10 HAWTHORNE BLVD - BUILDING INSPECTION ,, ;► The Commonwealth of Massachusetts
t'• Department of Public Safet ECEIVED ICES
�.
..\lassachusell.Stale Building Code l�� c7 t+l*r� 1i�14 LKfM11th
City of Salem
Building Permit Application for any Buildin o t o Dwelling
IThis Section For Official Use Onivl
Building Permit Number. Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block M and Lot W for locations for which a street address is not available)
/0 1s (- 70
No. and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building ❑ Repair❑ 1 Alteration ❑ 1 Addition ❑ 1 De ration ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other Specify: 1771A tA /A (11�
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): m'
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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-2r ❑ A-2nc❑ -A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ I-3❑ I-4 ❑ Mi 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 ❑ 118 ❑ IIIA- ❑ 1118 ❑ I IV ❑ AA ❑ 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 it outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
n•yuired ❑or trench ar spenh:
I rirate Cl or indcntif% Zone: or on site st stem ❑ permit d enclosed ❑ .
Railroad right-of-way: Hazards to Air Navigation: �L\ I li.n�ric t oinntis.iun Rvt„•t� Pn,t,,:
Not 1pphcable❑ I.Structure%\itliin dirpnrt,tppruddi,trr,t' Is thell Ienetc completed.'
n('111)1e1l to Iiutld cndosed ❑ Yes❑ or.No❑ Yes❑ \n ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
li.litwn nl Cede Use Croul+l.l: ft pe of Construcuon: OCCUpanl Load per flour:
17 ,r. the building contmn an Sprinkler Scstvm.: Spvctal Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
1N, me.im Address of Properly Owner
�r.,,Qll /Q �arttcrwe��lyo% _RslerL, / 01%70
43
Name(I'rint) �•�1 � %'Nu.andStreet City/Town Lip
c?71Var rmation•ta��.
Pn+peitylhcnrrConlactcl Into"rmalion" ;-J tt;?1i
�QMt Pn (d 7 2557- CIV 8
Title (� +'-� C'- {NTelef,K)ne No. (business) Telephone No. (cell) a-mad address
If applicable, the property owner hereby authorizes
Inc (�ti/tn s Sa�th-1 cl/ 70
Name Street Address City/Town State Zip
to act on the +ru+erh 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,U it cu. tt.of enclosed s pace and/or nut under Construction Coniml then check here O and sJup Section I0.1)
10.1 Registered Professional Responsible for Construction Control
-»q - 31Y3 -'Pti1�1 O )e�,nc�SfL
Name(fgi`ant) Tel"ihon�Nu. a-mail address d 17Oon NumbeALL To _ .t .,� fYUC. ,,�� ram^ _ r i � 1� &—Street Address City/Town State Zip e Expiration Date
10.2 General Contractor
( 5
Cum my Name: r7
Name of Pe espunsible for Construction License No. and Type if Applicable
.3 f1 7, , Sf a.l 4Z 0 73
Street Address City/Town State Zip
78 -IL- 9/N3 sb C - 72c - 1o3 r T P O i (6, F- . N C,4
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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 O 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. Mechanical (HVAC) $ Note:Minimum fee=$ (contact munit
5. Mechanical (Other) $ Enclose check payable to �`J `
6.Total Cost $ O`r`t!O• (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.
L" rl (— Po, // tii/L� L7 41✓k�1_ C1)�
Please pr nt annd ign name ritle Telephone \o. Dale
tiU're1 1dJress Cityi Tu+yn State Zip
.Municipal Inspector to fill out this section upon application approval:
Name Date
AUdantk Meat Meathe FAVEa, U00n
61 R Jefferson Avenue Salem, MA 01970 (978) 744-8143
i
Mar 18,2014
i
PRO OSAL SUBMITTED TO: Don Armell
-- --- _ - 10 Hawthorne Blvd ---
Salem, MA
(617)959-0489
We hereby submit specifications and estimates for: Wall Insulation Clapboard
(top floor only)
1. Install Class I blown cellulose—3`d floor walls
2. Touch up paint—paint to be provided by customer
WE PROPOSE HEREBY TO FURNISH MATERIAL AND LABOR COMPLETE IN ACCORDANCE WITH
ABOVE SPECIFICATIONS FOR THE SUM OF: $2,200.00
.................................................................................................................................................. ...............................
