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10 GARDNER ST - BUILDING INSPECTION i �28`q � � ► 1s RE( i¢\inn lth of Massachusetts CITY OF 9 ►(iSPEC� '' f� it�egulations and Standards Co ALEM Massachusetts State Building Code, 780 CMR SdMar lBa ^ �b Revised Mar 2011 Building 1��,��ppil ti T nstruct,Repair, Renovate Or Demolish a :J One-or Two-Family Dwelling This Section For Official Use Only f Building Permit Number: - D Applied: V n i l 1 U. /D 0#1 Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 10 Gardner Street 1.2 Assessors Map& Parcel Numbers I.1 a 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 It) 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Allison Canty Salem,MA 1970 Name(Print) City,State,ZIP 10 Gardner Street 978-808-1843 allisonecanty a gmail.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units f Other M Specify: Insulation Brief Description of Proposed Work: Blow in cellulose to the first floor exterior walls SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 3,779.55 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: 5.Mechanical (Fire $ Total All Fees: Suppression) $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 3,779.55 ❑ Paid in Full ❑Outstanding Balance Due: MAID ❑-M C�i�i L(1C:T'Dl` M4,4, .�1f, �q ►� i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-052576 10/03/2017 James Fortin License Number Expiration Date Name of CSL Holder U 50 Rundlett Way List CSL Type(see below) No.and Street Type Description Middleton, MA 01949 U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-998-4684 phil@air-tightweatherization.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 165640 3/15/2016 Air-Tight Weatherization, LLC James Fortin HIC.Registration Number Expiration Dale HIC Company Name or HIC Registrant Name 50 Rundlett Way phil@air-tightweatherization.com No.and Street Email address Middleton, MA 01949 978-998-4684 City/Town,State,ZIP 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 .......... IX 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 James Fortin to act on my behalf, in all matters relative to work authorized by this building permit application. Allison Canty 10/7/2015 Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. James Fortin �"�`"'�'" � 10/7/2015 Print Owner's or Authorized Agent's Name(Electronic Signature) Date 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 can be found at wLv .mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work is planned,provide the information below: Total floor 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" Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165640 Type: CLC Expiration: 31152016 Tr0 248557 AIR - TIGHT LLC. WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR. BEVERLY, MA 01915 Update Address and return curd.Mark reason for ehnnge. SCAJMAC5,11 Address Renewal Employment Lost Card -TG, License or registration valid for individul use only Ogre efConsumer.A lTainS Oasine»It«almion p y ;HOME IMPROVEMENT CONTRACTOR hcrore the expiration date. If found return to: Registration: 165640 Typo: Office of Consumer Affairs and Business Regulation v�mrV-, 'Ezpirtion: 3/152016 LLC 10 Park Plant-Suite 5170 Doslon.ALA 02116 AIR-TIGHT LLC,WEATHERAZAT10N JAMES FORTIN 10 PINE KNOLL DR. �_ v BEVERLY,MA 01915 Ondersroretary Not va to without Signature Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-052576 Construction Supervisor "'-, r I, ,,, JAMES E FORTING -. Grp 50 RUNDLETT WAYS, MIDDLETON MA�01 ` (--jZC CA_ Expiration: Commissioner 101O0f2017 � l The Commonlvealth of Massachusetts — Department gj/ntlustrialAceitleuts I Congress Street, .Suite 100 Boston, MA 02114-2017 Ivry iv.mass.gov/dia Workers' Compensation Insurance Affidavit: Geucral Businesses. TO BE P'11,ED WI'I'II TIIE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name:Air-Tight Weatherization, LLC _ Address:50 Rundlett Way City/State/Zip: Middleton MA 01949 Pholle 1/:978-998-4684 Are you an mnptoyer?Check the appropriate box: Business'rype(required): 1.❑✓ I am a employer with 30 •employees(full and/ 5. ❑Retail or part-lime)." 6. ❑Kcsfau ran l/liar/baling Fstablishmm'll 2.❑ I am a sole proprietor or partnership allot have no 7. Office and/or Sales(Joel, real estate, aura ctc.I employees working forme in;my capacity. 8. ❑ Non-profit [No workers' comp. insurance required l 3.❑ We are it corporation and its officers have exercised o. ❑ Fillertainmenl their right ofexentption per c. 152, p 1(4),and we have 10.❑ Maoul'acturing no employees. [No workers' comp. insurance required]"' I I.❑ Ilcalth Care 4.❑ We area non-profit organisation,staffed by volunteers, Insulation/Electrical will, no employees. [No workers' comp. insurance req.J 12.0 Olhcr_ •Any appliemst Ihpl checks Nos 01 nmsl also Jill nut the section below showing their workers'eompensalion policy inli+rmaliun. --It the eurlNm.te officers Nave esempled themselves.I'm Ilm a..I'malirnn has olhu a workers'compensation Pnlieq is re,plimd Red<uell un mgmtirnliun slmuld deck be>#J. !mar an engitrger dmt is prnnir/ing workeex'cnmpen.crrriorr ircenrrnrc<�tar n{I'emplgpecc. Retail,is the pottier iulimnation. Insurance Company Name:Guard Ins. Co. Insurer's Address: P.O. Box AH /16 S River Street City/State/Zip: Wilkes Barre PA 18703 policy it of Self-ins. Lic. I$AIWC 693663--J- --�"- L;xpiration Datc:7/1/2016 , Attach a copy of the workers' compensation policy declaralion page(showing the policy number and expiration dale). Failure to secure coverage as requirc(I under Section 25A of MGL.c. 152 call lead to the imposition of criminal penalties of a tine up to$1.500.00 and/or one-year imprisonment, as well :is civil penalties in the fount of a STOP WORK ORDER and a fine of up to$250.00 it clay against the violator. Be advised that it copy olthis slalcnlenr may he forwarded to the Office of Investigations of tlic DIA I'or insurance coverage verification. /do herchr certify, unde r the pains at renrrllics r f Perjury that the in(ormaliou provided above is true,and correct. Signature: Date: Phonet/:978-998-4684 Ofliciat Ilse otr/p. Do alit sprite in this area, to he caur/rteted hl:ci(v or town official. City or Town: Permit/License it Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.Cilyfrown Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone it: ' GG CONTRACTOR WORK ORDER Conser atlon Services Group 50 Washington St.Suite 3000 Printed: 9/28/2015 Westborough,MA 01581 Work Order Id: S79674P91645C271 Contractor Information Customer/Site Details Air-Tight Weatherization Allison Canty Email: allisonecanty@gmail.com 50 Rundlett Way 10 Gardner St#A Phone(Eve): 978-808-1843 Phone(Day): 978-808-1843 Middleton, MA 01949 Salem, MA 01970-4854 Site ID: S00050079674 L___. Total Installed Measures Location Description Quantity Unit$ Total $ Living Space Insulate Clapboard Sided Wall With 4" Dense 1,665 $2.27 $3,779.55 Installed Measures Total $3,779.55 'Road Blocks Type Status Notes Asbestos UNKNOWN Payments Incentive Payments Weatherization Incentive $2,000.00 Total Incentive Payments $2,000.00 Customer Share Total Customer Share $1,779.55 Less Deposit Of $593.18 Customer Share Balance(Due Contractor) $1,186.37 Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500