0124 1/2 FEDERAL STREET BPA-11-78 The Commonwealth of Massachusetts
U Board of Building Regulations and Standards CITY
y ) Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
�h�✓✓ Revised Junnury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 20(11
One-or Two-Family Dwelling
This Secti n or Official Use Only
Building Permit Numb : /J ate Applied: /
Signature:
Building Commissioner/1 t r of Build' Date
SECTIO :SITE INFORMATION
1.1 Prop21
dclre!A` i 1.2 Assessors Map& Parcel Numbers
1.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(11)
;71
cks(R)
Yard Side Yards Rear Yard
Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own r of Record:
co,i, /a � /3.
Nam Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ,c r— c,C, C./_.
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
6. Total Project Cost: 5 D. el Check No. Check Amount: Cash Amount:
0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ,,7? 7 -� /-:),
License Number Expiration Uute
Name ol'CSL• I IulJer 5-� List CSL Type(see below) ��
t- Description
Address / // U Unrestricted(up to 35.000 Cu.Ft.
R Restricted IR2 Family Uwellin
Signature M Maso Onl
ej ) 7 y /'��y3 RC Residential Rouling Covering
Telephone WS Residential Window.and Siding
SF Residential Solid Fuel BurninitAppliarice Installation
D Residential Demolition
5.2 Registered Home Improvement Coatraetor(HIC)
��' L✓e�c(-Lei " `� Registry ion Nun her
I IIC Company Name or IIIC Registrant Name
61 2 I��/2 S �9�`�- 519�� ly /
Address i i' �--� L ��( �y"� Expiration Date
Signature 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52. ¢ 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 of the building permit.
Signed Affidavit Attached? Yes ..........Aar No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner of the subject property hereby
authorize_�n c W - �i_ �"'� to act on my behalf,in all matters
relative to work authorized by this building permit application. -
Si alurc of Owner Date
SECTION 711b: OWNERt OR AUTHORIZED AGENT DECLARATION
1 %y (a t ,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 'u
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!Uo 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 110.R5,respectively.
2 When substantial work is planned,provide the information below:
Total tloors area(Sq.Ft.) (including garage,finished basementlattics,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 healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage'*may be substituted for"Total Project Cost"
ATLANTIC WEATHERIZATION, LLC
61R JEFFERSON AVENUE
SALEM, MA 01970
July 14, 2010
To Whom It May Concern:
Replace rotted facia boards
The work is being performed by Atlantic Weatherization, LLC,
The work is being performed at 124 1/2 Federal Street, Salem, MA.
Sincerely,
Eric Pain Owner
Atlantic Weatherization, LLC
Kevin Guinee, 124 1/2 Federal Street, Salem, MA
CITY 0F`S.UI&N1a iLXS,5ACHCSE7M
9t:QDOIG DEP.\RT WaT
120 W.jjm NGTON STRmW. !e'FILWIL
TEL (978) 745-9595
F.Vc(97� 7�0.96i/
KIStOEA"y ORMOLL TUO&WST-rMa d,
%"Yoz C)IRWMILOP pl.aLICPRO►[RTY/1KI DLNGCO-%OaSS10-NER
Wurkers' Compensaclon Insurance AlRdseit: Builders/Condrsccon/EleetriclsnslPlsmbers
sranllcanl Inforrnallaw nn ii Please Print LMbly
VaIT!ltlwtn+vaOraaeuariewlndtrnAW): rl�(�� �« ��.u-�� , 2�:..•'c-,,._.-.
CilyisollwZi �Z�I . ,; Phone* `L ?k �jjV
7wWworkwo,
wpkyo!Cbeeb tho sppntprlaft bees Type appro)ftt(rpulyd$
crphryo we. Q 1 me a general contactor ad I & Q Now eauauction
w(IWI and/or part-ties).• have hired tho at►eomraetors
ole pntpriseer tx peseta• listed an theattachdshtnL = 7. QRemodaling
have no amplayaaeThan m►eemrestont haw r Q pemolislao
far me is any capacity. workers'comp inamsaea 9. Q Building additionent'comp insurance 3. Q We are•eorparaslon and in I0.❑Electrical repair a stldicimr
requirmLl olMems have extref ed their
).Q 1 am a horrtsowtter doing ad work riaw of exernpriow per 11 OL 11.0 Plumbing repaint or addiliena
myself(No workeva'comp. c. IS2.j1(1).and we haw no 12.Q Roormitaira
insurance required.)r craplaymL LNG wakoree I3.0 odwr
comp insurance eeptim/.) 1i
'ANY appatar 11101616691111 bm ek Note eke tta as the rrrttm tekw a, , aril w-A 'Mmunwia pesky GAawrk a,
t t urwwnaa who Mika r alb aretbrir kdleYN they we Join dl weA sae tin No am"comma"~wihwi a saw aOhbwb.4in j.8.ei
f.wuwnwa dr cbwA tab Aw etas aMarM/ate aW Nw1.Awr Jw4y en wow 1Aa Anwearaawo nee th* m.T pesky iraawani
/eaa ew reeyirJo that 6 prwWd/wR wwrbnt'cowpeww6ow/amnsomJir aq eopto es eMrr,to A&/dfey and sfAr
;n/warw/wr n&
insurance Company Name -1.7 e-L-
Policy M or Self ina.Lie.M: 9rlHk),o 3 0 - Expiration
Jab Site Addrers l:Cy Z Fe Ce/1 `j/� w� City/SutNlip: /d9
.%ctsct a cop of tbs worben'compoua low pelky dowla siw pap(showing the polky numbor and aapiratlen daft)6
Mailun to secure coverage as regeirad under Salim MA of MOL t 152 can lead to the imposition of criminal ponaidee of■
me up to S 1.100.00 and/or one-yaw imprisonment,as wall an civil presides in the rare of a STOP WORK ORDER and a fine
Of up to 52io.00 a day iysinst the violator. Ile advivJ that s cupy,of this statements maybe rurwarded to the Ot71eo of
Inrc.ueariutu of dye MA for insurance coverage vaidLi tea .
