133 FORT AVE - BUILDING INSPECTION \-V
The Commonwealth of L[assachusetts
1:. Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Of Demolish a
One-or Tivo-Family Dhvelling,r i(i l M, nr jr;?
'this Section For Official Use Only
Building Permit Number. lJate pplied:,
Building Official(Print Name) Signature Date=-L
SECTION 1:SITE INFORMATION
Ll Property_ 3dress �t �U� Ll Assessors Map& Parcel Numbers
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: + I r
Zoning District Proposed Use Lot Area(sq ft)' `r r'Y" -tlJ Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.0.E c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesCl
SECTIONZ:, PROPERTY'OWNERSHIPL'
2.1 O er1 of Record:
Name(Print) City,State,ZIP
1 33 2,1V-SIO
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOR.W(check all that apply)
New Construction ❑ Existing Building Cl Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number ofUnits--L_ Other ❑ Specify:
Brief Description of Proposed Work=: cc a se �O -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: 11
Item Official Use Only,
Labor and iVfaterials
I. Building ; 1. Building Permit Fee:5 - indicate how fee is determined:
2. Electrical 1 ❑Standard..city/Town Application Fee
❑To tat PPoject Costa(Item.6)x multiplier
3. Plumbing $ 2. Other Fees: $
1. Mechanical (IIVAQ $ List: � (/
5. Mechanical (Fin. $
Sn rossi0n) — _-- lbtal All Fees: .$_
Check 110. Cluck AntounC ___Cash r\utunnt:
6 I'nf:11 Project Cost: $ a6do . U
i � 0Paid in Full ❑Outstanding 13;ilanca Duc: .____
SECTION 5: CONS rRUCrION SERVICES
5.1 Cotutruction Supervisor Liecnse (CSL) /3j /y
FrirW Pap __ License Number Exxpiratiou Date
Name of CSL I[older 3 HH"Stivet List CSL'rype(see below)
Celem IUA,Q,70 Type Description ,
No. and Street
U Unrestricted(Buildings s up to 35,000 cu. 11.
R Restricted l&2 Family Dweltin
City/rovn,State, ZIP M blasonr
RC Rootin Covering
WS Window and Sidin
`, SF Solid Feet Burning Appliances
9•7 k 7 7a/Y� I Insulation
1'cle hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) / y.Z-D 81 ? �j lY
Atlpf;C`yP�r'�wntaia...?",n,��I I C HIC Registration Number Expiration Date
I IIC Company Name or IIIC Wig r��Yt YLLJ P 1 AVmue
No. and Street Shim MA 01
13,s _�Vytly, Entail address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be corn leted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance oflfie building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR
/BUILDING PERMIT
I, as Owner of the subject property,hereby authorize f:/ ( 4 `
to act on my behalf, in all matters relative to work authorized by this building permit application.
/24
Print Owncr'� une(Electrontcsignature) pate
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Ite
ring my name below, I hereby attest under the pains and penalties of perjury that all of the information
ed in this application is true and ace to the best of my knowledge and understanding.
/3
CZ
ners or Authorized Agent's Name(Electronic Signature) Date
NOTES:
Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
t registered in the Home Improvement Contractor(HIC) Program),will tint have access to the arbitration
gram or guaranty timd under M.G.L. c. 142A. Other important information on the HIC Program can be found at
V.niass.tluv;oca Information on the Construction Supervisor License can be round at www.nrtss-1nLddLen substantial work is planned,provide the information below:
or area(sq. ft.) —(including garage, finished basementlattics, decks or porch)
ingarea(sy. tl - — l(abitable room counttterof ti rplaccs ------ Number of bedrooms - -_--_-
Number of bathroom; Number oC halt'baths _
Number ufdecks;porches
I\pe or cooling ;y;lciu _-_--- Fncluxd_._--
Upon - -- - -
V. l of tl I'r.,j:rt 1,priro Pool lge" urry he ,nb,tinit I t w I„tit Plojed Co<t"
Y. CITY OF S:u.E.tii, 1SS.ICHL'SETTS
r BLILOLNC;DEP.IR"[- ONT
120 7ASHLYGTON ' A°STi1EET, 3 FLOOR TEL (978) 745-9595
:<t1tDERL.HY DRISCOLI.
