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14 HERITAGE DR - BUILDING INSPECTION / V The Commonwealth of Massachusetts Department of Public Safety State Budding Code(780 C\Ili)Seventh Edition City of Salem Building Permit ApElication for any Building other than a I-or 2-Family Dwelling (rhis lectiun For Official Use OnlY) Budding Permit Number Date Applied: Budding Inspector: SECTION 1: LOCATION (Please indicate Block N and Lot ll for locations for which a street address is not available) K( yef1. A6(. at. SACEw� d/9 ?� G \'o.and Street Cite /Town Zip Code ' ame of Building(if )pplicable) SECTION 2:PROPOSED WORK If New Construction check here O or check all Thal apply in the two rows below Exiling Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other Specify: ADDITION OF SOLAYL Y001>VGV-r Are Building plans and/or construction documents being supplied as part of this permit application? Yes Wl No ❑ Is an Independent Structural Engineering Peer Review required? Yes gi-- No ❑ Brief Description of Proposed Work: /N,STAGL S'0"4 AWOh GE.P ON ROOF AJ' GA,e'r or A flrie lry - TfE'A EGEcrrtic SyBTbtitn- RCir"FORCE ,SCCELTar� Or9FT452.r AT PEr2 pG9ryJ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR gCHANGE IN USE OR OCCUPANCY F 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 HEIGHT AND AREA - Alb4 — A/o G14 0 NGC J Existing Proposed urs/Stories(include basement levels)&Area Per Floor(sq. ft.) a(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) bly A-1 ❑ A-2r ❑ A-2nc❑ A-3 O A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 X R-3❑ R-4❑ S: Storage S-1 ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA O IB ❑ IIA Cl110 ❑ IIIA ❑ [JIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) I Water Supply: Flood Zone In Fomta lion: Sewage Disposal: Trench Permit: Debris Removal: :N �rench wit nut he Licen.ed Di. .....il Site❑ Pubhi O� .0 heck if uutaZo 19.e,d Lunr I"r irate municipal � re.uocd �trench or f"CKJCAAr I'ricote❑ ur indrnulc Zone: nr on .rte.v.trm ❑ I )ode: - permit i.enclu.eJ ❑ 1'jvt4SrH' ,SW12L4 eel I Railroad right-of-way: Hazards to Air Navigation: \I\ I h,b,n, c R.,„-„ \ q .t)y'hcuhefY I Lti�nicturc,.ilhm airport appnad,.irr.t' I. Iheu' rt•,ie,r l'ietrJ' i,, Bo dJ end,"'rd Cl 1..❑ „r Ni,®" 1',.C3 \„ (Y SECTION 8:CONTENT OF CERTI FICA FE OF UCCUPANCY I:Jdnm nl l nJ, ...—_— Cw l,, upi.r _ Rp, �n l un.l ro ton: Occupant I , .0 per I In, r I1 ,,.Iha bwlJ in,;; ,n1.nn.tn Spn nAler}t.iem': Special?upulalwnv ..� _ _ SECTION 9: PROPERTY OWNER AUTHORIZATION .V,unv.m i Address of Prulocrty Owner p✓1,fvCETo�/ P2ppEe��'s' /llS !ve"S'1"/62o S� Gawe'cc/ rrrf9- v/8S/ _ - Name tPnnU .Nu and Street Cih/Town Zip Pro wrh'U,c na•r C ontart Information: �iLfS)bY'A.� . 978 -YSr. 9700 r3Y f7�8-/s- /oa9 /<s/iI//tn�./7,. rrncc%_. /IroDC� u; Cc Title Telephone No. (bustne..) Telephone No. (cell) e-maul addres.. If applicable, the pmperiv o,cner herebv authorizes xvrz fSH/GG/ryGTdN ///S oveurmteo ST. Gawec. rhp a ZPs-1 .Name Street Address Citv/Town State Zip to art on the pro pert +nv ner•behalf, trial I matters rciatice to work authunzed by this bu ildin• )ermt a , plication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (if building is less than 35,(XX)cu tt.of enot,,d s+ace and/or not under Construction Control then check here O and skip Sediun 10.0 10.1 Registered Professional Responsible for Construction Control CRAIS V2EE4AW0 4/13- Z64. 