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0008 CHARLES ST - BUILDING JACKET t The Commonwealth of Massachusetts INSPECTIO AG'.S Board of Building Regulations and Standards #IGE Massachusetts State Building Code,780 CMR,7" edition �N MICIPALITY ° SS Building Permit Application To Construct,Repair,Renovate th Demolish:a;- '..Rev4e JaM, One-or Two-Family Dwelling 1,2008 nip This Section For Official Use Only, Building Permit Nuruber:° " Date Applied: Stgpa d a. , Building CommissionedlnspedorofBuild' ,, Date SECTION 1:SITE INFORMATION 1.1 Proper �Address: ( 1.2 Assessors Map&4braeldfLmliers +++ SS C��a✓�eS l.la Is this an accepted street?yes_ no Map Number ceIP Numb 1.3 ZoningIuformation:` 1A 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: Pubfic❑ ` Private❑ Zone: _ Outside Flood Zone? ' Municipal❑ On site disposal system :❑ Check if yes13 SECTION2t:;NtOPERTYOWNERSEU 2.1 er'of Record _ /1 �G t + OYI-f pYTi linPtiV/� J7�, N nnt) M Address for Service: //lA'Ylpn Al - Signatuix ._ r L Telephone. SECTION 3:DESCRIPTION'OF PROPOSED WORK=(check all that apply) d New Construction❑ Existing Building❑ -Owner-Occupied ❑ Repairs(s).❑ tion(s) ❑ Addition ❑ Demolitions"''•" ❑ tAccessory Bldg.❑ Number of Units Other Specify: u Brief Description of Proposed Work2: "r. SECTION 4::ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only i (Labor and Materials 1.Budding ." $ 1. Building Permit Fee.$ Indicate how fee is determined-. 0 Standard City/1 own Application Fee 2.Electrical $. , g Total Project Cose.(Item 6)x niulhpha % x a 3.Plumbing $ 2: Other Fees: $. 4.Mechanical (HVAC) $ List: - 5.Mechanical (Fire $ Su ression) Total All Fees:$ �rr' Check No. Check Amount: Cash Amount: 6.Total Project $ '7��V - ❑paid in Full ❑Outstanding Balance Due ;. lair i Zce_ � coN�il Ac- tJ (� f y I s[SECTIONS: 'CONSTit n6NSERVICES 5.1 Licensed''Consti"uctioriSupervisor(CSL)-, ,, �"� �� � `� 2 3 �(' .LicenseNumber." - :Expiation Date NamebfCSIrHofder 3 Mon Street 'List CSL Type(see below) ... ." Description., • Address Salem MA 01970 U Unrestricted(up to 35,000 Cu.Ft Signature--: R Itzsury Only Fami1 Dwelling - M . aso Only RC Residential Reefing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation Residential Demolition 51 Registered Home Improvement Contractor(HIC) /y '/ 1Uentic Weadleri79tion_I J HIC Company Name gff "Regi„ lion Number - . Address MA 019 - .. Expiration Date . Signature Telephone .. -'SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G L.c.152 g 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 9EMc building permit. Signed Affidavit Attached? Yes.......... No...........O SECTION 7af-OWNER AUTHORIZATION TO BE COMPI:ETED"WHEN OWNER'S AGENT OR CONTRACTOR APPLIES.FORBUE,DING PERMIT I, as Owner of the subject property hereby authorize Cr, 'L �k f-l"i to act on my behalf,in all matters, relative to work authorized by this building permit application. Signature of Owner Date / -- SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION �^ I l u !"17 as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Er, t0cr_ Print Name ` 44 Signature of Owner or Authorized Agent Date(Signed under the pains and penalties of - - `'.NOTES: 1. An Owner who obtains a building permit to do his/her own work,of 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 tie'HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics,'docks 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 z Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost' ix Work Order North Shore Community Action Programs,Inc. Job Number.22333 119 Rear Foster Street,Building 13 Work Order Date:5/9/2014 Peabody,MA 01960 Ownership:Owner Phone:978-531-0767 Atlantic Weatherization Auditor.Chuck Gallant 61R Jefferson Avenue Email:cgallant@nscap.org Salem MA 01970 Cell:978-766-5521 Email:tpalm0l@comcast.net Phone:978-531-0767 x119 Phone:978-744-8143 RobertMonegro MAJOR REPAIR FUND- $575.00 8 Charles St GAS $6,604.35 Apt.2 NGRID Gas $7,179.35 Salem MA 01970 Total 978-335-1875 Safety Iss ue(s):Knob&Tube Wiring/Mildew Present/Lead Paint Possible a M1 Jar Authorized 11Acti6lM1 "Y ",. ` ".a e try.o .,F c ! ID r Y r Measure Description " i Commrments 4` "u § � Totalr..