10 MOULTON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
Massachusetts State BuildingCole, 780 CMR, 7a edition OF SALEM- RrvisvdJmmury
Building Permit Application To Construct . pair, Renovate Or Demolish a
One-or Tiv6-Fupfrly D ailing
"is Sectio For Offs ial Use qXly
Building Permit Number: Date pplod
Signature: 2 It)
Building Commissioned Inspecibif of Buildings Date "
SECTION 1:SITE INFORMATION
1.1 Property Addre 1.2 Assessors Map& Parcel Numbers
L la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq B) Frontage(ill
1.3 Building Setbacks(R)
From.Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided .
1.6 Water Supply:(M.G.L c.40.§34)- 1.7 Flood Zone Informatlon: 1.8 Sewage Disposal System:
Public 13 Private O Zone: Outside Flood Zone?Check if yesO Municipal O On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record: �y II—
(AA�r ,. U .S Se-1-1- /0 In eq
Name(Prim) Address lot Service:
�JL1A a 11 , t cI 1.4 ✓`•9
Signature - Telephone
SE'C PION 3:DESCRIPTION OF PROPOSED WORKS(chicksrll that apply)
New Construction O Existing Building O Owner-Occupied O , RePeirs(s).O , Alteration(s) O 1 Addition O
Demolition O„Accessory Bldg.O Number of Units 011ier. O Specify:
Brief Description of Proposed Work2:, 7ZV56 t (dlou a �1 " -K f1 Fnor de--30
52o,ro Cz-aa
. : ...
-3G
Pr,,,OAU ' -lam u.0.4-, .
ACTION*ESTiM,- D CONSTRUCTION COSTS
Estimated Costs:`
Item Lebor.and Materials ' : 011lelal Use:Only
1. Building S 1. Building Permit Fee S- Indicate how.fee is determined:
�.Electrical S - O Standard-Cityaown-Application Fee. -
O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire
Su cession _S Total All Fees:S
Check'No._ Check Amount: Cash Amount:_
6.Total Project Cost: S Ade7d. jol O Paid in Full O Outstanding Balance Due:
�Ic.��S.� /r'1✓�, � �c Alla.,., i-,� w<.�-1�w. :✓. `f„�
SECTIONS:.CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor(CSL) 1379-2 ) 3 (2-
t.� ,. x. '-,%ta- License Number Expiration Date
N:mt_ ul'C'S.•I I dJer �. List C'SL'fype Isee blow) \A-P
�; 15 -� Sail f Description
Address-B / WDResidential
lnrcslricted u to 75,000Cu.Ft.
estricted Id2 FamilyDwellin
Signuturc M Only
9)�6 2Yy—S'(Y 3 esidential Roofing Covering
I'dephune esidential Window and Sidin
esidential Solid Fuel Burning Appliance Installation
" - •_ - '_- - Demolition
5.2 Reglst red Home Improvement Conln tF or(HIC) Ly �0 8 9
/ }(
IIIC Company Name or 111C Registrant Name Regist ion Number
(a cft'J-- i Sun dL& /a Z
Address t,�
9 7 fr 7Y S ft j xpiration Date
Siynaturc - Telephone --- -
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152.1 2SC(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 ..........CF--' No...........O
SECTION 7r.OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, W:0,, w' 5 5 -e 1 as Owner of the subject property hereby
authorize C r, � mit-(-,--) to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTIII/ON"71a:OWNERt%OR AUTHORIZED AGENT;DECLARATION
1 (.L `'i��✓✓1 as Owner or Authorized Agent hereby declare
that the statements and information orrthe foregoingapplication are we and accurate;,to the best of my knowledge and
em�
behalf. C�/ . /
Print Name
Signature of Owner orAuthoriked•Agent. - Date'. -
70wner
the ins and penalties of 'u -
NOTES:
er who obtains a building permit to do his/her ownwork,or an owner who hires an unregistered contractor
tered in the Home Improvement Controctor(HIC)Program),will_Whave access to the arbitration
or guaranty fund under M.G:L.c. 1J2A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 790 CMR Regulations I10.R6:and I IO.RS,respectively.
