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30 BALCOMB ST - BPA-11-202 INSULATION The Commonwealth of Massachusetts 1 Board of Building Regulations and Standards CITY OF 3ALHM Massachusetts State Building Code, 780 CMR, T"edition r Reviser/Junuuq• Building'P'errnit Application To Construct,-Repair, Renovate Or Demolish a /. =//t1+ AOY = One-or Twu F milt/Dwelling This Secti n or Official Use Only Building Permit Number• - Signature: ''" lz&L Building Commissioned In to of lluildobl I I V Date SECTIO SI E INFORMATION I.1 Property Address: 1.2 Assessors Map& Parcel Numbers 30 A item n b 5,4— . I.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 11) Frontage(a) 1.5 Building Setbacks(it) Front.Yard Side Yards Rear Yard Required provided Require¢ .. Provided Required Provided " 1.6 Water Supply:(M.G.L c•40,§54) 1.7 Flood Zane Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public O Private O Checkif es0 Municipal O On site disposal system O SECTION 2: PROPERTY OWNERSHIP' rN!Cons 'off�acne-d S� nd / r10 irik S UO �do>M 6 Addreu fo(? 7e-: � z£� -�G� -YG7 �TelephoneSECTION3: DESCRIPTION OF PROPOSED WORK?(chick,all that:apply) uction O . Existing Building 0 Owner-Occupied a Repairs(s)?O Aheration(s) O Addition O Demolition O fAccessory Bldg.O I,NumberofUnits_ Other MO Specifg: Brief Description of Proposed Work':" JE;i) 56,1 &oci c t!l a/cr3e AAVS ✓ 7 SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Cosfs: Item Offlciat.Use Only Labor and Materials 1. Building S 1. Building Permit Fee'f_ indicate how fee is determined: O Standard Cityaown Application Fee 2. Electrical $ O Total Project Cost'(Item 6)x multiplier 3. Plumbing S 2. Other Fees: S ) " 4. Mechanical (tIVAC) S List: 5. Mechanical (Fire S Su ression Total All Fees: f O Check No. Check Amount: Cash Amount: 6. Total Project Cost: S `460• O Paid in Full O Outstanding Balance Due: �� 0 U UQ GEC Y SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) g 3 9 7') 7 h,i License Number Expiration Date rvame of csl.-i I1.I�Ifer - List CS'type(see below) 'i) �'�t / �"✓1 S S� f Descrip6on AJJres llnresoic'cd(up u to 35,000 Cu.Ft. R Restricted IB2 Famil Owellin tii��{tnnature M I Masonry Only RC I Residential Rouring Covering fdephone I WS I Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation t D Residential Demolition 5.2 Registered Hone Impprovement Cont ctor(HIC) �yZo- +1 .z31 !�7 I IIC Compan Name or HIC Registrant Name. Registration Number. Ca i � 1TG-s=�a=l &.A21- AJJress�6%L .978^ Expiration Date Signature - Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 2SC(6)) -Workers.Compensation Insurance eaffidavit must becompleted 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:..........13 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. Si- tore-of Owner - Date SECTION 96:.OWNER�OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare That the statements and inforrnation'orrthe foregoing application are true and accurate,ao the best of my knowledge and behalf. G C. Print Name Signature of Owner or Authoriznd Agent Date Si nedunderthe painsand- naliiesofPerim)• NOTES: r n Owner who obtains a building permit to do his/her own work;or an owner who'hires an unregistered contractor ot registered in the Home Improvement Contractor(HIC)Program), will ggi have access to the arbitration rogram or.guarantyfund under M.G:L.c. 1J2A.'Other importatuintonation onthe HIC Program and onstruction Supervisor Licensing.(CSL)can be found in 780 CMR Regulations I I O.R6:and I IO.R3,respectively. 2. When substantial work is planned,provide the information below: Total floors 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. ire Footage'*may be substituted for"Total Project Cost CITY OF S.U.E.1(9 jAkSSACHL:SETTS 811:ILDCIG DEPARTMENT 120 WAmiNGTON STRERT. 