall:Inaulatlon e�usffi belxreen&�ov�nersPoubs and e�de�far we0. Sunrooms: � Sumooms ttiet are thertnaly isolated fiom tlre buliding emebpe heve a ma�dmum fereatratbn lYfedor of 0.�a�M the mmdmum skyllgM U-fedar of 0.75.New wirWows erM doas aePeretl�8 Me swwan fiom conditloned spece me�the bWlmng Mertnal envelape requfremeMs. Vapor Referder. � vepor retarder Is U�stalled on Cre wmnNn-wlrKer side of all noo-verrted tramed ceilinge,wal�s.ana floors:or n hea been eetermineA Mat mdsWie w Ita fiea�g will not�mege Me ma0eriels:or other approved means fo avoid coMe�n a�e pmvWed. Comrner�: ProJect Title: RepoR date:09/30N0 Data filename: Untltled.idc Page 2 M 4 ' Mate�lals IdenlHicatlon and Installatlon: • � � Matedels end equipment ere inatslled In accadence with Me menu�cW�ers Inslellatlon instn�fiore. ' • � Insulettan Is inatalled In subetaMial owA�d wllh ttie surFace being Ireulate0 ard In e men�that achleves the�ated R-velue. ' � Meteriel8 end equipmeM are IdBntifled so thet oompliBnce cen be Cete�mined. � MenufscWrer manua�for all I�talletl heatlrq arM 000fin9 equlpmerrt mW servloe wafer heatln8 eqWprt�eM heve been p�ovided." � Insulatlm R-values arM gla�ng LLfadas e�e dea�ly madcetl on Mie bullding p�ns w spedficada�s. Dud Insulatlon: � Supply ducfs In eltics are IreulaEed to a minimum of R�.All other duds In urconditloned spaces or wlside fhe bWlding envelope aie InsWated to ffi least R�. Duck Constructlon and Testlng: � Building fremtrg caNdes ere rwt used as suppN duds. � All Jol�and seart�s of aly duc�,alr hanEle�s,fltter bmces,mW bulld6ig ce�uaed as�etum ducfs a�e s�slaMiely alrtlgM by means of fepeg.mastics.Iiquid sealaMs,gasketlrg or olhet eppoved dosure syatems.Tapes,mestics,e�M fa�s a�e�ated UL 181A M UL 1818 arW ere lebeled eccormng tD Me dud conahvctlon.Metal dud canneWona wlHi equipment antllor flltlnpe are rt�chm�kally festened.CAmp Jdnts tor�amd metel Auc�heve a confad lap of at least 1 12 Inchas end are fastened wXh a mhNm�m of three equa�N eveced sneet�netal screwa. �� JoIM ard semns coveratl wMh spray poyu�eU�ene foem. Whae a partlely hmcoessible dud canneclbn e�sTs.mechenkal festenera can be equely speced on Uie mq�osed Portlm of Me Jdnt so ae to preveM a hlrge eftect Cordinuousy x�elded arM loddnglype b�gfWmnal�Irds and seems on duda op�atlng et I�s tlmn 21n.w.g.(500 Pa). � All duds erd air hsrMleis a�e bcated wilhin m�dorred space. Temperadne Controb: � At lesst ore pmprammeble tl�emasfat le Na}elled to conhd ihe D���Y��8�and Ims setydnfs IMtlelizetl at 70 deg�ee F for Cre heatlng cyde a�W 78 degrae F for the codl�c�e. Hesting and Cooling Equlpme�k StrJrp: p Additlmal reqWrerreMs tor equlpment smrg are Indu�d by an Irepedlon fir comqience wNh the IrMert�etlanel ReslderAfel Coee. � For sy�eme aervirp multlple dwellfig�nils doarmentatlon has been submiCetl demor�ehstl�g m�0ence vWU�2009 IECC Commerdal Bullding Mecherdcel aiW/a SeMce Wffier Heatlng(Sedbns 5ai arW 504). Circulatlng Servlce Hot WaEer Systems: � qrwlatl�service hot water pip9s are h�sula0ed to R-2. � qradating seMce hoi waler systems Indude�au0wnetic a aocessible rtianual s+AOch Oo Wm oft tlie