71 HATHORNE ST - BUILDING INSPECTION 20 oa ClL l 032(
The Commonwealth of Massachusetts
q Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
` (This Section For Official Use Only)
N 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)
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nNo.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❑ 1 Repair❑ I Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other QQ Specify: (a'l iA r \eXl
Are building plans and/or construction documents being supplied as part of this permit application? Yes Yr No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Vnac
rA ✓ ` r k w oC ej VlriY p�
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 ❑ A-4❑ 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 ❑
1: Institutional 1-1 ❑ 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 ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 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❑ required ❑or 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 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
.Name and Address of Property Owner
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Name(Print) .r No.and Street City/Town Zip
Property Owner Contact Information:
CAAtCe_)f 9-ff-�T7q-�`-1
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address Ci own 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 O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Ana 2CAn�C5 -som- )� as
Name(Re tstrant) Telephone o. e-mail address Registration Number
31 W. n c � � ___T --.I---
Street Address /Town State Zip Discipline Expiration Date
10.2 General Contractor
A%V-Y�CCLYI Qx_)t�ch"nga
Company Name
A0-ae_ Scttl� H1C- 1�0'11o(.0
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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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 $ ' US 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 $ - t-� 3,Q'S (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 t b my knowledge and understanding.
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Please print and sign name Title Telephone No. Date
arc 3JoCesfi � kV �9�Q
Street Address ity/Town / State Zip
Municipal Inspector to fill out this section upon application approval: ^'
Name Date
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)
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"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
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 Existing Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans 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
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
1r EM
American Building Technologies (617} 7521570
Contract for Products/Service Work
This Agreement is made by and among
Noemi Lopez
71 Hathorne St
Salem, MA 01970
American Building Technologies (ABT)
2 Neptune Rd, Suite 439
Boston, MA 02128
1. DESCRIPTION OF WORK TO BE PERFORMED
1- Basement insulation
2-Air sealing
3- Door sweeps &weatherstrips
4-Wall insulation
Total: $4,483.05
Customer Signature: °u
cbvl—
Customer Name: (J(Ytlt l,G3P Date: C�
Contractor Signature:
Contractor Name: Date: I 1 It (�
t
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Huainessrorganintionnndividuaq:American Building Technologies — Jose Santos
Address: 2 Neptune RD #439
City/State/Zip:Boston MA 02128 Phone#: 617 233 8704
Are you an employer?Check the appropriate box: Type of project(required):
1 I am a employer with 5 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ]0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof rep airs
insurance required.]t employees.[No workers' 13.[�{Other insulation
comp.insurance required.]
•Any applicant that checks box#1 most also fill out the section below showing their workers compereation policy information.
t Homeowners who submit this affidavil indicating they ure doing all work and then hire outside contractors must submit a new affidavit indicating such.
lConuacmrs that check this box must attached an additional sheet showing the time ofthe sub�connactoa and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: Ace American Insurance
Policy#or Self-ins.. H'�(_C.�d�Lic.#: 2E 918 4 4 5 Expiration Date:: 10�/2 0/16
1 Job Site Address: I City/State/Zip: 8olk ,I, PAA, _oglo
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 r and penalties of perjury that the information provided above is true and correct.
Si mature: Date: 0.1 oZ
Phone#: 617 2 7
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i
Work Order
North Shore Community Action Programs,Inc. Job Number: 120281
119 Rear Foster Street,Building 13 Work Order Date: 5/31/2016
Peabody,MA 01960 Ownership: Renter
Phone: 978-531.0767
American Building Technologies Auditor: Marc Lorah
263 Western Avenue Email: mlorah@nscap.org
Lynn MA 01904 Cell: 978.587-5104
Email: rebeca@americanbuildingtechnologies.com Phone: 978-531-0767 x777
Phone: 781-598.7125
Noemi Lopez NGRID Gas $4,483.05
71 Hathorne St Total $4,483.05
Salem Ma 01970-3056
978-237-1936
Landlord Name: Altagracia Gomez
Landlord Phone: 978-979-5185
Safety Issue(s): Lead Paint Possible
Authorized Actual
Measure Description Qty Price Total Qty Total Comments
Basement Insulation
Sill/mudsill seal&insulate to R-19 148 $258 $381.84 148 $381.84
Doors
1" THERMAX or equivalent on 1 $60.00 $60.00 1 $60.00 check with owner interior bulk head
door
Fixed Sweep triple flange 4 $1852 $74.08 4 $74.08 Front&backto Apt and door to basement
Weatherstrip s/Q-Ion or equal 4 $5355 $214.20 4 $214.20
Misc Measures
Seal ducts with mastic or butyl 3 $76.65 $229.95 3 $229.95 supply and return ducts as needed
backed tape
Permit
Building Permit 1 $100.00 $100.00 1 $100.00
Date: 5/31/2016 Page I
Work Order: Job Number: 120281
Wall Insulation
Double nailed asbestos/aluminum 1074 $2.77 $2,974.98 1074 $2,97498 don't do hallways from outside
(dense pack)
Drill finish patch plaster(dense 200 $2.24 $"8.00 200 $448.00
pack)
Total $4,483.05 $4,483.05
Contractor Instructions:
Before Starting the Job: During the Job:
1.Please notify us 24 hours before starting or scheduling ajob. 1.This residence was built before 1978.Lead safe practices 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:
Attic Inspection form attached? Yes N/A (Circle One)
Certificate of Insulation posted? Yes No (Circle One)
American Building Technologies hereby certifies that this job was supervised and completed in compliance with all Department
of Labor Standards and Lead RRP regulations.
