28 CLIFTON AVE - BUILDING INSPECTION a The C'ommonwealth'of Massachusetts
} Board of Building Regulations and Standards CITY
8 u, , _ OFSALEM
Massachusetts State Building Code, 780 CMR 7 edition
Revised Jommq•
\ Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, ANN
One-or Two-Family Dwelling ' s"',`
This Section For Official Use Onl
1�^ Building Permit Number: A Date Applied:
Signature: P " - o s/ //
J Building Commissioner/Inspect of Buildings Date
SECTION I:SITE INFORMATION
1.1 Property A a: 1.2 Assessor Map& Parcel Numbers
Lla Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Proper'tr Dlgteslons:
Zoning DistrictProposed Use Lot Area(sq R) Frontage(R)
1.3 Building Setbacks(R)
Fmm Yard Side Yards Rear Yard
Required Provided Required Provided Required- Provided
1.6 Water Supply:(M.G.L c.40,§54)t 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑ Check`if es❑ Municipal O On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: . y
Name(Print) `` 11� Address.for Service:
47q- : 3-2S- YY3 5
Signatured Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK°(check.aB.tketeapply)
New ConaWction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)-❑ Alteration(s) ❑ Addition ❑
Demolition ❑ AccessoryBldg.❑ .:Number ofUnits. Other ❑.Specify:
BriefDescriptionofProposedWork': rnJS4svl( own celhlos�- _
A H
OC yy,,llw <L n`. lJdv r5
SECTION 41-1S. TIMATE&CONSTRUCTION COSTS
Item
EstimateA Costs:
011lclal Use:Only
Labor and Matenals . ._
1. Building S ":I. Building.Permit Fee'S Indicate howfee is determined:
2.Electrical $ ❑Standard CityiTown Application fee
❑Total Project Cost)(Item 6).x multiplier x
3. Plumbing S 2. Other Fees: S 1
4. Mechanical (HVAC) S List:
5. Mechanical(Fire S
Su cession Total All Fees:S
op Check No. Check Amount: Cash Amount:_
6. Total Project Cost: S 3 5o o . 0 Paid in Full 0 Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
.5.1 Licensed Construction Supervlsor(CSL)
LE.1cenuc
� �3 !1mher EXpiratiun Date2Name ol'CSL•I Io1Jer "Io � � - pe(see heluw)
e _ Desch ion
Address - 0DResidenlial
tricted u toJ5,000Cu.:Ft.
cted IB2 F l Dwellin
Signature - Oni
ential Roolin Cohn`
telephone .,, ential WinJow and S'din
emial Solid FuclBurnin A:' liana Installation
Demolition
5.2 Registered Home Improvement Contractor(HIC) / �/2 D (�0j
a Registration ber
I IIC Cwnpany.Name w i11C N S Mc —
�t � v e
2)/o-7/77
AJdress - 6 -
Fe 'S' 90 Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152.1 25CM).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will resufrin the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........O
SECTION 7&:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
o
L -r 4 Ze_6 4. /r 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.
JL5 /
Si ai of owner - .Date
1ECTION'711ac;OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the,statements ai information on the,foregoing application are we and accurate,to the best-of my knowledge and
behalf.
Print Name
Signature di owner or Authorized Agent Date
Si under the ainsand,je naliksof 'u
NOTES:
I An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will'M have access to the arbitration
program orguaranty 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 110.115,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 ofbathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
7. "Total Project Square Footage"may be substituted for"Total Project Coat"
EIG Fax Server 4/6/2010 3 : 15: 24 PM PAGE 2/003 Fax Server
QCORQ. CERTIFICATE OF LIABILITY INSURANCE M/ /20
0
PRODUCER. (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION
Eastern Insurance Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
233 West Central Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Natick, MA 01760
INSURERS AFFORDING COVERAGE- NAIC#
INSURED Atlantic Weat erization LLC INSURERA Arbella Protection Ins. Co. 41360
61 Rear Jefferson Avenue INSURERB: Arbella Indemnity Ins Co. 10017
Salem, MA 01970 INSURER C.
INSURER D:
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR kDD'L TYPE OF INSURANCE POLICY NUMBER POUCYEFFECTIVE POUCYEXPIRATION UMRS
GENERAL UABILRY SS00042816 03/20/2010 03/20/2011 EACH OCCURRENCE $ 1,000,00
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ SO,OO
CLAIMSMADE FX
OCCUR MED EXP(Any ane person) $ 5,00
A - PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,00
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2 oO0 QO
POLICYFX JEGT LOC
AUTOMOBILE UABRITY . 93827400003 03/20/2010 03/20/2011 COMBINED SWGLELMIT $
ANY AUTO (Es eeddent) 1,000,00
ALL OWNED)AUTOS
BODILY INJURY $
X SCHEDULED AUTOS (Per parson)
B X HIRED AUTOS
BODILY INJURY $
X NON-0O MEO AUTOS (Per exidenN
PROPERTY DAMAGE $
(Pe,eWd.nt)
GARAGE UABIUTY AUTO ONLY-EA ACCIDENT $
MY AUTO OTHER THAN EAACC $
AUTO ONLY: AGO $
RESSAUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR FICLAIMSMADE - AGGREGATE $
DEDUCTIBLEETENTION f $
WORKERS COMPENSATION AND 9111820309 03/2O/2010 03/20/2011 X WC STATu- oTH-
EMPLOYERWLIABILITY E.L.EACH ACCIDENT $ 500,00
A ANY PROPRIETORIPARTNERlEXECUTIVE
OFFICERNEMBER EXCLUDED7 E.L.DISEASE-EA EIAPLOYEE $ 500,00
K yes,deWibe wider E.L.DISEASE-POLICY LIMIT $ 500,00
SPECIAL PROV$IONSb.t.