� *„t'S`i- c > i'�f A. «a Attic Insulation R-10-12 restricted-slopes/floored 576 $1.46 $840.96 576 $840.96 fillw/cellulose R-30 restricted-slopes/floored fill 128 $1.59 $203.52 128 $203.52 w/ceBulose R-49 unrestricted-settled cellulose 616 $1.80 $1,108.80 616 $1,108.80 '.. e Attic Ventilation< r �-: , 4 ,£'k.o �. ���'�. r^�w '� 's�= t, Roof vent 865(A sq ft NFV)small 4 $90.00 $360.00 4 $360.00 l' BasementImulatwn Sill two-part foam w/fiberglass bait 20 $2.46 $49.20 20 $49.20 Fixed Sweep 8 $17.64 $141.12 8 $141.12 R-5 Ductwrap or R-max on door 1 $57.00 $57.00 1 $57.00 Repair/Refit Door 2 $58.00 $116.00 2 $116.00 Weatherstrip s/Q-lonorequal 8 $51.00 $408.00 8 $408.00 Date:5/92014 Page I Work Order. Job Number. 22333 Health&Safety , .y , . . a t, Clothes dryer vent including 2 $100.00 $200.00 2 $200.!0 Exhaust Duct ` Misc Insulation Domestic water pipe wrap 12 $2.95 $35.40 12 $35.40 Duct insulation R-8 10 $3.90 $39.00 10 $39.00 Misc Measures � fi a 50 CFM bath fan(replace existing) 1 $575.00 $575.00 1 $575.00 Attic sealing with two-part foam 3 $84.00 $252.00 3 $252.00 Basement sealing with two-part 2 $84.00 $168.00 1 $84.00 foam Blower door set-up with pre&post 1 $45.00 $45.00 1 $45.00 tests Weatherstrip(Q-Ion or equal)& t $67.00 $67.00 1 $67.00 R-19 attic batch �en•'-othgr Remove attic debris tic hatch cover r $ 2 $67.00 $134.00 2 $134.00 Replace at 4 40.00 1 $40.00 ' 1 0.00 $ x. w 5 Peiw t'W n. b m. Y A 'x.".'. a d.; �" p +n rb'� x'+N `#tk+a •."'4„¢%�.3 w^e ro f nT'i § Y'yvme' ' °` r a. ?i41 Building Permit 1 $100.00 $100.00 1 $100.00 Date:5/9/2014 Page 2 Work Order. Job Number. 22333 WafiInsulation t4 ° ; Z, Double nailed asbestos/aluminum 220 $2.59 $569.80 220 $569.80 (dense pack) Drill finish patch plaster(dense 735 $2.13 $1,565.55 735 $1,565.55 pack) „Windows «r Thermopane Glass Replacement 1 $188.00 $188.00 1 $188.00 Total $7,263.35 $7,179.35 Contractor Instructions: Before Starting the Job: During the Job: 1.Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978.Lead safe practices are 2.Obtain required building permit. required. 2.Total for Heath&Safety and Repairs cannot exceed$2500.00. 3.Davis Bacon time sheets required for ARRA work on US Department oflabor Certified Payroll Report Form WH-347. Additional Contractor Instructions: Attic Inspection form attached?YesN/A (Circle One) Certificate of Insulation posted?YesNo (Circle One) Atlantic Weatheri2ation hereby certifies that this job was supervised and completed in compliance with all Department of Labor Standards and Lead RRP regulations. Contractor Signature: Date: RRP.License#: I hereby acknowlege that all work has been completed and inspected. Customer Signature: Date: Energy Director. Date: Fiscal Officer. Date: Date:5/9/2014 Page 3 CITY OF SME&I IN -kSgACHUSET FS BL'n.DLN!GDEPiRTNW&NT ' • i 12o WASHiNGTOIV STREET,310 FLOOR TEL (976)745-9595 Fmx(978)740-9846 KIJBERLEY DRISCOLL THONIAS ST.PIERRB .NLLA.YOR.. DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLIRSS[ONER Wt rkers' Compensation Insurance AfiidoW Builders/ContractorslEtectricians/Plumbers Annlleant information please PrintLeeibiy. Atlantic Weatherim ion,LLC Name(BusittossiOrganization/Individual): venue Address: Salem MA 019M City/State/Zip Phone#: Arc yo n employer?Check the appropriate box: Type of project(required): I.F2,rl am a cmpioyo{with as- 4. ❑ 1 am a general contractor arid.1 6. C]New construction employees(full and/or part-tithe).' have hired the subr:ontraetois' 2.