23 CLIFTON - BUILDING INSPECTION The Commonwealth of Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code, 780 CMR,7 .edition, USE
(� Building Permit Application To Construct,Rep ' ,Renovate'Or.De' olisb a RevisedJanumy
��. One-or Two-Family el 'rig 1, 2008
This or O rcial s Only
Building Permit Number: D teA I
Signature:
wilding Co 'sion a uJdings Date
SECTION 1: SITE INFORMATION
1.1 Pro a Addre 1.2 Assessors Map.& Parcel Numbers.
1.1 a Is this an accepted street?yes_ no_ Map Number - Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District ProposedWse - - '. 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? Municipal❑ On site disposal system ❑
Public❑ Private 0Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownko
er'of Record:
Name(Print) Address for Service:
�n�..) c�a . - 781 - aa'�
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied [IT Repairs(s) ❑ Alteration(s) ❑ Addition ElDemolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
toot GPitw10-. e- t3,0S IS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Gstimated Costs: Official Use Only
Item Labor and Materials
I.Building $ - 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
❑Standard City/rown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ . 2. Other Fees:
4:Mechanical (HVAC) $ List: /7y/ l��_��f✓✓✓llV//
5.Mechanical (Fire $ - Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount: ,y
6.Total Project Cost: $ S$66 ,0 ❑Paid in Full ❑Outstanding Balance Due:
0C�-f�
SECTION Su CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
�79 `z3 i
License Number Expiration Date
Name of CSL-Holder . m � '� List CSL Type(see below) 1i
2
3 IRiltA SUVIA
Address Salem MAtNig7O Type Description
U Unrestricted(up to 35,000 Cu.Ft.
Signature R Restricted 1&2 Family Dwelling
M Masonry Only
_ RC Residential RoofingCovering
Telephone (' '/ W$_. Residential Window and Siding
l�J '
.2 b 7 v y —? /N,S SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company t eLLU M Registration Number
Address a1tt -k-M,I'SOIIAy/�A" 3 l)-1, /
Salem MA 01970 97'f '7 `I`/ SiY 3 Expiration Date
Signature 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 lssuanc f the building permit.
Signed Affidavit Attached? Yes ....:..... ff, No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR�C—ONNTRACTOR APPLIES FOR BUILDING PERMIT
I, !T/�u(f,+ / Q c as Owner of the subject property hereby
authorize C P. r✓ pk l ✓k to act on my behalf,in all matters
relative to work authorized by this building permit application. - -
a,-1," �-16 b L
Signamre of Owner .T Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION _
I, r.-c: �/� � ,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.
Print Name /
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 11 O.R6 and 110.R5,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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
=_ Office of Investigations
— 600 Washington Street
y` Boston, MA 02111
z. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Cont a'a°&rs/Eleetriciatis/Plumbers
Applicant Information Please Print Leaffily
Name (Business/organization/Individual): AIda lie`� � Ir
Address: 1�t1 .Jpffetsorr AvgCtue.
City/State/Zip: Phone #:
At y/oy-tm,employer? Check the appropriate box: - Type of project (required):
I.L I am a employer with. ' L 5. 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part-tini(*e; - have�hir(id the sub-contractors
2 ❑ I am a sole proprietor or partner- listed on the attached-sheet: $ I• ❑ Remodeling"
s4ip and have no employees These sub-contractors have 8. ❑ Demolition .
working for mein 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. ❑ 1 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.❑ Roof repairs
nsurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they ere doing all work and-then hire outside contractors musf submit a new aff1davifindicating such.
;Contractors that check this box must attached an additional sheet showing the.uame ofthe sub-contractors and their workers'comp.policy information.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information.
Insurance Company Name: �� f s C.U,
Policv # or Self-ins. Lic. #: 5 d (a�� fl 1 Expiration Date: _5 l L3
Job Site Address: 23 C � ' �'" City/St S/�14�J o��t
Attach a copy of the workers'. compensation policy declaration page(shovvmg 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 inndlor one-year imprisonment, as well as civil penalties in the fi rm 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?nay be forwarded to the Office of
Investigations of the DIA for insurance coverage verification. 'm
I do hereby certify un the pains and pen�altie^s ofperjury that the information provided above is 1r'ue.and correct:
Signature
y/.y Date.
Phone
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): . `
I. Board of Health 2, Building Department`3. CityjTown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
CQntact Person: Phone#: .