OTHER
OESCRIPTON OF OPERATIONS 1 LOCATIONS I VEHICLES i EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
ANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
CITY OF, SALEM BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
120 WASHINGTON STREET OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
SALEM, MA AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PMA V�
®ACORD CORPORATION 1988
ACORD 25(2001108)
Action Inc.
47 Washington Street
Gloucester, MA 01930
Tax Exempt Number: 042-389-332
Agency: Action Inc.
PROGRAM: National Grid ELECTRIC
JOB NUMBER: NE-ARC08
Work Order# NE-ARC08
Work Order Date: 11/12/2010 Job Limit:
Contractor: ATLANTIC Wx Per Unit $4500.00
Client: Northeast ARC K+T Yes=1 Nom
Street: 28 Clifton Avenue K& 0
City; State;Zip: Salem,MA 01970
Telephone: Larry LeGault: 978-3754435 Stand Alone Yes=1 Nom
Stand Alone: 1
Blower Door Test: YES
Inspect Knob&Tube: NO Contractor:
Attic/insulation Act Cost Est Cost Act Cost
Attic Flat R38 open $1.40
Attic Flat R30 open $1.30
Attic Flat R20 open 720 $1.23 $885.60
Attic Flat R10 open $1.15
Attic Slope/Flat R30 restricted $1.14
Attic Slope/Flat R20 restricted $1.35
Knee Attic Wall/Floor Transitionr F $2.40
Kneewall w/Membrane R12 $1.65
Kneewall Floor R30 $1.41
Attic Access Finished $84.00
Temporary Access $75.00
Crawl Space R19 w/poly Yap barrier $1.81
Garage mUng/noor R30(with approval) $1.21
R5/RMax on door .: $44.00
Vent Bath Fan $70.00
Roof Vent $66.00
Weatherstrip&R30 Attic Hatct. 1 $32.00 $32.00
Stack 12" $126.00
Propa Vent $3.25
12oof Vent 9135 $84.00
Gable Vent all Sizes $76.00
Soffit Vent $23.00
Ride Vent $18.00
Attic Bypass Air Sealing 2 $75.00 $150.00
r' Northeast ARC Pae 2 ional Grid ELECTRIC
Est Act Cost Est Cost Act Cost
Wall Insulafion
Single Nail Asbestos/asphalt $1.50
Dbl Nail Asbestos/Aluminum $1.52
Drill&Finish Wood Plug DP 112 $1.73 $193.76
Drill,finish patch sheetrock DP 24 $1.81 $43.44
Clapboard/Wood/Vinyl DP 1,008 $1.79 $1,804.32
Test Drill 4 Sides $53.00
r Se lin Limit:
Sin le Family=$400.00
Multi-Family = $200.00
Door Kit 2 $43.00 $86.00
Door Sweep $15.00
Seal ducts with mastic 0.5 $62.00 $31.00
Air Sealing Per Hour 1.75 $75.00 $131.25
Sash Lock $7.75
Glass Light $36.50
Blower Door:.pre/post test data 1 $45.00 $45.00
Total Air Sealing Cost $293.25 $0.00
Heating Systems
Duct Insulation&Tae Seams S-21 Ft $2.95
H dronic Pipe Insul up to 1" $3.25
H dronic Pipe Insul 1 1/4+u $3.33
Steam Pipe up to 1.5"+1.75" $4.68
Steam Pipe Insul 2" +u $5.48 .
Building Permit 1 $0.00
Action Approval needed
Lct�r0.� r �� $3,402.371 Est Total
$0.001 Act Total
i
4deense ar ragistra'dt»n vadt fos md1vh:16 use only y'
- '! iSBftrra4hx exph'atl>an date. kfIbumdr returnto;
titea� ansutner A lrs and Bosittest&U%giutnthin
liPIMtkPf&s8-Suite;5170 MI trv;tchusctta - oellartment of Public sJo,
Bsdsiontitik#0;3+3u Board of Building Regulations and Standard>
Construction Supervisor License
License. CS 8797*
Restricted to: 00
'&ssYv. iitSNil3j' [ira`'G¢16As ERIC W PALM
,I 3 HILTON ST
--- ---- -- SALEM, MA 01970
Expiration. 4/232012
( rnmi',"nvI Trg 22214
Restricted to: 00 - -
00- Unrestricted
a 1 2 Family Homes
Qfri've of Consamer Affvns&Busioese R2guU=don
FiQVI1AiIMPdFW>i xeNT COWIMOTM
Registration,�,�,yYt Ogg
Failure to possess a current edition of the Explrai L r Y2 Tr# 292174
Massachusetts State Building Code I 74" 'ifil k �� por
is cause for revocation of this license. ATLANTIC . ,..I �..C.
13111,E PALM `1Y`tf _ti
Refer'to: WWW Mass.Gov/DPS 64AJEFFER�Dt1q�s �
IAOLYM MA.01'970 .- TJrtdErareretsry
� J
r
Atlantic Weatherization, LLC
6 1 R Jefferson Avenue
Salem NLA 01970
To Whom It May Concern,
I, Eric Palm, owner of Atlantic Weatherization, LLC authorize my employee,
to pull permits for my Company.
Sincerely,
fZ.c�
Eric Palm
Atlantic Weatherization, LLC
Subscribed and sworn to before me
This 3F�Q— day of ne u wu 2010.
Notary Public
My Commission Expires:z� 20' o