3,5,9,10,11 HERITAGE DR - BUILDING INSPECTION The Commonwealth of Massachusetts
y Department of Public Safety
4• ! j \lasaduua•tts Slate Budding Code(780 CMR See enth Edition
City of Salem
Buildin�Permit Application for any Buildingother than a 1- or 2-Tamil Dwellin
(this section For t)fficial Use Only)
"v [holding• Permit Number: Date Applied: I� Budding Inspector.
SECTION 1: LOCATION (please indicate Block N and Lot N for locations for which a street address is not available)
7j 5 iOtl l+el\rTALt i3A 5f"- /� MH plCi 70 � �"
.\'o. and'Street City /To%,n 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
Exit ing Building❑ Repair❑ Alteration ❑ Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Changeof Use ❑ ChangeufOccupancv ❑ Other UK Specify:W=1Ls+(7 G105c75 jex/ LAkA9JQZ-AM--i
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 O r
Brief Descriptiunof Proposed Work: 13 -\ i/ f, l"D9Pjs O�ADQ C)F IOLYWrzw A"WAyo etirin ikAL
PnL•^f�.�e 1 VPNj N/, tner� TIhAP�a nI Nee4
SPC' sI! /�. rIJ S eireacTs
I:eTGIn _ -- __
-- L NDIZ �txanil5 V I
SECTION 3:COMPLETE THIS SECTION IF ISTIN BUILDING UN ERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY A/*
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): Y
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDINGG HEIGHT AND AREA rq CI+tN 5
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-I ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional f-1 ❑ 62 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 ®' R-3❑ R-4 ❑
S: Storage S-I ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special L'.vu:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
-IA ❑ In ❑ IIA ❑ IIB ❑ IIIA O 1110 ❑ IV ❑ VA ❑ VB ❑
I SFCriON 7:of"I-F INFORMA"rION (refer to 780 CVIR 11 1,0 for delai is on each item) _
t---'— —r--------
"lTench Permit: Debris Removal:
Watcr Supply: Flood 7one ❑tfomtation: Sewage Disposal: Lta•n+ed Di:. tl sit, ❑
J :\ trench tv.0 nut be f""•
I'uhhc ChEr"',
cf, o oWnide Ign„J /one® Indica h•municipal tl
i rcyu ord �rc trench or
I'ncale❑ �q uxlenulc %one:___" � r,,n ne.vstem ❑
I enrlo.r`I ❑
I2ai1maJ rigltboL wayy' T-- flazards to Air Navigation: ..nun...nn l_,"y•„ I'n
\.a .\ h:.iblc[9' I b.}Irurwrc t.nhw.orprt eF+pru.ieh.:rv.i' I+ Ihcn ret lets rnnl•Iclyd'
a(" •.r-rntn'Itud.l N. Yc•+❑ Qr
SF:CDON 8:CONTENT OF CF.RIIFICA rE OF OCCUPANCY
C,fwm :•i ( :•Jc _..__— �-e l�rinipi+i ftpa•oi llm+Irucu,vt; Occupant to.id p"t 1-1nv
ILq cc...
SECTION 9: PROPERTY OWNER AUTHORIZATION
.N.unu.uid .lddres.<ul ('ruperlr Owner
Pn,�cer� Pnaf�2n7;e3 1115 wwio I3 ST Lnw�tc 1 AnR flBSl
.Nana•(Print) No.and Street C it% I'ownqExptr.,tC.,ol)(LnDate
Zip
Pioperi, Uw ner Contact hiformallon:
P.- I 33A Po: �� rMP 4Tille Telephone No. (businv,,) Telephone:No. (cell) ddresaIf.)pplicable, thr properly n.v ner herebyauthorizes
lowed ,tiS�.Name Street Address City/Town Slaipio.iclon the ron•rt u�r ner behalf, inall matters relative Io work athorized by this building permtion.SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix tit buildin•is less than 3i,tXX)cn.it.ofenclosed s paceand/or not uudvrConstruction Control then check hekip Section 10.1)10.1 Re istered Professional Res onsible for Construction Control
Name(Registrant) 'relephone Nu. e-mail address RegibtrberStreet Address Guy/Tusvn State Lip DisciplExpiration Date
10.2 General Contractor
A01391 Ae5a/aee n1'7)�NSj 'NL WhA GnnS�c �2
Company Name:
�RSo✓ (LU ,✓C 4i✓ .15 $ mil (/
Name of Person Responsible for Construction License No. and Type if Applicable
`7 A AQ- PY- Ve --3LNi��T 1' ^'.� _ RA' Nk, � n-a 7�L7
Street Address City/Town State Zip
h951 .6791 5l _ 5l - �1 �nSon/• yir�tH�+ PGDnsatanro -,
Telephone No.(business) Telephone No.(cell) - e-mail address
SECTION 11:WORKERS'COMPENSA ION MSURANCE 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.or No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _d�z
1. Building $ Q0, O Building Permit Fee=Total Construction C K Insert here2. Electrical 8 appropriate municipal factor)_3. Plumbing $ Note:Minimum fee=$4. Mechanical (HVAQ $ (5D tslily)S. Mechanical (Other) $ Enclose check a tble toF Y•6.Total Cot $ (contact munici alny)and writecheck numbeSECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANTBy enl�g imy name below, I herebv attest under the painsanal penalties of perµury thatall of the informatd in thisrppiicolion is imeandaccurate to the bestof❑*v kn ledge and underalanding,
_��A!��''� � n�n� u30Y5[14v.u,r port .ind .ry;n na,mc fiUe
UaleCut/Tynan /
Municipal Inspechu to fill out This section upon appliyalimt approval _ -_ I��O� `''
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_ 1)ale
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The Commonwealth of Massachusetts
rt Department of Industrial Accidents
�� Office gflnvestigations
V-
600 Washington Street
Boston, MA 02111
www.mass.gov/dirt
Workers"Coinpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):��/j/�� �Ul✓.j; ��CT• C,I� (>/LO JOGf1tC
Address:_lt7/ CU a 10V67? Dd, 5-(/ 17C ?