❑ I am a sole proprietor or partner listed on the attached sEect.t 7• ❑Remodeling Tmsucooe6ave . , 8. © Demolitionship'awvenoploycc :: rJfcm ca acity.wokingormeina workers'.comp insirance. 9 ❑Building addition (No workers camp insurance: S. ❑ We are arcorporation and Its - - required j officers hove exercised their. 30.❑Electrical repairs or additions 3.[] 1 am a homeownerdoing all work right of exemption Per INGL , 1 I.�PI. ing repairs or additions, myself.[No workers'comp. c.,152, we have no.., 12.� f repair�s � ` mstrrance rcqutred,)t, , employees. [No workers' . T� comp instuance,rcquired.J. I3. Other 't—^j+f '.'Any appllctm that ah�ska bmeBl mlut atwi ml uut the sacfiaa bctow sMviing rhea wotkeR`compeaaaton polity infommtion. - t-I Inmauwa:ri who submit this affidavit indicating they sin doing all work and then We ooaida contmctoo must submit new affidavit indicting suck Tcmmiiim that chak this box must miachedan additimul shoit ihowing iho name of the su"nrractmi;aed lhelfwohm comp,policy Information. um ua employer that It"provlding Itiorken'rompensadon)asuraucejor lay emplayerx Belowas the policy atrdjab—site ormutlotc; ` tnw!an ceCompany Nante: �t f✓I Policy H.:orSrlf-ins.Lic.tl: - �ff/✓ �nn�V l3I' ( - Expiration Date: lob Site Adrift s:' �hlLJt� S�, CitylState/Zip:Ste} � Attat.b rr copy of the.ivorken'compensatlon'policy declaratlan page(showing the policy number and expiration date). Failure to secure coverage as required under Sectia125A of MGL c. I52 cart lead to the imposition of criminal penalties of a find up to S1.500.00 and/or.one•yeatimprisoninent,as well as civilpenalfies in the form of a STOP WORK ORDER and a fine of up toSM.00'adayagainstI the violator. 13e advkw:d that copy of this statement may ba forwarded to the Office of - Investigutions ur the DlA ror insurance coveraga ven ttcation. l do/rereby certijynuder they Ina all a !tier ojperfury that the hiforafaUou prodidedab ve it true and carries, Sitn tture: , '/ Data, 69�20I 1 LI P lone 4: Ofrrrul use only.:Do not write in this area,to be completed by cfy oiJown afjlc&L City or Town: Permit/I.Icense Issuing Authority(circle one): 1.hoard of ilealth 2.Building Department 3.CitytrownClerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact-Person: Phone d: '4 CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD1YYYY) 3/10/2014 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 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 C NT NAMACT Construction Eastern Insurance Group LLC PRONE (508)651-7700 FAX o: 233 West Central StreetADD EERIE INSURERS AFFORDING COVERAGE NAIC#' Natick MA 01760 INSURER AArbella Protection Ins. Co. 41360 INSURED INSURER B Arbella Inde!Mi Ins Co. 10017 Atlantic Weatherization INSURER c 0autilus Insurance Co 61 Rear Jefferson Avenue INSURER D: INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFICATENUMBER3faster 2014 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 IN 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. IN SR TYPEOFINSURANCE POLICY EFF POLICY EXP POLICY NUMBER MM/ M/O LIMITS GENERAL LIABILITY ' EACH OCCURRENCE 5 1,000,006 X COMMERCIAL GENERAL LIABILITY PR ISES aumi Dncel S 50,000 A CLAIMS-MADE ❑X OCCUR 500042816 /20/2014 /20/2015 MEDEXP(A onepemon) S 5,000 PERSONALS ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMP/OP AGO S 2,000,000 AEG PRO- LOC S AUTOMOBILE LU\81LITY COMBINED SINGLE LIMIT E S 11000,000 B ANY AUTO BODILY INJURY(Per person) S ALL OWNED X SCHEDULED 020015871 /20/2014 /20/2015 AUTOS AUTOS 9001LY INJURY(Pafacitlent S