38 STATION RD - BUILDING INSPECTION cl< 1-7 5
The Commonwealth of Massachusetts R CEIMY OF
Board of Building Regulations and Standards INS PECTi Orbs",ISU&1ihICES
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demon" VOI P 12: 2 1
�q One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A lied:
�/► '�"b // /9 /
p Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
(\ 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 1 ' ) S1VK%oto 'DP*
1 I.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:
J(Ef f _AAA W6-4( SltL�Uvl ARR O lgl D
Name(Print) City,State, IP
�K Soy �V 918-X15-001 IC+1/kNNFIJCaiclvud .com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other 0 Specify: 111 S Lk jlLl�{1
Brief Description of Proposed Work : I I
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 $ s
❑Total Project Cost (item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
1 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 1 t��q•1 ❑Paid in Full ❑ Outstanding Balance Due:
cna t L�� VD ln�)vo 111 Z3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS-aamAq 3 r�
gt<ao26f. WA-r.ri-MpQ"- License Number E pira on Date
Nanie of CSL Holder
14 Street List CSL Type(see below) V
No.and Street Type Description
swPseo� � 1 O l U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted l&2 Family Dwelling
City/To",State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
dd /- SF Solid Fuel Burning Appliances
7Dl'4z S AGd►'A�(Zsvj,vbnrwer??ak .eAA I Insulation
Tele hone Email address D Demolition
X�5••.2 Registered Home Improvement Contractor(HIC) 1 -775S9
fZ
NV1tDAJM4�Mi 3-_ otmAa .-r �JL HIC Registration Number Expvaf nDate
HIC Company Name or BIC Registrant Name
�� R4uwttnilalont Sr �Pr� • gOS7oN (!�q,�,i!•Co-tt
No.and Street Email add s
4 . �ssmv, Iill4 15m2 . 1R3-gl7o
Ci /Town, S ate,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 F-
to act on my behalf, afters relative to work authorized by this building permit application.
Pr' O er's a ctronic 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.
h I )I Als
PruftlOwneM or Authorized Agent's Name(Electronic Signature) Date
NOTES:
L 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.Qov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
,\ The Corrrnroniveafth ofNlassachitsetts
Department of Industrial Accidents•
Office of Investigations
600 Washington Street
Boston, MA 02111
^5==" iviviRlnass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual):
Address: (2t)r) 'i-m[ go-2`- ]
City/State/Zip: �� Phone #: r,5�—ZGr —X71�C�
Are you an employer?Check the appropriate box: Type of project(required):
CR I am a employer with_� 4. ❑ i am a general contractor and l
have hired the sub-contractors G. E]New constructionemployees(full and/or part-time).*
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling-
ship
emodelingship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers`
[No workers' comp. insurance comp.insurance.+ 9• ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.[:] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13-tFZbOther L
employees. [No workers' ,u � (;{/�G�7I
comp. insurance required.]
Any applicant that checks box"I must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name orate sub-contractors and slate whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I aln an employer that is providing workers'compensation insurance fol'Ilty enlp/gvees. Below is the policy andjob site
infornmtion. J
insurance Company Name: (I�p�'}4 ah� Che, �✓ f/1fUYG
Policy#or Self-ins.Lic.#: b'b16,V/Jit Abol Expiration Date:
Job Site Address: SS S-rpmo m ?WIN) City/State/Zip: Sytam d 44
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.
1 do hereki'certify turd r tl e p his and penalties of perjury that the information provided above is trite and correct.
S_iynature: Date: 1111,6S
Phone'k qZ 4 f
Official use only. Do not write is this area,to he completed by city or tolvll official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6.011ier
Contact Person: Phone#:
WORKERS' COMPENSATION AND EMPLOYERSLIABILITY INSURANCE PIC
OLY"'
Information IiVC o0 ooa,01
Atlantic Charter Insurance Company VDAC
NCCI Co.No.:29211 Policy Number: WCV01124501
1. INSURED: Prior Policy Number: WCV01124500
Environmental Abatement, Inc.
