B-20-767 - 0017 VERDON STREET - Building Permit 5 - zo- -7G
The Commonwealth of Massachusetts CITY OF
J( Board of Building Regulations and Standards SA EM
Massachusetts State Building Code,780 CMR Revised Mar 2011
! ` Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
his Section For Official iJse Only
1 Buldrng Perrntt Number Date Applied
Buildmg;Official,(Ermt Name) Szgnatu Date,
SECTION1„SITE INFORMATION `
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
17 ect Joul ST—
L la 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 PRQPERT,Y:0._ NER SHIP'
2.1 Owner'of Record:
kY�;
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
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 Other J91. Specify:�„/rq
Brief Description of Proposed Work2: A`1' Sr Q [n S..►A�1i H ��
Qr0 6 e!
SECTION,4 .ESTIMATED CONSTRUCT10N COSTS'
_.
Item Estimated Costs. Official Use Only
Labor and Materials
1.Building $ G� -Ov 1 Buildmg Permit Fee $ Ind-irate how fee is determined
❑ .Standard City/Town ltc App
2.Electrical $ atton Fee
❑Total Protect Costa(Item 6)`x multiplier,.. !:; x
3.Plumbing $ 2' Other Fees` $
4.Mechanical (HVAC) $ Li
5.Mechanical (Fire $
Su ression Total'AII Fees:$
Check No Check Amount Cash Arnoi nt 27 m :33
6.Total Project Cost: $ gJoa.00 11 Paid in Full' ❑out standing'Balan`ce Due J L
SECTION 5 CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
ly&s 11 '/ �1f/lv
License Number Expiration Date
Name of CSL Hoke-terLeblanc
List CSL Type(see below)
2 Pag 1
No.and Street Type. Descrprion
Plagts ; ,
U Unrestricted Buildin s u to 35,000 cu.ft.)
L
lu ZQ- R Restricted 1&2 FamilyDwelling
City/ ate,ZIP M Masonry
1—
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
POLAR BEAR INSULATION
PO HIC Registration Number Expiration Date
HIC Company Name or HIC RegistrantbVER,MA 01810 ^ '
tJn >,"'yLOA�i�ai
No.and Street Email address T
City/Town, State,ZIP Telephone
SECTION 6 WORKERS'E0MPENSATION INSURANCE AFFIDAVIT(M G:L c 152 § 25C(6)) ,
3.
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...........❑
f SECTION 7a OWNER AUTHORIZATION TO BE`;COMPLETED,;WIIEN
Y
OWNER'S AGENT,OR'CONTRACTOR AP:RLIES.F0KBUILDING.PERMIT,
1,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.
Print Owner's Name(Electronic Signature) Date
M.. SECTION 7Iz: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 an ccur to to the best of my knowledge and understanding.
Pr t Owner's or Authorized 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.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"
DocuSign Envelope ID:0725637C-FAF4-4EA6-81DD-556848468E9B
CLEAResulf CONTRACT
CLEAResult
50 Washington Street, Customer Name:KERI DOWNS
Westborough,MA,01581 Email:downskeri@gmail.com
Phone:617-905-6743
Premise Address:17 VERDON ST;SALEM,MA 01970
Mailing Address:17 VERDON ST,Salem,MA 01970
Project ID:4007835
Date:May 6,2020
Job 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.
Air Sealing 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
Attic Floor-9"Open Blow Cellulose 850 SF $1,547.00 $0.00
Damming 14 each $33.46 $0.00
Roof Vent-8" 3 each $327.90 $0.00
Walls-Wood Shingle-4"Dense Pack Cellulose 1770 SF $4,212.60 $0.00
Rim Joist-2"Thermal Barrier Polyiso 116 SF $554.48 $0.00
Door-2"Thermal Barrier Polyiso 1 each $90.44 $0.00
Crawlspace Ceiling-2"Thermal Barrier Polyiso 144 SF $688.32 $0.00
Crawlspace Ceiling-9" Fiberglass Batting 144 SF $424.80 $0.00
Blower Door Test 1 each $72.75 $0.00
Vapor Barrier-6 mil Polyethylene(with AS hrs) 192 SF $188.16 $0.00
Overhang-10" Dense Pack Cellulose 34 SF $171.02 $0.00
Total: $9,217.71
Program Incentive: -$9,217.71
Customer Total: $0.00
Payment
Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:$ 00 0 as a Deposit
payable to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CLEAResult,50
Washington Street,,Westborough,MA,01581.Final Payment:$0.00 as the final payment for the Work shall be payable to the Home
Performance Contractor(HPC)or Independent Installation Contractor(IIC)upon satisfactory completion of the Work.Customer
Page 1 of 4
DocuSign Envelope ID:0725637C-FAF4-4EA6-81DD-556848468E9B
understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$T,217.71.
