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B-19-1192 - 0029 BUCHANAN ROAD - Building Permit - y i". t` �. y�yA The Commonwealth of Massachusetts a UN i` .J Board of Building Regulations and Standards S M ' A Massachusetts State Building Code,780 CMR TQ�g OCT LE �.�� Rs AM11011 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: t O r lr-►r9 Zing Official TrintName) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers j 29 Buchanan Rd Salem MA 01970 1.1 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 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: Theresa O'Brien Salem MA 01970 Name(Print) City,State,ZIP 29 Buchanan Rd 201-240-0879 into@abtinsulation.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ .Demolition ❑ Accessory Bldg.❑ Number of Units I Other El Specify:Insulation Brief Description of Proposed Work:1)Air Sealinq 2)Attic blow in cellulose to achieve R-38 3) Blow in dense pack cellulose inside walls SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 10,965.88 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: $ y V 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ ;Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 10,965.88 ❑Paid in Full 0 Outstanding Balance Due: j SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 101378 10/18/2019 Jose A Santos License Number Expiration Date Name of CSL Holder List CSL Type(see below) IJ 37 W MILTON ST No.and Street Type Description HYDE PARK MA 02136 U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling ,City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances (781)598-7125 jobs@abtinsulation.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 163106 05/10/2021 American Building Technologies HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 2 Neptune Rd,Suite 439 jobs@abtinsulation.com No.and Street Email address Boston,MA 02128 (781)598-7125 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 ..........13 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 JOSE A SANTOS to act on my behalf,in all matters relative to work authorized by this building permit application. a � 10/7/19 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. Jose A Santos 10/7/19 (Print Owner's or Authorized Agent's Name(Electronic gna e) I 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.goov/d/djs 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" 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(business/Organization/Individual): American Building Technologies Inc- Jose Santos Address: 2 Neptune Rd. Ste 439 City/State/Zip: Boston MA 02128 Phone#:(617) 233-8704/ (781) 598-7125 Are you an,employer?Check the appropriate box: Type of project(required): 1.® I am a,employer with 5 _ 4. ❑ 1 am a general contractor and 1 6. ❑ New construction "employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a,sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp.insurance, 9. ❑ Building addition [No workers'comp, insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am aihorrieowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12. ] Roof repairs insurance required.]t employees. [No workers' 13XI Other Insulation comp. insurance required.] 'Any applicant that checks box H1 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 of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ACE AMERICAN INSURANCE CO Policy#or Self--ins. Lic.#: 6S62UB2E91844519 Expiration Date: 10/20/2020 Job Site Address: 29 Buchanan Rd 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 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 10/7/2019 Phone#: (61'7) 233-8704/ (781) 598-7125 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitfLicense# 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#: ACo 10/1 B/2o 1 CERTIFICATE OF LIABILITY INSURANCE °ATE'MM/ ' 019 s 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 Commercial Lines NAME: Ambrose Insurance Agency,Inc. PHONE FAX JAIC No Ezt: (A/C,No: 963 Eastern Ave E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Malden MA 02148 INSURERA: Atlantic Casualty Ins Co. INSURED INSURER B: Starstone National Insurance Co American Building Technologies,Inc.,DBA:ABT Insulation INSURER C: 263 Western Ave. INSURER D: INSURER E: Lynn MA 01902 INSURER F: COVERAGES CERTIFICATE NUMBER: CL19101829274 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 ADUL151JUKI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE O RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ MED EXP(Any one person) $ 5,000 A L035014011-2 10/17/2019 10/17/2020 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY CO Ea aMBINEDccidentS INGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 B X EXCESS LIAB CLAIMS-MADE 8331OH196ALI 10/17/2019 10/17/2020 AGGREGATE $ 1,000,000 DED I X RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE ERH ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NSCAP ACCORDANCE WITH THE POLICY PROVISIONS. 119R Foster St.Building 13 AUTHORIZED REPRESENTATIVE Peabody MA 01960 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD �y p ...._........................_._......---....._._........................_......._......._....__.._......_...._...._.._..._._._......._... ✓/� �OAJ/!24/t �0�✓C�19¢a1CU/1LG1E�t� Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TY0"Cornoration before the expiration date. If found return to: Registraton-= Expiration Office of Consumer Affairs and Business Regulation t1631 6� 05/10/2021 1000 Washington Street •Suite 710 i11 - -,/F& OGIESBoston MA 02118 AMERICAN BUiILtf�1 TECI i� ,INC. �suX JOSE ALVES-SAN,rt1Q8._- / 37 WEST MILTON ST fgPT='f( HYDE PARK,MA 02136 Undersecretary No valid W'IthouiAlIgnature Commonwealth of Massachusetts s Construction Supervisor Division of Professional Licensure Unrestricted-Buildings of any use group which contain Board of Building Regulations and Standards less than 36,000 cubic feet(991 cubic meters)of enclosed Constr r%IiiI rvisor space. CS-101378 rp ires: 11/27/2019 JOSE A SANTOS ; 37 W.MILTON-STREET,APT1 O HYDE PARK MA)02136 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Commissioner Call(617)727-3200 or visit www.mass.gov/dpl BUILDING PERFORMANCE INSTITUTE, INC. CERTIFIED PROFESSIONAL DESIGNATION EXPIRATION DATE r _107 Hermes Road;Suite 210 Building Analyst Professional 2/9/2022 Envelope Professional 2/9/2022 Malta,NY 12020 { (877)274-1274 en I ; www.bpi.org ' Jose Augusto Alves-Santos BPI BPI ID#:5014W9 I CERTIFIED PROFESSIONAL I sn (SEE REVERSE SIDE FOR DESIGNATIONS AND EXPIRATION DATES) BUILDING PERFORMANCE INSTITUTE, INC. I I NrBT OD S?!NSULATION Energy Savings Is Our Specialty Contract for Products/Service Work This Agreement is made by and among Theresa O'Brien 29 Buchanan Rd Salem MA 01970 American Building Technologies(ABT) 2 Neptune Rd,Suite 439 Boston,MA 02128 DESCRIPTION OF WORK TO BE PERFORMED 1) Air Sealing 2) Attic blow in cellulose to achieve R-38 3) Blow in dense pack cellulose inside walls Total: $ 10,965.88 Customer Signature: —ILA Q(G054zi p Customer Name: Theresa O'Brien Date: 10 / 7 / 19 Contractor Signature: Contractor Name: Jose Santos Date: 10 / 07 / 2019