46-50 NORTHEY ST - BUILDING INSPECTION IIIb cr- -7
The Commonwealth of Massachusetts "� ` jg !
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Board of Building Regulations and Standards SALEMC
Massachusetts State Building Code, 780 CMR 1 � dI
Building Permit Application To Construct,Repair, Renovate Or Demolish,a r2 N 33
0 One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D`aste Applied:
Building Official(Print Name) Signaturd Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
46-50 Northey St Salem, MA 01970
1.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 ft) Frontage(ft)
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:
Judith Murdock Salem, MA 01970
Name(Print) City,State,ZIP
46-50 Northey 860-604-8541 jmurdock65(a)gmail.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Othe ® Specify: Insulation
Brief Description of Proposed Work: uu n+ I u C'..jjuP .Q IG✓b'n.., (iUa..�
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:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplierx
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: . " Cash Amount:.
6. Total Project Cost: $ 10,047.36 ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
cs-075541 02/04/2017
Joseph A Ryan Jr License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) U
23A Sullivan Rd
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
Billerica MA 01862 R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
978-408-7832 joe(abmvinsulation.corn I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC)
180506 11/24/2016
Merrimack Valley Insulation HIC Registration Number Expiration Date
HIC Company Name or FBC Registrant Name
23A Sullivan Rd joe@mvinsulation.com
No.and Street Email address
Billerica. MA 01862 978-408-7832
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 Merrimack Valley Insulation
to act on my behalf,in all matters relative to work authorized by this building permit application.
see attached q —a(—
Print Owner's Name(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 application is true and accurate to the best of my knowledge and understanding.
Joseph A Ryan Jr q'a1- 1 (0
Print Owner's or Authorized 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
CONTRACTOR WORK ORDER
GLEAResuit
50 Washington St.Suite 3000 Printed: 9/15/2016
Westborough,MA 01581 Work Order Id: S17892P20857C234
Contractor Information Customer/Site Details
Merrimack Valley Insulation Mary Mitchell Email:
23A Sullivan Rd 48 Northey St Phone(Eve): 978-745-6896
Phone(Day): 508-943-8481
Billerica, MA 01862 Salem, MA 019703905 Site ID: 500002017892
3 Total Installed Measures
Location Description Quantity Unit$ Total $
Living Space Insulate Vinyl Sided Wall With 4" Dense Pack 1,053 $2.41 $2,537.73
Blower Door Test Only 1 $65.70 $65.70
Living Space Dense Pack 10"Cellulose In Overhang 40 $4.58 $183.20
Living Space Insulate 3rd FL Vinyl Sided Wall With 4" Dense 310 $2.57 $796.70
Installed Measures Total $3,583.33
.�_._..._..
........._
Payments ;.
Incentive Payments
Whole Building Incentive $3,000.00
Total Incentive Payments $3,000.00
Customer Share
Total Customer Share $583.33
Less Deposit Of $194.00
Customer Share Balance(Due Contractor) $389.33
For questions regarding assigned work: Contractorinbox@CLEAResult.com. For questions while performing work: 855-821-2205.
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PERMIT AUTHORIZATION FORM
I, MARY MITCHELL owner of the property located at:
(Ownets Name.printed)
48 Northey St SALEM
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor
listed below to act on my behalf and obtain a building permit to perform insulation and/or
weatherization work on my property.
X Mature
is Signature
Ab-a?-'l
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor U Date
Di
FwORce Use Only
Rev. 12132011
CONTRACTOR WORK ORDER
CLEAResult
50 Washington St.Suite 3000 Printed: 9/9/2016
Westborough,MA 01581 Work Order Id: S99956P14113C234
Coritractor Information Custo -a ite Details
Merrimack Valley Insulation Judith Murdock Email:jmurdock65@gmail.com
23A Sullivan Rd 46 Northey St Phone(Eve): 860-604-8541
Billerica,MA 01862 Salem, MA 01970JS860-604-8541
0
905 Phone(Day): 0
SitelD: S00000 5000999999
56
,. Total Installed Measures
Location Description Quantity Unit$ Total $
Door Sweep 5 $23.18 $115.90
Exterior Door Weather Stripping 5 $27.59 $137.95
Living Space Perform Air Sealing at Estimated 62-5 CFM50 1 $84.32 $84.32
Living Space Insulate Vinyl Sided Wall With 4" Dense Pack 1,053 $2.41 $2,537.73
Living Space Insulate Rim Joist with 6.25' Fiberglass Batting 2 $2.40 $4.80
Installed Measures Total $2,880.70
WorkOrder Notes
� Payments . i
Incentive Payments
Air Sealing Incentive $338.17
Whole Building Incentive $2,288.28
Total Incentive Payments $2,626.45
Customer Share
Total Customer Share $254.25
Less Deposit Of $84.00
Customer Share Balance Due Contractor $170.25
For questions regarding assigned work: Contractorinbox@CLEAResult.com. For questions while performing work: 855-821-2205.
