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50 VALLEY ST - BUILDING INSPECTION7- �2S M The Commonwealth of Massachusetts ,�daj � Board of Building Regulations and Statitfiif. S�17i, ") CITY OF Massachusetts State Building CodeSALEM; 780 CMR 4l Revised Mar 2011 Building Permit Application To Construct;[Repair, R&6v 01 heAigi a I One- or Two-Family Dwelling This Section For Official Use my Building Permit Number: Date App]' d: 17 Building Official(Print Name) Signature Date SECTION l: SITE INFORMATION 1.1 Property Address: 50 Valley St 1.2 Assessors Map& Parcel Numbers I.1 a 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 a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public❑ Private ❑ — Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Yesenia Pena Salem, MA 01970 Name(Print) City, State,ZIP 50 Valley St 978-828-0212 yeseniapena78@comcast.net No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other M Specify: INSULATION Brief Description of Proposed Work': Blown in cellulose to attic, insulate rim joist, air sealing install vent and replace basement door. SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1. Building $ 2,862.56 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑ Total Project Costa(Item 6)x multiplier x 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: $ 2,862.56 ❑ Paid in Full ❑ Outstanding Balance Due: `C�.� (P-d___ k-`fl -/t SECTION 5r CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS'052576 10/03/2017 James Fortin License Number Expiration Dale Name of CSL Holder U 50 Rundlett Way List CSL Typc(see below) No. and Street Type Description Middleton, MA 01949 U Unrestricted(Buildings up to 35,000 cu.R) R Restricted 1&2 Family Dwelling City/rown. State,ZIP M Masonry RC Roofing Coverin WS Window and Siding SF Solid Fuel Burning Appliances 978-998-4684 phiI@air-tightweatherization.com 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 165640 3/15/2018 Air-Tight Weatherization, LLC James Fortin HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 50 Rundlett Way phil@air-tightweatherization.com No.and Street Email address Middleton, MA 01949 978-998-4684 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 .......... CK No ........... 0 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorize James Fortin to act on my behalf, in all matters relative to work authorized by this building permit application. 5 l A Print Owner's Name(Electronic na ure) Date SECTION 7b: OWNEW 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. James Fortin (�""" " 7/27/2016 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. 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.gov/dns 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 Project Square Footage"may be substituted for"Total Project Cost" Work Order North Shore Community Action Programs, Inc. Job Number: 4909 119 Rear Foster Street,Building 13 Work Order Date: 7/22/2016 Peabody, MA 01960 Ownership: Owner Phone: 978-531-0767 Air-Tight Weatherization Auditor: Brandon Dorrington 50 Rundlett Way Email: bdorrington@nscap.org Middleton MA 01949 Cell: 781-540-8569 Email: inbox@air-tightweatherization.com Phone: 978-531-0767 x121 Phone: 978-998-4684 Yesenia Pena NGRID Electric $2,862.56 50 Valley St Total $2,862.56 Salem Ma 01970-1951 978-828-0212 yeseni apen a78@comcast.net Safety Issue(s): Lead Paint Possible Authorized Actual Measure Description Qty Price Total Qty Total Comments Attic Insulation R-30 unrestricted -settled cellulose 374 $1.61 $602.14 374 $602.14 Adjust as needed once accessed...Main flat area R-38 unrestricted -settled cellulose 144 $1.73 $249.12 144 $249.12 Front porch cavity blow TAKE PICS TO GET PAID Attic Ventilation Roof vent 865(A sq It NFV)small 1 $94.50 $94.50 1 $94.50 Add @ front 1st fl. porch roof to access for blow adjust depth as needed Basement Insulation Garage ceiling cavity filled with 144 $2.47 $355.68 144 $355.68 front porch sheetrock overhead floor blow blown cellulose dense pack Sill/mudsill seal & insulate to R-19 15 $2.58 $38.70 15 $38.70 Doors Basement/outside door-w/jambs 1 $515.00 $515.00 1 $515.00 solid core door PRIMED 2 TIMES OPEN TO WEATHER...price includes insulating w/ 1" TMax Fixed Sweep triple flange 1 $18.52 $18.52 1 $18.52 7777i7 or equal 1 $86.10 $86.10 1 $86.10 Date 7/77/?nitF Pave I Work Order: Job Number: 4909 Weatherstrip s/Q-Ion or equal 1 $53.55 $53.55 1 $53.55` Misc Insulation Domestic water pipe wrap 6 $3.10 $18.60 6 $18.60 Mise Measures Attic/basement blower door guided 2 $88.20 $176.40 2 $176.40 scaling with two-part foam Blower door set-up with pre&post 1 $45.00 $45.00 1 $45.00 tests Clothes dryer vent including 1 $105.00 $105.00 1 $105.00 Exhaust Duct Cut/finish attic-kneewall access 1 $123.90 $123.90 1 $123.90 main attic Bat area.....Discuss w/homeowner on exact location Vent kit/bath fan 2 $105.00 $210.00 2 $210.00 basement(if pons)and 2nd B. Permit Building Permit 1 $100.00 $100.00 1 $100.00 Wall Insulation Test drill 4 sides 1 $70.35 $70.35 1 $70.35 scattered voided cell existing...wood shingle Total $2,862.56 $2,862.56 Contractor Instructions: Before Starting the Job: Durinp the Job: 1. Please notify us 24 hours before starting or scheduling a job. 1. This residence was built before 1978. Lead safe practices are 2. Obtain required building permit. required. 2. Total for Heath & Safety and Repairs cannot exceed $2500.00. 3. Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH-347. Date: 7/22/2016 Page 2 Work Order: Job Number: 4909 Yesenia Pena 50 Valley St Salem Ma 01970-1951 978-828-0212 yeseniapena78@comeast.net a E„ Air-Tight Weatherization a�I'r�g/1t 50 Rundlett Way Middleton, MA 01949 978.998.4684 CONTRACTOWNER AUTHORIZATIONFOR CONTRACTOR TO PERFORM WORK I as owner/authorized agent of the subject property, hereby authorize James Fortin to act on my behalf, in all matters relative to work authorized by the building permit. Owner/Authorized Agent(Print): Yesenia Pena Date: Owner/Authorized Agent Signature. 1z5i'? �-5- Contractor Signature: �G""•"'-rd-' �-�"""'� Contractor:James Fortin Construction n�Supervisor License:CS-052576 Exp: 10/03/2017 4 Signature: 1.n Email: yeseniapena78@comcast.net Dnter 7/22/2016 Pape.3 '\ The Commonwealth of Massachusetts Department of lndustrialAccidents I Congress Street, Suite 100 Boston,MA 01114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le¢ibly Name (Business/Organization/Individual):Air-Tight Weatherization, LLC Address:50 Rundlett Way City/State/Zip: Middleton, MA 01949 Phone 4:978-998-4684 Are you an employer?Check the appropriate box: Type of project(required): l.❑✓ Iain a employer with 20 employees(full and/or part-time)* 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑1 am a homeowner doing all work myself. [No workers'comp. insurance required.]t l0 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly. I will ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.�Roof repairs 'These sub-contractors have employees and have workers'comp.insurance. 6.❑We are a corporation and its officers have exercised their right of exemption per MGL C. 14.❑� Other Insulation 152,§1(4),and we have no employees. [No workers'comp,insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. '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 of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer float is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Guard Insurance Companies Policy#or Self-ins. Lic. #:AIWC781370 Expiration Date:7/1/2017 Job Site Address:50 Valley St City/State/Zip: Salem, MA 01970 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 of perjury that the information provided above is true and correct. Sienature: ��'� ^^ .y' Date: 7/27/216 Phone#: 978-998-4684 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. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: A`OR& CERTIFICATE OF LIABII:ITY INSURANCE DATE 6m 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(les)must have ADDITIONAL INSURED provisions or 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 endorsement(s). PRODUCER CONTACT Jacqueline Marie Monies MassPay Insurance Services, LLC NAME, (978)774-4338 x705 F!u (978 774-1318 27 Garden Street, Unit 16 Arc N*: ) Danvers,MA 01923 ADDRESSEZONE : jackie@philrichardinsurance.com INSURER(S) AFFORDING COVERAGE NAG INSURERA: AmGUARD Insurance Company 42390 INSURED Air-Tight Weatherizalion, LLC INSURER 8: 50 Rundlelt Way Middleton,MA 01949 INSURER C INSURER D INSURER