City/State/Zip: WAII7E eiY�K�vrton 0✓ Phone #: ?V0 I-)q el t/g,y
Are you an employer? Cbeck the appropriate box: Type of project(required): -
I. ie I am a ern plo er with 205 4. ❑ I am a general contractor and I
I Y �— k have hired the sub-contactors 6. ❑ New ConStrUC ion
employees(full and/or part-time).'
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurautcc comp. insurance.•
required.]
5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself. [No workers' comp. right ofexemption per MGL 12 ❑ Roof repairs
insurance required.]p c. 152, §1(4),and we have no
employees. [No workers' 13.['Other SQ49R QAN�:LS
comp. insurance required.]
*Any applicant that cheeks box III must also f II out the section below showing their workers'compensation policy infito nation.
*Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Cralaactors that check this box must attached an additional sheet-showing the,narne of the sub-contractors and state whether or not those entit ics have
enrplgecs. If the sub-contractors have employees,they must provide their workers'carp.policy number.
1 am an einplayer that is providing workers'c'onrpetisatioti insu ance for my employees. Belon,is the policy and job site
inl6nnation.
Insurance Company Naric:.. C'�l'✓'vC �'/O�7`�NJ'bty //✓.(,
Policy#or Self-ins. Lic.It: �1? l6 410 Expiration Date:_-
Job Site Address: City/State/Zip: SA e,>n kill h of g 7e+
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required wider Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 tine
of up to$250.00 a clay against the violator. Be advised that a copy of this statement may be Forwarded to the Office of
Investieations of the DIA for instuance coverage verification.
/rin hereby certify under the ius mrrl pens/lies gjperjurp that tl+e inJnt•nr(dinti prnvi(le(1 abo�vve�i.v.true ati d correct.
Signature Date:
Phone#:
Official use ably. Do not write ir+.Iris area,m Ge crnnpleted In,city or town gfjicinl
City or Town:— PCrntit/L,icense#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cityfrovn Cleric 4.Electrical Inspector 5. Mouthing Inspector
6.Other
Contact Person: _ Phone#:
7
CERTIFICATE OF LAAMILITY NSURANCE
7-7
PRODUCI Phone 603 352-21 21 Fax: 603-357-8491. wFls aii
IIrIcw1E IS ISSUED AS A IVIA4TER OF INFORMATION
Clark MorLenson Insui.ance ONLY AND CONFERS NO 131GI-ITS UPON THE CERTIFICATE
P.O. Box 606 HOLDER. THIS CERTIFICATE DOES NOT AMEND, ExrEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Keene Nil 03431, 1
INSURERS AFFORDING COVERAGE NAIL#
IN uNID WSURCRA AIDE,Li can Intornat.i.ona.l. S�ecia.j,i
GroSo.l.ar INSURFRB:The Hartford
01obal. Rescluice Oj)lJons, Eric- DBA
601 Old R.ivei.* Rd. ; Sul Le 3 INSUR(ERGAlational. Union Fire Ins . of P
White River Jurict-J.on VT 05001 INsuRERMLibertY Mutuil.middle Market
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COVERAGES
THE POL)C12S OF INSURANCE, 131.,I,()tq HAVE Hi*:N issum) ro rm.,. INSURED NAMED A13011E POR THE POLICY PFRIOD INDICATED.
NOTWITHSTANDING ANY RII.QUIREMENT, TERM OR COWDYTION OF ANY CONTRACT ON OTHER DOCUMENT Wj'rfl RLISF]ECT TO WHICH THIS
CERTIFICATE MAY BE. (S.90") Oil MAY PHR*rAf.N, -mR INSURANCE AlIrORDEID BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TERMS, EXCLUSIONS AND CONDITIONS Oil SUCH POLICIES. AGGREGATE WMITS SHOWN MAY HAVE 131'.MN REDUCED 13Y PAID CLAIMS.
