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27 MASON ST - BUILDING INSPECTION
f:. h, The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 C\IR)Seventh Edition IWI' City of Salem Building Permit Application for any Building other than a I- or 2-Family Dwellin (This Section For Official Use Oniv) Building Permit Number: Date Applied: Building Inspector: SECTION l:LOCATION (Please indicate Block M and Lot 0 for locations for which a street address is not available) .') /1kl5on S1 5191e o 411 _ 0/42b 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❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No Is an Independent Structural Engineer ng Peer Review required? Yes ❑ No O3 Brief Description of Proposed Work: r Sa f//F fe�lan r 55� (I O/own cc l�ulo �S� i(5 e-/i Ayf 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): Y 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.) _±::j. SECTION 5:USE GROUP(Check as a livable) OF:*Factory y A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ nal 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑SI ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: SECTION 6:CONSTRUCTION TYPE(Check as a llcable) IB ❑ IIA ❑ fill ❑ IIIA ❑ tll6 ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) nRa1,ro,,,\d Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Y' Check itoutside Flood Zone❑ Indicate municipal ❑ A trench will nut be Licensed Diposal Site❑ required ❑or trench or specify: or mdentil\'Zone: ur un site svaem❑ permit is enclosed ❑right-of•way: Hazards to Air.Vavigation:(+(+hctturencnairportappr ,ch area' Is their ern •w onnple0.•d' Budd enclosed ❑ Fes❑ or No❑ Yes❑ \n ❑ SECTION 8:CONTENT OF CERTIFICATE OL NCY IL11Unn of G,dr: L'+c•GruuplsL rcpt of Cnnstrucuon: ipant Load per ploar: D,,v,the budding contain an Sprinkler Scstem.': Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION 1, W Name and Addyy�vs of Property Owner p/4 ?-2)(1, t ycus� /1��— 2,7 /77,,c,,,, 5> S° �e-�✓\ Name(Print) No..tnd Street Cih'/Town Zip Property Owner Contact bdormation: (A6--W n �eaawlf 97k -(y - ay-L9 4')t - Title Telephone No. (business) Telephone No. (cell) e-mailaddress If a plicable, the property' owner hereby authorizes � OAF 1 e) Name Street Address City/Town State Zip to act on the pro perho%%ner's behalf, inall matters relative to work authorized by this building permit a p plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If building is less than 35,M)cu. ft.of enclosed space and/or not under Com'truction Control then check here 0 and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control En c- Pa 1.n 978 .71q - T113 -rN/r, 0SF e Nam (ffjj��gistrant) Tele Ghon No. e-mail adddress 'N� Registration Numb C: f /L e',;� S Street Address City/Town State Zip Discipline Expiration Date 10.2 General fContract ffWtorr� 1 Za.T�11 AV\came e kms( I ci '1 Cum my Name: n 97 U 2 e_ Name of Peasorl eslx psis r Construction t License No. and Type if Applicable ya 0/9 Street Address City/Town State Zip 78 _R/Y3 A- - _ /03& T P 0 1 ( C, rr /- • Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506)) 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 $ j7 06 , 6D (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT ev entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this applicationis (true and accurate to the best of my knowledge and understanding. Er, r- I"A Please pr nt annd .ign name Title �Tcic a \o. ale �n'eet :\ddress City'/Town Atte Lip Municipal Inspector to fill out this section upon application approval: "� / Name Date Y \ Action Inc. 47 Washington Street Gloucester,MA 01930 Tax Exempt Number: 042-389-332 Agency: Action Inc. PROGRAM: National Grid ELECTRIC JOB NUMBER: NE-ARC09 Work Order# NE-ARC09 Work Order Date: 11/24/2010 Job Limit: Contractor: ATLANTIC WEATHERIZATI N Per Unit $4500.00 Client: Northeast ARC K+T Yes=1 No—O Street: 27 Mason Street K&T 0 City; State;Zip: Salem, MA 01970 Telephone: Larry,LeGault:978-624-2429 Stand Alone Yes=1 No=O Stand Alone: 1 Blower Door Test: YES Inspect Knob& Tube: NO Contractor: Attic/Insulation Act Cost Est Cost Act Cost Attic Flat R38 open $1.12 Attic Flat R30 open $1.05 Attic Flat R20 open $1.23 Attic Flat RIO open $0.91 Attic Flat R30 restricted $1.41 Attic Flat R20 restricted 1088 $1.35 $1,468.80 Knee Attic Wall/Floor Transitio $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 vap barrier $1.81 Garage milingifloor R30(with approval) $1.21 R5/RMax on door_, $44.00 Vent Bathroom Exhaust Unit 1 $85.00 $85.00 Roof Vent $66.00 Turbine $138.00 Stack 12" $126.00 Propa Vent $3.25 Roof Vent#135 $84.00 Gable Vent all Sizes $76.00 Soffit Vent $23.00 Ride Vent $18.00 Attic B ass 2Hrs Max 4.5 $75.00 $337.50 Northeast ARC Page 2 ional Grid ELECTRIC Est Act Cost Est Cost Act Cost Wall Insulation Attic stairs&walls 1 $130.00 $130.00 R19 FG bsmnt overhead 35 $1.50 $52.50 2" foam board 85 $2.17 $184.45 Interior Wall Blow $1,73 Clapboard/Wood/Vinyl 431 $1.70 $732.70 Test Drill 4 Sides $53.00 Air Sealing Lim' Single