Producer.
1200 Bennington Street DeSanctis Insurance Agency,
East Boston,MA 02128 Federal ID Number:275382735 Inc.
Risk ID Number: 100 Unicorn Park Drive
Woburn, MA 01801
Business Type: Corporation SIC 9999 NONCLASSIFIABLE ESTABLISHMENTS
Other Named Insured: Other Work Places:
2. POLICY PERIOD: The Policy Period Is From: 12/19/2014 To 12/19/2015 12:01 A.M.Standard Time
at The Insured Mailing Address
3. COVERAGES:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states liste
here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.The limits of our
liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insured:Part Three of the policy applies to the states,if any,listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
D. This policy includes these endorsements and schedules:
See WCE105
4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates&
Rating Plans.All information required below is subject to verification and change by audit.
Code Premium Basis Total Rate Per Estimated
Classifications No Estimated Annual $100 of Annual
Remuneration Remuneration Premium
See WC 00 00 01
Minimum Premium: Deposit Premium:
$550 $6,721
Interim Adjustment: Annually
Servicing Office: Total Estimated Premium $8,351
25 New Chardon Street Surcharge(s) 458
Boston, MA 02114.4721
i Total Premium and Surcharge(s) $8,809
Issue Date 12/16/2014 Countersigned By:_
Copyright 1987 National Council on Compensation Insurance ( Form:100mv
C77 QP
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 177555
Type: Corporation
Expiration: 1/2/2016 Tr# 247600
ENVIROMENTAL ABATEMENT, INC:. '-
GEORGE WATTENDORF III
1200 BENNINGTON ST .
EAST BOSTON, MA 02128
' Update Address and return card.Mark reason for change.
SCA t c 20M-05r11 Address Ej Renewal E] Employment Lost Card
V/L6 1(.�6AlJ)t0)[[UCIII��0�V'OL!!JJllC�fIJPI� -
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
NOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistr, on. 177555 Type: Office of Consumer Affairs and Business Regulation
xpiration: 112(2016,. Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
ENVIROMENTALABATEMENT;INC. -
GEORGE WATTENDQRFlilf
1200.13ENNINGTONSTJ-
EAST BOSTON,MA 02 '
_ 128Undersecretary Not valid without signature
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
I
Construction Supervisor
License: CS-090209
GEORGE V WATYENDOREL ' a
14 Millett Lane. a
Swampscott MA 01907y�I
Expiration j
03/16/2016
Commissioner
GCONTRACT FOR
Conner atlon PRODUCTS / SERVICE WORK
Services Group This service is brought to you through support from your local utility
C Thls Agreement vs made by and among, _ ,~ .�� +L 1 �
a and
i - Jeft Chafuled { ' a, L ' -.d e r1 .
