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7 HAYWARD ST - BUILDING INSPECTION (2) C't< g 5-6 The Commonwealth of Massachusetts WBoard of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: 2—0 Ll — Bwldmg Official(Print Name) - - Signature Z Da 4e SECTION 1:SITE INFORMATION 1.1 Tpe Address: �� 1.2 Assessors Map&Parcel Numbers V12 1.1 a Is this an c�eet?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(11) 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 Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Check if yes❑ Municipal ElOn site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Own of Rec%.: N4 MLS 1xiS5i I is S-0,,P in . All ON 76 Name'(P1unt) City,State,ZIP -7 &xw a Sf Y 7�'1-9�3-(oGRf No.and Stfeet Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=.(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ teration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number ofUnits_ Other Specify: lNaq,JCL74i T� Brief Description of Pro osed Work : "Labor 4 ESTIMATED CONSTRUCTION COSTS Costs: Official Use Oil Materials Y. I. Building Permit Fee:$ Indicate how.fee is determined:' ❑Standard City/Town•Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (AVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ 6.Total Project Cost: $ 7 Check No. Check Amount: Cash Amount: ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) T 7 G-7-7 T c� aal�N Name of CSL Holder License Number Expiration Date - 3 Hilton Street List CSL Type(see below) No.and Street - Type -Description. U Unrestricted uildin s u to 35,000 cu.ft. frown,State,ZIP rRKRcsMctM—eu1&2Fam ed 1&2 Famil DwellinCoverin and Sidin',tC el Burning Appliances W41 -D1YonTe honeEmail address tion5.2 Registered Home Improvement Contractor(HIC)Atlantic WeAerization,LLC I yzo9 Raw HIC Company Name or HIC Registr*l n venue HIC R istration Number Expiration Date No.and Street 001VIIIII& �� Email a s's^'� 1 Ci /Town,State,ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§'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 Issu of the building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize C� f C t C-4 l t1 to act on my behalf,in all matters relative to work authorized by this building permit application. Pnnt Owners Name(Electronic Signature) I `� Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of pequry that all of the information contained in this application!'llrue and accurate to the best of my knowledge and understanding. // aliq 1LY Print Owners or Authorized Agent's Name(Electronic Signature) Date NOTES: Jr. er who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(FUC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass soy/oca Information on the Construction Supervisor License can be found at www.mass.gov'dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable 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" e , WAF Work Order. North Shore Community Action Programs,Inc. Job Number: 100143 98 Main Street Work Order Date: 12/24/2013 Peabody,MA 01960 Ownership:Renter Phone: 978-531-8810 Atlantic Weatherization - - Auditor:Brandon Dorrington 61R Jefferson Avenue Email: bdorrington@nscap.org Salem MA 01970 Cell: 781-540-8569 Email: tpalm0l@comcast.net Phone: 978-531-0767 xl21 Phone;978-744-8143 Elaine Englehardt - NGRID Gas $3,857.79 5 Hayward St -Salem MA 01970 Total $3,857.79 - 978-741-3467 Landlord Name: Nicholas Bassila Landlord Phone:781-953-6695 - Authorized Actual ,Measure Description `1 ; _ Qty Pnce Total .Qty ' Total