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3-5 HARRISON AVE - BUILDING INSPECTION I l The CommonwealthA- WeCENW) husetts Department RVICES MassachusettsStat� - Building Permit Application for any Building other than a e o o-Family Dwelling (This Section For Official _ 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) No.and Street City/Town Zip Code Name of Building(if applicable) 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❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify.- Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ - Is an Independent Structural Engineering Peer Review��� �� Yes 433 No ❑ Brief Description of Proposed WorkAKJA itl �G��tA 10]C, �C tC1/1 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): I 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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-113 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 ❑ 113 ❑ IIA ❑ I113 ❑ HIA ❑ IHB ❑ 1 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- Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ requuedior trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Is Structure within airport ap roach 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: s � . allg SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner LeL f'iu� S 5 ��d�rzQtew��e S�r�w� �h bl_�b Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Sl w-p- q e _iZ7 _ 3:2 _ Title Telephone No.(business) Telephone No. (cell) e-mail address If apphcable,the property owner hereby authorizes Tom .►-�i 5 M t 1 l S _11 w�s� �cor�cn "IA 64 Name Street Address City/Town State Zip to act on the eroperty 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 bw1din is less than 35,000 m ft of enclosed space and or not under Construction Control then check here Vand 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 GJ6} = 1nJ jAo LJ\A Company Name ' ` �o 1S �` IUS cS to-7 ga3 -ty�2et Name of Person Responsible for Construction License No. and Type if Applicable 0IP tAA_ S �¢,K3ara, &V o t 60 Street Address City/Town State Zip ��---�0 o3�D - - _ �Od��IlS3b3�©� ►/�ddtx�. CoW( Tele hone No. usiness 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 $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechancal (HVAC) $ •Note:-I lmimum fee=$ -(contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ �w (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 to the best of my knowledge and understanding. Please print and sign name Title �� Telephone No. Date 3 Y�R Q'I 4 y� O'VR' s R 1 l'`n �1Q17 a Street Address Ci Town ty/ State Zip q Municipal Inspector to fill out this section upon application approval: Name Da ILI Work Order North Shore Community Action Programs,Inc. Job Number:Eanes(i) 119 Rear Foster Street,Building 13 Work Order Date:8/29/2014 Peabody,MA 01960 Ownership:Renter Phone:978-531-0767 Bay State Weatherization&Construction Auditor:Brandon Dorrington 89 Newbury Road Email:bdorrington@nscap.org Rowley MA 01969 Cell:781-540-8569 Email:m�oodhue@yaboo.com Phone:978-531-0767 x121 Cell:617-548-7808 Lola Eanes *� • L. NGRID Gas $4,498.56 5 Harrison Ave Total $4,498.56 Salem MA 01970 "Nocf1 - 329� Safety Issue(s):Asbestos on Pipes/Lead Paint Possible . .�� G. ��,•, ' :��� � � p1� �az fz ,tip t s �€ � 11eseri}ptlou 4 a _ Qty &Aai a� Comments ot Qty Pn jce m y TTotal ))y, kk h"s.Y ..K.i33* C 5�"4"i F$S" .".f * ,:£S� `d• Krf���',3M�y, e',. .' ' rr r+' �,.,.:x. :5"" IJ W t3'3S aS R-18-20 restricted-slopes/floored 400 $1.55 $620.00 400 $620.00 fill w/cellulose R-38 unrestricted-settled cellulose 863 $1.65 $1,423.95 863 $1,423.95 Aftk Venblatinn fib^' t ""rn •>: r;, sad gr- ++�' C w` Cn �, «_,,,'� t' °� � r :. �,;, r <,v^. ,z�.. ,-nk + Rectangular gable vent 1 $103.00 $103.00 1 $103.00 12 X 18 Rectangular soffit vent 9 $30.00 $270.00 9 $270.00 'DOO[6 , fs' .z,i� !..�" e, .,,,,m ,drt4"� ,i.+ �e�^ w"� ti���;•'S met.w—, i"3�i���<f,`�vAr`�5.. 'Y""n. f.�� :fi4 +..�" Fixed Sweep 2 $17.64 $35.28 2 $35.28 Repair/Refit Door I $58.00 $58.00 1 $58.00 Weatherstrip s/Q-lon or equal 2 $51.00 $102.00 2 $102.00 �nrF "' Hc91thr � x , < art ' * s &�..,4 `iw:;1:4c.,*.. ,..,+;` ,«x"11:r ^w=. ,mw n�:'. Pw �b' ..4.a.`�' ttax :u: Fw G : : a,sa' Clothes dryer vent including 1 $100.00 $100.00 1 1 $100.00 Exhaust Duct Date:8/29/2014 Page 1 �. } Work Order: Job Number: Eanes (i) +erq ar5�1.. C Jnanl$fioR +.':6[ x,',r' "'`« �'�..° 'e i1�gS, *»`a ` & 4>7rr '�.. ° `n �'xb ,t^} ^k,' ' "..r'„ •. i'sa;"•. �mFr�"p+�+zea..s*:�'.:ec��'ie �+r�a��,�3?+sSsr�'�*%��'�`.'.'. _ '�.*R�'��.�r£+vr"�S� S+tuk��»<a? N'�e.�Ea+����:''�``a"sir'vrsa'.�,.�'J'"a�+�.G�.a.`., ,"yr: Domestic water pipe wrap 6 $2.95 $17.70 6 $17.70 AN Attic sealing with two-part foam 3 $84.00 $252.00 3 $252.00 Seal ducts with mastic or butyl 2 $73.00 $146.00 2 $146.00 backed tape Weatherstrip(Q-lon or equal)attic 1 $35.00 $35.00 1 $35.00 hatch & R a1Tnsalation .z. y dax t1 " & d` ,.;,v"9stiC'kfi §v ,wk.�4- 8s, am'ur: ....'rt .wu-' "9y,. max. '..+'v`"v`PPCx h:' T Sx�S-.tt .