12 HERITAGE DR - BUILDING INSPECTION (2) h� The Commonwealth of Massachusetts
Department of Public Safety
A. •I'�P \laasadnrxgls Slate Budding Create 1:30 C.\IIi15e�enlh Edition
City of Salem
BuildingPermit A lication for an Buildingother than a I- or 2-Family Dwellin
(This Section For Official Use Only)
Budding Permll NL, be Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block If and Lot 0 for locations for which a street address is not availa )
I;. WeI6 TA6G OR SACEr^ al9 ?d _
No..end Street Ow /Tu.vn Zip Code dame of Building(if applicable)
SECTION 2:PROPOSED WORK
It New Construction check here O or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition Cl (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other X Specify: ADDITION OF S'0/..14yt rA0V%)GC-r
Are building plans and/or construction documents being supplied as part of this permit application? Yes .g/No ❑
Is an Independent Structural Engineering Peer Review required? r� Yes T&— No ❑
Brief Description of Proposed Work: /NST19 G[_ XO"A AW0gvC.GT OA/ ROOF A.f
PAar OF A Vrtclry -r/6A EGECrnic Syrr•S1'vt.
9C6'A/F0RCE &VIE 7L'» XF9FTE"2l A r p6K f 44N-r
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDIXONOR .
CHANGE IN USE OR OCCUPANCY
MIJ
re if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
se Group(s): Proposed Use Group(s):azard index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHTAND AREA - /(/ — A/O Cld A NExisting Pro
ors/Stories(Include basement levels)&Area Per Floor(sq. ft.)a(sq. ft.)and Total Height (ft.)SECTION 5:USE GROUP(Check as a licable)
bly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational O
F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ I-3 O I-4 O M: Mercantile❑ R: Residential R-1 O R-2 V R-3❑ R-4❑
S: Storage S-1 O S-2 ❑ U: utility O Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IBO IIA ❑ I1B ❑ IIIA ❑ IIIB ❑ 1 IV 1 VA VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 11 L0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal:
Pubhc :\i reach w•d not he I_ri Fined Ui. +o.it Sire❑
.0 he•d rf uub ida• 1=1u„J Lune Indicate municipal Nf M rrAN
rcc urred or trench ur cc[?, :
I'r,calc❑ ur unk•Nrlc 7_unc: rand r.enclosed ❑
~- Itailmad right-of-way: Hazards to Air Navigation: \I:\ I In1�•n, < .•nun,.-ism li......, Pen•,.
\,rt i\pl• ;:a(•Ic CsY 1, true lura IF+(,narh.I1 Llbut t le%Ic.c cmiplcicd.'
IttnlJ rncl,,.r.l Cl }c.0 �,r Xu®� Yc. ❑ \u fd�
SECTION 8:CONTENT OF CER-DFICA FE OF OCCUPANCY
I�.fil'on d ,o1r ��•c Gnnipi�r. _ r,pv of ,m.trucuun: . rlaupant per I111111"
11,•r�dm burldnp;c,u+l.iin.rn til.nnAlcr?r.tent': >prcial?opulaUnn� .
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nome.uid Addre>.sol Owner
p/2)tvCE1a// P/10Ar,0f?L-T //lS lyf3rFoi20 JY' Gat✓EG�/ r►rf�o/PS/
.Name lPrint) No.and Street C il,/Town tip
Pro puriv 0%%ner Contact Inform.ttiun:
�2fSr�'Y-a-•'�. 97B -'/S8'- e700/gyp 9�8_�s. /069 ks/+tllin�fi'"g��rncthn�/rop.i. t1; cc
Title Telephone No.(busmen.) Telephone No. (cell) r-mad address f
If.applicable, the properly owner hereby authorizes
�r/R f',}'y/LG/NG7a/✓ //1-C Alesorz o Sr. GOWE'L
.Name Street Addrexv City/Town State Zip
to act on the pro+rrl o„'ner:,behalf, in eII ma tiers rela ti%e to work au Ihnri zed by this buildin + permit a + pl ica(ion.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
Ilf building is Ices than 35,0o0cu. it.of enclu.rd<pace•and/or not under Construction Control then check here❑and.kip Section 10.1)
10.1 Re interact Professional Res onsible for Construction Control
CHAtS VrZCC4AN0 4111267_ Y GS vreelaA467er.x .sn.cio 1//70 f
Name(Registrant) Telep`o-o No. e-mail address Registration Numbe-
P° .sox -7v4 sn,f ✓7 IA 012SY MtcN 'ir✓w _/v��0 Zo/o
Street Address City/Town State Lip Discipline Expiration Date
10.2 General Contractor
6Loadr4L IZE"JOurett' ap71Gr�J" /A,c d�� G2eJb!✓42
Company Name:
-'I•Ra O'e NGA �S�By V
•Sr ti
Name of Person Responsible for Construction License No. and Type if Applicable
(_�LP�i4N 02 f cE�;yN r r ,1-3- 1CA,jlNft,4. CIA 017 6"r
Street Address City/Town State Zip
8-- 95r- 67171 Sir*-9S/ _ 6791 Jason. Pao in IQAM arosolm,cv.