dreulatlng pump when the ayatem k not ln use. Heatlng and Cooling Plping Insulatlon: � HVAC piphg oonveylrg fluMs above 105 degrees F a cMled flWds bdow 55 de�ees F are Ir�AaOed to RJ. Swimming Pools: � Heeted sMmmirg pOds Fiave an oNoiF heafer swihi�. � Pod hea0ers operetlng on naWral�or LPG have an electonk pflot OgM � Timer awit�iiea on pod heate�s aiM pumps are p�eaent Exce�lons: Where pubfic hesllh sfmWands�eQwre condmrais W�^G���. ��W�aPera�e wXhin adar-arWlw waste-heeHecovery sys0ems. � � Heatad swimml�pools have a cover on a at tlre water surtece.For pook hesOad wer 90 deg�ees F(32 deg�ees C)the ower has a mirdmum trisulaUon value of R-12 Ezceptlons Coveis are rrot requlred when 60%of the heetlnp ene�gy Is fian sita-remvaied ener�w solar energy sauw. LJghtlng RequliemerKs: � A mlNmum of 50 pe�cent af the lamps In pertnenently Inslalled Ilghtlng ibAuies can be categorixed as one at tlre follovWng: � (a)Comped flua�ent (b)T-8 or smeller d�meter lineat fluo�escent (c)4p lumens per wari for lamp wettage�15 (�50 lumens per watt for lernp waltage>75 and<=40 ProJed Tltle: RePOK date:09/30N0 Data fllename: Untltled.rdc Page 3 M 4 ' � (e)80 lumena per watt fior lamp vuattage>40 • Olher Requlrements: � Snow-and�e+neltlng aystemA wNh eneigy supplled f�om the servbe to a bWlding shell i�lude eutometic oon6ols cepable oF ahuping oif the aystem when a)the pavement tempe�ffiure Is above 50 degreea F.b)ro predplletlon Is feNng.and c)Me ou6door temperaWre Is above 40 degiees F(e menual shutofF ao�Mol Is elso p�rnlHeA to sedsTY�eQWreme�A'c'). C9RMcaEe: � A pertnaneM certllicete Is piwAded m or In tlre decMcel dkhibWm penel Ilstlng the pedomineM Insuletlon R-velues:window U-fadors:type mW eificlency of apace-COnditloM�aiW water he�i�eqWpment.The ceMflcate doea irot oover w obatrud fhe vlslbilily of fhe drt,vR direcOory label�se�Wce�soonned label a olher requhed labels. NOTES TO FIELD:(BWlding DepaMient Use Ony) prpjeq TPoa Report date:09I30N0 Date fllename: UMitled.rdc Pege 4 of 4 �8����ae Single 14" BCIO 90-2.0 DF Joist�.J01 BC CALC�3.0 Design Report- US 1 span �No cantilevers�0/12 slope Tuesday, October 12, 2010 Build 440 16 OCS � Non-Repetitive � Glued &nailed construction File Name: BC CALC Project Job Name: Description: J01 Address: Specifier: City, State, Zip: , Designer: Customer: Company: Code reports: ESR-1336 Misc: i z�-oo-oo 60.2-'I/2" 61.2-1/2" LL 720 Ibs LL 720 Ibs �� DL 2161bs DL 216 Ibs � Total Horizorkal Product Length=27-00-00 Live D�d Snow Wlnd RoofLive OCS(In.) Load Summary T�Description Load Type Ref. Start ErM 100% 90% 115% 133% 125% 1 Standard Load Unf.Area (ps� L 00-00-00 27-00-00 40 12 16 Controls Summary vawe %Allowable nura��on Case saan Disclosure Pos. Moment 6,192 ft-Ibs 54.4% 100% 1 1 - Intemal Completeness and accuracy of input must End Reaction 936 Ibs 57.7% 100% 1 1 - Right be verified by anyone wno would rely on Total Load Defl. U387 (0.828") 62.0% 1 1 autpui as evidence of suitability for particular Live Load Defl. U503 (0.637") 95.40�0 � � application.Output here based on building ' Max Defl. 0.828" 82.8% � � cod�accepted design properties and S an/De th 22.9 n/a � analysis methods. Installation of BOISE i P P en ineered wood roducts must be in 9 P accordance with current Instaliation Guide %Aliow %Ailow � and applicable building codes.To obtai� Bearing Supports Dim.