Family=$400.00 Multi-Family=$200.00 Door Kit 6 $43.00 $258.00 Door Sweep 2 $15.00 $30.00 Automatic Sweep $19.25 Air Sealing Per Hour 4.5 $75.00 $337.50 Sash Lock $7,75 Glass Light $36.50 Labor Only Charge 1.25 $60.00 $75.00 Total Air Sealing Cost $700.50 $0.00 Heating Systems Duct Insulation&Tae Seams Sg Ft $2,22 H dronic Pie Insul up to 1" $3.25 H dronicPi elnsull1/4+u $3.33 Steam Pipe up to 1.5"+1.75" Steam Pipe Insul 2" +u $5.48 Building Permit 1 $0.00 Action Approval needed A 1 / 1 $3,691.451 Est Total $0.00 1 Act Total Atlantic Well,LLC 61 1t Je �1ven�le Safety MA Q1970 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 WeatherlZatlon Address: 61 R Jefferson Ave . Salem, MA 01970 978 744-8143 Ci /State/ZI Phone #. City/State/Zip:p � ) Are you an employer?Check the appropriate box: Business Type(required): 1. ✓❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑ RestaurantBar/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 10.❑Manufacturing no.employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, I I.❑Health Care with no employees. [No workers' comp. insurance req.] 120 Other *Any applicant that checks box#1 must also fill 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 C. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Arbella Insurance Insurer's Address: '7 f46,5,2/,? S-1-- City/State/Zip: S/i l e7,✓1 10✓- O 1 C/-7 Policy#or Self-ins.Lic.#9111820309 Expiration Date:3/20/2011 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$250.0014 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 a�nd)penalties of perjury that the information provided above is true and correct Sign e; oil r/ / �� Date: 2 /a�2 Phone#' (978) 744-8143 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.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 04/0iz 10 PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A 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 0 INSURED Atlantic Weat erizatioo LLC INSURERA Arbella Protection Ins. Co. 41360 61 Rear Jefferson Avenue INSURERS: Arbella Indemnity Ins Co. 10017 Salem, MA 01970N!UR ER C: NSURER 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 NDD-L TYPEOFNISURANCE POLICY NUMBER POUCYEFFECTIVE POUCYEXPIRATION UNITS lift-NIRrGENERA.LIABILITY 8500042816 03/20/2010 03/20/2011 EACH OCCURRENCE b 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED S 50,00 0.AIMSMADE FX 1 OCCUR MED EXP(Any ane Person) S S'00 A - PERSONAL&ADV INJURY f 1,000,00 GENERAL AGGREGATE $ 2,000,0 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-CCMPIOP AGO f 2 000 00 POLICY X JEG LOC AUTOMOBILE LIABILITY 93827400003 03/20/2010 03/20/2011 COMBINED SINGLELPAIT S ANY AUTO Ea accident) 1 000 00 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Pei Parson) S B X HIRED AUTOS BODILY INJURY f X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY.EA ACCIDENT E ANY AUTO OTHERTHAN EA ACC f AUTO ONLY: AGO $ EXCESSN BRELLA LIABILITY EACH OCCURRENCE S OCCUR CLAIMS MADE - AGGREGATE S f DEDUCTIBLE S RETENTION $ $ WORKERS COMPENSATION AND 9111820309 03/20/2010 03/20/2011 X we srATu-EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000 A ANY OFFICERRd6MBER EXCLUDEOTXECUTIVE E.L.DISEASE•EA EMPLOYE $ 500,00 Ryes.09wit,eMeet E.L.DISEASE-POLICY LIMIT f 500 00 SGECML PROVISIONS bel. OTHER DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E IINATIGN DATE THEREOF,THE ISSUING INSURER WI LL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY CITY OF SALEM 1ZO WASHINGTON STREET OPANY N ND THE INSURER,ITS AGENTS OR REPRESENTATIVES.ALO, KApURN)RIZED REPRESENTATIVE C ! Rosemar Ful ha PMA V�w. ©ACORD CORPORATION 1988 ACORD 25(2001108) i4EnsE+or-ragjitnamlen valhifor tndivid'u4 useonlyI 6Efaflite•espfratihn.-dole. IfIaNndt retvrn to: opaeotcosou teerAMYns,•godBusiness'Reguiati" 10rsr LPbaa.-Suite5470 Vljtax:tcbuscn� - Dcliailmtniot Public Snici• Rostron,MA 0`4.16 Board of Building Regulation and 5tttndw d, . Construction Supervisor License License: CS 8797; Rest icted to: 00 ERIC W PALM 3 HILTON ST -------------- ------ - — SALEM, MA 01970 Ezpnancn 4/232012 ( uvnis.i::ucr Trfl 22214 mcg Restricted to: 00 00- Unrestricted 1 1 Family Homes Office of Consumer Albin&BaaFasos B.tgulation .. i K0,M,l£MVR .&K e1%T CONTRACTOR Regletraaopy.,�,y4�ns9 Failure to possess current edition of the Expirat f[$CLt12 Trdt 292774 Massachusetts State Building Code f1t ;-:_t is cause for revocation of this license. ATLAtATtt: W ';Ii': _.l��:C. ERIC PALM 1\,rtc Refer'to. WWW.Mass.Gov/DPS ,•AAILRNI MA.01•97d1 '1- ' tJo'det<sreatsa+ry 0000' 000 0 Ooeo Atl;oantilc Wealklhe��,t,,,, 61 R Jefferson Avenue Salem, MA 01970 • (978) 744-8143 To Whom It May Concern 1, Eric Palm, owner of Atlantic Weatherization, LLC authorize my employee to pull permits for my company. Since, Eric Palm Atlantic Weatherization, LLC Subsc%ed and sworn to before me This 18 day oc� c.� 2011. Notary Public My Commission Expireq_L2!_�3_, ,aO 0 BPI Certified 9 EPA and Mass. Lead-Safe Certified Authorized Honeywell and NGRID/NSTAR Contractor