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15 FOSTER ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY I Massachusetts State Building Code, 780 CMR, 7th edition OF SALEM Revised January Building Permit Application To Construct,Repair,Renovate Or Demofish a 1, 2008 A' One-or Two-Family Dwelling is Section For Official Use Only Building PermitNum r: Dat red: Signature: Z- •(y•// Building ommissio for of Buildings Daze IV SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcei 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 Yazd 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) Address for Service: Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 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 1.Building $ 1 " 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ /� ' 4.Mechanical (HVAC) $ List: n..,/`� //�� < 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 1 �� 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) a -1 b License Number Expiration Date Name of CSL-Holder V \ List CSL Type(see below) ddress J\ ZM Description LQ Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling ' �ture M Masonry Only l-\a-CA Z)\a " v �� � RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2Registered Home Improvement Contractor(HIC) IIIC Company Name or BiIC Re "staff t m Nae \ Registration Number czk. �- Vli \ �V e dress ,1 - 1- - , Expiration Date i - 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 Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize j C yv-, to act on my behalf,in all matters relat a to work ak th y this buildin Spit application. Signatureo caner Date SECTION 7b-.OWNER'OR AUTHORIZED AGENT DECLARATION 1, win Yy C�'�V) ,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. P ' e Si of,Owner or Authorized Agent Date (Si ed nder the pains and penalties of ) 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 110.R6 and 110.115,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"maybe substituted for"Total Project Cost" G.. I t . i .. ai + ACTION, INC 47 Washington Street Gloucester, MA 01930 Tax Fm agency NSGAP NGRID Application# I, PRQGRAM„ AARAWAP 0 ' JOB,NUMBER 1 0 . " DOE Wotk Order# 0 E S C performed? No Work Order,Date " ` 03/t6/11„ kW I I , ' Primary Cont,` ctor ' '' Air=Fight Weathenzatlon�:' ' , i ,I 'Other Cont actor I J' "I ! NA ;I #Bulbs Installed+� � S o od . �I Costo68'1bs So as �llent Daisy Fernandez nspt$125 00,Max F So 00 1 Street i150,: r Street Apt 1R o "Other 'Kin n q� it �IlCltyl,State Zlp' Selem,Ma `�! � ' 'I F ,i'01'970 "�ElectticaLWork Telephone 978 335 127g+ ' S'tount xeyspan , ilil$i A[�IOURt INdlt10[lal �Ii ,' BIOWef Door�eSt NOx !,I I' Ocher uCxlltyi a0 00 jj �'S1 n In9�ect KflOb&,(tube i+ ,P If III�NO !li I , I J,�,51' IIN I +i'i 3 i L� II it a ' 14 11 i i 6 Date Job Completed V ' + ,i ''+ ,'Estimated Repagl Total C$100 00- '. II j;` - P . iA`CtU81'RBpeIP1101aI,,;ii ,. . Act? " Cost EstC'dst Act Cost !]