(L x W) Value Support Member Materlal Installation Guide or ask questions,please BO Wall/Plate 2-1/2"x 3-1/2" 936 Ibs n/a n/a Unspecified ���«0)232-0788 befo2 installation. 81 Wall/Plate 2-1/2"x 3-t/2" 936 Ibs n/a n/a Unspecified gC CALC�,BC FRAMER�,AJST"' ALLJOIST�,8C RIM BOARD'"',BCI�, Notes BOISE GLULAMTM,SIMPLE FRAMING Design meets Code minimum (U240)Total load deflection criteria. SYS7Enn�,vERsn-wnn�,vERsn-RiM Design meets User specified (U480) Live load deflection criteria. P�us�,vERsn-Rinn�, VERSA-STRAND�,VERSA-STUD�are Design meets arbitrery(1") Mabmum load deflection criteria. trademarics of eoise cascade,�.�.c. Composite EI value based on 23/32"thick sheathing glued and nailed to joist. 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' —.•__ / � _. � � � -}�-- .___:__.. .--�-�{------�--_ .. _ _ I O � ` � ���t� Mc� �At�te ��rN �`N� �� e� c�� #� � I� N �- � � �6 �7 t�°i12 p�otzN 6T S/L li�N� � �q '� i �p " �tir �I-�ol� ��t-Tyt.ItAV � � �N 1� b lt�t� /Lpc M I.LL `�"18 -?91— �v +as� �— � . . . _ ` _ � p � � \ I � —-- _--_ --- 1� �1 "VR ` 1 �QR . - � . . \ / q i ' �v 1 /� � , �/c � � � � � / , - � � i \ l _ ` � R� � , —_ � � � � � / i � . __._ --- � .�r / � �i I p.^ \ � ._� � 1. �-t'iJ . / 1� ; � � I . _.i . V. . .� � ' \ � � . \ ' P\ ` ' Q_ -Q \ � � � �. \ � � \ � � � , \ � � I , � � ; � / , \ / � o�--- - � , / h � �- � � �O 1 � � \ � � . �` � � OR �❑ � M�.i,,4�F���y_ _��a�--��tna� � ������ s-r ���y �q-'� �,o n _ 'Z�"_"-��-- LfL�"iie_-1c�a l� — �� �- s�b�� Al�Hnoc� I.�� �_� , __ aC7s� ��f� - �i�l _ � . .. . � � qf �q/ � �'������ ��-_-__-LL/ �V �� . � ....,. ....a'- � . ��'"` �'h�,� y.�e e.��� , 6 � .�e,9 .� .�o.e.� r/'% }` i0�9/io_ .._ ___. ..,�..�.. �' .��, � ����,��_ �d-����.� , r.t_>,,,�,.�...��,. :. , - n� ��>is�.s�r� �9w /. i � � �j The Commonwealth of M�ssachusetts � , ' i Board of Building Regulations and Standards Town of e` �,k�� Massachusetts State Building Code, 780 CMR, 7ih edition guildi� v `\ Building Pertnit Application To Conswct, Repair, Renovate Or Demolish a �6iY0/� � ne- o T�vo-Fumrly�D}re!ling � This ection For Official Use Only Building Permit Nu er: Date Applied: � 2 _ 1 C7 � OG�. Signature: � Buil � g ommissione Ins r of Buildings Date SECTION L• SITE INFORMATION x 1.1 �P+roperty Address: 1.2 Assessors Map& Parcel Numbers - � f U ,Q?Ac-kL�xn S'� - 1.1 a Is[his an accepted s�reet?yes no_ Map Number Parcel Number ' �'�li 1.3 Zoning Informa[lon: 1.4 Property Dimensions: i Zoning Disiric� Proposed Use (,ot Area(sq fl) Fron[age(R) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided . t.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewaqe Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone7 Municipal O On site disposal system ❑ Check i f yesO SECTION 2: PROPERTY OWNERSHIP� 2.1 Owner�of Record: �/ '��iY�n l'-ee.Y�-I Tn�� ��boc'n ST . /` �me(Prinf) Address for Service: � �r7�� .