F.*-<(978) 7•W-9344
AL�YOR T41osc�Sr.PlEttjts
DIRECTOR OF PuLIC PROPERTY/BLMDLNG CONNISSIONER
Construction Debris Disposal Atttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition arthe State Building Code, 730 C&fR
Debris; and the provisions of biGL e 40, S 54; section l 11.5
Building Permit I# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as defined by r�IGL c
111, S 150A.
The debris will be transported by:
Atlantic Weatheriration LLC
(nama of haular)
The debris will be disposed or in :
(nama of
Ay l jd is d',
_(�JJresc of rS:ilit�l
signature ufpermit apptiunt
J.ttc
I
A CERTIFICATE OF LIABILITY INSURANCE DATE(MhuODmr)
3/11/2013
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 N CT Construction
Eastern Insurance Group LLC PHONE - (SOB)6SI-770O FAA
233 West Central Street L .
D
INSURE S AFFORDING COVERAGE NAIC It
Natick MA 01760 INSURERA:Arbella Protection Ins. Co. 41360
' INSURED INSURERB:Arbella Indemnity Ins Co. 10017
Atlantic Weatherization INSURER C Nautilus Insurance Co
61 Rear Jefferson Avenue INSURER D:
NSURER E
Salem MA 01970 INSURER F:
COVERAGES CERTIFICATE NUMBERig7wTER 2013 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. 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
R TYP50FINSURANCE POLICY NU BER POLICY EFF MOLICY EAP LIMITS
GENERAL LIABILITY EACH OCCURRENCE f 1,000,000
X COMMERCIAL GENERAL UABILITY P E E Es cu eTET n e E 50,000
A 7 CLAIMS-MADE Fx_1 OCCUR 8500042016 /20/2013 /20/2014 MED FXP(Any one arson E 51000
PERSONAL 4 ADV INJURY E 11000,000
GENERAL AGGREGATE E 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG E 2,000,000,
POUCV X PRO- LOC f
AUTOMOBILE LIABIUTY OMBINMe EDt SINGLELIMIT 1 000 000
B ANY AUTO BODILY INJURY(Per person) E
ALL OWNED X SCHEDULED 020015071 /20/2013 /20/2014
AUTOS AUTOS BODILY INJURY(Peraccoent) E
X HIRED AUTOS X NON OWNED P OPERTY DAMAGE
AUTOS Par.ccIn f
PIP-Basic S
X UMBRELLA IIAB X OCCUR
EACH OCCURRENCE E 1,000,000
A EXCESS LUIB CLAIMS-MADE AGGREGATE E 1,000,000
DIED RETENTIONli 4600047820 /20/2013 /20/2014 E
WORKERS COMPENSATION TATU- OTH-
AND EMPLOYERTUABILITY YIN
ANY PROPRIETORIPARTNERIMCUTIVE E.L.EACH ACCIDENT E
OFFICER/MEMBER EXCLUDED? NIA
(Mandatoryfyes.d In NH) E.L DISEASE-EA EMPLOYE E
Dyes, IPTION antler
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT f
C POLLUTION LIABILITY PL2003796001 O/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000
FA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,ACAitional Remarks ScheEale,If more space is required)
0
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
Rosemary Fulham/PMA
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved.
