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8 GIFFORD CT - BUILDING INSPECTION (3) The Commonwealth of Massachuseft's C If3kAC $ RV L)ti; CITY OF Board of Building Regulations and Standards SALEM i Massachusetts State Building Code, 780 fMRJUN 23 P 3: 2Mvised Mar 2011 r� Building Permit Application To Construct, Repair, Renovate Or Demolish a v� One-or Two-Family Dwelling �Q This Section For Official Use Only 1 Building Permit Number: Date Ainied: Arm ticJ 61d Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 8 Gifford Ct 1.2 Assessors Map& Parcel Numbers I.I 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 Pt) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.6.1,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: Monique Nelson Salem, MA 01970 Name(Print) City,State,ZIP 8 Gifford Ct (978)726-7819 monique.audette@gmaii.com gmail.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other M Specify: Insulation Brief Description of Proposed Work': Blown in cellulose to exterior walls SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials I. Building $ 5,556.96 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost' (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 5,556.96 ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-052576 10/03/2017 James Fortin License Number Expiration Date Name ofCSL 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,Slate,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-998-4684 phiI@air-tightweatherization.com I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 165640 3/15/2018 Air-Tight Weatherization, LLC James Fortin HIC Registration Number Expiration Date HIC C ommleNWHIC Registrant Name 50Ruttm phi]@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. flo ,o e N� Jun 20, 2016 Monique Nelson Mo,,;quJueisonWuoza.zol6) Print Owners Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 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 ( "_ — 6/20/2016 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 wy .mass.eov/oca Information on the Construction Supervisor License can be found at www.niass.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" CONTRACTOR WORK ORDER CLEAResult 50 Washington St.Suite 3000 Printed: 6/15/2016 Westborough,MA 01581 Work Order Id: S6525OP74961 C271 Contractor information Customer/Site Details Air-Tight Weatherization Monique Nelson Email:monique.audette@gmail.com 50 Rundlett Way 8 Gifford Ct Phone(Eve): 978-726-7819 Phone(Day): 978-726-7819 Middleton, MA 01949 Salem, MA 01970-2211 Site ID: S00050065250 i - -- Total Installed Measures Location Description Quantity Unit$ Total $ Living Space Insulate Clapboard Sided Wall With 4" Dense 1,224 $2.27 $2,778.48 Installed Measures Total $2,778.48 Road Blocks Type Status Notes Knob & Tube Wiring FIXED seen in BMT ceiling 11/10 Rcvd eval-no invoice will be applied, all K&T cleared. Lic 1f confirmed.2 family; 50065250&50065255 Air-Tight Weatherization 50 Rundlett Way Middleton, MA 01949 978.998.4684 CONTRACTOWNER AUTHORIZATIONFOR CONTRACTOR TO PERFORM W•• I as owner/authorized agent of the subject property, hereby authorize James Fortin to act on my behalf,in all matters relative to work authorized by the building permit. Owner/Authorized Agent(Print): Monique Nelson Date: Jun 20, 2016 /r o.v lyerso., Owner/Authorized Agent Signature: ^^°°, N.1 .n(J 20--200166-�— Contractor Signature: ��'""""'b� �•a-�"^" Contractor:James Fortin Construction Supervisor License:CS-052576 Exp: 10/03/2017 For questions regarding assigned work: Contractorinbox@CLEAResult.com. For questions while performing work: 855-821-2205. CONTRACTOR WORK ORDER CLEAResult 50 Washington St.Suite 3000 Printed: 6/15/2016 Westborough,MA 01581 Work Order Id: S65255P74967C271 Contractor Information Customer/Site Details Air-Tight Weatherization Monique Nelson Email: 50 Rundlett Way 8 Gifford Ct#1 Phone(Eve): 978-726-7819 Phone(Day): 978-726-7819 Middleton, MA 01949 Salem, MA 01970-2211 Site ID: S00050066255 Total Installed Measures Location Description Quantity Unit $ Total $ Living Space Insulate Clapboard Sided Wall With 4" Dense 1,224 $2.27 $2,778.48 Installed Measures Total $2,778.48 Road Blocks Type Status Notes Asbestos UNKNOWN steam heat Knob &Tube Wiring FIXED seen in basement 11/10 Rcvd eval-no invoice will be applied, all K&T cleared. Lic#confirmed. 