�Z 1 - I Z3�f Signamre Telephone SECTIOIV 3: DESCRiPTION OF PROPOSED WORK=(check all that apply) New Conswction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bidg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Workz: 'Rp IOfA �_�,Klte.d�w/fi S1'r���FL� o +vcLi ( ki1rL�� S�r_5�»I��J��a�s � �i n..0 nw5 �r 5m I I n!� rtv� c,..A � o �.vSNa-�� ti/.e w XG-sas Ilea4' �� s�f lt � �i✓ }` u���vlo S.sllCc�n� s�vr/ {%FLNIJ� Qc � ' �t k ff.r / a/ . .PGf.+ � IZ� 1)GL� SECTION 4: ESTIMATED CONSTRUCTION COSTS t�em Estimated Costs: OftlCisl Use Only Labor and Materials I. Building $ � b � � 1. Building Permit Pee: E Indicate how fee is determined: 2. Electrical g O Standard Cityliown Application Fee � ❑Total Project Cos[�(Item 6)x multiplier x 3. Plumbing $ , �� 2. Other Fees: E 4. Mechanical (HVAC) $ List: � 5. Mechanical (Fire $ Su ression Total All Fees:S Check No. Check Amount: Cash Amount: 6. Total Project Cost S t��� w paid in Full O Outstanding Balance Due: ,�b Q 7 (� �t � > � ` ( '��, SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Constructlon Supervisor(CSL) G� .Z� 'JJ � U�� �Q..- � ,�o� A—� ,� , f r�� Licensc Numbcr Expiratwn Dale � l � N�mc oFCSL- Hpldern ! �� �y�{ List CSL Type jscc bclow) `+�SS CL� ��S'�e� "-� Descri tion � A, Unrestric[ed u l0 35,000 Cu. FL) R Res-[ricled I&2 Famil Dwellin Signaiure { � M Mason Onl ��(J�y�/'y{��� RC Residential Roofin Coverin Tclephone � WS Residential Window and Sidin SF Residential Solid Fuei Bumin A liance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) I, y'� 5 Z �• �.w 1 11-- � NI Com any Name or HIC Registrant Ngme Registration Number ���s �c, 1za�t r�G'-�..��. cv ��3 � 2/k / �S� Ad�tsss� ���� ��L��yz�,���� Ezpi tion ate c 4c„_.., Signamre Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insarance affidavi[must be completed and submitted with this applicalion. Failure to provide this atTidavit will result in the denial of the Issuance oCthe building permi[. SigneJ A(fidavil Attached? Yes ....�.....� No........... ❑ SECT[ON 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT � , as Owner of the subject property hereby . authorize to act on my behalf, in all matters relative ro work authorized by this building permit application. Si nature of Owner Date SECTION 7b: OWNER� OR AUTHORIZED AGENT DECLARATION � � ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, ro the best of my knowledge and behal — . � � � �i.- l.L._ � Print Name /L�/v��� Signature of Owner a Dare Si ned under the ains and enalties of r u , NOTES: t. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor � (nol registered in the Home Improvement Contracror(HIC) Program), will no�have access to the arbitration �, program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and . � ConsWction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I 10.R5, respectively. � � 2. When substantial work is planned,pmvide the information below: � Total floors area(Sq. Ft.) (including garage, finished basemenUattics,decks or porch) � Gross living area(Sq. f[.) Habitable room count Number of Fireplaces � Number of bedrooms Number of bathrooms Number of half/baths ��. Type of heating system�i�GunleQ 4�e�h—�'+u. Number of decks/porches ���� Type of cooling system � flnclosed Open ' 3. "Total Project Syuare Footage" may be substituted for"To�al Project CosP' I, � CITY OF SALEM �� �a,,�.;,', ,,�il PUBLIC 1'ROPRERTY ' '�'"`"�'« DEPARTMENT ��z�� 11\11;7Ri 1[Y JRI1Ci��l.l. �'1.