Comments ,- Attic Insulation R-30 restricted-slopes/floored till 141 $1.48 $208.68 141 $208.68 w/cellulose R-38 unrestricted-settled cellulose 499 $1.47 $733.53 499 $733.53 rs Automatic Sweep 1 - $23.00 $23.00 1 $23.00 - Basementloutside door-door only 1 $367.50 $367.50 1 $367.50 Solid core door w/hardware Fixed Sweep 2 $15.75 $31.50 2 $31.50 Lockset>Schlage or equal 1 $73.06 $73.00 1 $73.00- R-5 Ductwrap or R-max on door 1 $51.00 $51.00 1 $51.00 Weatherstrip s/Q-Ion or equal 3 $45.50 $136.50 3 $136.50 37-7 e = :Health&"Safety �'j p,�,.x 's - v . p'.rt.. :+w 4- �..-c,.f... 4 e .�g.-. c' ..— i✓F� .�T -.s Clothes Exhaust Duct vent 1 $89.00 $89.00 1 $89.0 r � dryerg 0 Vent kit/bath fan 1 $89.00 $89.00 1 $89.00 Date: 12/24/2013. Page 1 WAP Work Order: Job Number: 100143 gsealingwith nsulation 463 $154.781 pipe wrap 6 $15.78 easureb two-part foam 1.5 $75.00 $112.50 1.5 $112.50 with two-part 1 $7500 $7500 1 575.00 _77-77- g 1 $100.0 Buildin Permit 0 $100.00 1 $100.00 Wall-Insulation.. Drill finish patch plaster(dense"pack) 922 $1 90 J$1 751.80 922 $1,751.80 All interior blow(brick ext) . Total $3,857.79 $3,857.79 Contractor Instructions: Before Starting the Job: Dunne the Job: 1.Please notify us 24 hours before starting or scheduling ajob. 1.Incorporate lead safe practices as applicable. 2. Obtain required building permit 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) Date: 12/24/2013 Page 2 WAP Work Order North Shore Community Action Programs,Inc.98 Job Number:Bassila(i) Pe Main Street Work Order Date: 12/24/2013 Phone:97S-531-8810 Peabody,MA 0 Ownership:Renter -88 Atlantic Weatherization - Auditor:Brandon Dorrington 61R Jefferson Avenue Email: bdorrington@nscap.org- Salem MA 01970 Cell: 781-540-8569 Email:tpalm01@comc2st.net Phone:978-531-0767x121 -- - .. Phone:978-744-8143 Rebecca Bassila NGRID Gas 7 Hayward St Total $3,229.29 Salem MA 01970 $3,229.29 Landlord Name:Nicholas Bassila - Landlord Phone:781-953-6695 T " ,. Authorized s `Actual " Measure Descnphon Qty - 'Puce _. Total Comments = 'Qty Total " •Attic Insulation - i restricted-slopes/floored fill 141 $1.48 $208.68 141 $208.68 w/cellulose R-38 unrestricted-settled cellulose 499 $1.47 $733.53 499 $733.53 Fixed Sweep 2 $15.75 1$31.502 $31.50 Weatherstrip s/Q-Ion or equal- 2 $45.50 $91.00 2 $91 00 Health&Safety Clothes dryer vent including 1 $89.00 $89 00 1 $89.00 Exhaust Duct - - - VentIdt/bath fan 1 $89.00 $89.00 1 $89.00 1Vhsc Insulation <'t777 `':_KRat"'=`'�".i. Domestic water pipe wrap 6 $2.63 $15.78 6 - $15.78 - Date: 12/24/2013 Page 1. WAP Work Order: Job Number: Bassila (i) MiscMeasures Ang with two-part foam 1.5 $75.00 $112.50 1.5 $112.50 ttic seali Basement sealing with two-part 1 $75.00 1$75.00 1 $75.00 foam Weatherstrip(Q-lon or equal)attic 1 $31.50 $31.50 1 $31.50- hatch WallInsulahon - Drill finish patch plaster(dense 922 $1.90- $1,751.80 `922 $1,751 80 -- pack) Total 53,229.29 $3,229.29 Contractor Instructions: Before Starting the Job: - During the Job: - 1.Please notify us 24 hours before starting or scheduling a job. 1:Incorporate lead safe practices as applicable. 2.Obtain required building permit. 