2 family; 50065250& 50065255 Air-Tight Weatherization 50 Rundlett Way Middleton, MA 01949 978.998.4684 CONTRACTOWNER AUTHORIZATIONFOR CONTRACTOR TO PERFORM WORK I as owner/authorized agent of the subject property,hereby authorize James Fortin to act on my behalf, in all matters relative to work authorized by the building permit. Owner/Authorized Agent(Print): Monique Nelson Date: Jun 20, 2016 Owner/Authorized Agent Signature: Contractor Signature: Contractor:James Fortin Construction Supervisor License:CS-052576 Exp: 10/03/2017 For questions regarding assigned work: Contractorinbox@CLEAResult.com. For questions while performing work: 855-821-2205. The Conrmonwealtlr of Massachusetts Department of ludusL•ial Acc•ideuts IF Congress Street, Suite 100 Benton, MA 02114-2017 Ivrvlu mass.(rov/tha Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED N'ITI3 THB 111IRMITrING AUT110RITY. Applicant Information I'Iease Print Lceibly Business/Organization Nan1c: Air-Tight Weatherization, LLC Address: 50 Rundlett Way City/State!%il): Middleton MA 01949 Phone #: 978-998-4684 Are you an employer? Cheek the appropriate box: Business"Type(re(Iuired): I.Q I am a employer with 30 _employees(f Lill and/ 5. ❑Iteuil or part-time).' 6. Iicslatu':ml/[Iar/Fall ng Fstablislm,cat 2.❑ I am a sole proprietor or partnership and have no 7. EJ Office andlor Sales (inc1. real estate, ao ),etc.) employees working forme in any capacity. l No workers' comp. insurance required] 8. ❑ Non-pro lit 3.❑ We area corporation and its officers have exercised `f. ❑ Hritertainment Iheir right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing eo employees. [No wokers' comp. insuruwe required)' 11.❑ 1Icalth Care 4.Q We are a non-profit organization, staffed by vo n lun. eers, Insulation/Electrical with no employees. I No workers' comp. insurace req.) 0 12. Other __-- •Any applie:ml Ibut checks bu.x ill must also lilt out the.se,,imn Inlow showing their wot'kers'c(.... nsldiun Policy inllumanoll, "it the corlxnnle oilieers ha, exemplcd Ihemsdvcs•bul the corpor:aion has Lithe clnpluycas,a w•nrkm:d cnngtons;diou policy Is myu ueJ Lind.ouch:w argnn i"t ion should check ho,fl1. /rou an enrplgper dirt is prow/ing worherv'cotuperrcrrrirrrr irrsnrnncr%ar nqt etuplghrec. Beltnv is the polity Lrlornrrrliom Insurance Company Nan,e: Guard Ins. Co. ,. Insurer's Address: P.O. Box AH /16 S River Street - City/State/Zip: Wilkes Barre PA 18703 policy,!1 or Self-ills. Lic. N AIWC 693663 `- ---- Exphation Datc: 7/1/2016 Attach a copy of the workers' compensation policy declaration page(showing,like policy number and expiration dale). Failure to secure coverage as required under Section 25A of MG1. c. 152 can lead to the imposition of criminal penalties ol'a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form, of a ti I'OI' WORK ORDER and aline of up to$250.00 It clay against the violator. Be advised Thal It copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. /tlo herchy certify, under the pailr,s if/ lenafoes t f/mrjtirp that are information provided above is true and correct. Phone if: 978-998-4684 OJlicial itee on/F. Do not Ivrite in this area, to he completed hr city or town official. City or Town: Perm it/License ff Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. CiIYfI'own Clerk 4. I.icensing Board S.Selectmen's Office 6. 0Ihe' Cootact Person: Phone f/: A�E® CERTIFICATE OF LIABILITY INSURANCE °A07/21/2015"' 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 CONTACT Elaine Zolotas MassPay Insurance Seruces,LLC NAME: FAX HONE 27 Garden Street,Unit 1B c o (ac,No): Darners,MA01923 ADDRESS: elaine@philrichardinsurame.com INSURER(S)AFFORDING COVERAGE NAIC a INSURER A: AnRGUARD Insurance Conpary 42390 INSURED Air-Tig ht Weatherization,LLC INSURER B: 50 Rundlett Way INSURER C: Middleton,MA 01949 INSURER D 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 TERNS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWLTYPE OF INSURANCE INSR SUER POLICY