\1'l�ft 1���WA1H1\1:10�S'IRELI' � $.�U'_\1.M.\11.\CIII'S1�.'IlSJ197I'. �ft:l.:778-'4i9i95 � P:�x:978-740�18iG Wbrkers' Compensation Insurance :V'fidavit: L3uildcrs/Contracturs/Electricians/Plumbers �pplicant lnfunnrtion Plcase Print Lecibly � � p V81Tlc (Bu�mcsvOr�anizatinidlndividuall: � �✓0. �!".a-.y��� /�i^Cn(2r✓+L lCri/'���AG"ITn 5 �t� � i :�dd���,�: -i ,(�� ss d'G �r. To���,-e.r�r V'`I e,l c� r s� 3 Ciry;Sc:icc;%ip� Phone ;�: il :\rc you •rn employcr? Check thc xpprupriate bus: 'I'ypc uf pruject(reyuired): ' I %' 4. ❑ I am a gcncral contrxtor and I 1.[�J�m a cmploycr wiih G. ❑ kew construction employres(full aneUor part-tima).' have hircd the sub-cuntracwrs 2.❑ 1 ;mi a sule propric[or or partncr- listed on rF.e attachcd,hcet. � �• ❑ RtmoJeling ship and hrvc no mnpluyces � 7'hese sub-contractors have 8. ❑ Demolirion working tbr mc in any cupacity. workers' wmp. insuranca. 9. � puildin�additiun (Ko workcrs' cump. iiuurance 5. ❑ We are u coiporution and its 10.0 Electrical repairs or additions rcquircJ.] UtTICCfS I18VC CX�I'CISC{I IflClf 3.Q I am a homcowncr duing all work right of exzmption per MGL I I.Q Plumbing rcpain or vdditions myself. [Ko��;orkers' cump. c. 152. y i(31,and we h;rve no 12.� Ruuf repairs insurance reyuirzd.J t cmployccs. �Ko workzrs' 13.0 Otl�er comp. in,urancc rci�uircd.j •n�ry:�pplic�nl tlmt ducks boz MI musi alsu lill uui�hc Kaian Lcluw shuwing�hcir wvrkcrx cumpcnavlion puliry infurrtu�iun. 'l lomcuwm;n whu xubmillhis a17J>vit i�dicuiny Ihcy a�e doing ull�wtk aiul thrn hin uutsid<cuNr:ierors muxi suhmi�a new al'f:davil indiuling.cueh. � �('omrxwa ihm che<k�his bos miu�anxh�d un addiiional.chee�shuwing Iho nsnu af thc sub<ontmctors anJ ihcir murkcra'cwnp.pulicy infurtnatiun. /mn w� ru�player thut i.s pruviding�varkers'compen.entinn iiisurnuce jor nry eu�p/apres. Be/nm is�he palrcy und job a�ite � �u urnmtion. . �� Insurancc Cumpany Vnme:��..__ .. _ .�� . . ..... ..___--.__._------ Pulicy�t ur SeiGins. Lic.t.': --_-........_. .. _.____- Expirution Date: Jub 5im Acldress: . Ciq;'Siatd"Lip: .�ttach a cupy of Ibe workers'cumpensatiun pnlicy� decl•rrulim� page(showing tLe policy number•rnd expiratiun drte). Pailure w sccure cocerage as required undcr Sedion 25r\ul'`IGL c. 152 can lead to the i�nposi[ion of criminal penalties of a � tina up to S1500.00�neUor wto-year imprisonmcnt, us wcll�s civil pcnallics in ihe form uf a STOP 1VORK ORDER and a fine nf up to 52�0.00 a day uguinst tl�e viola[or. 13c adviscd that a copy uf ehis,�utcment may be IorwarJed to lhe 017ice of lu��cstiga�i�.nu ol thc DIA Cor inswarc� cootr��c vcrilicaiion. I do drrchy crrlij�u dr +�pains m�d prni c.r u p ' fhu!N+e injunnu/ion/�ruviJcd uGovc is trut�urd coir�rl. . -- - '3 � ��—�7 I)atc' /�i��0� �ie:iaiurc: �, r�, � � ��� y7t ��i�� Ojficiuf use aidy. Do nn!u•rile ix/liix ureu, to be couip/etrd by city ur�orvn�JJiriu/. � Citv ur'1'���rn: -----._ . _ Permit/I.icense#.