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner
accoi ding to standard practices. Any alteration or deviation from above specifications involving
extra costs will be executed only upon written orders,and will become an extra charge over and
abov the estimate. All agreements contingent upon strikes,accidents,or delays aye beyond our
conti ol. Our workers are fully covered by Workman's Compensation Insurance.
I
......... .........................................................................................................................
...............:..............
..................
.
The bove specifications and conditions are satisfactory and are hereby accepted. you are
authorized to do the work as specified. Payment will be made upon completion ofwork as
outli ed above.
Plea sign and return one c py t e above address. ATLAf�T1C ERI I;ON, LLC
ACC TE ' � y /'CC TZ '
Eric Palm
DATE: �(&1 . Zy r 2
i
i
BPI Certified EPA and Mass. Lead-Safe Certified
Authorized Honeywell and NGRID/NSTAR Contractor
J
The Comnfonwedth ofMassachusetts
Depatz5netxf oflradustrial�eciderrts
O,f•f�ca oflsavavFcSctEazo -
600 Washington LSrreet
Boston,Mt1 0 M
' wwx.massgav/dip
Workers,s'Comprmatf nsatioa insurance 4*itdavit:Builders/Coll actors,'Il'Iectricians/�'i�ers
A ILCant Tl.if'OI'InatioL'-
Name(Buskess/Organizidua&dividual): Please —Le 2jilly
a 1 L,
Address: 61 R]eielson Avenue
City/State/Zip: Salmi'MA-01970
Ara
Phone.: y o
e yq n an employer?Check the appropriate boa:
I•LJ I.ma employer with_ 4. [(lam a general contractor and I �Pe ofpioject(regntr•ed):�loyees(fail . orpart time), have hued the sub-contactors 6. l0 New construction
.❑ _am a sole proprietor or.9 er- listed on the'attached sheet'
shipand have no employees 7. ❑Remade ire:Io ees Thew nab-contractors have
warping for me m any capacity. employees and have workers' 8 ❑Demolition
[No workers'comp•insurance roam.insuraabe. 9.
Buiidiog addition
3.❑ I ed] p• Q We at&a-corporatiou and its 10.[)P2ectdcal
gaahomeowner doing all work ofcam have exercisedtheir repairs or additions
myself(No workers'comp. rigbt Ofexemptkm per k% i l.[]Plmbmgrepaas or additions
insurance required]t c.152, §1(4),and we have no 12•O Rao
emmloye 13. .- Nrers yCc75)
'Anyapp&cantthate - comP•insurance req*ed.)
meovm bubox#lmnstskoin,outtheseceanbeiowshowbig&6woBre<s'cemgeo�II�potirym{o�yo .
ees who subtmt tbis affidavit indicating they are domgag work and then hire outsid omateac
tComraetont thstcheck this box ttwst attached an additional sheetshowm M mustsub�tanewa�
employees. Nihesub-contactarshave gthenameoftbesu daWtiadicatingsuch.
employees iheymustprovie@their war&ers' bSon��andsptewhetberornotthosaentt,,shave
Iam¢n p oy g �mP•vo&el number.
um Myer fhal isnrovfdar workers'compensation fnsarancefor Any employees Below rs th`sR04 y and job rife.
vtloPnaatrmi JJ Insurance Company Name:
Policy;`or Self-ins.Lic.#°r._ 7 B 7e
Job Site Address e/ ExPirationDate L3�20, /S
Attach a copy of the workers'compensation one d �ylSEate/Zip: dJ 97
Failure,to se policy eclaratioa page(showing the policy number and eapirattaa
cure coverage as required wader Section 25A ofMGL a 152 can Win to the' o date)'
fine up to$1.500.00 and/or one-year imprisonment;as well as civil penalties in the form of STOP W criminal ORK ORDER ofap to$250.00 a daya DER and
of P.