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) Atlantic Weatherization 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: Date: 12/24/2013 Page 2 A� CERTIFICATE OF LIABILITY INSURANCE F °p1IMMI0013 ' 3/11/213 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 CONTAC N ME: T COIIStrUCt:iOO Eastern Insurance Group LLC PNDNE (508)651-7700 FAX e, 233 West Central Street ADDRESS, INSURER(S)AFFORDING COVERAGE NAIC4 Natick MA 01760 INSURERAArbella Protection Ins. -Co. 41360 INSURED INSURER aArbella Indemnity Ins Co. 10017 Atlantic Weatherization INSURERCNautilus Insurance Co 61 Rear Jefferson Avenue INSURER D: INSURER E: Salem MA 01970 INSURERF: COVERAGES CERTIFICATE NUMBERMSTER 2013 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. INSR ADOL SUSA POLICY EFF POIJCY EXP LTR TYPE Of INSURANCE POLICY NUMBER WDDrYYYY) IMM1DDNYM UNITS GENERAL LIAmUTY EACH OCCURRENCE $ 1,000,000 X, COMMERCIAL GENERAL LIABILITY PREMISES Ea o=m $ 50,000 A CLAIMS-MADE OCCUR 500042816 /20/2013 /20/2014 MED EXP(Any one n) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT IN I 11000,00 B ANY AUTO BODILY INJURY(Per person) $ ALLOWNED X. SCHEDULED 020015871 /20/2013 /20/2014 ( ,� ALIT 0.S AUTO6 BODILY INJURY Per ectide $ X HIRED AUTOS X NON-OWNED PROPER DAMAGE AUTOS Per. 'tlent $ PIP-Betio $ X, UMBRELLA LIAR }[ OCCUR EACH OCCURRENCE 8 1,000,000 4 A EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I I RETENTIONS 600047820 /20/2013 /20/2014 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT - $ OFFICERIMEMBER EXCLUDED? NIA (Mande ryIn NB) E.L DISEASE-EAEMPLDYE $ If es,OeStdbe under DESCRIPTION OF OPERATIONS W. E.1-DISEASE-POLICY OMIT $ C POLLUTION LIABILITY FL2003786001 0/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ARsth ACORD 101,Addiffmal RewrN-Sebedule,U more-pats Is mqulmd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SALEM - ACCORDANCE WITH THE POLICY PROVISIONS. - 93 WASHINGTON STREET SALEM, MA 01970 pUTIi0R12E0 REPRESENTATIVE Rosemary Fulham/PMA •-"^�a` `"� ACORD 25(2010105) ©1988.2010 ACORD CORPORATION. All rights reserved. INS025 r7ntnrt5l n1 Th.acnan name and Inn.aro roniebrod madre of ARr2Rn nignzzax lJ—'L 3/11/2013 4 : 45 : 54 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MI1DD/YYYY) T IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS"ON THE CERTIFICATE HOLD 3 T5 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemeot(s). PRODUCER CONTACT NAME: EASTERN INS GROUP LLC PHONE 233 WEST CENTRAL ST Fax NATICK,MA 01760 E-MAIL ADDRESS: 22ML W INSURERS)AFFORDING COVERAGE NAIC# INSURED INSURERA: AMERICAN ZURICH INSURANCE COMPANY ATLANTIC WEATHERIZATION LLC INSURER B: INSURER C: 61 REAR JEFFERSON AVE INSURER D: SALEM,MA 01970 INSURER E: INSURER F: COVERAGES CERTIFICATENUMBER: THIS T REVISION NUMBER: OF INSURANCE LISTED ELO ❑TO THE INSURIMNAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR 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. LIMITSSHOWNMAY HAVE BEEN REDUCED BY PAID CLAIMS. WSR ADD SUB LTR LICY EXP TYPE OF INSURANCE L R POLICY NUMBER PO(MMI)MYYYY)LICY EFF E PO(MMDMYYYY)E LIMITS GENERAL LIABILITY CO IS MMERCIAL ACH OCCURRENCE GENERAL LIABILITY _ CLAIMS MADE r7 OCCUR. DAMAGE TO RENTED $ REMISES(Ea occurrence) MED EXP(Ary one person) $ GEN'L AGGREGATE LIMIT APPLIES PER: ERSONAL&ADV INJURY S POLICY =PROJECT LOG ENERAL AGGREGATE $ ODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE $ LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ - SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS Per accident) PROPERTYDAMAGE g (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YIN UB-58270121.13 03202013 03/202014 X WC STATUTORY OTHER MITS ANY PROPERITOR/PARTNER/EXECU-NE NIA OFFICER/MEMBER E%CLUDED> MN yes.erory In NH)tlespibe antler E.L.EACH ACCIDENT $ 500,000 U yes, I E.L.DISEASE-EA EMPLOYEE S 50 (000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMIT S 