X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Peraca nt 3 PIP-Basic $ 8.00 X EXCESS LAUAB X OCCUR EACH OCCURRENCE S 1,000,000 A umBREEXCESSLUIB CLAIMS-MADE AGGREGATE S 1,000,000 DED I I RETENTIONS 4600058654 /20/2014 /20/2015 1 3 WORKERS COMPENSATION i I M S ATIy OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandabry In NH) E.L DISEASE-EA EMPLOYE S If yes,de he under DESCRIPTION OF OPERATIONS Mow EL DISEASE-POLICY LIMIT S C POLLOTION LIABILITY PL200378602 0/1/2013 0/1/2014 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 i DESCRIPTIONOFOPERATIONSILGCATIONS/VEHICLES(Attach ACORD I 10%Addrdonal Remark,Schedule,if more space Is Iequlred) 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. 93 WASHINGTON STREET SALEM, MA 01970 AUTHORIZED REPRESENTATIVE Ronald Cleaves/SME ACORD 25(2010105) 1 01988-2010 ACORD CORPORATION. All rights reserved. INS025nninwM The ACORn name and lnnn om reniefar tf mark.of ar nRn aubuuaA A10-4 011414UlY / :41 :01 PM YAUt 00/Utiti rax berver A�& CERTIFICATE OF LIABILITY INSURANCE o3;2.2m4 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(es)must be endorsed. It 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 116 of such endmsemem(s). PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE 'FpX 233 WEST CENTRAL ST A/C No EkII, IA/C.Nol: NATICK,MA 01760 E-MAIL INSURER(S)AFFORDING COVE RAGE NAICA INSURER A:AMERICAN ZURICH INSURANCE COMPANY INSURED INSURER B: ATLANTIC WEATHERIZATION LLC INSURERC: 61 REAR JEFFERSON AVE SALEM,MA 01970 INSURER 0: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER, REVISION NUMBrR- THIS IS TO CERTIFY THAT THE POLICIES OO F 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. ''SR ADU SUB POLICY EFF POLICY EXP Lift TYPE DF WSURANCE INSRwval POUCYNUMBER MM/oomyy LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY DALIAGE TO RENTED S CLAIMSMADE❑ OCCUR EREMISEu MED EXP(Am'onepbson) Ii PERSONAL B ADV INJURY S GENERALAGGREGATE S GEM AGGREGATE LIMIT APPUES PER: PRODUCTS-COMPIOP ADD S POLICY JEGT I LOC $ -&140MO131LE LIABILITY ae4eOSINGLEUMrt S ANY AUTO ALL OWNED SCHEDULED BODILY INJURY IP@,P...) $ AUTOS AUTOS BODILY INJURY(Pe,acendwU $ HIRED AUTOS �OSWNED MOPE Y AMADE $ S UMBRELLA LUIB OCCUR EACH OCCURRENCE S EXCESS UAB HCLAIMS-MADE AGGREGATE S IDE01 JRETENTION$ S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS LIABILITY YIN X TORYLLIITS FA ANY PROPRIETORIPARTNEIVEXECUTNE❑NIA EL.EACH ACCIDENT $500.000 OFFILERNEMBER EXCLUDED? N 6ZZUB 03-20-2014 03-20-2015 (MarpW.ItnNH) 58270121 E.L.DISEASE-EA EMPLOYEE $500,12 IN Y Eewu u,Ner k DEes.RIPTIib NOFOP RATI NS I. EL-OISEASE-POLICYLIMIT $500,000 DESCRIPTION OF OPERA110NS I LOCATIONS!VEHICLES(Altaeh ACORO IM,AELHbMI Remarks Scrweub,H more epom Is required) ERTIFICATE HOLDER I CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 93 WASHINGTONST CANCELLED BEFORE THE EXPIRATION DATE THEREOF, SALEM,MA 01970 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOFIQ®REPRESENTAT� �f ACORD 25(2010105) The ACOI RD name and logo are registeredgm marks of ACORDCORPORAT(ON All rights reserved. 7�}t Massachusetts-Department of Public Safety f Board of Building Regulations and Standards Comtraction Superviiur _ - License: CS-087977 u, . F.RIC W PALM - 3 HMTON ST _ Salem MA 019707- Expiration Commissioner 0412=016. �nrrntaertmalf�trlfll(auarlrrr./C *1Dce of ConsomerAirairs&Busia�Regulation License or registration valid for individul use only ROVEMENTCONTR�40'fORbefore the expiration date. If found return to: istratiorc 142089 Type: Office of Consumer Affairs and Business Regulation iration: 31122016 . Ltd Liability Coryo lO Park Plaza-Suite 5170 Boston,MA 02116 ATLANTIC WEATHERIZATION L.L.C. - - - ERIC PALM 61R JEFFERSON AVE SALEM,NIA 01970 undersecretary Not vallil without signature