bstantial work is planned,provide the information below:
otaoosrea(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
). "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
''' DEPARTMENT
I'.il: pit) , l
' .,.�M I:QW'.WN\1...�V�1'atrT.X11111.�1.1K 11111
\I
tfr:'bry:7J4lMN •Fix:'/lt•1JS'4tJa
Construction Debris Disposal A171davit
(mNuired liar all demolition;,.I renovation work)
in accurdattce with the sixth edition of the State Building Code, 190 CMR section 111.3
and the rorisiuns of MGL c 40, S 54;
Debris. D condition that the debris resulting tlom
Da s, _ is issued with the
Building Permit N Geena.d wsaus disposal facility as defined by MGL c
this work shall he disposed of in a properly
I 11. S i 50A.
The debris will be transported by:
(leap ut hauler)
The debris will be disposed ur in
(marw ul xr tly
I;,,wr.,.ul xlh%1
.lrnaure,rl'Iwmlit applieant
f Jal!
CITY OF S.U.&M9 NLISSACHUETTS
Bt:QDLNG DEP-%M- i r
12o WA9HQNGTON MM. 1'a FILOGR
TEL (974 145-9595
FAX(978) 74&98"
KIS®ER"Y ORWOLL
. �AYO� THohW ST.PttiRs
1:311 WMto1PLaLtCPtOPEtTV/KlLDLVGCOMMISIONEel
Workers° Consnenastles Insurknes Allldaeit. Otailderi/ContractonlElthrtrlelanslFlumbore
s.unllcant Inforl"iflon
Pleas hint LISM
Vale!Iavu/r+l0rgaarranenlrrdrrtAulC / I i ���. �i, Q e—t'La A .`2�
Address, l I ✓� �FCI� , s° — u
City/StacdZijr 5`N
Arrr yea ewpkyert Chack the Appropriate,bas Type of project(require
r 1. an a employer Wilk ), o. Q 1 am a PMW caatnesot and 1 b Q Now eoawu mics
employer(Adl and/or part-uoutV have hired the at►earrecwe
2.Q 1 am a sots propriator m partner- lied on rlr attached shat: 7. Q Rantotklins
+hip and have no amptsyess Thera sub•comos mors have L Q 0smolidan
wortlns for me in any capacity. workers'comp Insuce ma, 9. Q OuiWins addition
(No workers*coop insurance S. Q We w a carperadas and is I O.Q Ftscnical repairs as,additiotr
r••�rstl of2k:ats have uamtlaad thrix
).Q 1 am a ho was Joint ad wort riahl olsamnpdos por MOL ll—C3 Plumbins repairs or addhi ns
myself(No Workers'corned c. 172.!10),std are haw no 12.0 Raaf repairs
inswanceMquiridjt '"op °tl 1 searitars' I).❑Othse
comp imarrancerepir Lj
•Any seers/iti rrrtrrar as e1 craw aero N We OW err lelw . , tart weave'otwernrra patty+a{rwulr
'r6w.wrwrma who vAn c db rraemb iM1eYM IMV era Limina d wad ere*m Mw waoidsawttttrrw ams,wtl wi a row alafkra 6dkoiry ane\
!C '-wiwa rhe saws,tab 6s,orad aatrhea as ad/tiwd ah"sha.iy es,owe ed'r6 rrreenowwa td rhb warhae•coop palby imarnedsm,
I'm me rsyfeys rAa►tb/red/Iw;rrareers'rew/naasdra lnwrrsaw fir aq eay/areua S�Anr 6 rAe paths,rue/fr1 alar
informs" nn
Insurance Company Name: /7�6e- 0.
Pa(icy a or Self-ins.Lie.N: 9 M),o 30 R Expiration Dow.
