355 JEFFERSON AVE - BUILDING INSPECTION �280o G� I O t Z s
The Commonwealth of Massachusetts E(�?1Q q?F
'4, Board of Building Regulations and Standards INSPECTR :SALTR''d! ES
Massachusetts State Building Code,780 CMR Revised Mar 2011
6� Building Permit Application To Construct,Repair,Renovate Or Demolish* DEC
DEC I S All: 3
One-or Two-Family Dwelling cU'
((� This Section For Official Use Only
Building Permit Number: D e Applied:
/7
Building Official(Print Name) Signature Date
( SECTION 1: SITE INFORMATION
r� 1.1_ ge�ddress: - I 1.2 Assessors Map& Parcel Numbers
I L llaa Is this an accepted street?yes `-nnol Map Number Parcel Number
Il 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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 yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
I-1 r]I Iy LbYrrwS
Name(Prin r City,State,ZIP
Tg�) kr&n >n Parr. q-R-V9 iV-45
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other m Specify: W1'
Brief Description of Proposed Work': � } \MCA \ L. �JC1')cAcA1 I .
� :5eC ) a RCA
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
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 (HVAC) $
List: n V,
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)
Cs- io73�Fr
3('js,ff, so-nvics License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
M�
No and Street Type Description
— U Unrestricted(Buildings u to 35,000 cu.ft.
i0, -
!, C. Y K--, ('J O Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
--C� �p� SF Solid Fuel Burning Appliances
IXLYAK��5 iC�S'� IfI�UiG yGM Ca'�'n's I Insulation
Telephone Email address D Demolition
5.2A, Registered Home Improvement Contractor(HIC) I C Q-5'Q� I acl
A _
ry-IPX t CPA r\ 1\�C u-CSF\ �P C k�`(Y`aCA\CLQ HIC Registration Number Ex ira ion Date
HIC Company Name or HIC Registrant
2 pEt_� Hca "t\�,-_ ��
N7o�.,and Street M p. Email address
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 YA rrbs- A g—r
to acct on my behalf, in all matters relative to work authorized by this building permit application.
/2 /0!1$
Print O er' ame(Electronic Signature) Date
SECTION 7b:OWNER' 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 a plication is true and accurate to the best of my knowledge and understanding.
/2h61k5
Print er' r Ay orized 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
(617) 7521570
American Building Technologies
Contract for Products/Service Work
This Agreement is made by and among
Haily Lyons
355 Jefferson Ave
Salem,MA 01970
American Building Technologies (ABT)
2 Neptune Rd, Suite 439
Boston, MA 02128
1. DESCRIPTION OF WORK TO BE PERFORMED
1-Wall insulation
2-Air Sealing&door kits
3- Basement insulation
Total: $4,197.76
Customer Signature:
Customer Name: O N VCiY1S Date:
Contractor Signature:
Contractor Name: Date: JTJI�
r � .
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
If www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(aasineasrorganizalionnndividaaq: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.[3 I am a employer with 5 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or painter- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. y
E]Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑Plumbing repairs or additions
myself [No workers' comp. c. 152,§I(4),and we have no 12.❑Roof rait'
insurance required.]t employees. [No workers' 13.❑LOther insulation
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 ate doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Commotors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Ace American Insurance
Policy#or Self-ins.Lie.#: 2 E 918 4 4 5 Expiration Date:: 10/2 00/16 /�
Job Site Address:,3t5 �t'fPl��f'X1 (`i"/G City/State/Zip:, _ki1 M A 0_g70
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 ceun thegins and penahies of perjury that the information provided above is true and correct.
Sionarure I 5% Date:
Date: I2�IUIIS
Phone#: 6V 2\43 04
Official 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.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
, t
Work Order
North Shore Community Action Programs,Inc. Job Number: LYONS
119 Rear Foster Street,Building 13 Work Order Date: 11/30/2015
Peabody,MA 01960 Ownership: Owner
Phone:978-531-0767
American Building Technologies Auditor: Marc Lorah
263 Western Avenue Email:mlorah@nscap.org
Lynn MA 01904 Cell: 978-587.5104
Email: rebeca@americanbuildingtechnologies.com Phone: 978-531-0767 x777
Phone: 781.598-7125
Haily Lyons NSTAR Gas $4,197.76
355 Jefferson Ave 1 Total $4,197.76
Salem Ma 01970.4438
978.979-0845
Contact Person: Haily
Safety Issue(s): Lead Paint Possible
Authorized Actual
Measure Description Qty Price Total Qty Total Comments
Basement Insulation
Crawlspace overhead insulation 4 It 120 $2.09 $250.80 120 $250.80 Right side of House crawlspace
high or less R-19
Sill two-part foam w/fiberglass batt 124 $2.46 $305.04 124 $305.04 Owner agree to remove some of ceiling to
access rim joist
Doors
Fixed Sweep 3 $17.64 $52.92 3 $52.92
Repair/Refit Door 1 $58.00 $58.00 1 $58.00
Thermax(or equivalent)on door 1 $57.00 $57.00 1 $57.00 bulk head door
Weatherstrip s/Q-Ion or equal 1 $51.00 $51.00 1 $51.00 bulkhead door in basement
Weatherstrip s/Q-Ion or equal 3 $51.00 $153.00 3 $153.00
Health &Safety
Clothes dryer vent including 1 $100.00 $100.00 1 $100.00
Exhaust Duct
Knob&Tube Inspection,fuses, 1 $175.00 $175.00 1 $175.00
wiring
Date: 11/30/2015 Page 1
l
Work Order: Job Number: LYONS
Misc Insulation
Duct insulation R-5 100 $3.47 $347.00 100 $347.00
Hydronic pipe insulation to 1 in. 100 $3.82 $382.00 100 $382.00
copper pipe R-5
Misc Measures
Attic/basement sealing with two- 2 $84.00 $168.00 2 $168.00
part foam
Seal ducts with mastic or butyl 2 $73.00 $146.00 2 $146.00 make sure top of ducts are sealed
backed tape
Permit
Building Permit 1 $100.00 $100.00 1 1 $100.00
Wall Insulation
Wood clapboard/shakes/shings or 832 $2.00 $1,664.00 832 $1,664.00
vinyl (dense pack)
Windows
Thermopane Glass Replacement 1 $188.00 $188.00 1 $188.00
Total $4,197.76 $4,197.76
Contractor Instructions:
Before Starting the Job: During.the Job:
1.Please notify us 24 hours before starting or scheduling a job. 1.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.