Contractor Signature: Date: RRP License#:
I hereby acknowlege that all work has been completed and inspected.
Customer Signature: Date:
Energy Director: Date: Fiscal Officer: Date:
Date: 5/31/2016 Page 2
Work Order: Job Number: 120281
FOR AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
Dryer CO 0.000 If Yes,indicate language:
Stove CO 25.000 Occupany change in last 18 months? Yes No (Circle One)
H2O Tank CO 0.000 Comments:
Heating System CO 16.000 Number of windows
Ambient CO 0.000 Number of rooms
Blower Door 0.00
Date: 5/31/2016 Page 3
-o -- -•• �� ��1J14vxu O : YD : OL AM PAUL 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATE(MRADD/YYYY)
71111111rQRTIFICATE 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.
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and Conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to
he certificate holder In lieu of such endorsements.
PRODUCER CONTACT
NAME:
AMBROSE INS AGCY INC PHONE FAX
70 MIJNROE ST STE S (A/C,No,EXt): (A/C,No):
E-MAIL
LYNN,MA 02101 ADDRESS:
237LY
INSURER(S)AFFORDING COVERAGE NAIC N
INSURED INSURERA: ACE AMERICAN INSURANCE COMPANY
AMERICAN BUILDING TECHNOLOGIES INC INSURER B:
INSURERC:
263 WESTERN AVE INSURERD:
INSURER E:
LYNN,MA 01904 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 0 TO CERTIFY THAT THE POLICES OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO 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. LIMITS BROWN MAY HAVE BEEN REDUCED BY
PAD CLAIMS.
WSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (LAI\DOIYYYY) (MKDMYYYY) LIMITS
GENERAL LIABILITY -ACH OCCURRENCE Is
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
CLAIMS MADE OCCUR. PREMISES(Ea occurrence)
ED EXP(Anyone person) $
GEN'L AGGREGATE LIMB APPLIES PER: PERSONAL S ADV INJURY $
ENERAL AGGREGATE $
POLICY PROJECT LOC PRODUCTS-COMP/OP AGG S
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS
(Per accident)
PROPERTY DAMAGE IS
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR El CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION S $
A WORKER'S COMPENSATION AND X wC STATUTORY OTHER
EMPLOYER'S LIABILITY Y/N UB-2E918445-15 10202015 10/20/2016 LIMITS
ANY PROPERITOWPARTNEWEXECUTIVE WA E.L.EACH ACCIDENT $ 1,000000
OFFICEPAAEMBER EXCLUDEW
(Manwary In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
It yea,describe under
DESCRIPTION OF OPERATIONS bolo E.L.DISEASE-POLICY LIMIT IS 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTONS/SPECIAL ITEMS
TFOS REPLACES ANY PRIOR CERTTFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECONG WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
NSCAP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
11911 FOSTER ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILLU DELIV D
IN ACCORDANCE WITH THE POLICY PRO
BLDG 13
AUTHORIZED REPRESENTATIVE
PEABODY,MA 01960
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988.2010 ACORD CORP R r g is reserved.
h733s9cltasCttS Depart-tent of Public SdV.- 'COnab't:!'tion S;;porvi5o:
®' Board of 3uiW i�g e2ccuta:iony and SEarecarda Restnctv,d to:
Unr lricfcd_31Jda;:gs of any use q!OSD sV,Och ccntifin
Lzenso:GS-'i073T8 teas than 35,00D cubit led�501 cubic Ni c: v,0`
Conrt_rtior.5•_pett l.or
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of Censamer Affairs&Busraess Reg
OME IMPROVEMENr CONTRACTOR License or registration valid for individual use only
gistiationc 163106 Type. before the expiration date. If found return to-
SIT172017 Corporafwn Office
Of Consnmcr Affairs and Business Regulation
t ♦* f 10Park Flaxa-suite 5170
AMERICAN BU1LOiNG TFCtHN LOGIES,INC- . Boston,MA 02116
JOSE SANTOS r
2 NEpTUNE RD.SUITE 439
° BOSTON,MA 02128 [3ndersaretary
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American Building Technologies
Energy Savings Is Our Specialty
263 Western Avenue- Lynn-MA 01904
Phone- 781-598-7125 /Fax-781-479-0727
www.americanbuildingtechnologies.com
Authorization Letter
I,Jose Santos, HIC 163106 and CS-101378 holder hereby give my authorization to Andre Aguiar
to act on my behalf regarding the Building Permit Application
71 Hathorne St, Salem, MA 01970
L 'L
4alnos
6/21/16