Job!lits Adrhipv`c 51 rte' -, City/SuWZip:
.teaeb a copy of tba workers'compeoanos Valley datwllsta pip(allowing tbs p lky somber and expired"daft)6
Failum to secure coverep as"Intel under3atiea 23A orStGL a. 172 can lead to the imposition of criminal pensldes of a
fine up to S 1.100.00 andfar one-year imprisonment,as well as civil penaltiq is the farm of a STOP WORK ORDEK and■Aos
.rf up o 52io.0o a Jay asainsi the violator. IM adviewl thats copy of this staternaat may be forwarded to the 011iee of
hrvcau gatiuru of rhe nlA for insurance coverage veritlealiaL
/./e hereby rrrllfjy�rr�_,ir�e*l�a,gmiwa rod ns,/Nesa/P::cj�r:�v;;4u Ike infMarllemynridod ub~is nw dad a'rrrrA
pure_
P`urea: Gl? _ 27//1
0/Jra01ere en/fid On not Write is this Yres,to AV,Mexplffew♦y city or lower n/fh•irl
City or ruwn: Yrrmit/Lleenst
Lsuint.whonly(circle ane):
I lluud of Ilral.b 1. Ruddlrs I)rparemvnc ). city/rows Clerk 1. Elsc.rim impector 7. Plumbing Inrpecror
6.t)ther _
L ,atact Pcrron: - . _ .. -Phone 1:
EIG Fax Server 4/6/2010 3 : 15 : 24 PM PAGE 2/003 Fax Server
AD-ORA CERTIFICATE OF LIABILITY INSURANCE 04/06/2010
04/06/2010
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
Natick, HA 01760 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE- NAIC0
INSURED Atlantic Weat erization LLC INSURERA Arbella Protection Ins. Co. 41360
61 Rear Jefferson Avenue INSURERS: Arbella Indemnity Ins Co. 10017
Salem, NA 03.970 NSURER 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 FIDUCYNUMBER FOUCYEFFECTIVE POUCYEXPIRATIONLM NSR DATE QAMIDD� DATE(MMIDD� 11MRS
GENERAL UABILITY 8500042816 03/20/2010 03/20/2011 EACH OCCURRENCE $ 1,000,00
X COMMERCIAL GENERAL LIABILITY OPMAGETORENTED $ 50,000
CLAIMSMADE FX OCCUR MED EXP(Any we person) $ S'000
A PERSONAL&ADV INJURY $ 1,000,00
GENERAL AGGREGATE S 2,000,00
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGG $ 2-'0-00'000
POLICYFX]PECO. LOC
AUTOMOBILE LIABILITY 93927400003 03/20/2010 03/20/2011 COMBINED VNGLELIMIT $
ANY AUTO (Ee ecddem) 1,000,00-0
ALL OWNED AUTOS
BODILY INJURY $
X SCHEDULED AUTOS IPS,pars°^)
B X HIRED AUTOS
BODILY INJURY $
X NON-OWNED AUTOS (Per..Id )
PROPERTY DAMAGE $
(Per..Ident)
GARAGE LIABILITY AUTO ONLY.EA ACCIDENT S
MY AUTO OTHER THAN EAACC $
AUTO ONLY: ASS $
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR �CLAIMSMADE AGGREGATE $
8
DEDUCTIBLE $
RETENTION E $
WORKERS COMPENSATION AND 9111820309 03/20/2010 03/20/2011 X WC STAT- OTH-
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT S 500,00
A ANY PROPRIETORIPARTNERIEXECUTIVE
OFFMERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ SO0,00
IF yes,desmioe under
SPECIAL PROVISIONS belay E.L.DISEASE-POLICY LIMIT $ SOO OO
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CANCELLATIONCERTIFICATE HOLDER
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 OBUGATION OR LIABILITY
120 WASHINGTON STREET Of ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
SALEM, MA AUTHORIZED REPRESENTATIVE
Rosemary Ful ha PMA