( 138 StauOn Rd Conservation Services Group(CSG)
`" Salem MA„01970.446b ., + d ` s Atm RCS, ,
ice- 1.. s 6 d syr k + � 60 Washington Street;Suite 3000, ,
y,� ,:' ,Site tD'500050094207 + ,�,+ a , � _ �>Westboroilgh iYlA 01681 ,�
,,.r t 1 q l` t-• i a ,?�r '"„ ,, . Reg No ;175484 i w ;: + s,
r d ' Cusiomef lD C000500949L5•` "� i yi , d q - „A 4 1 4
• 1 � Ctmtrect ID 20150921, WORK�`n+�-Ige y s� + ` : r s i '"�'S ti^'4 zMn't completed contrnet�{o eddresn'above) '.:
f �q � 6 L � '1. I'r Y } b .•P 4 A I l.Yi 1 0 ! J'f S�l
dV ..�_..� _.. a� .>.i•.IhJS,I �_.-..y 1__Ln..La .1�:•W♦ :4i'r a....+it_L»l!- vS.:.+-li... +.h E:�-F.„I.V J.fd.��_."✓vu�T . ...ac Pi��ka..-u-.�u.l u....-.ftr:V_���t'„�„
I. DESCRIPTIONOFWORK TO BE PERFORMED
Contractor will perform or cause in be perrormed the following work on these'Premises”in a professional reenter and in Wou deem with the terms of
this Contract,including the attached recommendada>_v/work order describing the work in detail(die'Work")whirl,are Incorporated herein by reference:
Description Quantity Location
Attic Fkior Open Bl—Cellulose 5_ 816 Living Space $1,142.40
52 Attic 5199_16_
Damming _-22_—�N/A 548.18
Sub Total: 51,389.74
Utility Incentive Share 51.042.30
Customer Contribution $347.44
Q
a
For office use only Printed:9121/2015 Page 2 of 2
If. PAYMENT � �C�' �/�
Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payniout gl:$�LcJ as a Deposit
payable to CSG upon stetting the Contract(not W exceed W of the total retell costa).Mail check&mntrxet W ISG,Attn:lttCS,50 Washington St-,Ste.
3000,Westborough,MA 01581.Final Payerenh"ail—"! as the final pgynrenl for the Work shall be payable to the Independent Itatxllation
Convector("UC")upon satisfactory_ aura Ictfon of the Work Cementer mdersumds that he/she will not be required to pyy the Utility Incentive Shore of the
Cmdmct price in the amount of E V �Changes to individual line hems midlor previous Incentives may mereose or decrease the size of die Utility incentive'
Stare.
111.DISPUTE RESOLUTION
71te IICand Osbnt hembyn"rui..Wnpmhi avancedothtthe essttlhM dm 0ChmadisputeconcerningtldsCunmrp,the IICat"adumtsuch dLsputemapriv embliralion
seMte whkh hm bmn oMmwd by thoOMm of Corton AfNm oM Mennen Regula ion rd QWanershall be m indred to submb.to such arbbn lm,as provided in M.GL c 142A
You may cancel this a Bement if it has been signed by a parry at a place other than an address of the seller, provided
you notify i e selljeq Iriting by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
usiness di foil I he signing of.this agree em. DO OT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Custp re ) _ �a0e I J Inth'c�a� �u 'i'ccted UC here,Uappl'cable (OR) bridal hereIryou want
r'u�,7elk� '� Participating Cothe program to ntra for
gna a Date ( Nmne of CSG Representative(Printed)
TERMS AND CONDITIONS APPEAR ON TRE REVERSE. 3614
J
RCS PLANVIEW DIAGRAM
Customer:_Teff Channen Home Phone: ( )-
Address: 38 Station Rd. Work Phone:
Town. Salem Cell Phone: (Any limitations for access by large truck? No X Yes If yes,describe:
Any specific directions or landmarks? No X Yes If yes,describe:
Site ID: 50094207 ', Energy Specialist: Seaman 303 Reviewed by:
A/S- Air seal for 8 hours and 3 door kits and sweeps
(1) Attic floor 6"CIBCell @ 816 SF
(2)Attic Stair Cover- lx
(3) Propavents- 52x
(4) Damming - 22'
34'
CSV (3)
BF (4)
(1) 5
(2) 3' (4)
CRV
26' 24'
(1)
CSV (3)
0 0 2' ASL ASL ASL
0
For Orrice use Only 34'
Bushes Ladder Neighbor Proximity Pocket Doors Insert Radiators Fence(s)
Existing Conditions X=Access ❑=Vents Note Inside Square R- Roof S=Soffit G =Gable
RV= Ridge Vent CS=Continuous Soffit COE-Continuous Drip Edge T=Triangle
Install O=New Access Note in Circle C=Ceiling W=Wall S= Sheathing Temp Unless Noted Otherwise
=Vents Note in Triangle R=8'Roof S=Soffit G=Gable M-12' Mushroom For Access
Rev 1/14