Tale hone 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 a lication7 Yes 9 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ E.7$if, Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ ( to Fj appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
S. Mechanical (Other) $
Endure check payable to
6.Total Cost is 23,V53.o Q (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 intormatiun con Luined in this
applicahon is true end accurate to the best of my knowledge and understanding.
,4 v1 v _ P/Cl/.4IVJoki gee, 1;v+,v,4 ct-jr-
I`Ico x•pant .md.ihn name title ielephonr 161 Date
ems_.7 Dam unr f� �j0 'tLl'� t� 6
I tit reel .lddre�> ( rt\';7uwn titot C)p n
Ntu nicipal Inspectur to till out this section upon application approval: t+u 20
The Commonwealth q/'Massachusetts
' Departinent nflndustrial Accidents
Office gflnvestigatiolu
41 F. ,t 600 liVashington Street
S Boston, MA 02111
r..,t
3 wwminas's,gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant tnformation 1 Please Print Leelzibly
Name (Nosiness/Organizationllndividual):(��/j/a� /�F.!Obti .` oO�Un/S' �/Ve• G'Ao,So&44
Address:15OZ r 21✓E7Z —
City/State/Zip: kAIM ,91VCCA— )VNG➢'Ib✓ Phone M k0a T?q Z/`WY
Are you an employer?Cheek the appropriate box: Type of project(required):
I.L�
,—J I,,! a employer with o S 4. I am a general contractor and I
emplainoyees
loyees(fill and/or par[-time)." have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor on partner-
listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working lot me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.-
required.]
5. [I We are it corporation and its i o.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required] ' c. 152,§1(4),and we have no
employees. [No workers' 13.[✓]'Other Sa�+9R QANtcCS
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inronnatiun.
f no who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Cori actors that check this box must attached an additional shece-showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-connectors have nnployces,they nnrst provide their workers'comp.policy number.
1 inn an employer that is providing worlrers'compensation insurance for rrry emidoyees. Below is the policy and job,s'ife
injmnation.
Insurance Company u, Name: .
Policy#or Self-ins. Lic.It: Z19 /6 410 Expiration Date:_ ti'112,0/0 .-
Job Site Address: 1^eR.tTb 4•__ City/State/Zip: SA e-),—t Ym A of q 7u
_
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 clay 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.
!rin hereby certify under the n ins and penalties o/•perjmy that the irtjmrnation provided above is trite and correct.
Signature: Dale: l e /qt _
-Z
QJ/icinl«se null'• Do not rvrile in this area,to he completed by ciry,,or tmvn nflicial.
