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184 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety \1a1N0chu.c11s State Building Code(780 CMR)Seventh Edition II City of Salem Building Permit Application for any Building other than a 1-or 2-Family Dwellin (This Section For Official Use Only) Building Permit.'Dumber: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a street address is not available) S I La-Fg A f/e 54h D 14-;0 ..No.and Street Cit)• /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration 11Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of ProposedWork: A � See.-( Aft, _ l i(('-1 cw,l(,,./aio -q p13 1�eti.(-Lo., 5C ay SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): r Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No. of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ AA❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 13H-4❑ H-5 131: Institutional 1-1 131-2 Cl 1-3❑ 1-4 Cl M: Mercantile❑ R: Residential R-113 11-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 10 IIA 13 IIB ❑ IIIA ❑ 1110 E3 I IVO 1 VA 13 VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public ❑ Check if nu Lade Floud Zone ❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ 1'1-1eale❑ ur mdentifv Zone: or on cite>vstem ❑ required ❑or trench )r.pecifv: permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: \I:\ I li,h,ric Itonv,t I'ri re�a \nt \pplicab le ❑ I"Vitro Claoe V, thin airport appnoach area' I.their rec IV•%% completed.' ,,r C"'I"nl to Hudd enclo.ed ❑ )e.❑ or No❑ Yes O \n ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY IidnwnulCude'. L'1e(;10ui+11l: rapeofCona«iclum: Occupant Load per Pbu,c L,c. Iha•budding contain an Sprinkler Sa'slem': Special Stipulations: � ` S SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of PropertY Owner Moo e SF - l8`( L�AfR-� 5f- /1//fi d/97y Name(print) No and Street Cit)/Town Lip Propert% 0%%ner Contact Inlurmauon: / 64-r/Leaou.,. IhAAa?yl 971' .6Xc d-t'Ly 9>P .C',/ - :21 �J/47 Title Telephone No (business) Telephone No. (cell) r-mail address IF applicable, the properly owner hereby authorizes All- 0/5P .Name Street Address Ciev/Town State Zip it act on the pro pert%owner's behalf, in all matters relaliye lu work authorized by this buildin g permit app I ica t ion SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (11 bolding is less than 35,1%1)Cu.it.of endued s pace and/or not under Construction Control then check here O and skip Section 1).0 10.1 Registered Professional Responsible for Construction Control Name((�Rpjy„gistrant) Tele ibun No. a-mail addres .A+6 Registration Numbet, Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 1 S tog Cum any Name: l.'tJ2 Name of Persuespunsible for Construction License No. and Type if Applicable .3 H�7SF 42/- Street Address .0 City/Town State Zip 78 -�- S{/4.3 fb�- X21 lo3G "'T P O i eb,cb2ycc s Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE. Item Estimated Costs: (Labor and Materials) Total Construction Cost(From Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost — $ 6() (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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. I'Ic,i.r fv nt .ink ihnrn,une rifle Trlephu 'o. )ale Ca 1 �� J�=�'� S,'✓� Jae.. �,. ��,�,-, /�f l3 strcel :Address Citi,iTuwn State 1p Municipal Inspector to fill out this section upon application approval: c J Nam Date } Action Inc. 47 Washington Street Gloucester,MA 01930 Tax Exempt Number: 042-389-332 Agency: Action Inc. PROGRAM: National Grid ELECTRIC !OB NUMBER: NE-ARC10 Work Order# NE-ARC 10 Work Order Date: 04/16/2010 Job Limit: Contractor: ATLANTIC WEATHERIZATI N Per Unit $4500.00 Client: Northeast ARC K+T Yes=1 Nom Street: 184 Lafayette Street KBT: 0 .,City; State;Zip: Salem,MA 01970 Telephone: —LarryLeGault: 978-624-2429 Stand Alone Yes=1 Nom Stand Alone: 1 Blower Door Test: YES Inspect Knob& Tube: NO Contractor: Attic/Insulation Act Cost Est Cost Act C st Attic Flat R38 open $1.12 Attic Flat R30 open 1564 $1.30 $2,033.20 Attic Flat R20 open $1.23 Attic Flat R10 open $0.91 Flat R30 restricted 28 $1.41 $39.48 Attic Slope/Flat R20 restricted $1.35 Knee Attic Wall/Floor Transitiorif $2.40 Kneewall w/Membrane R12 $1.65 kneewall Floor R30 $1.41 Attic Access Finished $84.00 Temporary Access $75.00 Basement Overhead RI9 fiberglass 35 $1.50 $52.50 Garage ceiling/floor R30(with approval) $1.21 R5/RMax on door $44.00 Vent Dryer/Bath Fan 1 $85.00 $85.00 Roof Vent Large 1 SF NFV 6 $95.00 $570.00 Turbine $138.00 Stack 12" $126.00 Propa Vent 74 $3.75 $277.50 Roof Vent#135 $84.00 Gable Vent all Sizes $76.00 Soffit Vent $23.00 Ride Vent $18.00 Attic Bypass 2Hrs Max $55.0011 Northeast ARC Pae 2 ional Grid ELECTRIC Est Act Cost Est Cost Act Cost Wall Insulation Single-Nail Asbestos/asphalt $1.50 Dbl Nail