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0008 CRESSEY AVENUE - BPA-12-1002
The Commonwealth of Massachusetts FOR L Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code, 780 CNM 7, 49 o° i t i USE Building Permit Application To Construct,Repair,Renova Ur Demolish a Revised Jmtuary One-or Two-Fa Dwelling .`- ..• � j1; ,F 1, 2008 This Section or tat Us my 0 Building Permit Number. e p ed: Signature: � � Z Budding Commission spector of Building Date SECTION 1: S r INFORMATION 1.1 Propertx Address: 1.2 Assessors Map&•Parcel Numbers, rcSSP si Ll a Is this au accepted street. yes no Map Number + r 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: I..&Sewage Disposal System: Zone' _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2�I Owner'of Record: g/Y ('o/r—r /0Clo/1 G4 g CrcSSey Name(Print) Address for Service: SignaNre Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ j Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': _ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials I.Building $ 1. Building Permit Fee:$ -Indicate how fee is determined: ❑ Standard Cityrrown Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x / 3.Plumbing $ 2. Other Fees: $:4.Mechanical (HVAC) $ List: AA 5. Mechanical (Fire $ Total All Fees:$ Suppression) Check No. Check Amount Cash Amount 6.Total Project Cost: $ a 5 G t' ❑Paid in Full ElOutstanding Balance Due: � r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) (P,79 ., License Number Expiration Date Name of CSL-Holder List CSL Type(see below) tk 3 ffiltoit-StMet { Address Salem MA` T9T 70 Type Description V ll -Unrestricted(up to 35.000 Cu.Ft.) SignatureR Restricted 1&2 Family Dwelling (/ M Masonry Only RC Residential Roolma Covering Telephone p r WS Residential Window and Siding d 7 Y y —ff /`/3 SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) / 10 0 g HICCompany @ Registration Number 61 It.de11'ersen dyed,.,,Address Salem MA01970 037�C 7 �-S(/Y3 �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 .......... pill No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, t--0-,'] G e-pCl Cj�-✓1 as Owner of the subject property hereby authorize C P, c-- R I -1 to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of CRvneT Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 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. E/. , P0. f Print Name Signature of Owner or Authorized Agent Date - (Signed under the pains and enalties of e h NOTES: I. 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 I IO.R6 and I I O.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 ofhalfibaths 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" RightFax 111-2 3/21/2012 6 : 26 : 51 AM PAGE 3/003 Fax Server x 3/21/2012 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 IMPQ RTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)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 NAME: 233 W CENTRAL ST PHONE FAX . - -(A/C,No,Est): (A/C,No): NATICK.MA 01760 -E-MAIL ADDRESS: PRODUCER CUSTOMER IDt. INSURED INSURERS AFFORDING COVERAGE NAIC9 ATLANTIC WEATHERIZATION LLC INSURER A AMERICAN ZURICH INSURANCE 61 REAR JEFFERSON AVE - COMPANY SALEM,MA 01970 INSURER B INSURER C INSURER INSURER E INSURER F. . COVERAGES 'CERTIFICATE NUMBER: 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. N071 V ISTANDA'O ANY REQl1HlEMpN'I',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 TYPE OF INSURANCE ADDL SUHR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR IkVD D/YYYY) D GENERAL LIABILITY EACH OCCURRENCE S .DAMAOETO RENTED S COMMERCVSL GENERAL LIABTILtrY PREMISES(Each occurrence O CLAHAs MADE O OCCUR MED EXPENSE(A ry one I ❑ PERSONAL&ADV. S INJURY ❑ GENERAL AGGREOATE S OEN-L AOOREOAM LIIATCAPPLIFS PER'. PRODUCTS-COMP/OP S ❑POLICY O PROTECT ❑ LOC AGO AUTOMOBILE LIABILITY COMBINED SINGLE S LIST epiEtch accident D ANY A= BODILY INJURY E Y (Per Person) O ALL OWNED AUTOS BODILY INJURY S (Per Accident. ❑ SCHEDULED AII'TOS PROPERTY DAMAGE S (Per accrdenl ❑ HIRED AUTOS S ❑ NON OWNEDAT.TIOS E ❑ ❑ tRQiItELLA LIAB ❑OCCUR - EACH OCCURRENCE S ❑ EXCESS LAAB ❑CILAIMS-MADE AGOREOATE S ❑ DEDUCIBLE ❑ REfF1JT10N$ E WORKERS'COMPENSATION WC A AND EMPLOYERS LIABILITY N/A STATUTORY YIN LIATS ANT'PROPRIETOR/PARTIJER/ EXECi. OFFICEP/MEMER B Y NIA 7PJLJB-5B270121 03/20/12 03/20/13 E.L.EACH ACCIDENT E500,000 EXCLUDED? E.L DISEASE-EACH(MANDATORY INNH) EMPLOYEE ESUU,000 Ifyes,des<ribemder DUCFJPT1ONOF DISEASE-POLICY S500,000 OPERATIONS below DESCRIPTION OF OPERAIIONS/LOCATIONSN MCLES(ARech ACORD 101,Additional Remarks Schedule,if more space is required) THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE hOLDER AFFECTING WORKERS COMP COVERAGE ..v..,�.,.:'o-awx .. `: ''+ „-Azar..�•.:._ .Cz,ELI. 7T N'.._;_ n .E : ':'..�.,_F�\�� ., we..