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
required to submit to such arbitration as provided in M.G.L.c 142A.
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 delivery,not later than midnight of the third business day following the
sic
Qon.9 ofdt�iy!s agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. os
'`— 5/17/2020 i 11:41 AM EDT
Customer Signature Date Indicate your selected IIC here, if applicable Initial here if you
want the Program
to assign a
Participating
Contractor
CLEAResult Signature Date Name of CLEAResult Representative
Page 2 of 4
I
The Comoro rwe th of Wassaei usetts
Department of°In€astrial Accidents
Office a 'Ivesttgiots
600 Wdshington :street
Boston. AM 0211
www. ss.goarJia
orkers' Compensation Insurance Affidavit: Builde.rslcontraetors/Electricians/Plumber,-
: Iicant nfo aation Please .Print Le�ilaly
al1e(Btsil�ss. anizatiot? 'ridi� dual: 'SOLAR BEAR INySU ATION CO INC
Address:P.O., BOX 958
AND-OVER.MA 018 4 0 ' o'll ;978-686-5185
over?Check the appropriate box. - }
Ark you an etnFlTvpe of pro}eet required):
i
I am a genera! contr?cw �_nd I
1 F al:a etttptoyer i tt`I q 6. } etv coststnlcti,n
¢ employees(full "T or Part-time).-
I.lci[."hired Yl?e Si? -ci)i .2a�`s.z?s '
--i; listed on ttt?e auae!?e,d Sheet. Remodelnff
l w-i sole proprietor or tner-
Sh p and have no employees these 5ifl� coiitia^ teis have I �. � Demelieic)n
r employees and her �,or-k et-s' I
vt�ork-in'e 'forme 'in any capacir,. � 9. � Bwki 11n2 adcl[TIe?s?. :
i ?c «ori e eor€ip. insurance We
insurance
�.. We aCe a co?N �r3il� !3 a� t.t� j � f O.f� Erec�i&I repairs- or cd dli€;OT1
Teou.tred. 4
Z' y officers have em iie tr'it [[[ � � .u-jn`amj reDar or cdditio S{l am a.hor o-wner doinc al work
;
F rishtof e\emption Le. -�4GL ,
myself lNo Nvo'rkers, coup. I Roof:repairs
:ttsorance requiree<i,j c. I3? 51 1. 3,iu,,e Via.: .no 4 WEATHERIZATION
eiriployees. ;Ni V. Q-F; er, > t 13.� "-_ -- -
F
i comp. insi:;_-ance requir4d,j L
E
€An- asa.l,z=a dia cbcckS box r 1 musk also 611 out.the section beta+ dh it�r it>?.i�e cL' C i p�iiCc'laSiOTC 2�tif?i,
t' t1S'Ct.4'(h41'f4Ei,$w-ho s€tbmit.$arts af'idavit indicating they a>e doi s ati Aorik•aTed then h,..' ua.F de contractors must submit a.new at�da�'i;�'Tti:Cai3 itc Slil'`1.
ICcj,Lt de -w,,that c tt- zhis t?o\ttitlst attacbed at,additional stte.�t.showing itsc namie o" fS.:.C.O`C 3n4 stai.wiie he;or not ilhose er,,' rie�[3,-c
.have- pioyecs,they rust provide t:•ierr worker, cf nip p itcy awnber.
f am,,an,employer d.-at is providing workers'compensation insurance,jeer rrlt,employees. Below v is th:e polfcy and,joh site
infaadan
MGAURD INS Co
Insurance Company Name: A
Policy s or Self=ins. ?ic.=:POWC 129014 �T 'LYPira*ion Date:61101/2020
Job Site Address-, l 7 V t rdtl hCktv;`States"Z p--5 1!