City or Town:— Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other _
Contact Person: 1'Imone#:
/"d4,P6,dl/ D,a �e EI(4I( �� KITE OF II_.�/�I�)ILITY ��SURANCE DATE/20 0 IYYYV)
7/3:1. 209
PRODUCER phone: 603-152-2121 Fax: 603-359-8491 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Clark - Mortenson Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 606 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Keene NH 03431
INSURERS AFFORDING COVERAGE NAIC#
INsuaien INSURERA:Alnerican International
Gro Solar. Suite
Inc. DIIA INSURER c:National UiwsuREa B:The Hartford Fire _I _ f P
Global Resource Options,
re Ins. o _
601 Old River. Rd. ; Suite 3 —
White River Junction VT 05001 INSURERMLi_berty Mutual Middle-Market
INSURERE:
COVERAGESTHE 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 IJESCRIBED HEREIN IS SUBJECT 'TO ALL THE
TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR OD-L I� POLICY EFFECTIVE POLICY EXPIRATION
L Y S l -�yp�QEINSURANCIi POLICY NUMBER T MILD jY ATE rMjP2/YYI LIMITS
C GENERAL LIABILITY 493020 8/l/2009 8/1/2010 EACH OCCURRENCE_ $ 1,-000,QQQ
X_ COMMERCIAL GENERAI LIABILITY PREW`ESREO -ITTEO
I PREMIS[5(Ea occomnce)__ 5].00.,, OOO
CLAIMS MADE LJ OCCUR MED EXP(fV,onnporson) $10, 000
PERSONAL&ADVINJURY S I,_000, 000
GENERAL AGGREGATE $2, OQO, DOC)_
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2, 000, QQQ
X
_ POLICY PRO- LOC -� - -----
J- T Pro Ct Aug_ 'S _000 000
B AUTOMOBILE LIABILITY 492997 8/1/2009 8/1/2010 COMBINED SINGLE LIMIT
B X ANYAUTO 493000 0/1/2009 8/1/2010 (Ea acdaen0 $ 1, 000, 000
ALLOWNEDAUTOS
— BODILY INJURY $
SCHEDULED AUTO$ (Par porsnn)
X HIRED AUTOS -----_--�----BODILY INJURY S
X ,NON OWNED AUTOS (Peremident)
PROPERTY DAMAGE $
(Per accitlem)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
_ ANYAUTo OTHERTHAN eAAC_C ..5 _
AUTO ONLY: AGG $
A EXCESSIUMBRELLA LIABILITY 492930 8/1/2009 8/1/2010 EACHOCCURRENCE __ $5, 000 000
X OCCUR CLAIMS MAC- AGGREGATE 5 5, 000. 000
S
DEDUCTIBLE $ it
RETENTION S:LQ 000_ _ Is
* WORKERS COMPENSATION AND 491640 8/1/2009 8/1/2010 WCSTAls oni
EMPLOYERS'LIABILITY --
ANY PROPHI XECUTVE EL.EACH-
ACCID , Q
OFFICERIMEMBEREXCLUDED9 Yes E.L.DIBEASE-EA EMPLOYEE § 1-, QQQ, QQQ
SPECIAL PROVISIONS
NS belaw C.L.DISEASE POLICY LIMIT 51 OQQOOO
II OTHER 493126 8/1/2009 8/l/2010 Li,idt $2,224,000
Inscallat ion
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
eneral Liability Per Project Aggregate is $5,000,000
Aorkers Compensation Coverage Part A Applies to the Workers compensation Laws in the States Listed Here: CA, CO, MD,
IA, MT, NH, NJ, NY, OR, VT
Excluded Officers: James Rescr, CFO, Jim Merri.an,, COO, Wayne St Jacquent,Clo, Doratliy M Wolf.e,President, Jeffery Wolfe,
EO
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE IJESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
Global Resource Options, Inc. DHA WILL ENDEAVOR TO MAIL N/A DAYS WRPCCEN NOTICE TO THE
GroSolar CERTIFICATE HOL•DE'R NAME]) TO THE LEFT, BUT FAILURE 'CO DO SO
601 Old River Rd. ; Suite 3 SHALL IMPOSE NO OBLIGATION OR LIA131LITY OF' ANY KIND UPON
White River Junction VT 05001 THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
.41/;7e
ACORD 25(2001108) ( ACORD CORPORATION 1988
�12P �noonn�eauwealtl n�✓ .r�u4eCla
Board of Building Regulations and'standards
Construction Supervisor License
a - License:''CS 95884
- •�`�` Birthdate: 12/2/1977
Expiration: 12/2/2010 Tr# 95884-
^-+ Restriction: 00.
JASON QUINLAN-
180 MAIN STREET#B42
BRIDGEWATER, MA 02324 Commissioner
J!!Ga/�
Bo JI wloCBwldmb Regu linoas and Stnnd•u ds
HOME IMPROVEMENT CONTRACTOR
Re is� r 8 tration: 159879
Expiration: 6/9/2010 Tr# 269363
TYPO: Private Corporation
GLOBAL RESOURCE OPTIONS dba GRO SOLAR
DAVID RICHARDSON
601 OLD RIVER RD SUITE 3
WRJ, VT 05001
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