29 HARBOR ST - BUILDING INSPECTION �s t"
G< l l S
The CommonWe11Uff4MaWfsavAusetts
Department of Public Safety
VYU Massachusetts Sta�irj�i�lg�Ci le�J$0
Bu g of Building Permit Application for any er than a One-or Two-Family Dwelling
O (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1 29 Harbor St Salem 01970
No.and Street City/Town Zip Code Name of Building(if applicable)
1 SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ 1 Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other El Specify: Insulation/Weatherization
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No El
Is an Independent Structural Engineering Peer Review required? Yes ❑ No M
Brief Description of Proposed Work: Air sealing,install weather stripping,blow in cellulose to attic and walls
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA [3 IIB ❑ IIIA ❑ IIIB ❑ IV VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required ❑or trench or specify: 50 Rundlett Way
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Middleton,MA 01949
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Daniel Albert 29 Harbor St Salem 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Owner 301 642 7823 781 636 0350 exchaoordo@gmail.com
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
James Fortin 50 Rundlett Way Middleton MA 01949
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here®and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Air-Tight Weatherization,LLC
Company Name
James Fortin CS-052576 exp:1/03/2017 Construction Supervisor
Name of Person Responsible for Construction License No. and Type if Applicable
50 Rundlett Way Middleton MA 01949
Street Address City/Town State Zip
978- 998- 4684 978- 998 - 0690 inbox@air-tightweatherization.com
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes® No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 7,206.07 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 7,206.07 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 tothe best of my knowledge and understanding.
James Fortin Contractor 978- 998 -4684
Please print and sign name t�J\ Title Telephone No. Date
50 Rundlett Way Middleton MA 01949
Street Address City/Town ,7 tate Zip
cj
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
= Departuteut of ludustrial Aceideuts
l Cougress Street, Suite 100
Bostou, MA 02114-2017
t_ „) Ivlpluntrrss.gop/din
Workers' Compensation Insurance Affidavit: General Businesses.
TO 13E FILED WITH THE PERMITTING AUI'11ORITY.
Applicant Information Please Print Legibly
Business/Organization Name:Air-Tight Weatherization, LLC
Address:50 Rundlett Way
City/State/%ily Middleton MA 01949 Phone #:978-998-4684
Arc you an employer? Check the appropriate box: Business Type(re(luired):
I.❑✓ I am it employer with 30 _employees(11111 and/ 5. ❑Retail
or pan-time).* 6. ❑RostauranUBar/Eating fstablishmcnl
2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(inel. real estate,auto,etc.)
employees working forme in any capacity.
[No workers' comp. insurance required) 8. ❑ Non-profit
-1.❑ We are it corporation and its officers have exercised 9. ❑ Entertainment
their right ofcxcntption per c. 152, $1(4),and we have 10.❑ Manufacturing
oo employees. [No workers' comp. insurance required i* 1 1.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers, Insulation/Electrical
with no employees. [No workers' comp. insurance reci j 12.❑'/ Other_ _
'Any applicant that checks hoc tl I mist also Jill ouI the section hdnw showing their wurkcrs'eompca,aliun Iwliey iniirnvatiun.
`*It lice cmixmte on'ficers have e.xcmpled Ihem.d'e ,huh the enrpmaw,,n has other cmpluyccn,a workers'compensation polip.is required and such:w
wii.mimtion should duck huz tl I.
l nor on enq�/gyer Hurt i.c providing workerx'coutpen.entian irrcnrnnc•e far nn�c+nplgVice+'. Below is lire policy in jarmation.
Insurance Company Name:Guard Ins. Co.
Insurer's Address: P.O. Box AH / 16 S River Street
City/State/'Gip: Wilkes Barre PA 18703
Policy 11 or Self-ins. l..ic. N AIWC 693663 Expiration Datc: 7/1/2016
Attach a copy of file workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGI.c. 152 can lead to the imposition of criminal penalties ol'a
line up to s1,500.00 and/or one-year innprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to$250.00 a clay against the violator. Be advised that it copy of this slatennenl may be forwarded to the 011ice of
Investigations of the DIA lot insurance coverage verification.
I do hereby certify, undera
the pains al enables of perjury that the iuformalion provided above is trite and correct.
Si ,rn ore
Phone tl: 978-998-4684
Of
licial use only. Do non write in this area,to be completed by cily or town rrllicirrl.
City or Town: Permil/License h
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. Citylfown Clerk 4. Liceusilig Huard 5.Selectmen's Office
G. Othcr ., ---
Corrtnel Person: Phone tl:
we'w'.m;lv,gnv/dig -
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 021 16
Home Improvement Contractor Registration
Registration: 165640
Type: LLC
Expiration: 311512016 Trtl 248557
AIR - TIGHT LLC. WEATHERAZATION
JAMES FORTIN
10 PINE KNOLL DR.
BEVERLY, MA 01915
Update Address and return card.Durk reason for change.
sU I c xnos Address Rencwal Employment Loss Card
License or registration valid for individul use only
Omceof Conemner AlTdn&Husiness Regulaliun g
- f10ME IMPROVEMENT CONTRACTOR before the expiration(late. If found return to:
Registration: 165640 Typo: Orrice of Consumer Affairs and Business Regulation
Expiration: 3/152016 LLC 10 Park Plarat-Suite 5170
s•` Boston,,NIA 02116
AIR-TIGHT LLC.WEATHERAZATION
JAMES FORTIKNOLL �4 \�
10 PINE KNOLL DR. ;J�--,/f1� _ v �•'�
BEVERLY,MA 01915 C.dersecrrta n' Not cn id without 5ignnlu rc
(�� Massachusetts Department of Public Safety
I V Board of Building Regulations and Standards
License: CS-052576
Construction Supervisor
lk
JAMES E FORTINi
60 RUNDLETOETT WAYS {
MIDDLN MA;-01 `
Expiration:
Commissioner 10/0312017
� J
• �Unii
.V
PARTICIPATING
mass save CONTRACTOR
swkw ttatwm aa•rw aflbancy
PERMIT AUTHORIZATION FORM
I, Daniel Albert owner of the property located at:
(Owners Name,printed)
29 Harbor st Salem
)property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor
listed below to act on my behalf and obtain a building permit to perform insulation and/on
weatherization work on my proper,,,
X
Owner's Signature /
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Air-Tight Weatherization,LLC 10/5/2015
Participating Contractor Date
01 .
FwOffice Use Only
Rev. 12132011
To Whom It May Concern:
I, James Fortin, do authorize Phillip Morris to act as my agent in the process of applying for
building permits and other necessary documentation pursuant to the conduct of business by
Air-Tight Weatherization LLC.
Vrr�
igna ure Date
State of Massachusetts
County 7_SC)'_-X
JGlxrne to me known to be the person (or persons)
described in and who executed the foregoing instrument, and acknowledged that he/she/they
executed the same as his/her/their free act and deed.
HEIDI S DFFRA;;• CO
q,4 Notary Publtc
t a COMMONIVEALTH OF t:!ASSACHUSETTS
Mq Commission Expires
14 October 2. 2020
Notary Public
Print Name:
My commission expires:
Air-Tight Weatherization,LLC • 50 Rundlett Way 9 Middleton, MA 01949 • 978.998.4684 t