against the viohstar. Be advised that a copyof this Statememmybe forwarded to the OjEce f d a lure
In°esheatiops ofthe DIA for ipstuanee co a verifrcatioa
I do he+•ehy ce a Oder tF, p enalties o er' that the infoi=a*n ravided/�J fp f P above&free and correct Sittnahlre: _ .
one k
Date: y/a. //!�/
� ` 7�G/^
0 use only, o not write in this area,Woe comp d by crty orfown o.(fuiaZ
City or T,own:
PermitUeense
IssuingAuthority(circle one):
Y.Board of health 2.Buil '
5.Other �ngDepartmenf3-CIWOwnClerk 4.Electrical Inspector
i.-Plumbing lnspector
Contact Person:
Phone
ACORO®
CERTIFICATE OF LIABILITY INSURANCE
DATE(NWDD/yyyy)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
3/10/2014
BELOW- THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE q CONTRACT BETWEEN THE ISSUING INSUREORDER By AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.IMPORTANT: c the ions oath holtler, rt ADDITIONAL INSURED, the policy(les)moat be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such ondorsement(s).
PRODUCER
Eastern I M
nsurance NAME:Group III E: COnaLrnCtlOn
NA
233 West Central Street PHONE (508)651-7700 FAX
Ep
Natick MA 01760 INSURE 3 AFFORDINGCOVERAGE
INSURED INSURER A ArbaIla ProteCtion Ins. CO. NAIC II
Atlantic Weatherization INSURER BArbella Indemnity Ins Co 1360
61 Rear Jefferson Avenue INSURER Co . 0017
c:Naut7,lus Insurance
INSURER D:
Salem MA 01970 INSURER E:
COVERAGE$ CERTIFINSURER F:
THIS IS TO CERTIFY THAT THE POL C ES OFI NSURACATE N11 1 STIED BELOW HAVE BEEN ISSUED REVISION NUNI
TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWDHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOMENT 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
TYPEOFINSURANCE
GENERAL LIABILITY - POLICY NUMBER MMUCYEFF POLICY EXP
UMffS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
Pp MADE
CLAIMS- X OCCUR R00042816 /20/2014 ME AI Eecc mftwm S 50,000
P
/20/2015 MED EXP(Any one an
3 5,000
PERSONAL&ADV INJURY S 11000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY X PRO- PRODUCTS-COMP/OP AGG S 2,000,000
Lac
AIrTOMO8ILE LIABILITY
S
H ANY AUTO COMB NED SINGLE UNIT
a�4 1 000 000
A�0 ED 11T0S X ACUTOS D BODILY INJURY Per 020015871 /20/2014 ( Person) S
X HIRED AUTOS X AUTOS
NONWNED /20/2015 BODILY INJURY(Per accident) $
Perew'eTY DAMAGE S
X UMBRELLA LIAR X OCCUR PIP-Basic S
A EXCESS uaa 8,000
CLAIMS-MADE EACH OCCURRENCE S 1,000,000
DED RETENTIONS 600058654 AGGREGATE S 1,000,000
WORKERSCDMPEAUTION /20/2014 /20/2015
AND EMPLOYERS-LIABILITY S
ANY PROPRIErORMARTNER/EXECUTIVE YI N WC STATU- OTH-
OFFICEReneatory/NFMSFR EXCLUDED? ❑ NIA(M In NH) - EL EACH ACCIDENT S
D ySd Qeeryioe uMer
DESCRIPTION OF OPERATIONS cemw EL DISEASE-EA EMPLOYE S
C POLLIITION LIABILITY EL DISEASE-POLICY LIMIT S
00378602 0/1/2013 0/1/2014 GENERAL AGGREGATE
$1,000,000
DESCRIPTION OF 0PERATIONS/LOCg710NSl YENICLES EA POLLUTION CONDITION $1,000,000
(AttaeA ACORD teL Ae4itlona Remarl®Seheeuie,Nmore apace is requhee)
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF CLT EM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
93 WASHINGTON STREET
ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM, MA 01970 AUTHORQED REPRESEMrgmE
Ronald Cleaves/Ma ���
ACORD 25(2010/05)
INS0261PDtnrttT nt The er-nan ,,,d Inns,w runi¢hrorl Me'*a M srnOn0R CORPORATION. All rights reserved.