ACORD 25(2001108) - ®ACORD CORPORATION 1988
Nov 24 2010 11 : 51 - HP LASERJET FRX page 3
CONTRACTOR WORK ORDER
Conservation Services Group Printed: lir 12010
Contractor Information Custom ite Datails
,
Eric Palm WILLIAM WISSER Phone (eve): (919) 593-607
Atlantic Weatherization 10 MOULTON AVE
61 R Jefferson Ave Phone (day):
Salem, Ma 01970 SALEM MA 01970 2524 O Site ID: S10003978
044
Appointment Details
Completion Deadline:
Location Desefl on Quantity Unit S Total$ Notes/Ravi ons
Work Order: ATLANTIC-2010112
KFL Kneewall Floor Den'se Pack 10" 144 2.09 300.96
KSL Polylsocyanurate 2" 180 2.76 496.80
ASI Attie Slopes Int Dense Pack 6" 180 2.04 367.20
KWL Kneewall3.5"FGBatt+1"Polylso89 2.48 245.52
KFL Kneewall Floor Dense Pack 6" 36 1.93 69.48
AFL Open Attic 11" Cellulose 128 1.34 168.84
OVERALL Propavent 2'or 4' ` 18 3.20 57.60
RMJOIST Rim Joist 6.25' Fiberglass Batting 90 1.80 162.00
ASL Slope Attic 6"Cellulose 90 1.08 95.40
Total for Work Order ATLANTIC-2010112: $1,963.80
Grand Total: $1,963.80
Road Blocks �
Asbestos Possible Asbestos Containing Material Observed
REMNANTS ON FHW PLUMBING
Combustion Safety Failed Revisit Passed
(RTL111)3IRD IN CHIMNEY AT D/AG AUDIT. CUSTOMER TO GO THROUGH LOAN TO CONVERT TOGAS, (CHIMNEY
REMOVAL FOR RENOVATION) UNCERTAINABOUT POSSIBLE NEST IN UNCAPPED CHIMNEYAND BLOCKAGE. NOT
TESTED DHW,OVEN, TESTEDAND PASSED
Eric W.Palm #87977
3 Hilton Sheet Exp. 4/23/126 ��
Salem MA 01970 978-744-8143
Atlantic W64etinfion,LLC H.C. #142089
61 R Jefferson Avenue Exp.3!12/12
Salem MA 01970 978-744-8143
Conservation Services Group-40 Washington Street-Westborough, MA 01581 -800-480-7472
I
v
-I Utense or re',giatsartAon valid for individul use only
btfare-the-espirattba-0ate. 111100ud;retµrn to'.
offlee ofConsumer ASfaivs-acrd Business Regulation
13.Park Etaza--Sntte5918 Massuchusett+ - Department of Public Satci�
Roston,ll AO'3 16 - - Board of Buildim,, Regulations and Standard,
Construction Supervisor License
License: CS87971
Restricted to: 00
ERIC W PALM
iiFaf realtftesltlitaf� 3 HILTON ST
--- — -------_ SALEM, MA 01970
Expiration: 4/23/2012
( anmisainrr Tr#: 22214
Restricted to: 00 -
bf"' ' U11r-estricted ✓i;e �iowrnrnnwea.�l� a�, aaaac/uae!G
1G,1 2 Family Homes
:"flfitce of Consumer A4#airs&nesinese Repiladon
D;;1'=WEMEU7 CONTRACTOR
Registratio - A*Z089 .
Failure to possess a current edition of the Ezp'IraC 2 Telt ?82174
Massachusetts State Building Code 7SileKi �h}I� por
is cause for revocation of this license. ATLANTIC I �,L:C.
�.. EW PAI A -L�f� r r y,,•
Refer'to: WWW.Mass.Gov/DPS 81RJEr',ZS0I4 .
'AALEM MA 011970 Undetscemrsry
IkL
i
Atlantic Weatherization, LLC
6 1 R Jefferson Avenue
Salem MA 01970
To Whom It May Concern,
I, Eric Palm, owner of Atlantic Weatherizstion, LLC authorize my employee,
to pull permits for my Company.
Sincerely,
Eric Palm
Atlantic Weatherization, LLC
Subscribed and sworn to before me
This -�3v-oUay of 0) 2010.
cc 2ucn c L-t v cva' —
Notary Public
My Commission Expires: kapI t2-010