35 PARK ST - BUILDING INSPECTION The Commonwealth of Massachusetts &Aray" q OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR W18.11) OCT -5 R °r 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
Ohne-or Two-Family Dwelling
Taia S„eed#in I=or ORiaial:Usa ,Only
^- BAWding Peradt.Nun Date Applied:
_� liuilrlUogOtltcisl:(PrudNenre� Sigoaltna —
SECTION T SITE INS OSA ft01V
1.1 P pe
Adess: ) 1 12 Assessors Map&Parcel Numbers
lL1
l.la Is this an accepted street9 yes_ no Map Number Parcel Number
1.3 Zoning Information: 14 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(a)
1.5 Building Setbacks(ft)
From 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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public 13 Private 13 Check ifyes❑
S$t�'ION2: PIiOPI1:RTydWNER$IIXPt
2.1 O err of gecord: ptU o A- f �
(},c <R4.
Name(Print) City,State,ZIP
3r- I�r�yL� JT `j7B 7YY `f689
No.and Street Telephone Email Address
SECTION 3.DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building jq Owner-Occupied �I( Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Des cn��tion of Pro used Worl2:
i, owN � GL
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use.Only
Item (Labor and Materials
1.Building $ 1, Buikffing Pe.it Pee:$ ladicate how fee is detemtined
0 Standard City[rown Application Fee
2.Electrical $ ❑Til project Cost''(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ '
5.Mechanical (Fire $ Total All Fees:$
ression
CAtedc No. (Meek Amount: Cash Amount;
6.T tal Project Cost: $ J� El Paid is pal ElO,ulStandirtg Balance Due:
(gQstt�t,p�
10
SECTION 5: CONSTRUCTION SERVICES
5.1 Con ction Supervisor License(CSL) /G2Z rJJz ( f
-; G/}-(i�'I License Number Wnfitiod Date
Name of CSL Holder
List CSL Type(see below)
Type
No.and Street - -
cS'i>-(.K41/t ,(A /r(ARC
Unrestricted din to 35,0u()on.tt.
Restricted l�2F ' Ihveilio
City/Mown,State,ZIP Masonry
Roofin Covering
S Window Siding
Solid Fuel Burning Appliances Insulation
Tel hone Email addreDemolition
5.2 Registered Home Improvement Contactor(HIC)
111617 ( 12/
HIC Registration Number ate
HIC}omTy Zor HIC Repstrant Name �(,s lv�
hum Ca it CGsr•Nz%
No.and Street ISAAC IL4 0/,o 7f Email address
Ci /Mown State ZIP Tel hone
SECTION k WORKERS'COMFEMATIO N ROURANCE AFFIDAVIT OL.G.L e.152.4 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 ..........X No...........X
SECTION Tat OVMR AIYM6R1ZA1a0N TO sE COWOLETED WHEN
9WMR'S ACENT ORC ORFO-Rte,- M PEMffr
I,as Owner of the subject property,hereby authorize ,CC1%r✓tV L�
to act oonn�my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 76:OWNEW OR AUTHORIZED AGENT DRCLARATWN
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contame in this application is true and accurate to the best of my knowledge and understanding. -
0 /o //
Print Owner's or ihoflzed Agent's Name(Elec6lnic Signature) Date
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
wtivw.mass.sov/oca Information on the Construction Supervisor License can be found at mmy mass.sov/dos
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 ProjeG Square Footage"may be substituted for"Total Project Cost"
i
- � rs�r Yrnni urnim:ra�l>i u��C•�t✓oaJur�t4tc/!'
Office of Consumer Affairs&Business Regulation
yM 6AOME IMPROVEMENT CONTRACTOR
l IZegistration: 111617 Type:
r PExpimtion: 1/12/2017 Private Corporatic.^
MASS WEATHERIZ4TION, INC
RICHARD LAMBY
3 OCEAN AVE
SALEM, MA 01970 Undersec ketxry
Massachusetts Department of Public Safety
®'r Board of Building Regulations and Standards
License: CSSL-102293 C
Construction Supervisor Specialty
RICHARD LAMBY _
3 OCEAN AVENUE
SALEM MA 01970 '4 f
( ..tin Expiration:
Commissioner 05/03/2019
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.govldia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/OrganizationNa�me1l
:
Address: 3 () C(- hl e� q c
City/State/Zip: SfiLAu-n HA- Phone#:
Are y u an employer?Check t e appropriate box: Business Type(required):
l. I am a employer with employees(full and/ 5. ❑Retail
orpart-time).* 6. ❑Restaurant/Bar/EatingEstablishment
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] S. ❑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 ]0.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.E] We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.jqOther 2 Kv
*Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy informs ion.
**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#I.
ant an employer that is providing workers'c mpensation insurance for my employees. Below is the policy information.
Insurance Company Name:_`tp-I1;yC12V ,/
Insurer's Address: Jr / p'l��C SV
City/State/Zip: �(aLf7 U/i Mp�6
Policy#or Self-ins.Lic. Expiration Date:
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 nature?