au5u uan 1w-1 J/ ic/cull -/ :cl : Dv AM YAUE 55/066 Fax Server
ACC3Ra CERTIFICATE OF LIABILITY INSURANCE 03-12.2g14
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 policypes)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 endorsemem(s).
PRODUCER CONTACT
EASTERN INS GROUP LLC NAME:
233 WEST CENTRAL ST PAS No Eu:HONE FAX
No:
NATICK,MA 01760 EMAIL
nRPqt
INSURERS)AFFORDING COVERAGE NAICA
INSURER A:AMERICAN ZUflICH INSURANCE COMPANY
INSURED
ATLANTIC WEATHERIZATION LLC NSURER B:
61 REAR JEFFERSON AVE INSURER C:
SALEM,MA 01970 INSURER D:
NSURERE:
INSURER F:
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 TYPE OF INSURANCE AGO SUB POLICY EFF POLICY EXP
L INSR WVD POLICY NUMBER MM1)N1'YYY) (MWI)D)YYYYI UMITS
GENERAL IUMBILRY
EACH OCCURRENCE §
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS-MADE❑ OCCUR I ' E
MED EXP(AM mepe,s,,n)
PERSONALAADVIWURY §
GENERALAGGREGATE $
GENLAGGREGATELIMITAPPLIES PER: PRODUCTS-COMPA)P AM S
POLICY PRO
JECT LOG S
AUTOMOBILEUABLITY MBI ED SINGLE OMIT §
it
i ant
SCHEDULED BODILY IWURY(Per permn) S
AUTOS BODILY IWURY(Per a¢vJenl) $
NON-OWNED
AUTOS OPE Y AMAGE S
S
U
MBRELLAR OCCUR EACH OCCURRENCE S
CLAIMS-MAOE
AGGREGATE §
ENTIONS
$
S COMPENSATION WL STATU- OTM-
LOYEflB'LIABILRY YM X T:11 LP.IITS EA
PRIETOR/PARTNERIEXECUTN� $SOO,000
IEMBER EXCLUDED? r-rN/A 6ZZD803-20-2014 03.20_2015E.L.EACH ACCIDENTy in NH)ile under 58270121 EL.DISEASE-EA EMPLOYEE $500.000
TIO OFOPERATION I. E.L.DISEASE POLICY LIMIT $500,000
OESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AHach ACORD 1M,Additional Rurmrk Sdmduk,H man".Is required)
EHJIFICATE HOLDER CANCELLATION
CITY OF SALEM - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
93 WASHINGTON ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
SALEM,MA01970 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
AUTHORIZED REPRESFNTATW ` f
ACORD 25(2010ro5) The ACORD name and logo are registered marks ACORDCORPORAl10N.All rights reserved.
)fit iilassachusetts-Department of?ablic Safety
Board of Bufiding Regulations and Standards
Construction Supen hor
License CS-087977
ERIC W PALM
313II.TONSr- i
SALEMMA-01970 —
commissionE+pir-tion
er 04/23/2014
.- a TGomillaileaw/Ma�'Plllauac�ate/(.
WOffice of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
gistration: 142069 Type: Office of Consumer Affairs and Business Regulation
piration: 3/12/2016 Ltd Liability Coipo- 10 Park Plaza-Suite 5170
Boston,MA 02116
ATLANTIC WEATHERIZATION L.L;C. -
ERIC PALM
61 R JEFFERSON AVE G� z�
SALEM,MA 01970 Undersecretary Not valid without signature