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PARTICIPATING
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PERMIT AUTHORIZATION FORM
I, JUDITH MURDOCK owner of the property located at:
(owner's Name,printed)
46 Northey St SALEM
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor
listed below to act on my behalf and obtain a building permit to perform insulation and/or
weatherization work on my property.
X
Owner )gnature
/D
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
a.
ForC ffrce Use Only
Rev. 12132011
CONTRACTOR WORK ORDER
CLEAResult
50 Washington St Suite 3000 Printed: 9/15/2016
Westborough,MA 01581 Work Order Id: S01119P15368C234
Contractor Information Customer/Site Details
Merrimack Valley Insulation Abby Hardy-Moss Email:
23A Sullivan Rd 50 Northey St Phone(Eve): 860.604-6541
Phone(Day): 860-604-6541
Billerica,MA 01862 Salem, MA 01970-3905 Site ID: 500050101119
" Total.Installed Measures
Location Description Quantity Unit$ Total $
Blower Door Test Only 1 $65.70 $65.70
Living Space Insulate 3rd FL Vinyl Sided Wall With 4" Dense 310 $2.57 $796.70
Living Space Insulate Vinyl Sided Wall With 4" Dense Pack 1,053 $2.41 $2,537.73
Living Space Dense Pack 10"Cellulose In Overhang 40 $4.58 $183.20
Installed Measures Total $3,583.33
Payments
Incentive Payments
Whole Building Incentive $3,000.00
Total Incentive Payments $3,000.00
Customer Share
Total Customer Share $583.33
Less Deposit Of $194.00
Customer Share Balance(Due Contractor) $389.33
For questions regarding assigned work: Contraotorinbox@CLEAResult.com. For questions while performing work: 855-821-2205.
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PERMIT AUTHORIZATION FORM
1, ABBY HARDY-MOSS owner of the property located at:
(Owner's Name,printed)
50 Northey St SALEM
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor
listed below to act on my behalf and obtain a building permitto perform insulation and/or
weatherization work on my property.
xawfs Signature
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
01 �°
for Office Use Only
Rev. 12132011
CERTIFICATE OF LIABILITY INSURANCEDATE(MMIII
02/242Q16016
THIS CERTIFICATE 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 NOTCONSTITUTEA CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,.AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this Certificate does not confer rights to the
certificate holder in lieu of such endorsemengs).
PRODUCER CN TACT Carolyn A Coughlin
Charles J Coughlin insurance PRONE --- ----------------
(97B)957-3586 '1 NP:,
74Uinley Street ° °E"' ----------t-�- Z --
R O.Box 10 ADDRESS, carolyn@coughlinins.com
Dracut,IVA 01826 INSURERAaAFFORDING COVERAGE NAIC.a. __
wsuRERA- Northland Insurance Company 24015
INSURED Merrimack Valley Insulation Corporation JGseph A_Ryan,Jr. INSURERS, Safety Standard 39454
23A Sullivan Road INSURER C: Torus Specialty Insurance Company A0159
N. Billerica,IvA01862 ------------- _-- ._-. _---------__.---------
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wsuREeD: --
INSURERE_ _
wsURBi F: --' _---- ---
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTRAOL POUCYFF POLICYEXPNSR_ INSID P--N_MB—R hIwD FNMnrO
UNITS
A �, COMMERCIAL GENERAL LIABILITY IWS274182 01/21/2016 01/2112017 EACH OCCURRENCE 5 1,000,000
CLAIMS—MADE F�lOCCURI I5AIM�r TO RENTED PREMISES Earn — 5 700.000
I t NEDEXP(AW*nnpmm) S 5.000
PERSONALSADVIMURY S 1,000-,000
G�E/NL AGGREGATE UNTAPPLIES PER: GENERALAGGREGATE IS 2,000,000
O.