+' i,, $43.00� "', I +� Ljr Door Swee .: ' Automatic'Dobr $22 'Mr.'o alln 12=I`"'art,foa'm °'er hour l "i+ '.2 - �'' f it I i%,$75!OC ' " hi o i4fticAvSe�lik"12� artfoain, euhour $75.001i. IWeathef5tfl !WIndOW erSlde 1 ' +I 'i $5 O� - , IF I k ISeal Dubts .r' 4§tic Lt $82 00 Iv + . 1 �N7/S&InsuL'Attic HatchB30 FB ICI $32.00!"i i [,I it swoG,Nfltl . !' $0.00. liii'+ ff ii I ilfi V7"' riil. :'.. $0.00 � 777777 IIII $000 ,:. $O.�0 411 @athefl2atiOn TOtals:Vrti, I„Illi ,' ,'i,+,�'1 I' i, ";' $150�f00'i. IS! $0s00 r:ro! t1! Iil pl}I' 1 i; u i I1-t , it, I,,a 1 .:'I IiI I L.,1„L,L, l I- _ InSUlatlonu':!;: II1i'i1'I(hi : ' ESt tail' ai,' i„ACta',il 'ii. ;I!.'IGOst, EStCOSt,+ 'I HACtGOSt Attic FlatiR38�o en, ,[i!i!1^I' ', Ili r;. $1.40` 6�,1 AttlC'FIatIR3010 en,ii,�°+;;', i ,.iFlls i �ihl ,Hi i!iSI Ll r'$1''.30'1{I Attic'FIaVSIo"esfR30''restncted" ;+ I' $1141 "'" '' Att c FI&SIo"es,Rtv 20+te"sfncted i !'I l $1.351 AtticKheev✓efR131FG 1,11 P1= r " " Attic KWill Rai Gell� imembrane' I+" %#fflC Kmee vall Floor,R30;rest G.'sulate'AtticiStalrs&'Walls. 14130.00 i' 'A Sidewalls'-'uln hR15'DR' Ir tenor Wa11 R1'31I,Plaste�'R13 DP; •'. "'" $1.81' I festDnll SIdewalls 4 sides P , $60 00 duct Insulation R5&Seel Seams' " 12.95. n ', ' H' dromc Pl"e'Insul to 1'iiR5 I' +$3 25 rr SteamlPl e-'fnsulto1125",RS i" $5:25 �HW PI Ihkmtion1RS i,t 6 4 $2 50 $15 00 1 + ` Insulate Doo ( $44.00 @ Sill 2 art toam FG'Batt R19 I , T 230 h $2 00 �,F 'I @A60.00I 'I ,I l Ni+ Iill,,(IP„i P 1, rlilil i, , - I�W'T75100 i1,l1 If - d$0'00 i ImsulahonlTotals 1L � Iu I +'I A i l !Ii '!i�l�/Ai i, Ii r �' 'l iu � i!11, I,, ' �'.�� 11�9e,!�i l!.I ri li il.l'r.11H a. ' .0 .'li !�. ,n' 1 1� �u, -1w.. Jdli. il. i, i i. 0a14y Fernandezi I,. + ,11'1c;iji, t.11 Page 2 I a"11, 1 DOE Other Measures I. Est ; ;'Act Cost,, . ; Est'Cost , ActCost Roof Yent-small $76.00 i,! GableV.ent'rRedtam ulaf' ' " $88.001 V.n IReIacementlWindow-'73 ui Vin I Re lacemerh W,inCow-83 ui :$400100 '" ! Xlii IRe Iacemenf. i66ok'93ui „i li$41+0.06, Vin I Re lacement Wlndow�-10,1 ui Vh IRe 1 Bsm t,Ho r pper�Vilindow �'.! '+ b $32500 �!� • ' ,• Steep Pre-Hun .Door w%Cite $6110:00 Solid Core'Door.w/Hardware. $35000, FaucetAerator r $15:00 . IE. 777-77 Low Flow'Showerhead' $25.00 I61'owe[Door: Test $45.00' d Window Grids-iper sash $20.00 !'.' $100'00 Otht-r Totalss $0.00 kh Ener Con§ervaklon ; !. " " „Esb Cost. I Act Cost i; Total's: Maz;$10;000`s00 „ '"' ,,, .I If i ';'$625"G001 ,' $OAO •"I Re alrs, '!i a. '+ a' _;,. Est Act p++Cost,." EstC:ost Acf,Cost 6'uildin Perrnd Fee' „e 1 $100.001 Door Threshold . lif fi 'IT f,10$40.00;i' +! @, h iRe air Door hlln e,' ": 'I I$25 00 + Slide Bolt a �,I ,, f' �$20i00 aI .I. IIf " , , Sash Lock $9.25 d.77 Glass Re lacement-tofi4ui �s R, <• $42.00 li„ " "' $0.00. �h -" tl +. q! ;i;i $0 00 r „ A 1 'a la 1": + 1 1f f x f 11 y r F, I� Health+&.Safet 'I'. �, hI, dI r f )!