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B-19-1224 - 0044 BEAVER STREET - Building Permit E CIE 1 0 . The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY M 1 Massachusetts State Building Code,780 CMR Z 19 10V v 1 A 10, Revasedar 2011 Building Permit Application To Construct, Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: 5tku e 65 /-v,0 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 44 Beaver St. Lla Is this an accepted street?yes no Map Number Parcel Number r ' 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) \1 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: Merrill Kohlhofer Salem,MA 01970 Name(Print) City,State,ZIP 44 Beaver St. 978-727-4600 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition , ❑ Accessory Bldg. ❑ Number of Units Other Specify: Solar Brief Description of Proposed Work 2: 5 Sg_ layover SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1,000 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cose(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: $ 1,000 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 88720 4/10/20 Paul Eaton License Number Expiration Date Name of CSL Holder List CSL Type(see below) U 20 Patterson Brook Rd. Unit 1 No.and Street Type Description U Unrestricted(Buildings u to 35,000 cu.ft. W.Wareham, MA 02576 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry noRC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances (508)291-0007 tristan.souza@trinitysolarsystems.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 170355 10/11/19 Paul Eaton/Trinity Heating&Air DBA Trinity Solar HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 20 Patterson Brook Rd. Unit 1 tristan.souza@trinitysolarsystems.com No.and Street Email address W.Wareham, MA 02576 (508)291-0007 City/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 ..........id 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 Paul Eaton to act on my behalf,in all matters relative to work authorized by this building permit application. Please see attached letter. 10/24/19 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. Paul Eaton __ 10/24/19 Print Owner's or Authorize ent'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.gov/dpss 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"maybe substituted for"Total Project Cost" AeCP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/20/2018 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 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 NAME: Mark Grasela Arthur J.Gallagher Risk Management Services, Inc. PHONE FAX 4000 Midlantic Drive Suite 200 AIc No Ext:856-482-99001..,Noy 856-482-1888 Mount Laurel NJ 08054 ADORIESS: CherryHill.BSD.CertM@AJG.com INSURERS AFFORDING COVERAGE NAIC 0 INSURER A:HDI-Global Insurance Company 41343 INSURED TRINHEA-03 INSURERB:Llbe Insurance Underwriters Inc 19917 Trinity Heating&Air, Inc. DBA Trinity Solar 28 Patterson Rd INSURERC:American Guarantee and Liability Ins Co 26247 Wareham, MA 02571 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:411228819 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICYNUMBER MMIDD MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY EGGCR000065618 12/31/2018 12/31/2019 EACH OCCURRENCE $2,000,000 CLAIMS-MADE OCCUR A AG O N D PREMISES Ea occurrence $500,000 MED EXP(Any one person) $0 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PR - POLICY�ECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY EAGCR000065618 12/31/2018 12/31/2019 COMBINED SINGLE LIMIT $2,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ BA UMBRELLALIAB X OCCUR 1000231834-03 12/31/2018 12/31/2019 EACH OCCURRENCE $21,000,000 C X EXCESS LIAB EXAGROD0065618 12/31/2018 12/31/2019 CLAIMS-MADE AEC 1448324-00 12/31/2018 12/31/2019 AGGREGATE $21,000,000 DED RETENTION$ $ A WORKERS COMPENSATION EWGCR000065618 12/31/2018 12/31/2019 PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIEiOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1.000,000 OFFICERIMEMBEREXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I I I E.L.DISEASE-POLICY LIMIT $1,000,000 A Automobile EAGCR000065718 12/31/2018 12/31/2019 All Other Units $1,000/$1,000 Comp/Collusion Oed. Truck-Tractors and Semi-Trailers $5,000/$5,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Evidence of Insurance 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. Evidence of Insurance AUTHORIZED REPRESENTATIVE ('~� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Trinity Heating&Air DBA Trinity Solar Address: 2211 Allenwood Rd. City/State/Zip: Wall,NJ 07719 Phone#: (732)780-3779 Are you an employer?Check the appropriate box: Type of project(required): 1.STI am a employer with 300 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.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑lam a homeowner and will be hiring contractors to conduct all work on my property. twill 10❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole I LgElectrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑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 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: HDI-Global Insurance Company Policy#or Self-ins.Lic.#: EWGCR000065618 Expiration Date: 12/31/19 44 Beaver St. Job Site Address: 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 thepains andpenalties of perjury that the information provided above is true and correct. Signature: Date: 10/24/19 Phone#: (508)291-0 7 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#: Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvementt'Contractor Registration Type: Supplement Card - - ---- Registration: 170355 TRINITY HEATING&AIR,INC. - �` t, I -� Expiration: 10/11/2021 D/B/A TRINITY SOLAR K 4 2211 ALLENWOOD RD WALL,NJ 07719 - scn 1 zon Update Address and Return Card. �, nosn�l7 7.2E- l��G'�riir7rXzrcflLC/f of�/��iLkJrr,C/.ir.:rfll Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:SUvolement Card before the expiration date. If found return to: Registration Empiratiion Office of Consumer Affairs and Business Regulation 170355`4 ' 10/11/2021 1000 Washington Street -Suite 710 _ °- Boston,MA 02118 TRINITY HEATING&-AIPt;tN�i_ D/B/A TRINITY S01-AR h PAUL EATON 20 PATTERSON BR00K ROAD UNIT 10 .�i f�,/ i P12- WEST WAREHAM,MA 02576 Not valid Without signature Undersecretary i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ConstruCtrbri"gupervisor CS 088720 <, E-*pires:04/10/2020 t PAUL A EA74y14 - " 11 ET '7 COMFORT STRE I' BRIDOEWATE MA°'02374r Commissioner C'4 Consbuctlon Supwvisor Unrestvicted-BUNIMI+s of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a currerAedition of the Massachusetts State Building Code is cause for revocation of-this license. For information about this license Call(61Z)727-3200 or visit www:mass.gov/dpl