;attach a copy,of the workers'compensation polio,declaration pane(showing the polio'number and expiration date).
s�gfWre to secure coverage as required under Sectlog -IiA.of N,4GL c. is J2 Ca lead to Jle Imposition 03 crimIna pei?2!t:eS Oi Z
Fine up to S1,500.00 andlor one-year imprisonment as ti�e!1 as civi re .,tie; it:the.fort of a STOP WORK ORDER:and a fine
of up to S230.J0 a day against the violater. Be advised that a copy of tl?i S state,xeni may be forvarded to the Office cf
Investigations o;the DLAV far insurance coverage tier'€€ca€i.on.
d,dti keredxtr eer€i�r under die pains and penalties of perjury that the infc)rmation provided above is true and correct.
Siat?ature D, _.._ Date:
i�l�otie,9,78--4071-7638 _
i,
Ofjmiat use only. Do not write in this area,to be completed bi cin or tovv`r official F(
i4
r
City or Towns: PermittLicense? rt
IssRi g Authority(circle one):
I. Board of Health ?. Building Department 3. Cits-/Tom>n Clerk 4-Electrical Inspector ;. Plumbing Inspector 1,
h..Other
Contact Person: -- -- Phone 4: !�
JI :'OATE(tAMJOt)7YYYY! ..
,Q►cc�rrr� . CERTIFICATE OF I.IABII.:ITY�INSURANC'E
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CAfM- FICATE'DOES"NOT.AFFIRMATIVELY`OR NEGATIVELY A ND.EXTEND OR"ALTER THE:COVERAGE AFFORDED BY THE A0,LIES
NTAT#VE OR PRODUCER,AWD THE'CERTIF1C1kCONSTtTUT£A CflNTRACT'BETWEEN THE ISStIiNG lAlStlliER(S);AUTHORIZED"
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REPRESS
IMPORTANT N tlle,;cyrlllleate.holder,Is An.ADt)NNAL INSURED,_#Ise^pollcy(les),must be endowed. N SUBROGATION IS WAIVED,subject to
the term.sand candltf of the'*Icy rertaln polkW nmy require an ei*memwvL'A statement not,t,"confer rIghts to the
certil(cae"holdern.Iteli cf such cndorserrihngs).
Llada ;'3ogdanowice
Znaurance Salutioxis-.Corporatson j603)382-4600: * .ieoa�ss2-acaa
13ab@scasr'60`Westville Rd aibe cam
• _ w "AFfdROiNG COVERAGE NAIL
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COVERAGES CERTIFICATE"NUMBER:CL20529d6532 REVISION NUMBER:
THIS"IS TO CERTIFY,THAT THE POLICIES OF IN$URANCE LISTED BELOW HAVE BEE(N.ISSUED TO THE INSURED NAMEDABOVE-FOR THE POLICY'PERIOD
INDICATED.-NOTVI'tH-sTAWDING ANY REQUIREMENT,TERM:OR'CONDITIOIN OF ANY CONTRACTOR OTHER DOCUMENT V.VTH RESPECT TO"WHIgH THIS
CERTIFICATE MAYBE ISSUED OA MAYPERTAW,THE INSURANCE"AFFORDED BY THE POLICIES DESCRIBED IIEREIN.IS SUBJECT TO ALL THE TERMS,
EXCLUSIONSAND CONDITIONS OF SUCH POLICIES,LIMITS SIHMNN BRAY:HAVE BEEN REDUCED BY PAID CLAIMS.
LTRTYPE Of INSURANCE .. - POLICY EFF POUCV E%P'
POLICY HUtABEA UNITS..
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ClearResult is an addt oral ineuredwon.a prisaary, non-cantribntory basis witli raspecet to General
7r3 abi`13 ty, `auto"anti Bxcaese^3 iatiility'Per'oirittan contrast:
CERTIFICATE HOLC)ER CANCELLATION"
' SHOULD ANY OP,THE ABINE'DESCRIBED POUCIFS BE CANCELLED"BEFORE'
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED'Nd,
CltearEiras`ult
r ACCORDANCE WITH THE P0UCY PROVIWNS.-
r 50 1�ashizlgton St` ; .
AMTHO JZED-REPRESENTAnME _
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Keith Maglia/LJS
A.
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).198$-Z01d ACORD'GUR tAATION.°AII>tlgttitsi`rs'saived.