/,entClothes;D, ertniEzCenor ' l,: '' �1i911$85f00�' 'i�'i +I 4 ++ Vkcrtn6ath„ExhaustFanutoiFtendr� �� +IP1l'�I$65'.001 , II++II " 'll �t11 ,• a Re lace D' e'r Hose" 11 7 $�.DDI:f 'p14 {' , ;a If U .F - II t J $O.DD tlil, I i'I I — ' •y;;i $0A0 Ill it ,+l, I .f., 14 Re air,ITiot:liMax,f$2500001. � . �91.t11, �I,, ,'N,r'"' "I? �L;1V11 'fi, p1 �11 ,' ;! ' ;ra ' , ;.$10d100 '+'t � , •; $0.00",l�i(r I, J fl, j!Wful("lIII illl IffjJ., t, if 1 1„ r' 411111l , { ill'!' QL )',I �IIWOrkdOfder_3ublTOtal l,' ' ', f I ,I :1:,U, ly .nl I� a ' Ih11 {i!I 1,1k$72500 �" ',L! $D.�a a r ' „fll I i ili , f a4,f III f 1 f V II I,J1ll ii f t, d ,l , l ,I II I(II fI f , � I,I II 11 If.�t i „ i I , 14 1 Ills i' 1f ,- ;L.1 f4 kill�ll f , ! , I f + I. I it I „I I II If 1 1 l N l II ,L i t il', f I. H41 f i ' f II_ f 'f,Il�' I , ` Iis lif ll , ll� , F 1r 1df 'h I . t f I , Ij, pi`) U III Ioi h _.,r} f I. _ � ,,n _:. I, 7.� Measures "''i Est 'zi " Hck h,If Cost ',. ` ' '+ EstC9st h I "s AdlCost +Other= , • {- �- r: Heatin 'S stem Re air ! $Of00 i' $0 00 'l t r_' 1 f ',Action,approval only 1 1 � �, I I if Ir + ' f, :I ., aP:I{f' '.Ii +, ,! i� II ' f !f Estimated Job Total r ,' $725 00, Jgb,cannoYexCeed 1�0,00000 h 1 f :l 1 Illf IIJi If, I! I ,- u§ , I �.I Job minimum $200 D0 11r n „ Job brand Total0 00 ra: I�: f . ,, AUDITOR ",, ,Brando,� Dornngton .,III" , t� 1, I I,: ,,a.,,, , ,..� �' . ,., •.+ , , NSCAP 98 Main Street l Peabody, MA 01960 #I. 6 'I '1 'I Agewy " NSCAP' ' Client A ' 71- 3t�onp# F " PR©GRAM , Keys an d 20333 Idi Il I I, I P , ) p i alit IIL pl , i it II i' " e' ,n 1 I! , l t i II ,1 III i, ij ,(,a IwOC�C'�Idel'#i li 1' Q I t f I,I 1 Il li ifl i{ V11', t yl! ! , a t II 'I : iti it F ,ihLl',Work©raerlDate ul„ j:1 03/,16/111 ' III ' 'JobLtmit l 'aiil{i'l t1 itII ,I , III I}' 9JO fI,,I , lj,Ii it I ,i , , t t � { t l II 1 . 111. " I, h' ;aPrunar�Contractor i,l, II Air-�3ght Weathenzahonl' 4 I :1 Per Unit $45QA OOr �' Il I'I Id UJ'll'I'I, lit,'I' J' , I �[heC IIl}�'aCtOr - i „ ' ' -it '- Lf it ,iit it J i ' 1 l f t , III I I IStreet f5ltFoster,StreetdApt 1R, t , ,; ' ! ', K$T I , p I, „I }�t� 0I i iIIII a! I'sll 'III I '� I „I ' i > f 71n III 1, i, IIIq, ,,,, i ii �t't^t�,i State Zlp Salem,Maf-1,l til ,, l it Ji r4,il'lll f , i , , Il 4 '4 NOI ili Lt Tel hone 978 335 1279' ° II i Stand'A'lone I, ? 4'I '' I' l'4r I„i111 Ii#I GI- 1 1 t I, II ;I ' ., tl' 71 II, iMlal,it,I'' i ,¢li' l41 tl lxi II IP. {I! t } ''I'141,i�', I , fee Code III, a I I, J,,i try i J it I I It itlt I III It'I III, f II uli. ,P h$IoWOI)n.QOL Vest I „',I -.4 I If l I- , f h a I �O -II AN 11},I ll� I�i,i, i�,, }-J 'l' J4i 't hll° lull ( t 14 I .... 