Date: O
Phone#: ry '�—/- W/
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
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NMSSAFE
Fax# 617-727-7749
www.mass.gov/dia
Fonn Revised 02-23-15
2016/06/1311 :27:02 2 /2
/ ' ® DATE(MMIDOIYYYY)
ac�oiza CERTIFICATE OF LIABILITY INSURANCE
06/13/2016
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 NOT CONSTITUTE A 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 endomement(s).
PRODUCER CONCNAIME T Barbara Amankwah
EASTERN INSURANCE GROUP LLC Ac N Ext: 781)261-2113 nc Na:
wDDRESS: bamankwah@easteminsurance.com
233 WEST CENTRAL ST. INSURER SI AFFORDING COVERAGE NAIC R
NATICK MA 01760 INSURERA: TRAVELERS INDEMNITY CO OF AMERICA 25666
INSURED INSURERS
MASS WEATHERIZATION INC INSURER C:
INSURER D:
3 OCEAN AVE INSURER E:
SALEM MA 01970 INSURERF:
COVERAGES CERTIFICATE NUMBER: 60727 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.
INSR TYPE OF INSURANCE NSD
DL SUER POLICYNUMBER M��IYYYY MWDDNYYY LIMITS
LICY EFF POLICY EXP
LTR IDDL WVD
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE 10 RET
CLAIMS-MADE El OCCUR PREMISES Ea n.uF-..Dente $
MED EXP(Any one person) $
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY F-1 JE T O LOC PRODUCTS AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea.cadent
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED N/A BODILY INJURY(Per acddenp $
AUTOS ADTOTOS
HIREDAUTOS NAUON-OWNEDS PPROPPERdTY DAMAGE $
$
UMBRELLADAB OCCUR - EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $
ROTDEO RETENTION$ $
WORKERS COMPENSATION
ANDEMPLOYERS'LIABILITY X STATUTE .ERS
YIN
ANYPROPRIEfOR✓PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 500,000
A OFFICEWMEMBERD(CLUDEDl N/A N/A N/A 6HUB51344938A15 09/03/2015 09/03/2016
(Mandatary In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
N/A
DESCRIPTION OF OPERATIONS I LDCATIONS/VEHICLES (ACORD 101,Addition.[Remerks Schedule,may b.attached if more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this Cerfificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.govAwd/workers-compensafionfinvestgations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Town of Newton ACCORDANCE WITH THE POLICY PROVISIONS.
1000 Commonwealth Ave
AUTHORIZED REPRESENTATIVE
Newton MA 02459 " �
DanieLM.CrDtiv,Pey,CPCU,Vice President—Residual Market—WCRIBMA
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
ChYOFSALEA MAS"S'ACIMl
BlnoN,wy�a�
Fax
uoA.�iwsaar.3-
I>st�7S9995.
SD�1BY 1 74P.04
�� 7lrofAtS'LYaentN
DmmcwnQ'PUmxrr/Btvxmaawwmm
Construction Debrjs Disposo►/Af WfvW
(required for~all demolition andrenovation workf
in aoowdww with the sbM editors of the State&"W Code, 780 OUX Sec W ULS DeM
and the POWskm of MGL o10,S54;8kdAft Permitil is iswed wide the
conftVn df the debris resW ft from this Work SINN be diWOnd of in a properly&emd
waste depwN bcftyas defined by MGL c lily S]SM
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
�U na(pSd CY'
(name of facility)
_ C�.I�G✓css S S`��
(address of fadity)
Signature f applicant
� Ih
ate
Work Order
North Shore Community Action Programs,Inc. Job Number: Wilson
119 Rear Poster Street,Building 13 Work Order Date: 9/14/2016
Peabody, MA 01960 Ownership: Owner
Phone: 978-531.-0767
Mass Weatherization Auditor: Marc Lorah
3 Ocean Avenue Email: mlorahQnscap.org
Salem MA 01970 Cell: 978-587-5104
Email: rnasswxCDcomcast.net Phone: 978-531-0767 x777
Phone: 978-741-3471
Dionne Wilson-Ineligible NGRID Electric $4,425.75
35 Park St Apt 2 Total $4,425.75
Salem Ma 01970-4927
978.626-2273
Landlord Name: Oscar Mario
Landlord Phone: 978-744-4689
Safety Issue(s): Lead Paint Possible
Authorized Actual
Measure Description Comments
Qty Price � Total Qty Total
Attic Insulation
R-49 unrestricted- settled cellulose 1100 $1.89 $2,079.00 1 1100 1$2,079.00
Mise Measures
Attic/basement blower door guided 1.5 $88.20 $132.30 1.5 $132.30
sealing with two-part foam
Weatherstrip(Q-lou or equal) & l $70.35 $70.35 1 $70.35 j
R=code,attic hatch
Wall Insulation
Wood clapboard/shakes/shings or 1021 $2.10 $2,144.10 1021 $2,144. 0
vinyl (dense pack) ,
Total $4,425.75 $4,425.75
Date: 9/14/2016 Page l