NUMBER MMIDD/YYYY MICY EFF MtIWrYYYY UNITS TR GENERALLIABILITY EACH OCCURRENCE $ DAMAGE TO REMED COMMERCIAL GENERAL LIABLRV PREMISES Ea occurrence S CLAIMS-MADE 71 OCCUR MED ERP(Any one person) S PERSONAL BADV INJURY S GENERAL AGGREGATE $ GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ POLICY PRO- LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BOD"'INJ RY(Per accitlenp $ AUTOS AUTOS rJON-OWNED PRORTY DAMAGE S HIRED AUTOS AUTOS PerPE accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTION$ $ A WORKERS COMPENSATION AIWC693663 07/01/2015 07/01/2016 J WCSTATI} I ER oTH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXEOJTIVE - NIA E L.EACH ACCIDENT S 1,000,000 OFRCERIMEMBER EXCLUDED? (M Andaturyin NH) EL.DISEASE-EA EMPLOYEE S 1,000,000 0 yes,tlescdbe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS r LOCATIONS VEHICLES (Attach ACORD 101,Additional Remarks Schedule,K more space Is requlredt CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120Washington St 3rd Floor ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA01970 AUTHORIZED REPRESENTATIVE _� �✓ iy /✓ f ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDYYYY) 3/9/2016 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 have ADDITIONAL INSURED provisions or 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 TGA Cross Insurance, Inc. NAME: TGA Cross Insurance Inc. 401 Edgewater Place, Suite 220 PNHCNEEq t. 781-914-1000 FAX NO), 781-246-2601 Wakefield, MA 01880 E-MAIL ADDRESS: switchboard@tgacross.com INSURERS AFFORDING COVERAGE NAIC# wwwAgacross.com INSURER A: Arbella Protection 41360 INSURED INSURER B: Air-Tight Weatherization, LLC 50 Rundle INSURER C: tt Wayy Middleton MA 01949 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 28898957 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. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICYNUMBER MMIDDIVYYY MMIDDIYYYN A ✓ COMMERCIALGENERAL LIABILITY 8500046432 3/5/2016 3/5/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 1z OCCUR PREMISES(E..P.Ennsmeet $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY� JECT PRO ❑ LOC PRODUCTS-COMPIOP AGG $ 2,000,000 PRO- OTHER $ A AUTOMOBILE LIABILITY 1020015286 3/8/2016 3/8/2017 COMBINED aBc tleD SINGLE LIMIT $ 1000000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY ✓ AUTOS HIRED NON-OWMED PROPERTY DAMAGE S ✓ AUTOS ONLY ✓ AUTOS ONLY Per accitlent $ B ✓ UMBRELLA LIAB OCCUR 4600052930 3/5/2016 3/5/20WEACHACCIDENT RENCE $ 4,000,000 EXCESS LIAB ✓ CLAIMS-MADE $ 4,000,000 DED ✓ RETENTION$10,000 $ OTH WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ER ANYPROPRIETORIPARTNERIEXECUTIVE ❑ NIA IDENT $ OFFICERIMEMBER EXCLUDED? (Mandatoryin NH) EA EMPLOYEE $ R yes,describe underDESCRIPTION OF OPERATIONS below POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached X more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CIttyy of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1AWashington Street, 3rd Fir ACCORDANCE WITH THE POLICY PROVISIONS. Salem MA 01970 AUTHORIZED REPRESENTATIVE /1 �( t Thomas I Gregory ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 2e998957 1 223720 1 16-17 GL, AWD, UEA I Jill Dexecre 1 3I9/2016 9:32:51 w (EST) I Page 1 of 1 ��i� �iooyriryzo��uvecoLG� d�C>G���cl�eG� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Coytor Registration Registration: 165640 c--. Type: LLC ,, —=-�� si= Expiration: 311512018 TAt 419291 AIR TIGHT WEATHERIZATION, LLC- `r - 'If JAMES FORTIN j=l 50 RUNDLETT WAYy,`!- MIDDLETON, MA 01949 GG� —"_-- „_ /Update Address and return card.Mark reason for change. Address Renewal D Employment 0 Lost Card S A 1 p 2eM4)5/1+ t•9/,00,.rvro.urrca(/b o�Cvf(nsurc/<rse/G ,�ps�J� Massachusetts Department of Public Safety —4X2Office of consumer Affairs&Business Regulation V Board of Building Regulations and Standards OVEMENT CONTRACTOR h�J License: CS-052576 rR=Rn: �165640 Type:xpiration 3M5/2018 LLC Construction Supervisor r , AIR TIGHT WEATHEI�QAMON,.LLC`` JAMES E FORTIN- r �•�� �,. +.. 50 RUNDLETT WAYS MIODLETON MAC 01 JAMES FORTIN 50 RUNDLETT WAY _ - �•,�,�s-1 MIDDLETON,MA 01949 Undersecretary ''r+` +ro" ` Expiration: Commissioner 1010312017 C -