1�_ e l' 1 •i,t , • a ...a ,I F. till 'P3i i' I #, ' ectKnob!6d'TjXWWo„ Ii II niEl_ec',C.obtiactor ' L{„"l , ,'!;li I II ,r IIL, . : ', R ', III tall 11 I 6 iliii -�,I)� J,lt, �IAL1411 Yh,ti NII I' {IC � ,.'. Y t I..:v!2 Y {il .I � i, ill .A Attle'RIISU18t1b I'l gjlf i lti�!nj tl ly'ilq#'I I'I lilll ,l ' i II Estl:FJ„ I I !I J IdG fl �P d I J t 7 llp, , JAi,11 l�Gt 1 I ! Ik,t Ost 1�I _Ili: :'.�St t m :. Is :.t ACt Gust..( ' �ii't �I� � , I Ai �.:ii 1, {I' I." th : ,^ a „I, li[ II d,!J I,I , li ll.l I P I 1, 1..!it II ,, _ I .I ,r ..i .4 i r "I: a :.•tli I.I ... i9, .,,LJ 4 t I, , l t,I ! III 'Fj f lu ,.I( i SLICIFIa�t•Rr318�0 eniY�, i'h , y' Fljl li yl t,lti l,l y'I#l�i#� I, . I' 4 H t .,t,h,;A �, ' yl IP ' i' ,{?I 11l i.ktll fl i1dllii tlir 7l ylµt IIII II,J , t •fimmm- i II 0.1 "f II 141 � ' " L ArtICi]at'R�O,0 en� I���•, .H,`�- ��. ,III, „ 1 ,I$P.3D�, i411 kih9, ��, �II I f :I y�yll l i�q,,w'J,. II Ii. ,,,)Pill J6.d'lI�t1M,i l i I al lll'I t jlf.l,l' ,!I, (;LI!'i °dt ll, hflC9)jl�at} .D t,O en,{.aliHfi 11e „�,�C+ifl 11 ,I „i nt Nnt7� 1'. . ,: , :,I - III Ilan. II$1.23:I•i ll� ,1.14 I J l l q 1 '.� n li l'nti'ral , I.niq t��t.li;:liili i �;l ;�i '; i, hI,yIS .. •,'� i, 1 i$lii15 Lit I.il'�'I i;ll } -:itllli v)ti ::;11•j ' I'yii' Amc,l lat LtIA,o en a.# 1 i„�., n 1 I n' n• fll. U 1 ,,III i, G Amc$lat)Slo eR30' estncted Ih±h�{ t9'� ',;, II 1, , ,3:' l.IJI' ( ' IiN; i= a l ul I nl, �. AtticlFlatrslto OlR2�L%a, �tnQtedy;llllfu,�4111i'{l4, !iijlg l� al ll�l;l f' ll�',$13'S; 1 11 , all „'r fi ,J �I Iift tl . II „ , I I, H 1 �ttta'�I t,yy. .�.t y I jlat/S9.o rR10(t'e8trlatac5;�nl�il li,��1' Ir 1 �IC�I� I .'I .0 ti, , I• ,I'.I„$a 24L�n t !.,. e, "i �I I '�..!I{a , I If„In!-,Ih' Il.W t,Ji,:p„ , JI iJ Ij III +_, ,p:I i,.i , dill l -,IP zl i I' 1'l I AtMcKgee a11tR13JLI •li, .,tl,lui�llla'llbl,'Sha�i��, ,,', {lt, �;ly.ltl$1,251 ,,1'lu >fll111 .du fib?' t,! , ,'I. ! Inl, u^ , I IJII II'p u I fµ 111 f( i f i ry, n 1 .1 ,i ){nCCWalll Pl),�Or1101tE CIGCCdII I,I� II�i, °.[.J,I h��P7 ' $1!�IJ 4 Yl1l,ry f ,IAl,fi4 ,it Y 'hi ,..• , r I Iva it"I , 0YP It -' f 'I Fj'-1n1She`d.7�mC,ACCess. 'S,"�kk.,I _yy. .11ltp: n�IV , I'll• II I: SIDO OOil�lill}ukdn I'. P �'.l,p Tern ' I,,, ,i�Athc'Acce'ss!'14i°,y,6il 'np'i:i!i,�I�lll7niia?�I " ,''.;�i„� j, Ih,:'I I ' tl ,a lII t I'il-,JrE $75 001 't� ,I,, ;r. J l .es - • a L:,r Er'& �S BC ,Ri119WIP 1 �Ga OIIDarrl�,''hlhll YI,'I IJIi I� ., n o r, r _ i, dl _ ;±,'L1 I' Yu{I It'a Iv G ;;I, Gana e.Ceilin , .lopr A301(Wrtkh�al raval 'a , �,:I . .t;' .:.,;IAla lla n "•n I , �LI I I, iji„ ill p Aa�4 I , • i 1l7 ill ll A I �� ilti,{ - '� ih ,r.l ,t III! Ihermadornelnli< ,I,An��I l i 1 L! it"i.l tt� �": n�.l,,, a 5.00 I ...... i n ,la +L Iit ROOfdn�Ontl'aTa J'I u.