�.' '. r' x _ «�..... Drill finish patch plaster(dense 151 $2.13 $321.63 151 $321.63 pack) Wood clapboard/shakes/shings or 507 $2.00 $1,014.00 507 $1,014.00 vinyl(dense pack) Total $4,498.56 $4,498.56 Contractor Instructions: Before Starting the Job: During the Job: 1.Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978.Lead safe pyAdees are 2.Obtain required building permit. required. 2.Total for Heath&Safety and Repairs cannot exceed$2500.00. 3.Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH-347. Additional Contractor Instructions: Certificate of Insulation posted? Yes No (Circle One) Attic inspection form attached? Yes N/A (Circle One) Bay State Weatherization&Construction hereby certifies that this job was supervised and completed in compliance with all Department of Labor Standards and Lead RRP regulations. CBattraog�/ftature: Date: RRP License M Page 2 Unrestricted----Buildings of any use group which--. contain less than 35,000 cubic feet(991M )of enclosed space. Failure to possess a current edition of the Massachusetts state Building code is cause for revocation of this iicenSe. For DPS licensinginformationvisit: w _mass.Gov/DPS SMILN£0 auoasstux;ue UOU � fR. 0%10 V]N Apogg?d Zd.dV.Lr1HMS ling 6 - YYHWSINNHU :a=uaom ' - x4si ua<fns uut>_iitgeao� ' : =tepue&S.Rue Sutpljn2';op:eag /2 tdaErC S�;Gnu ;�.tauayaed ,- m2asnt;�esseVJ 1� �s Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot # for locations for which a street address is not available) No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other(if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) " 1 DATE(MM/DDNYYY) AC CERTIFICATE OF LIABILITY INSURANCE 8/27/2014 li - 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 C NTA T Lauranzano Insurance Agency NAME. Berkley Assigned Risk Services 107 Dodge Sit a/c.No.En (800)634-4589 jnrc.No.g 866 215-8118 Beverly, MA 01915 noDRess. PoricySeNices@berkleyrisk.com INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A. Acadia Insurance Co. 31325 Bay State Weatherization and Construction LLC INSURER B'. 89 Newbury Road INSURER C: INSURER D. Rowley, MA 01969 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 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. IN R TYPE OF INSURANCE A DL UBR POLICY NUMBER P LICY EFF LI Y LAP LIMITS LTR INSR MD MM/DD/VYYV MM/DD/VVVV GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGETO RENTEDPREMISES Ea occurrence $ ❑ CLAIMS-MADE ❑ OCCUR ❑ ❑ MED EXP(Any oneperson) IS PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGG IS POLICY ❑ JECT ❑ LOG $ AUTOMOBILE LIABILITY ❑ ❑ INED IN LE LIMIT Ea accitlent $ ANY AUTO $ BODILY INJURY Per arson ALL O ❑SCHEDULED AUTOS AUUTOSS BODILY INJURY Per accident $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident) $ ❑ $ UMBRELLA LIAR ❑OCCUR ❑ ❑ EACH OCCURRENCE $ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ DED ❑ RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ❑ ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L EACH ACCIDENT $ 500,000 A OFFICE/MEMBER EXCLUDED? NIA ❑ WC-20-20-004736-01 05/14/2014 05/14/2015 IMandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500-000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space.is required) Election Category Election Status Name All Entities/Insureds: Other Exclude Mark Goodhue Bay State Weatherization and Cons CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Gloucester City of THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVEREDIN 3 Pond Street ACCORDANCE WITH THE POLICY PROVISIONS, Gloucester, Ma 01930 AUTHORIZED REPRESENTATIVE rf. Signature: { '� ACORD 25 (2010/05) BRAC 3139 Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this.The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark'IN"When VgLkable No. Item Submitted incomplete I Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm ma r ' e repeaters) '-6- I-IVAC 7 Electrical 8 Plumbing(include local connections) 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland etc. 11 Specifications -12 " 'Structural Peer Review - 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 ExistinK Building Survey/hivesfigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Miff ation Documentation 20 Other(specify) 21 Other(Specify) 22 Other(Specify) 'Areas of Design or Construction for which plan are not complete at the time of application submittal must be identified herein Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town - State Zip Discipline Expiration Date IVame.(Ilegistrant) Telephone No. e-mail address Registration Number Street Address Cr Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Z Discipline Expiration Date Street Address City/Town State i Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ;: OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistratlon 179564 Type: Office of Consumer Affairs and Business Regulation xpiratlon 81f81Z016 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 BAY STATE WEATFIPRIGATIt' J 8 �' CONSTRUCTION KELLY GOODHUE 3 k31 Aw 89 NEWBURY RJROWLEY,MA 019ndersecretarY f hout signature