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 93 WASHINTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. SALEM,MA 01970 AUTHORIZED REPR TA�/E :ta.._...:. Wit. .: ACORD 25(2010105) The ACORD name and logo are registered marks of)FORD . IUoU-2010 ACORD CORPORATION. All rights reserved. v 1�! Massachusetts -Department of Public Safety _ Board of Building Regulations and Standards R Construction Supenisor ' License: CS-087977 11 ITS ERIc w en1.M` 3IULTONSf SALEM 11gp-0197+0, - Commissioner Expiration 04123=14 Once Af coos. alu'aioesso r - V - HOME IMPROVEMENT CONTRACTOR - Registration y.142089 Type: Expiration 3/12 2014 Ltd Liability Corpor A TIC WEATHERIZA it. L L C. ERIC.PALM �' 61 R JEFFERSON AVE �� ��_ SALEM,MA01970 Undersecretary f The Commonwealth of Massachusetts Department ofludustrialAccidents 0,ffscc oflrsvesftgat(ons - 600 Washington Street Boston,ALL 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/pIumbers Apolicant Information PIease Print Legibly Name (Business(agmizadon/Individual): -Address: 61 R Jefferson Avenue City/State/Zip: Salem MA'01970 Phone.#: 97k 71,/y-8ly 3 �'e ypu an employer?Check the appropriate box: 1. I am a employer with 4. 0 I am a general contractor and I [13.0'Ce" project(required): employees(full and/orpart time).'" have hired the sub-contractorsew construction 2 I am a sole proprietor or partner listed on the attached sheet emodeling ship and have no employees These sub-contractors have B. emolition wdrking forms in any capacity employees and have workers' [No workers'comp.insurance comp.insurance t- uilding addition required.] 5. 0 We are•a-corporation and its ectrical repairs or additions 3. I ain a homeowner doing an work officers have exercised their umbing repairs or additions myself(No workers'comp, right of exemption per MGL o insurance required)t em ploy employees. [ and wehave no /S,1Q��j ' employees.[No workers' comp.insrrranre required.] - }Any applicant thatchwim box#I must also fill out the section belowshowing thevworkem,coWensadon policyinforn ation 73ommwmr`s who submit this affidavit indicating they arc doing all work and then him outside couueetors must subadtanew a&davit indicating such rContractors thatcheck this box must attached an additional sheet showing thenaine ofthe sub-conttactots and state whelheroraot those entities have employees. kthe subconbactdrs have employees,they mustpmvide their workers'comp.policy number. astion.employer that lsprovidiag information. workers'compeusatioW insurancefor my employees Below is thepohey and jab site '7 insurance Company Name: Z-44, y'j Policy#or Self-ins.Lic.m_ -5 8a70111 Expiration Date: l3120 �j//,U,f Job Site Address: ITGte ttvn �r� �� . Gity/State/Zip: /gyp e rrl/7 d1970- Attach a copy of the workers'kompensation 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$4500.00 and/or one-year imprisonment;as well as civil penalties in the fora of a STOP WORK ORDER and a fine of up to$250.00 a day against thq violator. Be advised that a copyofthis statement maybe forwarded to the Office of Investisat' tul of the DIA for insurance coveraee vtxification. d do hereby ce under atryrgrt ¢Wallies ofperjury that tine information provided abov is true and correct Silmattue: G Date 2-1 H Phone O cia use only. a trot wrrie in this area,l6 be comp by city or mwn offrcial [6. ity or Town: Permit/License# suing Authority(circle one): Board ofHealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector Otherontact Person: Phone#: nnnn I ..i A