`2 i,, '�! I!!I I''' '14II, (i`il,l ' i.l I,'JR' 'I .hi.tl$9500t Inl, ,Y ,1f i-t iC, II I 111, Jii 1 1�,n ..: t'. „ - I� 1 f I,A' -•I} l p L ,i l•' ROOf,V0nt 6mallt l'.I''.�)At,h, li ,.'!l.•..k. Jf I111a,'Il'al i� , �i` i`.#l$76 DDI � ,PI 7 ,l, =„I 10 J,i� bl , ,i„ ILI ^• Tudbine.�eIlt �.ul .f_l i J• �I~ 'k$1160 DD E dl t .7 �,�iIf 12°'StackVernJ { Ilti'lit`, 1 11n !4l .N.i'. I51•i ;' - $145D0111 I „ , ,...is ,' I i.;i II , ;il ]It0of Vent ��il �tiP �, I III!.I,'h' l i,�•lII ; $ Y L' s I t f " i I•:u�it i.i ri , t it I. i '�S 3.75 �; Iir (rablC�jentl laps SlZes�hl"�' 'L,1� 11�,IIPtittk 6' L.n' ,I'�li ' i.-I' , ,,h�$8$po r�•u It11 .'h'�, t,, 1i91i ' FI Soffi 'I It If ,tP "ilp d N „l.0 , a?i- v _ .tit f l it it 1?ent2) I,J '' �'.ii�I U �, I -'hi 'r,6 ti'I,� _ A It. , : $26.00 --- i Itlt IP' ,I r -'S e - it , , 'r Rdd a Pent{( eraln rR.)i x,l,: !i 9! t„ III' .i.. $22 00, .i, ,mA:., i a I.t(. . , t-k. ,I • Amc Au S'ealoig 2'- art foam. 2 liours $75 00, u �%ent D 'eilBatfilPant!Jti 1,�,i!, r.,l ,l ' $85.00 '71',. 1385100,. jr, Ili 1 If I ,t,,, ,J I,. 4,t Kndb&,Tube Wirin .Ins ectioIl $125 OOI,jilt 1 hr ' I ' 9, f r - I , , '' >•Datsy,F''eLTlande2 IT 7�5 itr EStilliii lI. ..r lliAet . I' l�il �:O6t.iL !i:1 1'uEst^t)Ost � AQt Mast- Wallelneulatlau,1 f:; sY• ¶i �,�II Sin'`le'Nai7ad Asbestos/A"a halt DP " j,$21,1!0, I-_, DoIT uble Nailed Asbestos!Alumiiurri DP 77 $2120'.% I 3I161C' Stu6ea ' ' I !I : : iGl, I$2.75�,"I u I Ulterior Wall Blow Plaster DP '. " 340 $,1.81yt l`'s r$6115! lit I Cla boaid('Wood S)iin lel/Vm`1 DP : . „ $1 70`, t'l ; I' ; Test Dn114'rsides 1$60 001 , It LE 1r :t , '1 ll, .I ll• r !`- ,r ` t n , n f�j ,r �al I; ,FIB 1 u'^ I I!I , 'J1u t _ S11t 50811a Lllalt it ill T t1 k IT l't TIE* r ill I ++ !SIL 1C FeiLd rWBIO,SY0P1)aarl=,i$40Q,.1 �.II IuJ ' 1,it 1 ! I ' ,il+ i0 Irk I, I 'I �' t t, ;r y IT ile �11 �lersl=$ZDDr II �5 Il,tt lz III 1l71.ll :' l {I' 1 _ I: ti, n r t' l 1:ft'r 41 ( l j1 - II l , ai Nt II n� i ]]OOP'Ktt' lit .I .'''_ ' `;;{ l' 1 i r "!ill$43 00, i I l�I , '� . r poor'Swee 1 " III,I { „ r II �nl h al $15'00� iil + 7 ir ' UtOI118t1,CI'J)OOCi S,Wee r 'II C a l l ''" l i ,fu,4 ti' 3 ,{$22100 Flt h l C I' { , t l 11 x AtTSealin I(3,howsmaX t'{'. • !':[I j 2' Y$75'001. ' t . '$LS0100 k, I' t' t ;41 ashLdclC :ll! r ll1 ,I t lfi 'u.•r SIP Itr ]ih' ItY+= v'e' ! I t i 11 + r{ I' t ,m{J! $9 25, �G , 4'I , y3s6 RB 13CeIIlellt 1 n; ,,,f Lr"4 r l .I i lri$42.00 �I +BlOWER'DIOOF Seto .ISw i t� �1 'II {I 6{I qn Y r 1 i b P l l. ( tEll u Il l}$45 Op Ilij , { rl I '. r ", I7 of I rr „hIi Ii tt f,I IIYr I I' + �'I J YI 1 1 { .19 t r� r 'all r 1. ail N jl 11'., f 9 -' d i t S.I I i I rblr ll. t 1 I TE 1 1 e. 4,Ir 1{I. III I , !1t1 I ,nill v'111';Ni FII III, IrI1 1NI, ...I{t rlp t i :Ir1 11 I'e tI-_ �;{ li p l '' l a d: l r r. s e le: -:it,1'. j "I •!