E INSURER 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. INSR AODL S BR POLICY EFF POLICY EXP LTR TYPE OF INSURANCEJ=JIM POLICY NUMBER IMMIDDIVY"I IMMIDDYYYYILIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIM&sMDE F] OCCUR DAMAGE TO RMI e RENTED S MED EXP ons person S PERSONAL S ADV INJURY S GENT AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S POLICY PRO- 1-1JECT LOC PRODUCTS-COMPlOP AGG S OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 8 M ANY AUTO 80DILY INJURY(Per pen n) S OWNED F I ASCHEDULED AUTOS ONLY UTOS BODILY INJURY Perpmdenl) 5 HIRED NDN-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY PIXe eri 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE S DED I I RETENTIONS I S A WORKERS COMPENSATION AIWC781370 07/01/2016 07/01/2017 _N&PE1AATJTg ERN AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUfiVEE.L.EACHACCIDENT S 1,000,000 OFFICEWMEMBER EXCLUDED? O N!A IMandatonJ In NH) E.L.DISEASE-FA EMPLOYEE $ 1.000.000 It s,desrnbe er dw t.000.000 DESCRIPTION OF OPERATIONS below ELDISEASE-POLICY LIMB 5 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES IACORD 101,Addlllp0al Remark*Scbedulo,may bo allachWll more*peso 1*mqulred) Proof of Workers Compensation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St 3rd Floor Salem, MA 01970 AUTHORIZED REPRESENTATIVE A ®1988.2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD A�® CERTIFICATE OF LIABILITY INSURANCE DAT3/s/2o,sYYY, 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 pl icy(ies)must have ADDITIONAL INSURED provisions or 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 endorsement(s). PRODUCER TGA Cross Insurance, Inc. CONTACT NAME: TGA Cross Insurance Inc. 401 Edgewater Place, Suite 220 PHONE FAX Wakefield, MA 01880 IAIC,No.E-MAIL ' 781-914-1000 ac No: 781-246-2601 ADDRESS: switchboard@tqacross.com INSURER 5 AFFORDING COVERAGE NAIC k www.tgacross.com INSURERA: Arbella Protection 41360 INSURED INSURER B Air-Tight Weatherization, LLC 50 Rundlett Way INSURER C: Middleton MA 01949 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 28898957 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 ADDLSUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCEIN= POLICY NUMBER MM/DDIYYYY MM/DDIYYYV A `/ COMMERCIAL GENERAL LIABILITY 8500046432 3/5/2016 3/5/2017 EACH OCCURRENCE $ 1,000,000 DAMA ET RENTED 100,000 CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY F JECT L] LOC PRODUCTS-COMP/OP AGO $ 2,000,000 OTHER $ A qOMOBILE LIABILITY 1020015286 3/8/2016 3/8/2017 COMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OME ONLY ✓ SCHEDULED BODILY INJURY(Per accident) $ AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY ✓ AUTOS ONLY Per accitlenl $ B ✓ UMBRELLA LIAB OCCUR 4600052990 3/5/2016 3/5/2017 EACH OCCURRENCE $ 4.000.000 EXCESS LIAB ✓ CLAIMS-MADE AGGREGATE $ 4,000,000 DED ✓I RETENTION$10,000 $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY YIN STATUTE I ER ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED' F-1 N/A (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Lilty of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington Street, 3rd Fir ACCORDANCE WITH THE POLICY PROVISIONS. Salem MA 01970 AUTHORIZED REPRESENTATIVE Thomas I Gregory ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 28898957 1 223720 116-17 GL, AU9b, UMa 1 Sill Denctre 1 3/9/2016 8:32:51 AM (EST) I Page 1 of 1 021bl&4:hadUiOe , Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Conitrktor Registration Registration: 165640 Type: LLC Expiration: 3/15/2018 Tra 419291 AIR TIGHT WEATHERIZATION, LLC=i _ i 1 .LAMES FORTIN 50 RUNDLETT WAY MIDDLETON, MA 01949 Update Address and return card.Mark reason for change. .. - ❑ Address 0 Renewal © Employment © Lost Card SCA 1 0 Whi-0511 Massachusetts Department of Public Safety OMce of Consumer Affairs&Business Regulation Board of Building Regulations and Standards ME IMPROVEMENT CONTRACTOR License: CS-052576 Registration. {1i6w0 Type- Expiration 31752078 LLC Construction Supervisor , { Ldp- AIR TIGHT WEATHERIIZA-TION 1-.LLC JAMES E FORTIN-, R a 50 RUNDLETT WAYls r MIDDLETON MA;01 - JAMES FORTIN _.__,y 50 RUNDLETT WAY MIDDLETON,MA 01949 Uudersecremry '//,�� �` u r—j=K lil..__ Expiration: Commissioner 1010 312 01 7