1"'ROOK TIM (971) 745-9595 FAx(971A 7�49tiN Kl.'.®EA"y DRISCOLL THOSWST.PMNN MAYOlt OiRw 'O R OF rL BLiC PROPERTY/@U ILDLNG CO-%MISfIO\EK Wurkers' Cotnpettssllon Insurance AlMdavit. OullderyContraetoralEleetrtelsnslPlumAen snnllcant Information /n I Please Pr(ntL.cz&k Valve Idus,er rOryaluanawltwir.d W1' A r L 1 I-n Y-I cl -21 ,i ,...—. .When:_ Z. i r�- City/StatdZip Sol /JZ 1'fwne Al 9 y 5 7NoworkewWVrcowp6 wphyts!Check the appropriate boat Type of povied(regslydS mployer will_ t. Q I s s a pp vtwat contractor ad I ❑Nv canstrstctiesw(IWl and/x part titer)a haw Abed eke wtsrractseslo pmptiss.tr patenenlistdaa thrauchd alecat= 7. ❑Remalsling Aave tr wmpbyss Thera wtbcarneeolan haw w ❑Iastmlitirt farms ie asy eapsiry. workers'eomp�iteatrrasoa 9. Q ItuiWing aeldltion ewW comp, insurance S. Q Wo on a corporation and is I O.Q taaCtrll al repairs or addition rcquitod) Oaks hew exerd ed tlralr ).Q 1 am a ho mari raw doing all work ride of eawnption par MGL I I.Q Plumbing repairs or addidow mywIL(Ne workers'comb. t I S2.f 1(41 and was betty no 12.Q Roof tepsirs insurance requiead.(► e1nployess'(NO wo'barr 13.00 tbar comp,inemance re¢ireal •Aey atryYra/nr aasrar 6s II err aYs rla err the arts 6rlw tlswfq lay+vast'mapls�r yetky ie/rwlaeea ,it. who Seat"06 afild"inaladws Itwr ass hits as wsA ad Ike Alta writ elararsn rater avlltab a new am keil trdteri.la aw► l.wtrw.ww,ar ra.o,W M nllrr atresAaa r.aeitiwl der dwwlq Ilr aaww rf M wlbawerlaraane.Ile thalr wwaaw'reatp.reltq i/aawrara /wr aw Yaspleyre/rA1e.b�wv/d/wt'tarr�Raes'rem�eraedrr/.wteuows�JA►q tatptAlryets se/M1etr 6 de pNteJ etd 00 9M inferaradarit, n In<urrnce Company Name: fie Ge- (0. Pnlicy e orSelf:ins Lie.N: q l0-x0 3Uo( Expiration Dw: 3 Je lob Yin Addn:— 9 91/&M 6 CityiSlawwZip: /19l9 .utacb a cep of Ike worriers'campatnaden pelky declarull"pep(Skewing the Ps"snnbw and eaplratlss deb)6 Failure to wrtum coverage as regained under Satlas 23A of NGL e. 1.12 cas lead to the imposition of criminal penalties of line up to f 1.500.00 aaWw one-year imprisonment,as well of civil penalties is the form ate STOP WORK ORDEK and a AM Of up to$250.00 a Jay jlpoinst the violator. Ile adviwnt that a copy of this slatanwul may be rorwurded to the Mice of 111�'callrallYN.d'Jts AIA far insurance coverage v ritk:uica /der he►eay eeffi r/YJaajor rAe poike end didyYj/e►/Yq rAw tAw infMM1/M providedYg&/~irs�nW and earreca O/JJe%e/Yat Yn/yF izo 00/.vri'v i.Mj!Air-Yee&%ter.Al_eeenplrlyd tiv eiy ar reeve n/llriw City or ruwa: muing.wharay(circle une): 1, t1YarJ ut Ileullb 1. HualJlna Mpartmene ). citytrown Clerk S. flectrital Ineprctor 1. Plumbing Impactor 6.tllher t .,.tract reason: _ .. Phone e: CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT construction Debris Disposal A171davit (mquired lur all demolition:uxl mnovatiun work) In aceunl uxe with the si�tlt edition of the State Building Code, 730 CMR section 111.3 Debris,and the provisions of MGL a .5 issued Building Permit is issued with the condition that the debris resulting from Bui work shall be disposed of in a properly License wrote disposal facility as defined by MGL c his , I1. S13UA. The debris will be transported by: tnanre ut'hauler) '1•11a debris will be disposed or in (n,una ul xr fly 4)V-5 J-e c .�anarure.rl,wrmit�pylieane /z S�/�o d I d.. Oct 22 2010 8: 47 HP LHSERJET FAX Page 5 CONTRACTOR WORK ORDER Conservation Services Group Printed 10f22 Contractor Information Customer/Site Details Eric Palm RICHARD THOMAS Phone (eve): (978) 767-1678 Atlantic Weatherization 30 BALCOMB ST Phone (day): (978) 767-1678 61 R Jefferson Ave Salem, Ma 01970 SALEM MA 01970 1552 p Site ID: S10003979790 Appointment Details Completion Deadline: Location Description Quantity Unit$ Total $ Notes/Revis Work Order: ATLANTIC_2010102 EXTERIOR Wall Ins. Clapboard Siding 4" Cellulose 920 1.71 1573.20 Total for Work Order ATLANTIC_2010102 : $1,673,20 Grand Total: $1,573.20 Road Blocks Asbestos Possible Asbestos Containing Material Observed BASEMENT Combustion Safety Passed HEAT LOAN F/NANACING FOR REPLACEMENT BOILER Eric W. Palm 3 Hilton Street Exp.p. 4/23 4/23/12 Salem MA 01970 978-744-8143 Atlantic Weatherization,LLC H. C.