�1',I, I 'I �n l!l ". 1''li. ri +n n( I•, ::1 illr ":c { - ! 1 f •�' T - IT _1� 4 � I`- Il.Jilq TOtal�'AIr.S.eehn ast : 1,1 �' .0 I l4 tI 'l. I d a I .... - $91 LSp Qo I F 1 t I:Ii IT Ilt l'.¢ �, I Irr :a l , l tl,.� II IKI 1i 1111 it 4,'' : t1n �BatIL �S;StEID MP'.ds4le8 II , t .. L,i j+ {n fIl 1. � t 1 r {,-J,L ' If a I,I �D{uct IInsulatio'm& Seali{Seams s 'l'ift), "' '„ �., I {,. '"I jl II f I$2 95 �,!`Iry'", ` l _' + , :r•'; Ll �Irallla pl 01 usb1addktOlr!.) PtI ,'II,'tr' ;,l,+L i.I tI'i 'lllh{i 125t ,rl ry{n+ , t114{, . . -. .. Ora IrnV� ,Ioq Irt F ,jtrll + f ul , III) H IdT0711Ci�"1,,B'ILsll1aU4II 11'25ri-I-)IZ5 PI''ti.' 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I{ii I'1 , I.!IH III 1 tr if II t Q I+ r 1 u I!I tr {�II ,ll III{,i,lh I dill I II1 1 C' It lih - :. II II {II lil :I II Ilirl{t17� 1i �II Ij III, I IItI !' a II II::I{ U 1 r� l t ll PI+ It'I t = N I!I Ill rltlr U 1 al it l , ll II t,fll :,�atll + III 1 r'I {51ry1 II It 1' 1 IN•I fl -1 it f 7 " `i tl Iliiti 1{:jll i1111 r.11t 1 Lr 7 di ll Ilt t', I.` d I,I� ���� I Il j� r' {i !II1II{Mi r� �{ t +'l I�I rLj'I FI n '� r•J t{ r I li, iEi!rp d !It r t 1 hall +nn, tJ I13911 It .1 .R rt ,I p III {'I h •�: ,.••I,j till"I �1. I ,$V OOb, i�Ct Total Office of Consumer Affairs and usiness Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home improvementGC:onn"ctor Registration T Registration: 165640 om �'1 Type: LLC Expiration: 3/15/2012 Tr# 294587 AIR -TIGHT LLC. WEATHERAZATION 1 JAMES FORTIN rr4 10 PINE KNOLL DR. BEVERLY, MA 01915 ;-_._, Update Address and return card.Mark reason for change. Address [:] Renewal Employment Lost Card DPS-CA1 6 50M-09/WG101216 ¢ Pa7,rm,mt<�rea/.rye o�✓G/.aaaac�u� a @@@ - Office of Consumer Affairs&Business Regulation or registration valid for individul use only - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration n 165640 10 Park Plaza-Suite 5170 Expiratiorr RN311512012 Tr# 294587 Boston,MA 02116 TypeR Il LLG+f AIR-TIGHT LLC:WEA7HERAZATION z- JAMES FORTIN 10 PINE KNOLL DR � 'i 4�'46--� -- �— - BEVERLY,MA 01915"`-":�_`"- Undersecretary Not valid without signature K 'Iat;a fim ctr.S Del,a *. -,i ..ii'Ps 11 I': `!.f1• Board of B.t11ding Rc•ula:inns and SGmdards Construa-ic.a SJP�i visor Lic:. sue License: CS 52576 i Restricted to: 00 JAMES E FORTIN 10 PINEKNOLL GAR s 1 BEVERLY, MA 01.915 E-wati,.i: t0/3/2011 r'onnnivsi^n`T Tr#: 200 The Commonwearth of Massachusetts Department of Industrial Accidents Office of Investigations 600.Washington Street Boston,MA 02111 Tj www.massgov/dia trorsE1 u mbers Workers' Compensation Insurance A 'davit: Builders/Con aP1 a"prrint) bl A li ant nio a 'on G � Name(Businesslorpnization/Individual): Address: \ <�) -1 01` \, City/state/Zip: Phone 0: _— riate box: Type of pro]eet(required): Are you an emptoyer4 Check the app 4 Q I am a general ctmtractar and 1 6, El New construction 1. I tiro a employer wilt + have hired the subcontractors employees(full and/or part-time). 