INS025rsrnrnn m Ths'ArrTgrl namn an,1 loon a.a wnialn.a,l. a.ka of AY npn
Rightfax C3-2 3/11/2013 4 : 45 : 54 AM PAGE 2/'002 Fax Server
r ® CERTIFICATE OF LIABILITY INSURANCE DATE( ll1DD/YYYY)
1201
T4 I
TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. IS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE 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 and endorsement. A statement on this certificate does not confer rights to
the certlflcate holder In lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
EASTERN INS GROUP LLC PHONE FAX
233 WEST CENTRAL ST (A/C,No,Ext): - (A/C,No):
EMAIL
NATICK,MA 01760 ADDRESS:
22MLW INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY
ATLANTIC WEATHERIZATION LLC INSURER D:
INSURER C:
INSURER D:
61 REAR JEFFERSON AVE _ INSURER E:
SALEM,MA 01970 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THISIS TOCERTIFYTHAT-THE P INSURANCE LISTED BELOW HAVESEENSS TO THEINSURED NAMED ABOVE FOR THEPOLICYPERIOD 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 1$SUBJECT TO ALL THE TERMS,EXCLU$IONS AND CONDITIONS OF SUCH POLICIES. UMITSSHOWNMAY
HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDD\YYYY) (MWDQ%YYYY) LIMITS
GENERAL LIABILITY =ACH OCCURRENCE
$COMMERCIAL GENERAL LIABILITY
CLAIMS MADE DAMAGE TO RENTED S
OCCUR. EMISES(Ea occurrence)
ED EXP(AM one person) $
ERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER'. ENERAL AGGREGATE $
POLICY PROJECT LOC PRODUCTS-COMP/OP AGG S
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTYDAMAGE $
(Per accident)
UMBRELLA LIAR r7 OCCUR EACHOCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE S
RETENTION $ $
A WORKER'S COMPENSATION AND WC STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-5B27012L13 03/202013 03202014 X LIMITS
ANY PROPER EER EXCLJIDED? CUTIVE � N/A E.L.EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDWE
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 500.000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED
93 WASHINTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM,MA 01970 AUTHORIZED REPR TAE
ACORD 25(2010/05) TheA CORD -and are registered marks of ACORD 1966-2010 ACORD CORPORATION. All rights reserved.
Customer Name: Kathy Winn Contract. -
Address: 133 Fort Avenue
Salem Readbiacks:
MA,01970 lVene
Subcontractor Name: McLaughlin Weatherizatlon
Site ID: SOD002148050 _
NSL Work Order U 0Q0C0000000Mo1oKAC _
Billing Utility MassSave Pricing-NGRID 2012
Measure' - - Quantity 5coped Quantity Installed - Unit Unit Price Subtotal-
Insulate Rim Joist with 6.25"Fiberglass Batting 144 Square Ft. $1.75 $251.42
Insulate Wood Shingle Sided Wall With 4"Dense Pack Cellulose 1221 Square ft. $1.85 $2,258.85
Perform Air Sealing at Estimated 62.5 CFMSO Per Hour 2 Hour $69.30 $138.60
Change Order Detail:
Original amount of scope $2,648.87 '� �n- _- /
Change from scope revisions $0,00 Owner I lib✓ /11
Change from scope additions $0.00
Final amount of scope $2,648.87 Atlantic
Total change order difference $0.00
*Change order math above will calculate if"Quantity Installed"filled out in
Excel,otherwise Ignore the above section
Please Indicate any materials Installed that were not on the original workscope below:
Product Type Measure Quantity Installed Unit Unit Price Subtotal
..Ss� ._ ... _ ..
unrestricted-Buildings of any ase group which
_,xns cs-087977 # _ •" - contain less than 35,000 cubic feet(991 ma)of
enclosed space.
RRIC W PALS`
$ALUM MA-01970 }
Failure to possess a-current edition of the Massachusetts
Co'mmrs "r 0412312014. - _ - _ State Building Code is cause for revocation of this license.
For UPS Umnsininformation visit w .Mx .Gov/DPS
^,., Otficcn osamer.
y\
�— I HOME IMPROVEMENT CONTRACTOR - License or registration valid for individul use only
S� tiRegisira0on_ .142069TYPe: _ a before the aspiration-date. Iffoaud return to:
�`E piratiore 311212014 Ltd Liablity Corpora _ Office of Consumer Affairs and Business Regulation
A�7 `fIG WEATHER2ATIOlJ I:.:t,.C. E 10 Park Plaza-Suite 5170 -
Boston,NU.02116
ERIC PALM "
61 R JEFFERSON AVE
SALEM,MA 01970 -
L•ndersccrcmry
i Not valid without signature