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B-20-779 - 0053 BELLEVIEW AVENUE - Building Permit The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY M Mar Massachusetts State Building Code,780 CMR SA Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling Thts Section For OffictalUse Only Building Perrmt;Number Date Applied Budding Official(Print Name) Signature Date SECTION 1 SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 63 1-E'V re%A/ A JE 1.1 a Is this an accepted street?yes o/ 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 OWNERSffiP1` 2.1 Owner'of Record: L Mal E S-r. ®Al is 4F��- ram) 01970 Name t) City,State,ZIP e'"tG4sT No.and Street Telephone Email Address .SECTION 3 DESCRIPTION'OF PROPOSED WORKZ(check all that apply) - New Construction❑ Existing Building fit Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Af Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: "6 R "JA LDS . l AJ5 v L A / 6 2 W S. A 77- fit-^r— /aJ ST^t_1_ P n p,F c_/_EtiJ j f1�R SECTION 4 ESTIMATED CONSTRUCTION COSTS_ Estimated Costs: Item Official Use Only Labor and Materials 1.Building $ 1 Building Permtt Fee $ Indtca.a how fee ts:determined 2.Electrical $ ❑Stat dard C ty/To M Apphcahon Fee ❑,Total Protect Cost(Item 6)x multiplier x 3.Plumbing 4.Mechanical (HVAC) $ 5.Mechanical (Fire $ Suppression) Total All Fees:$ �� CheckNa Check Amount Cash Amount 6.Total Project Cost: $ g J`g ❑paid in Full:, ❑,Outstanding Balance JUL 29 AM82 JUL - _ ;SECTION 5 ,CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) d 4 1 C H rt-1 License Number Expiration Date Name of CSL Holder Sr_ List CSL Type(see below) No.and Street T. Descnphon Unrestricted(Buildings up to 35,000 cu.ft. �S 4 o OCR S—f E-1Z AAA <D 1 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Sidin Gj.j g GKA r G SF Solid Fuel Burning Appliances 4,/-I A 5 2,2-7 ��9`�c�a1S 3°�a�v./ET'@ .CDC I I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 14AM G� L Lc � L©� � �13 �� HIC Registration Number Expiratt ion Date HIC Compan Name or HIC Registrant Name q 71� c<P t 1 s� s��t e as 370, AJe-r& No.and Street q T B Email address C1—oJGer7�� y�3 �7�� 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.......... No...........❑ : SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR'APPLIES"FOR BUIIDING,PERMIT , , s 1,as Owner of the subject property,hereby authorize IM K-EI q-o, / S'A 4-4--a.d 1H V-M 'g apt to act on my behalf,in all matters relative to work authorized by this building permit application. ��v n S'7' aaJ c-,E J� Print Owner's Name(Electronic Signature) Date SECTION,7b OWNERr„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. Print Owner's or Authorized Agent's Name(Electronic 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 fimd under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.g_ov/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 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" r The Commonwealth of Massachusetts Department of IndustridAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectriciandPlumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant.hdormation Please Print Leeibly` _.... _ - Name(Business/Organization/Individual): t-f►—M � Address: City/StatelZip:6�� . n� _ Phone# Are you an employer?Check the appropriate box: Type of project(required): 1. lama employer with 7. ❑New construction 2. 1 am a sole proprietor or perpte tship and have no employes working for mein 8. Remodeling any capacity.(No workers camp.insurance required.) 9. ❑Demolition 3.Q I am a homeowner doing all work myself(No workers'comp.bwrance required.]t 4.❑1 am a homeowner and will be hiring contractors to conduct all work on try property. (will 10 0 Building addition ensure that all contractors either have workers'compensation umusnoe or are sole I L[]Electrical repairs or additions proprietors with no emVloyees. 