Asbestos/Aluminum $1.52 Brick/Stucco ???? $2.75 Interior Wall Blow $1.34 Cla board/Wood/Vin 1 $1.39 Test Drill 4 Sides $53.00 'r Sealing Limit. Single Family=$400.00 Multi-Family= $200.00 Door Kit 2 $43.00 $86.00 Door Sweep 3 $15.00 $45.00 Automatic Sweep $19.25 Air Sealing Per Hour 10.5 $75.00 $787.50 Blower Door Test&Air Sealing 1 $45.00 $45.00 Glass Light $36.50 Labor Only Charge 1.5 $60.00 $90.00 Total Air Sealing Cost $1,053.50 $0.00 Heating Systems Duct insulation&Tae Seams Sg Ft 20 $2.95 $59.00 FHW foam wrap for pipe to 1" 232 $3.25 $754.00 MW foam wrap 11/4-1 1/2"ID pipe 71 $3.50 $248.50 Steam FG wrap 2-3"ID pipe 147 $7.25 $1,065.75 Building Permit 1 $0.00 Action Approval needed n, 9C $6,238.43 Est Total 'V $0.00 Act Total At1a i Wea etiz EjoqLLC`�G� 611 R'�1e�'eiso>i�v�n�e Sal01970 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:Atlantic Weatherization Address: 61 R Jefferson Ave City/State/Zip: Salem, MA 01970 Phone#: (978) 744-8143 Are you an employer?Check the appropriate box: Business Type(required): 1.0 I am a employer with D-- employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑. I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 100 Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care with no employees. [No workers' comp. insurance req.] 120 Other *Any applicant that checks box#t must also till out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Arbella Insurance f �_ Insurer's Address: / V ` o-1 o C (Tc S� City/State/Zip: ON )0 Policy#or Self-ins.Lic.#9111820309 Expiration Date:3/20/201'1 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: // 4a, Date: Phone#: (978) 744-8143 O1Jicial 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia EIG Fax Server 4/6/2010 3 : 15: 24 PM PAGE 2/003 Fax Server ACORQ CERTIFICATE OF LIABILITY INSURANCE 04/0/2010 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 INSURERS: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 kOD-L TYPEOFINSURANCE POLICY NUMBER POLICYEFFECTIVE POUCYEXPIRATION LIMITS GENERALLIABILITY 8500042816 03/20/2010 03/ZO/2011 EACH OCCURRENCE S 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,00 CLAMSMADE OCCUR MEDE)(P(Any wePers ) $ 5,00 A PERSON&&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ Z,000,00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 21000.000 POLICY X FRILOC AuTOMOBIIE LIABILITY - 93827400003 03/20/2010 03/20/2011 COMBINED SINGLELIMIT ANY ALTO (EA ecddeM) $ 1 000 OO ALL OWNEDALTOS BODILY INJURY X SCHEDULED AUTOS Pei perwn) 3 B X HIRED AUTOS BODILY INJURY $ X NONAWNED AUTOS (Pe,accident) PROPERTY DAMAGE $ (Pet accldent) GARAGELIABIUTY AUTO ONLY.FA ACCIDENT S MY AUTO OTHER THAN EAACC $ AUTO ONLY: AGG $ EXCESSNMBRELSA LIABILITY EACH OCCURRENCE S OCCUR OCLAIMSMADE AGGREGATE $ S DEDUCTIBLE $ RETENTION S S LWRKERS COMPENSATION AND 9111820309 03/20/2010 03/20/2011 X We STArU- OTw EMPLOYERS'UABILTTY E.L.EACH ACCIDENT $ 500,000 A ANY OFFICERMIEM EREXCLUDEED ECVTIVE E.L.DISEASE-EA EMPLOYEE $ SOO OO Nye%dewibe weer E.L.DISEASE-POLICY LIMIT S 500.000 SPECIAL PROMSIONSbel. OTHER DESCRIPTION OF OPERATIONS!LOCATIONS I VEWCLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS CERTI CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL _30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABIUTY CITY OF SALEM 120 WASHINGTON STREET OF ANYK ND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. SALEM, 144 AUTHORIZED REPRESENTATIVE Rosemary Fulha PMA G�� ♦ ®ACORD CORPORATION 1988 ACORD 25(2001108) • iu#+adnaas.4.,sstun rand for issdWidlsf us'.my A�i behnartllaaaglsgGlbm48Re. GLYIXvsnd;a6tgtba eo; @TlldacfiCtimutwr#dTal�+am'tD:Buelnxea$k¢aite4ion Boston, A 9NYa3,zTD � M iutI o u tot i Uytnnmcio ul Public S;dvi, S'bima.'�16�5'P'6 ` � Bout(I ul Buildin Regulniinn• and Slim dunb Construction Supervisor License License CS 8797't Restricted to: 00 f9utarSi&4aBblp ERIC W PALM j 3 HILTON ST SALEM, MA01970 �-/s/E Expiration 4232012 t ........ ...... Try 22219 Restricted to: 00 00- Unrestricted i f:'1 2 Family Homes Otf7 a4 Rani ar A4SsFex.A.Bxetacss Brgultn'on . lPf�M1F dN1®f .851@10.M:F©AI7S[On6l4�R lug , Failure to possess current edition of the expini Q Tex 292174 Massachusetts State Oull'diog Code 7s1r-ei spor is cause for revocation of this license. ATLANTIC ERio: Referto: WWW.Mass.Cav/DPS 03 iReFFERS'QAi - Aiacem..tma«rasa ;. raaaen.«emaTr � ` ` ^ , fAt I a n t Pic, We a h a, U �iA ]p��CSO� �«�OU� ���|GD0 ��& 01Q7O + /Q7A\ 7��.A1�� - - - � �� - Salem,. ��. � . � ~ ~ `,. ~/ . . . " . .° ToWhom |tMay Concern � 1, Eric Palm, owner of Atlantic Weatherization, LLC authorize my employee to pull permits for mycompany, Sincerely, Eric Palm Atlantic VVoatherizatinn. LLC Subscribed and sworn Vobefore noe This IS day011. / Notary Public � MyCommission Expi � � ` BPI Certified wEPA and Mass. Lead-Safe Certified