1,13 1W—ODT I;OLIGYI- FECTIVE VOIACYI;XJ;f1l2fAf1ytj1N
iL
--I?iNSRI;--- -F9ijI--WJAS it 0JANC IL- POLICYNklmorn )A T E lonff Yj _j)Ammm Y
-- IY RANCLE T
c GENFRALIJAHii.RY —F4 19-10 2.0 8/1/2009 8/1/2 01.0 -DAPAGE To REUTM) I_000 1 OkQ
I COMNIF.[iGIAI.Gi-FIFF�AI.IIA1311iry PREMISE,",
I S100-000
LX-
Cl AIMS MADE I OC XUR 510, 000
PERSONAL A ADV INJURY 1_000 000
-
I GCNLRAIA0CRLGAUr I S2,0001000
GENI AGGREGATE I Hill I APPLIES PER: PIROOUC rS-GOMPIOPAGG S 2, 000, 000
---LIPOLICY E-1 11 C .......... _X -- _�,RU G 009 8 1/2 01( Project- Aycl 00, 000
13 ALI OMOBILE LIABILITY 492997 8/.
1/2 GOMf I ED 9INGLE LIMII
13 X ANY AD to 493000 8/1/2009 8/1/201A lco F:1 000, 000
ALL OWNED ADI Osq HGDII Y IN II PRY
SCHEOULLOA0103 (Nu
BODILYINJURY
X NON OWNED AUTOS
PROPERTY DAMAGE S
GARAGE:IJAH11.11 Y AUTO ONLY-LA ACCIDEN r S
ANYA(JIO ol I Eft ni"N FIAGG �S
AIJTOONI-Y: .-AEG
A I CXCESSIUMURM-1 A LlAmu ry 492930 8/1/2009 8 1 2 0 10 I EACH OCCURRENCE -.s 5 000, 000
OCCUR F1 Ct AIMS MAC` AGGREGAIE $ 5, 000, 000
A RE rENU0W s 1. ot 0 0
F) WOGIKVRS COMPENSATION AND 191.640 8/1/2009 8/1/2010
EM111,11YERS'LIABILITY
ANY PROPRIETORIPARTNEWEXECUTIVE -E.L.EACH ACGIDENJ s I _000-,-Qoo
OFFICER)MEMBEREXCLUDED?ye., EL.DISEASE-EA EMPLOYEE ii I, 0 0 0 0
SPECIAL FIR0VISIONSIll,11111 E.L.DISEASE--POLICY LIMIT $
OTIMIZ $2,2211,000
4931.26 8/1/2009 8/1/2010
DESCRIPTION OI°OPEF2ArIONSILOCATIC)NSIVI IilCt-ES)EXCi-USIONSADDrDflYI:NDOFtSI'MI:NFISFIEGIALFIFIOVIStONS
Uolfo,Pre.,�iclolit felIery tk�jfe,
[Lkllera.1 Idabil.ity Per llrcljeCt: Aggregate IS $5,000,000
"., CoverageCvelqe Pn ,- Wk .,�k, A ApplAe,3 L. Lh ., ,- Coli,pens�,Liojl Laws in the States LiisVed liere: CA, CO, MD,
i A, MT, Nil, NJ, NY, OR, VT
Xhldocl Ol]ricenq: jalnLR Ke�.o,, CIO, Ji,. Me COO, W.yRe fl� lacqitesu.,C DOrOLhy [,I
----------
GERI IFICATE HOLDER CANCELLATION
SHOULD ANY Of' THE ABOVIl. 1)F,PCRfRED POLICIES BE CANICEI,1,1-10
REFORM THE I,,'XVIRATJON DATE THIKIZE01', TIN, ISSUING INSUREIZ
Global ReGSource Options, 1.11C. DEA WfL.L, ENDIlAVOR TO MALL N/A DAYS WRITTEW NOT(CF, To I'll];:
0)"Scd.ar CII.PT111CATE HOLDER NAMI33 TO THR L.RPT, BUT FAIWRE 'I'O DO SO
601 Old River Rd. ; SmLe 3 SHALL IMPOSI.I. NO 013I.IGATION OR 1,1A13ITA,TY 01 ANY KIND U110M
Wli.iLe River Junction V'r osool. Tllli: INSURER, ITS AGENTS OR R1.1,11RUSENTATIlVES.
AVINORWIDREPRESENTATIVF
ACORD 25(2001/013) @ACORD CORPORATION 19H
k u J/� tt,'r rN Jlt No9e(Ll((/ oU�',:/Ll;JJn!/i4rerl� ,
t`MA
`hr Ro. d III UwldillL Riignlnbo vc and 51 nid a ds -
Construrtion Supervisor License -
License: -CS 95884
Birthdate: .121211977
I
Expiration: 12/2/2010 Tr# 95884
Restriction: 00
JASON QUINLAN
180 MAIN STREET#B42 r,�__ '3' �f
BRIDGEWATER, MA 02324 Commissioner
I 6o nd orRuddmf Rcgu hVums and Standards
'1 id I(ti HOME IMPROVEMEN r GUN 1 RAGl OR
Ro s 159879
- 6/9/2010 il'# 26936.3
TYI)O: Private Corporation -
GLOBAL RESOURCE OPTIONS dba GRO SOLAR
DAVID RICHAIRDSON
601 OLD RIVER RD SIil 1-1Z 3 -
WPJ. V'I 05001
A dmin is(rn for