#142089 61 R Jefferson Avenue Exp. 3 /12112 Salem MA 01970 978-744-8144-8143 Conservation Services Group -40 Washington Street-Westborough, MA 01581 -800-480-7472 EIG Fax Server 4/6/2010 3 : 15 : 24 PM PAGE 2/003 Fax Server ACORa CERTIFICATE OF LIABILITY INSURANCE 04/0 i 010 PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 233 West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick, MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED Atlantic Weat erization LLC INSURER Arbella Protection Ins. Co, 41360 61 Rear 3efferson Avenue INSURER B: Arbella Indemnity Ins Co. 10-017 Salem, MA OIL970 INSURER C: NSURER D: INSURER E: COVERAGES 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POUCYEFFECTIVE POLICYEXPIRATION LIMITS GENERAL UABILITY 8500042816 03/20/2010 03/20/2011 EACH OCCURRENCE E 1,000,00 X COMMERCIALGENERALLASILITY DAMAGE TO RENTED E 50,00 CLAMSMADE �OCCUR MED EXP(Any we persm) E 5.000 A PERSONA-&ADVINJURY E 1.000,00 T GENERAL AGGREGATE E 2,000,00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPIOP AGO E 2,000,00 POLICY X JEG LOC AUTOMOBILE LIABILITY 93827400003 03/20/2010 03/20/2011 COMBINED SINGLELIMIT E ANY AUTO (Es eodewt) 1 000 OO ALL OWNED AUTOS BODILY INJURY E X SCHEDULED AUTOS (Per person) R X HIRED AUTOS BODILY INJURY E X NON-OWNED AUTOS (Per accltleM) PROPERTY DAMAGE E (Pe(eoaidert) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT E ANY AUTO OTHER THAN EA ACC E AUTOONLY: AGG E _ EXCESSJUMBRELLA LIABILITY EACH OCCURRENCE 8 OCCUR E-1CLAIMSMADE AGGREGATE E E E DEDULTIME RETENTION E WORKERSCOMPENSATIONAND 9111820309 03/20/2010 03�20�2011 X WCSTATU- O E R EMPLOYERS'LIABILITY E.L.EACHACOMENT Is 500,00 A ANY PROPRIETORIPARTNEVEXECUTIVE OFFICERIVEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE E 500100 If yes,Eew m under E.L.DISEASE.POLICY LIMIT $ 500 00 SPECIAL PROVISIONS W. OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS O SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY CITY OF SALEM 120 WASHINGTON STREET OF AMY UTHORIZED RE UPON RESENTE INSURER,ITS AGENTS 0R REPRESENTATIVES. SALEM, MA AUTHORIZED REPRESENTATIVE �� —E •E RosemaryFul ha PMA Y^'�"— ©ACORD CORPORATION 1988 ACORD 25(2001108) Nlassachusctts - Department of Public Safct� 1 Restrictedto: 00 Bn:u•d of Buildim,, Relations and Standards ' Construction Supervisor License 00,_ Unrestricted License: CS 87977 I-1 2 Family Homes Restricted to: 00 - =i ERIC W PALM i . Failure to possess a current edition of the 3 HILTON ST Massachusetts State Building Code SALEM, MA 01970 is cause for revocation of this license. Expiration: 4/23/2012 Refer to: WWW.Mass.Gov/DPS �!'r (-unuu ii=iunc,. Tr#: 22214 OtTice of Consumer Atfain&.Busiuew RegulatI WONIEAMPR £HENS CONTRACTOR License or registration valid for individul use only Re9ist1•atlnit...�42089 before the expiration date. If found return to: I: Expirat � 2"12 Tr# 292174 Office of Consumer Affairs and Business Regulation Typi1 . ,�i_ er 10 Park Plaza-Suite 5170 ATLANTIC ".I� .0 W� Boston,MA 02-116 ERIC PALi✓it 11,R BEFF£RSOIJ - "SEM,MA 01:971). '-' 1JodtYsecretsty /,✓ �� Not valid without signature ATLANTIC WEATHERIZATION, LLC 61R JEFFERSON AVENUE SALEM, MA 01970 November 1, 2010 To Whom It May Concern: I, Eric Palm, owner of Atlantic Weatherization, LLC, authorize my employee, Paul Belfiore, to pull permits for my company. Since Eric Palm Atlantic Weatherization, LLC