1,10 hereby eerdly ender the owe."and na/Nra e/Jer/ary Awl the injererwdew prwriddrd it true Need 6-eruct
S-/` -2
O/flcie/Nre Nn/n ne wee wrier in this Nreq to M.murp/etd eJ rilJ OI Ntrw.i//k•iNL
City orruwa: - t•rrmlr/A,:cenue__ -- ---
Ltafng.\athonry Icirclo unel
t. Iluard ul Ilealrb 1. Ruddlwa Ilcpartmvnt I Cily/rows Clerk 6. flectrirai Wipector 1. rtumbmii Impeeror
6.Usher
Phones:
CITY OF SALEM
PUBLIC PROPRERTY
�" DEPARTMENT
i -cv.w in::;•vjj14141� �, .�i�isIM'm '..:r�•:
construction Debris oDxl p eoal t71d,vit
(mquired
. 730 CMR section I
In accord uxe with the si.tdt edition of the State Building Code I I.3
Debris.and the Drov'swns of MGL a . S issued
_ is issued with the condition that the debris resulting m
Building Permit Nam_: licensed waste disposal facility as defined by MGL c
This work shall be disposed or m a Properly
I 11. S I50A.
The debris will be trunsported by.
'
(its of haYlef)
The debris will be disposed or in
Vw .
Arum u) x� fly
jv�,yr-5 d:e 66110 o ✓�
( Wmmssill *Wilily)
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EIG Fax Server 4/6/2010 3 : 15 : 24 PM PAGE 2/003 Fax Server
ACORP, CERTIFICATE OF LIABILITY INSURANCE 04/0izoio
PRODUCER (SO8)6S1-7700 FAX (SO8)6SS-88S3 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, NA 01760
INSURERS AFFORDING COVERAGE NAIC#
INSURED Atlantic Weat erization LLC INSURERA: Arbella Protection Ins. Co. 41360
61 Rear Jefferson Avenue INSURERS: Arbella Indemnity Ins Co. 10017
Salem, NA 01970 INSURERC:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTNITHSTANDING
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICYEXPIRATION LIMITS
GENERAL LIABILITY 8500042816 03/20/2010 03/20/2011 EACH OCCURRENCE $ 11000,00
)( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50 QQ
CLAIMSMADE F_X]OCCUR MED EXP(Any one person) $ 5 00
A PERSONAL&ADVINJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP ASS $ 2,000,00
POLICY X JEC LOC
AUTOMOBILE LIABILITY 93827400003 03/2O/Z01O 03/20/2011 COMBINED SINGIELIMIT $
ANY AUTO (Ee.odd rtt) 1,000,000
ALL OWNED AUTOS BODILY INJURY $
X SCHEDULED AUTOS Pei person)
B X HIRED AUTOS BODILY INJURY $
X NON-OWNED AUTOS (Per swldem)
PROPERTY DAMAGE $
(Per S=Ident)
GARAGE LIABILITY jAGGREAGATE $
IDENT $
ANY AUTO A ACC $
AGG $
EXCESSM1IMBRELLA LIABILITY $
OCCUR CLAIMSMADE $
8
DEDUCTIBLE
b
RETENTION b
WORKERS COMPENSATION AND 9111820309 03/20/2010 03/20/2011 X WG srATu- oTH-
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000
A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.DISEASE-EA EMPLOYE $ 500,000
OFFICERMIEMBER EXCLUDED?
M yes.t =IW under E:L.DISEASE-POLICY LIMIT $ 500,00
SPECIAL PROVISIONS belay
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
CERTIFICATE HOL
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
,may_DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAIULRE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Cm OF SALEN
OF ANY K ND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES..
120 WASHINGTON STREET
SALEM, MA AUTHORIZED REPRESENTATIVE 1" Y"— ^"��
T
Rosemar Fulh PMA V�
(VACORD CORPORATION 1988
ACORD 25(2001108)
ATLANTIC WEATHERIZATION, LLC
61 R JEFFERSON AVENUE
SALEM, MA 01970
May 14, 2010
To Whom It May Concern:
I, Eric Palm, owner of Atlantic Weatherization, LLC authorize my employee,
Damian Anketell, to pull permits for my company.
Sincerely,
Eric Palm
Atlantic Weatherization, LLC
y !�lassachuscth - Dcparmtrnt of public Side �
Board of Buil( ingRcgudations and Standards
Construction Supervisor License
License: CS 87977
Restricted to: 00
ERIC W PALM
3 HILTON ST
SALEM, MA 01970
Expiration: 4/23/2012
(linuui..iuncr
Tr#: 22214
� _ ��eali� �✓�aoac%uoel
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR
Regis4 atio
n..v ,d42089
11
Exptrat�on 3f1212D12 Tr# 292174-
TYPe� �t Lttl/EISAIRYCgrpor
I ATLANTIC WE A I E�,ZAT,tONa L'L.C.
,{ ERIC PALM
I 81R JEFFERSONrAVE
-� -- �:
SALEM, MA 01970 `,v• ' ----�_
� Undersecretary �'