� .,,• ` CITY OF SALEM 120 WASHINGTON ST � SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SALEM,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED 1EI RFSINTADW 8rt.an.MacLecwv 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: Q th%f 'ficate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms antl condirl Iis 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 ConstructionNAME: PHONE Eastern Insurance Group LLC A/C,No . (508)651-7700 NC No: _ -M AIL 233 West Central- Street AEDDRESS: ` PRODUCERCUSTOM 00024397 Natick MA 01760 INSURERS AFFORDING COVERAGE NAICO _ INSURED INSURER AArbella Protection Ins. Co. 41360 INSURERS Arbella IndednJaity Ins Co. 10017 Atlantic Weatherization INSURER.C:Zuri ch—American Group 61 Rear Jefferson Avenue INSURERDBeacon Hill Associates Inc INSURER E Salem MA 01970 INSURER F: COVERAGES CERTI9I0AfeN0MBER3,9+STER'-2012 REVISION NUMBER: ' THIS IS TO CERTIFY THAT THE POLICIES AF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO 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 TYPE OF INSURANCE POLICY NUMBER MMIDCY EFF MM!ICDY EXP. LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMA X COMMERCIAL GENERAL LIABILITY PREMISES Ea occu ante $ 50,000 A CLAIMS-MADE X�OCCUR B500042816 /20/2012 /20/2013 MED EXP(Any one arson) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: - _ PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X P RO- 71 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO 38274'00003 /20/2012 /20/2013 BODILY INJURY(Per person) $ , B ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULEDAUTOS ar PROPERTY DAMAGE X HIREDAUTOS \ (Peracciden0 $ X NON-OWNED AUTOS Uninsured motorist BI split limit $ Undeonsumd motorist BI split E X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DEDUCTIBLE $ A RETENTION E 1 14600047820 /20/2012 /20/2013 $ L. WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOWARTNER/EXECUTIVE YIN E.L.EACH ACCIDENTOFFICERIM $ (Mandator,In H)EXCLUDED? ERTIFICATES TO HE ISSUED E.L.DISEASE-EA EMPLOYE $ (Mandatory In NH) If yes,describe under IRECTLY BY CARRIER E.L.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS below D POLLUTION LIABILITY PL200378600 30/1/2011 0/1/2012 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addltlonal Remarks Schedule,If more space Is requlmd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF SALEM 93 WASHINGTON STREET SALEM, MA 01970 AUTHORIZED REPRESENTATIVE - Rosemary Fulham/P29L ACORD.25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts 0=. Department of Industrial Acidents Office of Investigations 600 Washington Street Boston, MA 02II1 " www.mass.gov/dia W Workers' Compensation Insurance Affidavit: Builders/Contrac%rs/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Q UG Address: lil:$�J>Sfleesett Av�trite, City/State/Zip: Phone #: Are yop-an employer? Check the appropriate box: Type of project (required): 1. I am a employer with. '3L S. 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or partrtime)--t have hirgd the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t ❑ 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 officers have exercised their 10.❑ Electrical repairs or additions required.] of 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.[J Roof repairs insurance required.] t employees. [No workers' 13.0 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 are doing all work and then hive outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: 1 t C L1 AM e-1 i G0. y Gl c , Policy#or Self-ins.Lic. #: S o o l Expiration Date: o ,tom � Job Site Address: n C f G SS ,Z A-e- City/State/Zip: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 7 zs� . I do hereby certify under theeppaains and penalties ofperjury that the information provided above is true and correct. Signature �/ L'//`" Date: Phone#: Official use only. Do not write in this area, to he completed by city or town official t City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CityPlbwn Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: CONTRACT . .. Printed: 5/3201 Work Order Id: S56980P59907C29 Contractorinformatio t CustomeNSiti petails Atlantic Weatherization Concepcion Gan Phone(Eve): 978-210-3461 61 R Jefferson Ave 8 Cressey Ave Phone(Day): Salem, MA 01970 - Salem,MA 019704506 - .Site ID: S00002056980 TOtal`Installed'Measures.. Location. Description Quantity Unit$ Total$ Living Space insulate Rim Joist with 6.25"Fiberglass Batting 44 $1.94 $85.36 Living Space Dense Pack 8 Cellulose In Garage Ceiling 3l)l). $2.17 $651.00 Living Space Insulate Multiple Siding We11.1With W Dense Pa - 885 $2.40 $2.124.00 Living Space Perform Air Sealing at Estimated 62.5 CFM50 - 1 ' $75.25 • $7525 Installed Measures Total $2,935,61 Road Stocks h � Type Status Notes Asbestos UNKNOWN WorkOrder Notes ( ymetits Incentive Payments Air,Sealing Incentive $15.25 Weatherization Incentive $2,000.00 Total Incentive Payments $2,075:25 J Customer Share Total Customer Share $860:36 Less Deposit Of $286.78, Customer Share-Balance(Due Contractor) $573.58 J u/ Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 - (508)836-9500 Q-1 f�! Massachusetts -Department of Public Safety Board of Building Regulations and Standards Unrestricted-Buildings of any use group which Construction Super%kor License: CS-087977 contain less than 35,000 cubic feet(99 tm3)of ERIC W PA r:r > enclosed space. LM- -rs 3HILTONS'r SALEM MA-01970 F 5F,X " ' ti`" Expiration Failure to possess a current edition of the Massachusetts Commissioner 04/2312014 State Building Code is cause for revocation of this license. Frn DPS Licensing information visit: w -Wtiss.Gov/DPS Office . HOME IMPROVEMENT CONTRACTOR _- Registration: st42089 Type: 1 ( License or registration valid for individul use only before the expiration date. If found return to: Expiration: 3/12I2014 Ltd Liability Corpor Office of Consumer Affairs and Business Regulation ' WEATHERIZATION L:},:G. { 10 Park Plaza-Suite 5170 A TIC -- -. Boston,MA 02116 ERIC PALM i' , a_4 o 61R JEFFERSON AVE" SALEM,MA 01970 A Undersecretary 0, Not valid without sign ure