6S f/'70S Name(Registrant) Telep'o^"No, a-mail address Registration Numbe- pe .sox -71(6 6nS eA 012 -r metrij, nuns _ 61 Zo/s Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 64vdAL /ZEJau ect' oQnON� //uc �60- G2erb�.4a Company Name: 9SS8'1 V .TR SON CJ+Jt NGAw Name of Person Responsible for Construction License No. and Type if Applicable %14 0276`' Street Address City/Town State Zip s,- 9Sr. r,ni Sow-9S/ - �791 J0.s0^. C�vin ICLA a grosoL-Ciro, Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'C NMENSATION 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 submiUed with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.Is a si ned Affidavit submitted with this application? 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 i $ ff 7 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical c.( $ j appropriate municipal factor)=$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost $ b S 0 S 9. (contact municipality)and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I herebv attest under the pans and penalties of perjury that all of the information containeddlh,, application is true and accurate to the best of my knowledge and understanding. 11,i,e print and ,ign name title Telephone\u. GPS._� /4�RIbe' Uf�)r f� TZ�+ iy4L4 r� /Yr4 OZ767_ ?creel .WJrv+e C t1-/7ot,-n titate zip 2L 16 Municipal Inspector to fill out this section upon application approval: \time Uate j i The Commonwealth nfMassacfzzasetts Delraritrzent gf Industrial Accidents '- Office of Investigations n, 600 MINhington Street Boston, MA 021.1.1 ivia,minass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nance (Lltisincss/Organization/Individual): ��/lOtt1.r �/UC. U/2D SO/..AaC Address:_/,7/ r rZ.O 2tl/E7Z jed SU /7F 3 City/State/Zip: PM7Z 44/2t2 J41"C470F/ Phone #: o"00 3741 Arree,, m to er yoo with n an employer?Check the appropriate box: Type of project(required): Llv I 1. a a eat 0 S 4. ❑ I am a general contractor and I P Y . - k have hired the sub-contractors 6. ❑ New construction employees(full and/or part-lima).' 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' q. ❑ Building addition [No workers' comp. insurance comp. Insurance.— required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs of additions 3.❑ I air a homeowner doing all work officers have exercised their I LE] Plurnbing repairs or additions myself' [No workers' comp. right of-exemption per MGL 12 ❑ Roof repairs insurance required.]t a 152,§1(4),and we have no 13.[✓rOlhcr S6Gr;R QAN�lS' employees. [No workers' comp. insurance required.] 'Any applicant that checks box#1 nmst also GII out the section below showing their workers'compensation policy information. t nomcownce,who submit this amdavit indicating they me doing all work and then hire outside contractors must submit a new affidavit indicating such. +Cons}actors that check this box must attached an additional slicer-showing thpmamc of the sub-connnctons and state whether or not those entities have employees. Ifthe sub-contrnetors have employees,they mast provide their workers'comp.policy number. fan+nit employer tkrtt is providing worliers'compeosntion insurance for my employees. Below is the policy nod job.s'ite hilnrnration. Insurance Company Name:.. Gl�� N'IOAe`I'�E r✓J'bry ✓/V.(, Policy#or Self-ins. Lic.#:_ /f? 0 Expiration Date: �tt'l Job Site Address: 1 `f Her,, Mfe I /L . City/State/Zip: SAGE->—t Y11.4 of q7o 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 line 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 line 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 I do hereby certijj,antler the / its marl penalties of perjtt+y that the h fio-mation provided above is trite and correct. Sill lature Dale: /! /,V 0 rr Phone#: 8a 2 299 -STdr Official use only Do not write in this area,to be completer!Iry city or tororr official. City m•Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Pl uabing Inspector 6.Other Contact Person: Phone#: ORD'" CERTFICA E O ��ABUTY I�IT;'ISURAIl�C 77./311/MIUD/Y 6W�S.P 2009 YYY) u _ PRODUCER phone: 603-352-2121 Fax: G03-357-8491. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Clark - Mortenson Tnsurauce ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 606 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Keene NIT 03431 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC SI INSURED INSURERA:AIRecican International_Special CroSolar INSURERB:The Hartford Global Resource Options, 1.nc. DBA ---- — 601 Old River. Rd. ; Suite 3 INSURERC:National Union Fire Ins. of P White River Junction VT 05001 INSURER D:Liberty Mutual_Middle_Market INSURER E: COVERAGES ,�— TIIE POLICIES OF INSURANCE LISPED BELOW HAVE BEEN ISSUI3D TO THE INSURP.D 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. AGGREGATE LIMITS SHOWN MAY HAVE: BEEN DEDUCED BY PAID CLAIMS. INSR ADD'LI POLICYEFFBCTNE POLICY EXPIRATION LIE INSRQy- TYPE OF INSURANCE POUCYNIIMBER DATE IMM/DDB', DAjgfMMIDI)ffYI LIMITS G GENERAL LIABILITY 493020 8/1/2009 8/l/2010 EACHOCCURRENCE $1-DA --pQp -pQQ X I COMMERCIALGENERAL LIAI ILELY PREMISESIVGE BEN TLlS— _ PREMISES(Ea nccumncc)_ $100, 000 A CLAIMS MADE u OCCUR NED EXP(Any one person) SSLO 000 PERSONAL&AOV INJURY S 1_ _ _ GENERAL AGGREGATE S 2, 000_,_000 __ _ _ 2,.QOO, OQQ GEN.LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S X POLICY PRO -- LOC Project A EJ9 'S 000 000 � ' B AUTOMOBILE LIABILITY 492997 8/l/2009 8/1/2010 COMBINED SINGLE LIMIT B X I ANYAUTO 493000 8/l/2009 8/1/2010 (Ea acGmm) _ $ 1, 000, 000 1 ALLOWNEOAUTOS BODILY INJURY S SCHEDULED AUTOS — $ HIRED AUTOS - BODILY INJURY $ X NON-OWNEDAUTO$ (Pera¢itient) PROPERTY DAMAGE $ (Pe,acci,lanl) GA RAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANYAITO OTHERTHAN -EAACC- 7 AUTOONLY:_ AGG $ A EXCESSIUMBRELLA LIABILITY 492930 8/l./2009 8/1/2010 EACH OCCURRENCE $51000,000 X ElOCCUR CI AIMS MAC'1 AGGREGATE S5, 000, 000 _ _ S DEDUCTIBLE X RETENTION $1.0, 000WC D WORKERS COMPENSATION AND 491640 8/l/2009 8/1/2010 1 1j9 OF_R EMPLOYERS'LIABILITY ---"" - El.EACH ACCIDENT S 1, QQQ, 000 OFFICEANY PROPRIETOILPXCLUDEIEXECUTNE - lf,,dIUMEMDERE%CLUpE09 Yes E.L.DISEASE-EA EMPLOYEE Sl QQQ QQQ II Yns.Uoscriba antler '— SPECIALPROVISIONSbelow EL DISEASE-POUCYUMIT $1 000, 000 B oTWER 493126 8/l/2009 8/1/2010 Limit $2,224,000 L)stal.l.ation DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS eneral Liability Per Project Aggregate is $5,000,000 :lorkers Compensation Coverage Part A Applies Co the Workers Compensation Laws in the States Listed Here: CA, CO, MD, iA, FIT, NN, Na,- NY, OR, VT Excluded OLfi.cers: James Resor, CFO, Jim Merri.anl, COO, Wayne St Jacgpest,C]:Q, Dorothy M W.Ife,President, Jeffery Wolfe, EO CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBE]) POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, 171E ISSUING INSURER Global Resource Options, Inc. DSA WILL ENDEAVOR TO MAIL N/A DAYS WRITTEN NOTICE TO THE GroSolar CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE. TO DO SO 601 Old River Rd. ; Suite 3 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON White River Junction VT 05001. THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 '� :J/L¢ V/04IUYlLd)tl//l,fLLL/L O�✓lrLLjPdQ.C�.(ldC�.d ^•} • I �yy Board of Bnddmg Regulations and Standards 1 Construction Supervisor LlCense a License: -CSC 95884 • Pil Birthdate: 12/2/1977 , p Expiration 12/2/2010 Tr# 95884 ? .. Restriction: 00 JASON QUINLAN 180 MAIN STREET#B42 �-�- BRIDGEWATER, MA 02324 Commissioner - t /w t!'nl�i lr nniucv��/ r� !fr•;.rrr�nr.!(� .Bn nd of Building Regolatmns and Stundau(is '��_i1 T11„ rId HOME IMPROVEMENT CONTRACTOR Registration: 159879 "<•- Expiration: 6/9/2010 Tr# 269363 TYPO: Private Corporation - GLOBAL RESOURCE OPTIONS dba GRO SOLAR DAVID RICHARDSON 601 OLD RIVER RD SUITE 3 Administra for