Customer Name: Andrew Turchon Contract
Address: 23 Clifton Ave
Salem Roadblocks:
Massachusetts,01970 None
Subcontractor Name: Atlantic Insulation
Site ID: S00002042080
NSL Work Order# OQOCOOODOOOLnUnKAK
Billing Utility National Grid
vF,3,` i °. tia>r "fie
�.e,�?sulb„�"`3-�.� �,»� �:�� �, ' �" �Rt%a�tW�SEORe�< ,a �1 � �1 gri" rrbt
12"Roof Vent(mushroom vent) 1 „�,. - Unit $113.40 $113.40
Damming 7 ! Square Ft. $1.59 $11.13
Air sealing in preparation for insulation 2 ` Hour $69.30 $138.60
Attic Floor Densepack Cellulose-8" 670` °'x ', Square Ft. $1.92 $1,286.40
Insulate Clapboard Sided Wall With 4"Dense Pack Cellulose 981 .cw.�,.._,.,,. ;,.t � Square Ft. $1.76 $1,726.56
Insulate Clapboard Sided Wall With 4"Dense Pack Cellulose 1102 �'_, ' : _.,-. , Square Ft. $1.76 $1,939.52
Door:Thermax 2"(per door,32sq.ft) h Unit $45.00 $45.00
8"Roof Vent 2 , , � ��?� Unit $81.90 $163.80
Attic Floor Densepack Cellulose-6" 39 a a s"v -4: �, � Square Ft. $1.72 $67.08
Rim Joist 6.25"Fiberglass Batting 97 _.' k.a,,.. Square Ft. $1.75 $169.75
Insulate Wall from Interior w/4"Densepack Cellulose 43 , k;va •! +a s�^v.I Square Ft. $1.85 $79.55
�-
e f � tes �< ,� r :" v,� � ,r"� � � � � r � 79 ��•
Change Order Detail: ,
Original amount of scope $5,740.79 -P1TER+ *rtsYx �?eEl
n
Change from scope revisions $0.005 �B1 , .
rtSs(kx r$r
Change from scope additions - $0.00 `"p4E ii81IN �E S
Final amount of scope $5,740.79 "
us ao s ;," xFr� w8
- Total change order difference $0.00
k,Owner (
Atlantic
CERTIFICATE OF LIABILITY INSURANCE 3/19/2012
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:, 11 the6 �art,,ificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms im condix�foo, 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 endorsoment(s).
PRODUCER CONTACT Construction
NAME: _
Eastern Insurance Group LLC PHONE Ed, (508)651-7700
233 West Central Street E-MAIL Dp SS:
PRODUCERCUSTOMER ID 1)0024397
Natick MA 01760 INSURERS AFFORDING COVERAGE NAICN
INSURED INSURER A:Arbella Protection Ins. Co. 41360
INSURERS Arbella Indemnity Ins Co. 10017
Atlantic Weatherization INSURER.C:Zuri ch-Ameri can Group
61 Rear Jefferson Avenue INSURERD9eacon Hill Associates Inc
INSURER E:
Salem MA 01970 INSURER F:
COVERAGES CERTIFIOATENOMBERji%STPR'2012 REVISION NUMBER:
THIS IS TO CERTIFYTHAT 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 ADDLSUBR TYPE OF INSURANCE POLICY NUMBER MMIO YEFF MM%ICYEJ(P.
LTR LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED—
X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occunence $ 50,000
A CVtlMS-MADE ❑X OCCUR 8500042816 /20/2012 3/20/2013 MED EXP(Any one arson) $ 5,000
PERSONAL S ADV INJURY W2,000,000
GENERAL AGGREGATE $GEN'L AGGREGATE LIMITAPPLIES PER: _ PRODUCTS-COMP/OP AGGPOLICY X PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT(Es exiaen0ANY AUTO938274D0003 /20/2012 /20/2013 BODILY INJURY(Per person)ALL OWNED Al170S BODILY INJURY(Per accident)
X SCHEDULED AUTOS PROPERTY DAMAGE
X HIRED AUTOS (Peram 0iden $
X NON-CANED AUTOS Uninsured motorist Bl SIA limit $
Undennsured motanst at split $
X UMBRELLA LIAR X OCCUR - EACH OCCURRENCE S 1,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE 5 1,000,000
DEDUCTIBLE $
A RETENTION $ 1 14600047820 /20/2012 /20/2013 $
C WORKERS COMPENSATION AC STATU- IOTH-
ANDEMPLOYERS'LIABILITY _
ANY PROPRIETOR/PARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $
OFFICER/MEMSER EXCLUDED? NIA
(Mandatory In NH) . RTIFICATES TO BE ISSUED - E.L.DISEASE-EA EMPLOYE S
❑yes.RIPTIOe under IRECTLY BY CARRIER E.L.DISEASE-POLICY LIMIT $
DESCRIPTION under
OPERATIONS below
D POLLUTION LIABILITY PL200378600 30/1/2011`.10/1/2012 GENERAL AGGREGATE $1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it 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
ACCORDANCE WITH THE POLICY PROVISIONS.