ACORD 25.(20W01) Ttfs ACORD name and logo are registered marks"at ACORD
INS028 t2o�any
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CERTIFICATEOF UASILITY INSURANCE '
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THIS"CERT1FtGA'1'E!S ISSUED AS A,IIi1ATTT;R OF INFORMATION ONLY AND CONFERS NO-RIGHTS UPON THE`CERTIFICA•TE HOLDER THIS
CERTIFICATE"DOES NOT:AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVE.RAGE'AFi 4RoEt)By THE PL3liGIES
BELOW. ATE OF IRlSURAIdCE DOES,NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING°INSURER{S},AttTiiORiZED
RTePRSENTATT1l9"OR'PRODUCER,AND THE CERTtfiCATE PER.
IAAPORTANT =lI:Z; C@rrtllic8le t?I;Il.Js a�n.ADAITlONAL"INWRED;the;pcikyQes}Inusfhave ADDITIONAL!AISURED prtwitions'or be,endansed.._`
H SUi3FtOGATI0R IS NiA1'VED,subjeist to le.terriis an CondMbft of the poiwy,eertaln'poileles may require an 411ddrseme* A statement on
tllls cert iica#e do$a$;"rNsi,Ctlrlter.I lghis to the e iflCata-holler iri lleti o4 su tl erldo rsefr►ant{s.
ALttDinaticbata Prticessing in irarlce.AganCy,Inc;, E
Adp Boulevard IBI A FOAR1PKt CUVERAGf NAB H
NJ 47068 INSURER At AmGUARo Ir mante Compsny �2390
INSURED aN$LgM e.
POLAR BEAR INSULATION CO INC i * INSURER c
PO BOX 958 ;sI,REI;o
34SURER E:`
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AAA 418ID iNSUReR'I
COVERAGES."" CERTIFICATE NVfAI3,ER: 1341727 REV"ISION,NUMSFR:
THIS IS TO;CERTIFY.THAT THE POt iCiEB""OF"1PISURAtilCE`USTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE'POUCY PERIOD
iNDICATEO. NOTWITHSTANDING ANY REOUIREMENT,TERM OR.CONDITION OF ANY CONTRACT OR OTHER DOCUIv?ENT Yi+iiti"RESPEGT TO WHICH THIS
CERTIFICATE"MAY.BE ISSUED OR MAY:PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN It SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND OONOITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I �i:T� TYr'Etlf INSUfiANCE POLICY NUMBER :� �'i 1{i:�.`Y"�� uAN7s
COHThTERL1tIL GENERAL L1AaIUTY EACH OCCURRENCE
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A DPPICERtMEMBEREXCLUDED? �N NIAI".N POWC129414 411011242fl 41X3112421 — ----
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GTrRTIFICA�"E,NOLDER CANCELLATION
hr
SHOULD ANY"DF THE ABOVE DESCRIBED POLICIES BE CANCELI fD,$EFORE
THE EXR1RATtONDATIx.FHEREt3F, noTICE.WILL BE:D,ELIVER15-6'IN
CLEAftlasult Evarsciurse,arlt NatlDna!Grid `., ACCDRt3APICE•N1iTli THE POLICY,
PRLYVISIONS..
AUTHOFMO REPRESENTATIVE
} VVesibcaiot�' A+lA 41581�
"19 -2DlSAC7flY3`CORPO>AlOI4 AE.;rt
ACORD*25(20!SIi33) The ACORD,name and' 7
-reserved : -
'01
I"o are'I�#stered rltarks of AGORtI
office of Consumer Affairs and.Business Regulation
1 t 0 flingtnn Street-Suite 710
Boston, Mo. cflusetts 02118
Home Im rOVe ntractor Registrafiion
4: Type, corporalion
rrt Registration: 187822,
r #
POLAR BEAR INSULATION CO..INC. ���� — � � z�� Expiation: 33519872fl29
P.O.B£rX"958I '
ANDOVER,MA 01810
Update.Address and Return Card.
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SGA 4 9.2OV-051t7
G�arraiaaa�zcrte2is oa �:e�ls
Office of CansunW Affairs Su-sirs Regulation ist,,Won valid for individual use only:
Home IMPROVEMENT C€WrRACTOR bei6ra c exp1ration daft. If found return to,
TYpE CorooraG t)iiii a of Consumer Affairs and Susir;ass Rez ul 3n
135f981213Z9 'iota Washington Street -Suite 7 tfl'
POLAR?$EAR' t NC.
Boston,MA o2118
PETER LESLANC,
i
a : 110t valid wthutsl"ature
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