3 HAMILTON ST - BUILDING INSPECTION ` 3a.
The Commonwealth of Massachusets
} Boar)Of BuilJing;Rrgulations andStanJar4s CITY
3 !Ill Massachusetts State Building Code, 780 CMR 7 Fd�jon
OF SALFM
'w Revised Junuury
j� Building Permit Application To Construct, Repair, Rengv.l{g�r� mulish a 1. I
IOne- or rivo-Family Dwelling
This Sect' r Official Us nl
Building Permit Number: ate red:
Signature:
uildmg Cum over ns Date
SECTI 1:SITE INFORMATION
1.1 Property Ad,dJrass: 1.2 Assessors Map dr Parcel Numbers
I.I a Is this an accepted street?yes no Mop Number - �pa;Ke Number.
1.3 Zoning Information: 1.4 Property Dlmensloaa r
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
1.5 Building Setbacks(R) . . _
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 Zooe.Information: 1.8 Sewage Disposal System:
Zone: Outside Flood ZoneT
Public❑ . Private❑ 'Check if es❑ Municipal lhr site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 pert of getccord 5��
C�o+ d �'ar T 3 NarY) , IJM cl�
Name(Print) Address for Service:
.Telephones
SECTION 3: DESCRIPTION OF'PROPOSED WORK(C6eckp1/that apply,)
New Consrruchon.❑ .Existing Building❑ :Owner-Occupied ❑_ F,Repa(rs(s1.O__ Alteration(s) ❑ . Addition ❑
Demolition C1.1 Accessory Bldg. ❑ Number ofUnit _ p(her ❑ Spniry:
Brief Description of Proposed Work':
U-77 75
SECTION 4 ESTIMATED et)NSTRUCTION,ZOST§_
Estimated Costs
Item „ 011lglal Use,Oply
Labor and Materials _ _. ._.- _..,� ,,
I. Building S 1. Building Pernilfee:S " Indicatrhow fee is determined:
�. Flrctrical $ ❑Standard 'City/Pown'ApplicatiowFee
❑Total Project Cosl..(Item 6).s multiplier x
3. Plumbing S 2; Other Fees: S
a. Mechanical (fIVAC) S List:
5. Mcchanical (Fire S
Suppression) Total All Fees:$
Check No._Check Amount: Cash Amount:
ti. Total Protect Cost: S I labqO Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
S.I Licensed Construction Supervisor(CSL) 7 9 —� a=FQ
Rle- License Number Expi tion Name ul C'SI.• I IulJer 310 •SOOList C'SL Type(see below)"�`hN fDescri Address U Unrestricted u to 35.000 Cu
R Restricted"IR2 Family.Dwellinit
Signature � M Mason Only
G/� RC Residential Rourins C,overin
felephone � WS Residential Window and Siding
ry7� _ -7 y y _g y 3 SF .Residential Solid Fuel`Bumin A' pliarwc Installation
D Residential Demolition;
5.2 Registered Home Improvement Contractor.(HIC) y)L-0 y
I IIC Com �p� ITC-Re r•t ame egistration Number
p 03 @ 2fV
Address ���/�// �
MA 01970 ��� )y y- �l V"� "Expiration Date
Signature Telephone -"
SECTION 6: WORKERS'COMPENSATION INSURANCEAFFIDAVIT(M.G:L.e:152.1 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 Issuanceo ee building permit.
Signed Affidavit Attached? Yes .......... No...........C3
SECTION 7a:OWNER AUTHORIZATION Ta BE COMPLETED.WHEN
OWNER'S,AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize �/ (M to act on my behalf, in all matters
relative
tto�work authorized by this building permit application.
Siaturture of Owner Date
SSE1 TION 7dp"OWNERI'OR AUTHORIZED AGENT,DECLARATION
as Owner or Agent,hereby'declare
that the statements and information omthe foreggmg application are true and accurate,.to the best,of my,knowiedge and
behalf
Print Name
Signature of Owner or Authorized iCgent.
7AnOwner
the ains and% nalties of -'u" "- -
NOTES:
,,. er who obtains a building permit to.do hi!Vhcrown work,or an owner who him an unregistered contractor
istered in the.Home mprovement Contractor(HIQ.Program),will ad.have access to the arbitration
or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
ction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1I0.R6and 110.R5, respectivelybstantial work is planned,provide the information below:
rea(Sq. Ft.) (including garage, finished basement/attics,decks or parch)
Gross living area(Sq.Ft.) ffabitable 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"
,
The Commontipeahh of Massachusetts
Department of Industrial Accidents
i Office of Investigations
:* 600 Washington Street
/ Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ap
plicant
t In Legibly
Information Please Print Le
�p Y
Nalrie(Business70rganization/Individual): AC]1A1Q�(EathCr17RE Q% I C
61!fi'1dferson AvW=
Address:
City/State/Zip: Phone #: Z 7 .y V �l Y
Are you an employer?Check the appropriate box: Type of project(required):
4. ❑1 am a general contractor and I
1.k f I am a employer with,�2' �� 6. ❑ New construction.
employees(fufl and/or patt tune)_y,;-t have.hire i the tib-contractors'
2:❑ I am a sole proprietor or patmer'' hsted'dn i!hv attachW sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• Demolition
d have workers'an
working for me in any capacity. employeest 9. ❑ Building addition
comp. insurance.
workers' comp. P r additions
[No P d i 10.❑ Electrical repairs o
� 5. We are a corporation an is
required.] ❑ �
3.❑ I am a homeowner doing all work
officers have exercised:their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t C. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box Nl must also fill out the.section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and thou him outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those enddes have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site
4
information.
