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26 WEST AVE - BUILDING INSPECTION ZZs c5- t+ s2-S � The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR SALEM 77� W t �sea� Ll Building Permit Application To Construct,Repair, Renovate Or Demolish a 1' 20 One-or Two-Family Dwelling I This Section For Official Use Only Building Permit Number: Date Applied: I (f( i Building Official(Print Name) Signature Date .1� SECTION 1:SITE INFORMATION ` 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 26 WEST AVENUE SALEM MA L la Is this an accepted street?yes no Map Number — Parcel Number — 1.3 Zoning Information: 1.4 Property Dimensions: i I iZoning District Proposed Use Lot Area(sq ft) Frontage(ft) L1.5 Building Setbacks(ft) Front Yard j Side Yards Rear Yard Required ; Provided Required Provided Required Provided i 6 ater Supply:(M.G.L c 40,§54) 11.7 Flood Zone Information: 1.8 Sewage Disposal System: � Zone: Outside Flood Zone? Public IJ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: KARYN REARDON SALEM MA 01970 Name(Print) City,State,ZIP j 26 WEST AVENUE 508-527-0209 KARYNREARDON(a_HOTMAIL.COM No.and Street Telephone Email Address i SECTION 3:DESCRIPTION OF PROPOSED WORIe (check all that apply) New Construction❑ Existing Building❑ ; Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ j Demolition ❑ Accessory Bldg.❑ Number of Units Other M Specify: WEATHERIZATION Brief Description of Proposed Work': ADD CELLULOSE INSULATION FROM THE EXTERIOR TO THE WALLS PER THE RECOMMENDATIONS FROM THE MASS SAVE UTILITY PROGRAM SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 2,121.43 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee❑Total Project Cost'(Item 6)x multiplier x 3 Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: coi 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 2,121.43 ❑Paid in Full ❑ Outstanding Balance Due: I , I0111j MAtltEn i SECTION 5: CONSTRUCTION SERVICES i 5.1 Construction Supervisor License(CSL) j CSSL-102168 11/10/16 MICHAEL S. CARBONNEAU LicenseNumberExpiration Date Name of CSL Holder List CSL Type(see below) 21 LENNY LANE No.and Street Type Description U _Unrestricted(Buildin sup to 35,000 cu.ft.) HUDSON NH 03051 I R Restricted 1&2 Family Dwelling City/Town,State,ZIP RC Roofing Coverin ! WS Window and Siding SF Solid Fuel Buming Appliances 603-598-3491 SERVICE@CARBONNEAUINSULATION.COM I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 162729 04/06/17 CARBONNEAU INSULATION LLC HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 21 LENNY LANE SERVICE@CARBONNEAUINSULATION.COM No.and Street Email address HUDSON NH 03051 603-598-3491 Ci /Town, State,ZIP I 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 I this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......:.. U No ...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. i SEE ATTACHED Print Owner's Name(Electronic Signature) Date F SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION I By entering tuNnarne be w,I e eby4estirindrthe painsand penalties of perjury that ail of the information cont",,rA lica n is a ao the best of my knowledge and understanding. � Print Owneruthorized 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.eov/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: iTotal 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 j Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. Project Square Footage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): CARBONNEAU INSULATION LLC Address:21 LENNY LANE City/State/Zip:HUDSON NH 03051 Phone #:603-598-3491 Are you an employer? Check the a propriate box: 1.[ /�I am a employer with / 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship 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 doingall work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no 12.[:] Roof repairs employees. [No workers' 13.0 OtherWEATHERIZATION comp. insurance required.] *My applicant that checks box#1 must also fill 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 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 that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:RIVERPORT INSURANCE COMPANY Policy#or Self-ins. L//i--c. #,:/WC-28-833--007604-00 Expiration Date:66//33/2017 Job Site Address:�CR W � (/1(/el'(,f.{Q- City/State/Zip:_t�( �_/Yt � 1970 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 viola r. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the for insuranc Le±e verification. I do herebylmtr epins a pen 'es ofperjury that the information provided above is true and correct m Siature: Date: C?Id 7//(P Phone#: & Q 5-6%O //�� qq_)??V9l 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#: CARBINS-01 SSIMOES CERTIFICATE OF LIABILITY INSURANCEs/s/2o1s E HOLDER.THIS DATE(MMMDNYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTSUPONTHE CERTIFICAT CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED E BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUR D BY THE POLICIES AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)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 endorsement(s). PRODUCER AAADR TACT Commercial Lines E: Ap letree Insurance Agency NE 33 Indian Rock Rd.,Bldg 5,Ste.3 o E 603)881-9900 FAX Na: (603 594-9840 Windham,NH 03087 L ESS: INSURE S AFFORDING COVERAGE NAICI RERA:MarkelAmericanInsuranceCc 38970 INSURED RER B:Safe Insurance Com an 33618 Carbonneau Insulation LLCRER C:RIVerport Insurance Co 36684 21 Lanny Lane RER D: Hudson,NH 03061 RER 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 RESPECTTO 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 KM LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/pC FF MPOOLIC EXP WOD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE EACH OCCURRENCE $ 1,000,000 OCCUR 3C41687 06/09/2016 06/09/2017 PREMISES Eeoccunance $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL a ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑ PRO- � LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: 8 AUTOMOBILE LIABILITY COMBINED ANGLE LIMIT Ea a $ 1,000,000 B accident) ANY AUTO 6229579 06/09/2016 06/09/2017 BODILY INJURY(Per parson) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED HIRED AUTOS X AUTOS P PE D E $ Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS W16 CLAIMS-MADE MKLVIEUL100043 06/09/2016 06/09/2017 AGGREGATE It DED RETENTION$ WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY PER ERH C ANY PROPRIETORIPARTNER/EXECUTIVE YIN WC-28-83.007604-00 06/03/2016 06/03/2017 E. EACHACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) Ifyes,tlescdbe under E.L.DISEMSE-EA EMPLOYE $ 500,000 DE SCRIPTIONOFOPERATIONSbebw E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If mora apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 41 Massachusetts-Department of Public Safety Board of Buifding Regulations and Standards C'iart*IFuCtivn supe cisair }'keciu385 License: CSSL-102168 S { P4 Pyo♦1@g HRA S C U 3,SON NH 4305I t J N {, 071Z.- ..ar<i „f i, iii kci? Expiratturl COrrtrrtisfiner 1119 06 ��.�4 �pLTNaJY[P}PF�F'Fd{IJ}f�5'^lI .)]eif`PT IFHCF,!^t <}fiace ut C.ausumcr Allain aavincws Rcgta3asisrn License or registration valid for individul use only 44k1E IMPROVEMENT CONTRACTOR before the expiration date. If found return to: r,„ (Registration: 162729 Type: Office of Consumer Affairs and Business Regulation „ E.xpiratiom 41WO17 LLP t6 Park Plaza-Suite 5179 .r.� Boston,NIA illt}fi CARBONNEAU INSULATION,LLC. g� a MICHAEL CARBONNEAU p 2 LENNY LANE. ,..i e,......, _. q iii "A 114 _ HUDSON,M03051 tioderseeretary ., Not valid without signature },k^a'estri+tTed fludd€ngs ofan%,use.grunp%%fast:}t Massachusetts »Department of Public Safely COWAin }hart?5.flw Lutoc cert �49Ena$ f f Board of Building Regulations and Standards 090d Spa Ce Couitruetlun 'y`Ipvnicof L€cantse: CS•097814 wpt€, 1t eb .�' t- il R - C NK _ g rp A C . 8 i° f.. l.671{}O®1deTF3 ;; n fipa tx76k5#5's aYu-'�'4tat e£€.;'78 ZF4 toad h'*AVSACstb�t#m o Stern Me016r4 Code Ws vain 0'M,tart y ,` `k EXp3{a4$t(}3't err Mxtsama*wtwt=waasrnaaxaa v:o+ r,e,^�uxxn.&artL3rti K" 0111 mil CorMusxlarrrr CONTRACTOR CLE AI eSU It 50 Washington St.Suite 3000 Printed: 7/14/2016 Westborough,MA 01581 Work Order Id: S66840P76737C243 Contractor,Information CustomerlSite Data Carbonneau Insulation Karyn Reardon Email:KARYNREADON@HOTMAIL.COM 21 Lenny Lane 26 West Ave Phone (Eve): 508.527-0209 Phone(Day): 508.5 Hudson, NH 03051 Salem, MA 01970-5454 Site ID: 50005006684006684 0 I otal Installed Location Description Quantity Unit$ Total $ Blower Door Test Only 1 $65.70 $65.70 Living Space Insulate Vinyl Sided Wall With 4" Dense Pack 853 $2.41 $2,055.73 Installed Measures Total $2,121.43 %W5p* &J--ia-R6ad Blocks, ,1,a:.'" 1..R :�. t'� .'. i"; Type Status Notes Knob & Tube Wiring FIXED 06/08 Rcvd eval-no invoice will be applied, all K&T cleared. Lic# confirmed. '4e"'.a. %' zs - k,0£#'kz5 �'A •.�. a y -0..+a x. ,ie: � ardge ., �:E4 ,'T." 4 ti:: Incentive Payments Weatherization Incentive $1,591.07 Total Incentive Payments $1,591.07 Customer Share Total Customer Share $530.36 Less Deposit Of $176.78 Customer Share Balance (Due Contractor) $353.58 For questions regarding assigned work: Contractorinbox@CLEAResult.com. For questions while performing work: 855-821-2205. +�yt�rai Permit Authorization mass R. save Form PAYI4�G Site ID: 500050066840 Customer: KARYN REARDON i KARYN REARDON owner of the property located at: (Owr=er's Name,priuted) 26 West Ave SALEM (Property Street Address]_..._~ (City) .._.._.__.----- - _-.__...____.--- - .______-.._.___._ —-------- —_..--_..._________.-..—. -__._.. .tract._.......__ - - heheby 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. l Owner's Signature: .. Date: I FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: r7 I Participating Contractor Dafe C�"�® CLEAResult ® 50 Washington Street,Suite 3006 • Westborough,MA 01581 • 1840-980-7972 Fier Office Use only Rev, 102015