CITY. OF SALEM
93 WASHINGTON STREET -
SA M, MA 01970 AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PMA �—
ACORD 25(2009109) 01988-2009 ACORD CORPORATION. All rights reserved.
INS025(2omoil) The ACORD name,and logo are registered marks of ACORD
RightFax C2-2 3/26/2012 7 : 26 : 52 AM PAGE 6/027 Fax Server
'.-n -ATE OFINT, ita- NOR, srxengix
THIS CERTIFICATE IS ISSUED AS MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 41,713ND,EXTEND OR ALTER THE COVERAGE AFFORDED By THE POLICIES
BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORMD
"PRESENTATIVE 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 CONTACT
EASTERN INS GROUP LLC PHO14E AG
23'�;'Al CF14TRAL ST (�140.Ek): eo):
E-MAIL
NATICK,[VIA 01760 ADDRESS:
PRODUCER
CUSTOMER ON
INSURED INSURERS)AFFORDING COVERAGE NUC#
ATLAITTIC WFATHFRIZATION LLC INSURER A AAMUCAN ZURICH INSURANCE COMPANY
61 RF-bRJEFFFRSON AVE INSURER B
SALEM,MA 01970 INSURER C
INSURER D
INSURER E
INSURER F
COVERAGES CERTIFICATE NUIVIEIHR REVISION NUMBER:
TIII:'IS TO CERTIFY TRAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAUED A.Bovr FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREILIENT,TERM OR CONDITIU14 OF ANY CONTRACT OR OTHER DOCULIENT WITH RESPECT TO WHICH THIS
CERTIFICATE.LIAY BE ISSUED 13R MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERLIS,
E=LUSIONS AND CONDITIONS OF SUCH POLICIES.LRETS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAWS
RN 7S—R TYPE OF INSURANCE AIML SUER POLICY NIMIBER POLICY EFF POLICY EXF LI11ITS
LTR INSR AVVI) JMAIDD (bMVDDArYYY)
GENERAL LIABILITY
D niIIdsJaxDE D cccm
&
0
C-EI'L hGGXES�KTET—T APPLIEfPFB
$
OYOLICY OPE=T OLO; IAGG
AUTOMOBILE LIABILITY CWfBBIPS�SINGLE
LHDI
BODILYIISIIIIx
0 P117krzo RxPeno
P T,OLLRIFD Xuros
D
0
D $
0 EMCXS1LuX O'CTA I,x
0 nXI==
0 MTMTIwu$
urc
WORIUERS' COMPENSATION
A AND EI.IPLOYERS LIABILITY V/N T=8 —
[::N: NIA ?PJUB-SB270121 0312W12 03120/13FRCH $500,000
$500,000
(NAeeDATomy M Irm
DEXLEI'TIOU oP EI'DIBIAKE-POLICY $500,000
CIS ARYPRIOR CMT13TICATEISUMED TOTEDE C "SaR CONT GE
ER
CITY OF SALENI SHOULD AN, OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
93 VCAS'HINGTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
SALENI,ILIA 01970 In ACCORDANCE WITH THE POLICY PROVISIONS.
t P4assachusetts- Department or Public Safety
Z Board of Building Regulations and Standards Unrestricted-Buildings of any use group which
Cm.lrucliwi Supen i.or
m
contain less than 35;000 cubic feet(9913)of
_icense: CS-087977
< „ enclosed space.
ERIC W PALM_
3 HTLTON ST
SALEM MA-01970
ti Failure to possess aa
commissioner o4/23/2014rrent edition of the Massachusetts
E 1.� xpira on State Building Code is cause for revocation of this license.
-for DPs Licensing information visit: vmre.Mass.Gov/DPS
4
. Office of"coos mer ans�c"Ba£in s&tgu74hof Ou
HOME IMPROVEMENT CONTRACTOR_ License or registration valid for individul use only 1'
Type: .before the expiration date. If found return to: -
r^Registratlon t420B9 P j
'I Expiration 3J12(2014 Ltd Liability Corpor I Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
kA19'WMd1)'lG WEATHERIZATION 1,a:C_ I Boston,MA 02116 i
i
ERIC PALM
61R JEFFERSON AVE
SALEM,MA 01970 Undersecretary j
Not valid without signa ore I
t