7. Q Remodeling listed on the attached sheet.t 2.❑ 1 am a sole proprietor or Partner' Then attb_aontmetorshgve g. Q Demolition ship and have no employees workers'comp.insurance. 9, []Building addition working for me in any capacity. 5 Q We are a corporation and its lo.Q Electrical repairs or additions iNo worker'comp•insurance officers have exercised their required.] right o£exemption per MGL 11.Q Plumbing repairs or additions 3.0 1 am a homeowner doing all work Roof repairs c. 152,§1(4),and we have,no 12.0 myself.[No workers rAmp. employees.[No workers' .� insurancerequired]t 13.�Other �r\c��OV� _ comp.insurance required.] 6o fat out the action below showing drab workma'compemadon policy tntbrmation, each. *Any appgcent out checks box X I roan a ova t Homeowners who check 0 this affisdn�ched an additional dthem showing the mum of the sule-e nnnsamn and ttheir wcrkon*comp-policy ommdon. IContractoratkat chak this box I ass an employer that is providbw workers'cotupeasatiOn insuwuce for my employees, Below is the policy and job site lnformatian . L t^\-^ _ % Insurance Company Name: Policy#or Self-ins.Lie.#: X/��', -,� . t 7 b \ � � Expiration rmrr )r City/StateMp: r �c��5— ' Job Site Addrrsa: --�� shawl thepolicynumber and eirpiratlon date). Attach a copy of the workers'compensation policy declaration page( ng tntder Section 25A of MGL c. 152 can lead to the imposition of criminal Penalties of a Failure to severe coveragerequired pas civil enaldes in the form of a STOP WORK ORDER fill fine up to$1,500.00 artdlor tine-year imprisonmerd,as we p 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. 1 do hereby certify under Ike Pala and penalties ofpedury that the information provided above is trite and cor►ect Phone#. • q1�h Got � a�o�� Official use only. Do nor write in this area,to be completed by city or town gffictaL City or Town: Permit/License# leaving Authority(circle oue): 1.Board of Hearth 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person. Phone#: 1234 lftl� �Danversbank a AIR-TIGHT WEATHERIZATION om Dmcm=tS ,9EJ 10 PINE KNOLL DR. 918-777'1 2f BEVERLY,MA 01915 53-7116-2113 (978)998-4684 . . PAY TO THE - d ORDER OF �P DOLLARS z, m MEMO .. AUTHORIZED SIGNATURE 0001, 234u■ 1: L37ii621: 35 31086811' AIR-TIGHT WEATHERIZATION 1234 AIR-TIGHT WEATHERIZATION 1234 I PRODUCT OLT104 USE WITH USED ENVELOPE Deluxe For Business 1-800-225-63800r www,nebs.com PRINTED IN U.S A. A A 00 M f J ENDORSE HERE i n'] NOT '44WE STA"P OR S[G'+ E1E OWN Ti4-7 NE 4 — in: . runty G Jo-+r :S[1 h-to�., ::[w.'^ �•� thor::' ray d orc,-d nd,,try ou'd-'n ^ S cv,ty P Tu Rr 'u:t-of doCuM..nt Ai.er.:tion: