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B-19-722 - 0028 BUENA VISTA AVENUE - Building Permit 25 1 The Commonwealth of Massachusetts Board of Building Regulations and Standards w Ulf Massachusetts State Building Code,780 CMR SALEIvI Building Permit Application To Construct,Repair,Renovate Or DenAtlh`h " One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: - i Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION J1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 28 Buena Vista Ave L l 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: Zone: _ Outside Flood Zone? Q' Public❑ Private❑ Check if yes❑ Municipal[3On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' �{f{ 2.1 Owner'of Record: (� Robert Polo Salem. MA 01970 + $� Name(Print) City,State,ZIP ` 28 Buena Vista Ave No.and Street Telephone Email Address 3 SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Insulation �. Brief Description of Proposed Work :1)Air Sealinq 2)Attic blow in cellulose to achieve R-38 (-6 3) Blow in dense pack cellulose inside walls SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: 1) Item Labor and Materials Official Use Only 1.Building $ 11,028.40 1. Building Permit Fee:$ Indicate how f is determined: J 2.Electrical $ ❑Standard City/Town Application Fee �. ElTotal 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: $ 11,028.40 ❑Paid in Full ❑Outstanding Balance Due: 1Iz� - , � v � r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 101376 11/272019 Jose A Santos License Number Expiration Date Name of CSL Holder List CSL Type(see below) u 37 W MILTON ST No.and Street Type Description U Unrestricted(Buildings u to 35,000 cu.ft. HYDE PARK MA 02136 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 ..........® 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. �d6o /Q9�9 7/5/19 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 accura o th st y knowledge and understanding. Jose A Santos 7/3/19 Print Owner's or Authorized Agent's Name(ElectroWc SigVatur Date NOTES: l. 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. og_v/oca Information on the Construction Supervisor License can be found at www.mass. og v/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 halfibaths 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" I yr Ac,iogo CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDnYYY) l0/17/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS t 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 be endorsed. If SUBROGATION IS WAIVED,subject to the term;: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 endorsements. PRODUCER CONTACT NAME: Mary O Demala Ambrose Insurance Agency, Inc. PHONE FAX IAIC. o t• AIC No): 70 Munroe Street, Suite D AIL ADDRESS:mdemala@prescottandson.com INSURERS AFFORDING COVERAGE NAIC p Lynn MA 01901 INSURER A:Atlantic Casualty Ins Co. INSURED INSURERB:Torus Speciality Ins CO American Building Technologies, Inc. INSURERC: 263 Western Ave. INSURERD: INSURER E: Lynn MA 01904 INSURERF: COVERAGES CERTIFICATE NUMBER:CL16101823870 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 ADOL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER I DIY IDD YY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FO OCCUR DAMAGE TO RENTED 100,000 PREMISES Ee occurrence $ X L035014011-1 10/17/2018 10/17/2019 MED EXP(Any one person) $ 5,000 PERSONAL SADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑PRO- JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 B X EXCESS LIAR I.CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ X 8331OH185ALI 10/17/2018 10/17/2019 $ WORKERS COMPENSATION - _ AND EMPLOYERS'LIABILITY YIN STATUTE X ERH ANY PROPRIETOR/PARTNER/EXECUTIVE WC Certificate to be 10/20/2010 10/20/2019 E.L.EACH ACCIDENT $ 1,000 000 OFFICERIMEMBER EXCLUDED? El N/A (Mandatory In NH) issued by carrier E.L.DISEASE-EA EMPLOYE $ 1 000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ 1,0001000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more apace is required) Insulation Contractor Action Irac and National Grid USA its direct and indirect subsidiaries and affiliates shall be named as Additional Insured on Commercial General Liability Policy Description of Operations: North Shore Community Action Program CERTIFICAy'E HOLDER CANCELLATION (978)531-1012 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE NSCAP THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 119R Foster St. ACCORDANCE WITH THE POLICY PROVISIONS. Bldyi. 13 Peabody, MA 01960 AUTHORIZED REPRESENTATIVE J S'Scholnick/SJG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) r 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.KI I am a employer with 5 _ 4. ❑ I 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 required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ t am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.91 Other Insulation *Any applicant that checks box N1 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, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. 1 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.#: 6S62UB2E91844518 Expiration Date: 10/20/2019 Job Site Address: 28 Buena Vista Ave 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. I do hereby certify under f1se pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: 7/3/2019 Phone#: (61 233-870 / (781) 598-7125 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 S.Plumbing Inspector 6.Other Contact Person: Phone#: f i no nv BT INSULAT10N Energy Savings is Our Specialty Contract for Products/Service Work This Agreement is made by and among ,Robert Polo 28 Buena Vista Ave,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: $ 11,028.40 Customer Signature: AP494&At& Customer Name:Roberto Polo Date: 7 15 / 2019 8 JOA k-- Contractor Signature: Contractor Name: Jose Santos Date: /3 /19 r _... _...._...--_..._.........__._....—-...._...._ _- — ----— -....__.._....... _-_- _....._.......................... __....... ..... __ J/Le �i�mmo�t�uea.�l�o�✓ol�¢J1¢C/ludetlu Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TY E:Corporation before the expiration date. If found return to: Re r ExiArstion Office of Consumer Affairs and Business Regulation 631flr}= 05/10/2021 1000 Washington Street -Suite 710 ij E N'F Boston,MA 02118 AMERICAN BUILptO�TEC€iN(�tOGIES,INC. Al . I JOSS ALVES-SAfVTOS� I / 37 WEST MILTON SfJAP7 �° HYDE PARK,MA 02136 Undersecretary No valid wvIthouthignature £ Commonwealth of Massachusetts a Construction Supervisor Division of Professional Licensure I 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, -- &t%iapprvisor space. ^ f CS-101378 " E kiDires: 11/27/2019 ANAL w JOSE A SANTOS#L, 37 W.MILTON STREET APT.1 ' HYDE PARK MA702136 - � r�C}1Sfi i 11�� • 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 www.bpi.org ° `4y -'* Jose Augusto Alves-Santos BPI BPI ID#:5014929 j CERTIFIED_ PROFESSIONAL sn (SEE REVERSE SIDE FOR DESIGNATIONS AND EXPIRATION DATES) ' BUILDING PERFORMANCE INSTITUTE, INC.