12.Q Plumbing repairs or additions 5.01 am a general contractor and I have hired the subvoatractom listed on the attached sheet. 'these subcontractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.D We area corporation and its oflicas have exercised they right ofexemption per MGL c. 14. Other . -rFt&.-cA 152. 1(4),and we have no employees.(No workers'comp.insurance required.] ......... *Any aWicmt that chocks boz p h must also fin dim t he section b"%-showing their wortters'compensation policy infon ation. +Homeowners who submit tiffs affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the n&contcactors and state whether or not those entities have _.employees. If due sub-contractors have employers,they must provide their workers'comp.policy number. I am anedpoyer that isprovVog workers,com pensaAon insurance for my employees Below is the policy and job site informadom Insurance Company Name: r!. /13E0z-24 Al Q`f(,� ems(L Policy#or Self-ins Lic.#: _ sg 1 y.d__ cal 9...(o_.'/ Expiration Date:- t t.. Job Site Address: 3 t-t=t t pL,J ArQ t= _ City/StateMp "I' � 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 S250.00 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 tiereby cer rfy under tkepains and penalk'es ofperjury that the itaformadon provided above is irue and correct Siirk re: . __ _.. Date:- �02� a Phone.#: offWal use only. Do not write in this area,to be completed by city or town oftWal { City or Town:. Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#:. _ -- DATE(MM/D A`CORv�® CERTIFICATE OF LIABILITY INSURANCE 07m/2020 D/YYYY) 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 WANED,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 endorseme s. PRODUCERCONTACT- ColletteTardiff Tarpsy Insuranw Group,Inc. NAME: 442 Waiter Street PH�NE 781-246 2677 (A1/C,No):781-2240973 Walefield,MA 01880 ADDRESS: Cdiette@tarpeyinsLaanCe COm INSURER(S)AFFORDING COVERAGE NAIL N INSURER A: Phoenix Insurance Co 25623 INSURED HRM Group LLC,The INSURER 8: Travelers IrldernrityCo of IL 25674 4 Haskell Street _ U Muhral Ins Co A0256 Gloucester,MA01930 INSIRHtc by 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 INURED 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, EXCLUSION AND CONDITION OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1LT R TYPE OF INSURANCE ADS Sly POLICY NUMBER MMIDD/YYYY MM/DD LICY EXP LIMITS LTR i A V1 coMMERCIALGENERALUABILiY 68050141-643 07/16/2020 C7/16/Y021 EACH OCCURRIRCE $ 1,000,000 GE CLAIMS-MADE F2 OCCUR OPRE�INISES Ea'o:Ncc'urrrrence $ 300'000 MED EXP(Any one person) $ 5,000 PERSONAL S ADV INJURY $ 1,0w,ow GENL AGGREGATE LIMIT APPLES PER: GENERAL AGGREGATE $ 2,000,000 / POLICY ❑, 4 LOC PRODUCTS-COMP/OP AGG $ 2 000.000 OTHER: $ AUTOMOSILEWIBILITY C01=11 SINGLE LIMIT $ Ea accident ANY AUTO BODILY KMY(Per person) $ OWNED SCHEDULED BODILY Wft1RY(Per accident) $ AUTOS ONLY AUTOS HIRED NONOWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ B IUMBRELLALW6 OCCUR CUP344$1`28D 07/162= 07/16/2021 EACH OCCURRENCE $ 1,0,ow EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$5,000 $ C WORKERS COMPENSATION 01408964-01 11/09/2019 11/09/2020 �A7UiE AND EMPLOYERS'LIABILITY ANY PROPRETORIPARrNEWEIECUXNE ❑ N/A EL.EACH ACCIDENT $ 5W,000 OFFICER/MEMBER E)CLUDED? (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 500,000 'Yes' describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe 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 City Of Salem ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA 01970 AUTHORU M REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(201W03) The ACORD name and logo are registered marks of ACORD . CITY OF SALEM, MASSACHUSETTS F - F BUILDING DEPARTMENT 98 WASHINGTON STREET,2ND FLOOR TEL: 978-745-9595 K MERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition & renovation work In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris, and the provisions of MGL c40,S54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 111,S150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: fr<VA-r� Dons (name of facility) $ OJDl�usc�a .t7 ..-:.CT- Z-5&VO CAC-C--1 (address of facility) Signature of applicant (today's date) `� �rri t�[riiviiut-iswtiuir�v � v r cricwuur Oigoe of Consumer Affairs and Business RegukMon One Ashburton PW9-Suite 1301 Boehxt,A pmeeft 0MOS , Moms Improwrnb�tb"acbOr Registradon E3�ptr1 18047� Fil�il Imp WC 0�1194r?.0®D " 4 HASKELL ST G OUCESTER MA 01980 Addl M aid!MWM C" WAt a so*oW oeils�ar cn...�r Nedra e>,ilwd....naNrron How IMpROVENIGR COplpilla R moo OOsUon vad for NaradtMF W6adtr •Me bdM tha dab.d atWd ragrnNW CwMbo d Oorwarir Illlitlra and 4uinas RaprtBorr '?` a7/9oF CMa Plaaa•8nNa tI101 FIFA 0140IFP t k+ 9oabn.IMA Mae MIMIAEL8ALllA 4 HASWELL ST G 1lrlild MINION! GLOUCENIEtFt.MA tIIBAti Commommem of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Coriskfrvisor CS-066671 r Tres:04/0412022 MICFIAEL R$"OM J k-e-''1 7. 4 HASKELL SJREEV GLOUCEST M MA . ♦' ' UISti�I:10N� Commissioner DocuSign Envelope ID:DA377E54-CB72.4358-9376-E76AA4613B10 CLEAResulte CONTRACT sm wastwupon saam customer Name LYME ST ONGE wesiborovsk H,01581 Email:lstonge7@cooncastnet Phone:978428-4501 Premise Address:53 Beffeview Ave,Salem,MA 01970 Mailing Address:53 Belleview Ave,Salem,MA 01970 Project ID:3988745 Date:Feb.20,2020 .lob Description Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference. Measure Description, Location Quantity Unit Total Cost Customer Cost Air Searing at Estimated 62.5 CFM50 Per Hour 8 hr $740.64 $0.00 Door Sweep(with AS hrs) 3 each $75.93 $0.00 Exterior Door Weather Stripping(with AS hrs) 3 each $90.21 $0.00 Door-2"Thermal Barrier Polyiso 1 each $90.44 $22.61 Garage CerTtng-8"Dense Pack Cellulose 312 SF $917.28 $229.32 Overhang-8"Dense Pads Cellulose 68 SF $315.52 $78.88 Walls-Vinyl-4"Dense Pack Cellulose 1090 SF $2,888.50 $722.13 Walls-Buffered Interior-4"Dense Pads Cellulose 207 SF $525.78 $131.44 Attic Floor-14"Open Blow Cellulose 1028 SF $2,241.04 $560.26 Walls-Vinyl-6"Dense Pads Cellulose 96 SF $288.96 $7224 Damming 20 each $47.80 $11.95 Roof Vent-Turbine 1 each $166.06 $41.51 Hatch-2"Thermal Barrier Polyiso 1 each $46.28 $11.57 Rim.foist-2"Thermal Barrier Polyiso 16 SF $76.48 $19.12 Blower Door Test 1 each . $72.75 $18.19 Total: $8,583.67 Program Incentive: -$6,664.45 Customer Total: $1,919.22 Payment Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:$639.00 as a Deposit payable to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CLEAResuft,50 Washington Street,,Westborough,MA,01581.Final Payment:$1,280.22 as the final payment for the Work shall be PLEASE SEE NEXT PAGE Page 1 of 4 DocuSign Envelope ID:DA377E54C872-4358-9376-E76AA4613610 payable to the Home Performance Contractor(HPC)or Independent Installation Contractor(IIC)upon satisfactory completion of the Work Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of $6,664.45.Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. Dispute Resolution The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Contract,the IIC may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be regwiml t3 submit to such aftbrahan as prmmdladl In MLG.IL c 1142A- You may cancel this agreement if it has been signed by a party at a place other than an address of the seller,provided you notify the seller in writing by ordinary mail posted,by telegram sent or by defivery,not later than midnight of the third business day following the signing of this agreemenL DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. UomSfgned by:: 44ftit �- "A Al 2/26/202015:53 PM EST os Custome E,'E432-- Date Indicate your selected IIC here,if applicable Initial ere you want the Program to assign a Participating Contractor Garrett Hodgson 2/20/2020 Garrett Hodgson CLEAResutt Signature Date Name of CLEAResult Representative Page 2 of 4