---._....- - -- -. ... . . .. .. . _ . �. I+suin�:\ulhurily (cirdc oncj: � �� 1. It���rJ uf 1(c:dth 2. 13uildiu� Ucparunenl 3.Cil�'/fo���a C'ierk 1. Llectrical luspecfor i. plumbing Inspecror ��,. G. Olhcr __._. . _ � Cuiu�cl Pcnuu:. _..._ . . .- ----- 1 honc#: Information and Instructions ;\isssadiu;etts Gcneral Laws diapttr 1�2 reyuirrs ail amployrots ro provide wurkers' compensu[ion tix thcir cmployees., Pur,u:uit w this siatu�e, an rmp(upre is defined as"...avery person in diz service uf anoUier under any contnet of hire, ' ctpress or implicd, oral or writmn." � :\n r�nployr.r is dcfined �s"an individual, partnership,7550C3:1[1011,corporation or other legal entity, or any two or more ot ihc Forogoing zngaged in a joint en�erprise, and including the legal rzpresenea[ives uf a deceased employer,or the � rccoiver or ttustee ol':m individual,pa�menhip,associatiun or oeher legal entiry,employing employees. However the ownet of a dwelling house having not more than three apartrnents and who resides therein, or�he occupant of the dwclling huuse of another who employs persons tu do main[rnance,cunstruction or repa'u work on such dwelling hou,e O!UIl tFIC erounds or building appurtenant thereto shall no[becaust of such employment be deemCd w be an employer." S1GL chapeer 152, §25C(6)also staces chac"every state or local licensing•rgency shall w�ithhold the issuance or � � renewal uf a license or permi[to uperafe a business or to construct buildings in the communwerlth for any applicant who has not produced ncceptable evidence of compliance with the insurance coverage required:' Additionally, �iGL ch.�pter 1�3, }25C(7)st:ites"Neither the commonwcalth nor any of its political subdivisions,hall ancer into any contr�et for[he perfomiance uFpublic wurk until accept:�ble cvidznce ot compliance wich thz insurancc requirements ok�his chaptar have been presan[ed W the contracting authority." Applicants - Plzase fill uut the wurkers' cumpe�uation affidavit completety,by checking dte boxes thaf apply to yuur situation and, if � necessary, supply sub-contractor(s) nxme(s},address(es)and phone nwnber(s) along with their certiFica[e(s)of insw�ance. Limiied Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees ulher than the membtrs or partners, are not required to carry workers' compznsxtion iiuurance. if an LLC or LLP docs have cmploytes,a policy is rzquired. Be advised that ehis affidavit may be submitted to[he Departrnent of [ndustrial .Accidents for contimiatiun of insurance covurage. Also be sure lu sign und du[e the •rftidavit. The al'ticlavit should be retumed ta die city or town thut the applicxuon for the pennit or licznse is being roquested, not the Uepartment of �fll�ll5[C18�!