i �/ i POLICY JE T 1�LOC i I PRODUCTS-COMPMPAGG 5 2.000.000
I OTHER: i is
B r AUTONOSILELNBILTY I 6205006 X11/252015 11/25/2016 1 cCO sBINEDD SINGLE LUST is 1,000,000
ANY AUTO _ HODILYINJURY(Pw Person)
'N
ALLONED / SCHEDULED
�._ AUTOS v AUTOS I i HOOILYIWURY(Persvdant)I 5
�.V.HIRED AUTOS V,AUNOOWNED I I PPRerO cuaeTMinL MGE I'S
IS
C VurneRELLA LNB ' �°OCCUR ;675931161ALI 01/21/2016 01/212017 EACHOCCURRENCE 5 _ 1.000.000
EXCESS LIAR I CUMWSAL1DEI i 1 AGGREGATE S 1,000,000
IDED RETENTIONS 10,000 i I S
D WORKERS COMPENSATION -
AND@dPLOYERS'LIABILRY �f TAME I I ER
kw PROPRrETOWPARTNERIEXECUrrvE YIN I I IFI-EACHACGDENr S 1,000,000
OPRCERAdEMBER EImLUDED? NIA
IMandalnW in NH) ( E1015EA5E-EP ERiPLOYE 5 1.000.000
If yyees.dcsaft uMcr -
DESCRIPTIONOFOPERATIONSW. I EL DISEASE-POLICY UNaT S 1.000.000
OESCRIPTIONOFOP VONS/LOCATIONS/VEHICLES-(ACOROIDt,Atldidoeul RemaN¢SNntlut°,may MaBa°heE it mom spam Ls mquuptQ
JOB DUTIES:Insulation Installation:Additional insured companies respectively are Action Inc.and National Grid IDSA,its direct and indirect parents,
subsidiaries and affiliates in addition to Colmwnly Teanavork Inc.,ARCD.Inc.and EV ExJUURCE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W
ACCORDANCE WITH THE POLICY PROVISIONS. .
.
AUTHORIZED REPRESENTATNj/JJ
E � /1 � V
01988-2014 ACORD CORPORATION. All,rights resented.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
21
The Commonwealth of Massachusetts
Department of industrial Accidents
O�tce of Tnvestigatiors
600 Washington St
Boston;f_VUz 02111
•:vc:,..mass,rov'dia
"vi'orkees Compensation€nsurance AMdairit: Builders[ContractorstwLlectricians(Pfnmber
A nplkaiton information—Please Print Legibly
:Name(BusinessfOrgaui=an&axndividualfOwner:,(- f._Mc: 141/& -I-t.)k0-lc�7uw �v
Alddress: a-3 A 6c;-llzvfat.112'•
City/StateZip."btl C-ICA lata CiBha- Phone=.': x-15 �Fss 3485
i Lre von an employer` Axe you the homeowner? Check the appropriate number:
1. E am an employer with employees(foil andior part-time.
t _ I am a sole proprietor or partnership&have no employees woridng for me in any capacity_
i 3. _ I ani a homeov�ner doing all.•rock m:°self. ("No workers compensation insurance required_)
_ I am a Qenxal contractor&I have hired cue sub-contractors!Lied on the attached sheet
(These contractors have warkers comp.insurance and 1 have ai-eacfied a cone of their ins_)
5 we are a corporation and its officers have e=-ercised their right of exemption per M--T�cls§I
('J,and we have no employees.fl-No workers comp.insurance required.) 1
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o wayvVctutthat checks bogei mus:alsonitoutthesecioa helot sho..in�theirworEsrs'�m.poticyisonation. i
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j affldacti lneucaarry such.
_ Conc_ctors that check:his bog mustattad8 as addi5aaai sneer shon�r, the a::me ei tfie>uh-cuav'acmrs�d Y„e:r:•rorkxrs' y
compensation Policy hdle :aeon_
Type of project,(required): Check appropriate= i
_ r 7 _Remodalin-S- Demolition 9__Building addition 6- �e� ..onstruction :_ _ � d_..
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j 10._electrical 11._Plumb.Iv. 12 13_ v^uer , _rS �Crxte:
i nm an empto-~er that is pre.idia^_:Tori urs' fasuraace for my employees. Bem,is the ootin•aiob sic iso_
Insunaitce-company TNN am e:
Pohey 0 or self-ins-Lic._ snira:tion Date:__
job S tte Address:
.4:-tach a copy of vtarkers cormensation policy declaration page(sho:cing the polis'camber and egpi:afion date.
4ailam to SeCL're cOY.-doge as required under Section 25A of N'L?c_ 152'tet lead to the imposition of criminal
aeaairees pf a ane up to SI OC90 and.'or ono year i .prisonm-a,,,s�.Jeil as civil penalties in the fo n of a
=TOP WORK ORDER and a fine of ip to-S'_50.00 a da,-against the violation- Be advised that a copy of this
.:cement ma: be forwarded to the Ofce of Investigations of the DIA for insurance coverage*ratification.
do hereby cur=t under the pains and penalties if perjuri than the in£•rma::on pro,ided above is nue and cornet
Date:
Phone
OfIciai use only: Dc no-write in dais at--a-to be completed bit city or to r+n official_
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Phone
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and Business Rggulation
10 Park PlaZa-Suite 5170
Easton-Massaen"setts 02116
Home improvement Contmetor-Registration
P.egistr25on: 180505
Type:. comora5on
MERRRViACKVAII i ExplraGon: 71i2el201s :r° 211.624
JOSEPH RYAN�IZSULA110NGOP.P -
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