Insurance Cotnpany
Policy#or Self-ins.Ltc.#: � 1 /� _ O Expiration Dcte: 32-
Job Site Address: N- i �I l 5- City/Statq/Zip:_5AL-er !f_12t:a:=
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify underlhepains and penaliles ofperjury that the information provided above is t ire and coned
Siena ur�e G� `1/ Date f I a
P_ hone# 7� N J,
Official use only. Do not write in this area,to be completed by city or town official .
City or Town: PermittLicense# —•
Issuing Authority(circle one)':
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing inspector
6.Other
Contact Person: Phone#:
CONTRACT
Printed: 3/12/201
..;,..,..... .... Work:Order Id: S29900P3286?C29
Contractor Information CustomerlSite'Details
Atlantic Weatherization Richard Jendrysik Phone (Eve): 978--741.2155
61R Jefferson Aye 3 Hamilton St Phone(Day):
Salem , MA 01970 Salem, MA.01970.3113 Site ID: S00002029900
- Total Installed Measures
Location Description Quantity Unit$ Total$
Living Space Insulate Wall From Interior With 4"Dense Pack166 $2.00 $330.00
Blower Door Test Only 1 s60:00 $60.00
Living Space Insulate Clapboard Sided Wall-WItn:4"Dense _ 63.0 $1.92 $1,209.60.
Installed-Measures Total $1,59%60
Road Blocks
Type Status Notes
Knob& Tube Wiring. FIXED Active k and T k&t clear for ext walls License#22814 1/10/12-AA
Payments
Incentive Payments
Weatherization.Incentive $1,199.70
Total Incentive Payments $1,199.70
Customer Share
Total Customer Share $399.90
Less Deposit Of $108.30
Customer Share Balance(Due Contractor) $291.60
Conservation Services Group-60 Washington Street Suite 3000-Westborough;MA 01581-(508)836-9500
ACO-I?- CERTIFICATE OF LIABILITY INSURANCE 1
° 3/16/2011
03/16/2011
PRODUCER 508.651.7700 FAX 508.655.8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Eastern Insurance Group LLC - Main 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 Weatherization LLC INSURERA: Arbella Protection Ins. Co. 41360
61 Rear Jefferson Avenue INSURERS: Arbella Indemnity Ins Co. 10017
Salem, MA 01970 INSURERC: Chartis
INSURERD: Nautilus Insurance Company
INSURER E:
COVERAGES
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 MAYBE 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 D' TYPE OF In POUCYNUMBEq FFECTNE P C PIRATION UMW
LTA DAT MMID DATE MMIDD Y
GENERAL LABILITY $500042816 .03/20/2011 03/20/2012 EACHOCCURRENCE $ 1 000 000
X COMMERCIAL GENERAL LIABILITY PREMISES Eeoccurrenw $ 50,000
CLAIMS MADE [Xj OCCUR MED EXP(Any one person) $ 5,00
O
Aff-- PERSONAL S ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000 000
POLICY X JECOT LOC
AUTOMOBILE LIABILITY 93827400003 03/20/2011 03/20/2012 COMBINED SINGLE LIMIT
MYAUTO (Ea accident) $ 1 000 000
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per Parson) E
B
X HIRED AUTOS
BODILY INJURY §
X NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per a (dent)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
ALTO ONLY: AGO $
EXCESS UMBRELLA LIABILITY 4600047820 03/20/2011 03/20/2012 EACH OCCURRENCE $ 1,000,00
X OCCUR CLAIMS MADE AGGREGATE $ I 000,QOO
A $
DEDUCTIBLE
$
RETENTION $ $
WORKERS COMPENSATION WC1616071 03/20/2011 03/20/2012 XST
AND EMPLOYERS'UABIUTY YIN TOR'LIMBS ER
ANY PROPRIETORIPARTNER/EXECUTIVE❑ E.L EA CH ACCIDATU_ENT § 500 QQQ
C OFFICER/MEMBER EXCLUDEDT
(Mandatory in NH) E.L DISEASE-CA EMPLOYE S 500,00
R yECIALPROVISI dowdner er E.L.DISEASE-POLICY LIMIT $ 500,00
SPECIAL PROVISIONS below
OTHER CPLO152189210 10/01/2010 10/01/2011 General
OLLUTION T.aTHILITY Aggregate - $1,000,000
D Each Pollution Condition -
$1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
CITY OF SALEM REPRESENTATIVE&
93 WASBINGTON STREET AUTHORIZED REPRESIMATNE
SAIIEM, MA 01970 Rosemary Fulham/PMA
ACORD 25(2009101) 01988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
}Qt Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Cuustruction Supervisur Unrestricted-Buildings of any use group which
License: CS-087977 contain less than 35,000 cubic feet(991rW)of
enclosed space.
ERIC W PALAd- -r4.
3 A EM S'F
5ALEMMA-01970 P n
l@
�o
Expiration Failure to possess a current edition of the Massachusetts
Commissioner 04/23/2014 State Building Code is cause for revocation of this license.
For DPS Ucensinginformation visit: w .Mass.Gov/DPS
Office o060o ume�'�Prn
HOME IMPROVEMENT CONTRACTOR
License or registration valid for individul use only
Registration: 142089 Type:
� 'i
' Expirabontion: 3/12/201 before the expiration date. If found return to:
Ltd Liability Corpor i Office of Consumer Affairs and Business Regulation
A W TIC WEATHERIZRTION L L,C, 10 Park Plaza-Suite 5170
Boston,MA 02116 t
)
ERIC PALM � - ; - jsf
61R JEFFERSON
SALEM,MA 01970
i' Undersecretary
.r lair'
bout signa Not valid wit u re
i