�l'CLl�Cf1IS. St10U�t� YOLL�18VC BIIY (�LLCShORS CL(�'�fdlllU' [t1C�JW Of If y0U iIIC CCI�1LCt(� l0 Ob[i11R il WOf�(C15� compensation policy,please call the Depxrtment at the nwnber listed below. Self-insuroJ companies should enter their sclf-insurance license number on the appropriate line. City or'fown Offlcials . Plcnse be sure tha[the affidavit is complete :md printed Iegibly. The Deparhnent lias provided a spacc u[the butWm - of[ha aftidavit for you to ti11 out in die event Ihe Oftice oF Investigations has to conlact yuu regarding the applic�nt. Plc�ue be sure to till in the pennidlicense number which will be used as a reterence nwnber. In additioq an applicant �hat must submit multiple pCrmic'lice�vsc applicu[ions in airy given year, need aily submit one affidavi[indicaring curtent policy information (if necessary):u�d under`7ob Site Address"[he applicant should write"all locutions in (city ur [own)."A cupy of the aftidavit that has been offici•rliy sd�mped or marked by the ciry or town may be proviJed to thz applicant�s proof chat a vulid�ffidavit is on file for future pe�mits ar ticenses. A new aftiduvi[nmst be tilled out each yzar. Whare a home owner or citizen is obtaining a licenst or pzrmit not related to any 6usiness ur commarcial venture (i.e. a dog licznse nr permit to burn leavzs ete.)said persun is VOT required to complete this affidavit. l�he Otlice of(nvesti��tions would tike to diank you in�dvancc fur your cooperatiun and shoulJ you have xny yuestions, pleosa du nu� hesi�atz to give us u calL � : Thc Dcparnntnt's address, telcphone and fax number. � The Comruonwealth of Massuchusetts DzparUnent of Industrial Accidenu Ottice of[nvesdgations 600 Washington Street Boston, NfA 021 l l Tel, t� 617-727-4900 ext 406 or 1-877-MASSAFE a.�„�d 5-�r,-os Fax #617-727-7749 www.mass.gov/dia �^�''" %,:. CITY C)F SALLM .: y. r, ' =, ` p�A'� Pt1BLIC PROPRERTY _�•: a .. ��< `�y ' �` J�' DEPAR'I'?�1ENT ' '°Fa*N,V4u:i �_�tIP.. nl!''1 .'I:h� i !I `�I ��.'�"�; I'� u�.�illh��:�+�'�IHI:1'T � y.\I I�11. \I.\�i\� :!! .I 1 �.'I � ' �I����: v;8.-�;�);v5 � I�:�x:7'SJ�:�'�5a6 Construction Debris Disposal Aftidavit (r�yuire� lur all dcmulition and ivno��atiun �wrk) �I In :iccurduncc with thc sixth edition oFthc State Buil�ling CoJe, 7S0 CA9R scction I 1 L� Dcbris, and Ihe provisions of MGL c 40, S 54; t3uilding Permit i! is issucd with the ca�dition [ha[ the dcbris resultin� from this ��•urk shau ne d�si,o5�a or�n a properly liccused waste disposal facility as detined by MGL c 1 t 1, S i 50A. The debris ���ill bc trmsportcd by: /Ul��� S�Iie-- C�1�`"�` t InumcoChaiJer) � I he dcbris �vill be disposed of in : �(��'1'L�S.S I1�2 Ca-„h�--� (n�me uf(acility) JiN�".17i�OlT �.� ��i'-'�� (address u(t�cili�yl �� ����� - - signaturc of prrmit applicant � �Z �o U � �t:,c� _-- i�i,��.�i:,.,,. , � -,�.�. � - -,�� _ � ��,_� ,� - - ---- �c.A" h�K V� L�' ' � ' _�--__ � 1 -- ------------ , o a _ - - - , - - - �---� . ; ; � � � ; , � c� ; � , . � , , ���- I �'�-�� .� �,. � , O r.���� ,��•�� �� ! ' Kt�.tN V � . . I ; : �5 ! ' ; — _ � ��=#�a'r_ _. � � - - �N�N� . � . . � � i�� ChSE.k� . .. �„ � , ___ . . - . .. : M -�. � . .: � S Cp , � ;� � � � I �� > 1�i > _ . . �%� .. . Iy:"�y �. �i���- •Y�11 �� � . . 1' U I �- � ' . . . ' . Z*'V � h � � . � S!?.:f. .k . . . ��� . .:� .. . , . — ' ..— _' . __ _ _ _.__'_ . . . - . . . . � _-... __ .� ._ __'__ � _... ' _" '...' . . - . : . . . I . . —� -� �e � ! � ��� `. 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