Date: 11/30/2015 Page 2
1
Work Order: Job Number: LYONS
Additional Contractor Instructions:
Attic Inspection form attached? Yes N/A (Circle One)
Certificate of Insulation posted? Yes No (Circle One)
American Building Technologies hereby certifies that this job was supervised and completed in compliance with all Department
of Labor Standards and Lead RRP regulations.
Contractor Signature: Date: RRP License#:
I hereby acknowlege that all work has been completed and inspected.
Customer Signature: Date:
Energy Director: Date: Fiscal Officer: Date:
FOR AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
Dryer CO 0.000 If Yes,indicate language:
Stove CO 0.000 Occupany change in last 18 months? Yes No (Circle One)
H2O Tank CO 5.000 Comments:
Heating System CO 6.000 Number of windows
Ambient CO 0.000 Number of rooms
Blower Door 0.00
Date: 11/30/2015 Page 3
---o••------- �+ + 11/ J/ GV1:J C : 401 OZ ACI PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DO7YYY)
T T IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRODUCER,AND THE CE]FMFICATE HOLDER-
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to
he certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
AMBROSE INS AGCY INC PHONE FAX
70 MUNROE ST STE 5 (A/C,No,Ext): (A/C,No):
LYNN,MA 02101 E-MAIL
ADDRESS:
237LY INSURER(S)AFFORDING COVERAGE NAIC p
INSURED INSURERA: ACE AMERICAN INSURANCE COMPANY
AMERICAN BUILDING TECHNOLOGIES INC INSURER B:
INSURERC:
263 WESTERN AVE INSURER D:
LYNN, MA 01904 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS is TO CERTIFY THATTHE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWIT HSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF MY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH MIS CERTFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,ID(MUSIONS AND CONDITIONS OF SUCH POLICES. LIMITS MOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
INSR ADD SUB PODGY EFF DATE POLICY EXP DATE
LTq TYPE OF INSURANCE L R POLICY NUMBER (MIADDIYYYY) (MATODNYYYY) LIMITS
GENERAL LIABILITY -ACH OCCURRENCE Is
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 0 OCCUR. DAMAGE TO RENTED $
PREMISES(Ea occurrence)
ED EXP(Anyone person) $
GEN'L AGGREGATE LIMB APPLIES PER: PERSONAL S ADV INJURY $
ENERAL AGGREGATE $
POLICY �PROJE('.T LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE $
LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAR [71 OCCUR EACHOCCURRENCE $
EXCESS LIARL�j CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKER'S COMPENSATION AND X. I WCST
EMPLOYER'S LIABILITY Y/N UB-2E91 8465-15 10202015 10/20/2016 LIMIATUTORY OTHER
,IS
ANY PROPERITOWPARTNEWEXECUTIVE
OFFICERIMEMSER EXCLUDED? WA E.L.EACH ACCIDENT $ 1,000,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
II yes.des.im-oder
DESCRIPTION OF OPERATIONS W. E.L.DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
NSCAP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
11SIR FOSTER ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL P_E DELI VBWD
IN ACCORDANCE WITH THE POLICY PRO
BLDG 13
AUTHORIZED REPRESENTATIVE
PEABODY,MA 01960
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988.2010 ACORD CORP R r g is reserved.
Massachusetts Oeparbnent of Public.Safety COnstruction S•apervisor
Boardof Building6teipul<ngian ncf Standards. RestnckW to:
Lkcrose- SCS-tp1378 lesst!mnct d 000 cts.bic a`amy use icacp WS) CPnEaico
Cin strustiwa Sul;*rvisor �,I %W soa cubic?ee.[(99 i cu ism. crsp o.
A 1
JOSE A.SANTRS y
37 W. MILTON STREET
IiN'DE PARK MA 02.998
(' f'r iDdre to possess a awerrt edition of the ti mwchpiseus
Expiration'. St2te SWIdima Code Fs cause Rir FeV=aliorr gl thts liaensP.
CasanmissaQricr IMU2917 DPS Licensingfin[ ,
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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
355 Jefferson Ave, Salem, MA 01970
ose antos
12/10/15