15 HERITAGE DR - BUILDING INSPECTION `
The Commonwealth of Massachusetts
It
`;'f Department of Public Safety
F,• 'I'�,P \la>sachusvtl.State Budding C ode(,So CMR)Sv%enth Edition
I City of Salem
Building Permit A Iication for any Building other than a 1-or 2-Family Dwelling
(rhis Section For Official Use OniY)
Budding;Permit Number: Date.Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a street address is not available)
5 If n;TAB[ On . SACEY^ 019 '7d
No.and Street C ih' /T,n,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
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other Specify: ADDITION OF SO L.A yt y✓10DVf.6l
Are building plans and/or construction documents being supplied as part of this permit application? Yes O�No ❑
Is an Independent Structural Engineering Peer Review required? Yes rill— No ❑
Brief DescriptiunofProposed Work: /NSTALe- 5'0" 2 AloDu(-61 ON ROM As
/0Ai21— eF A Vrft/ry -r/6p EGEcrrilc 17 rEnt.
REEAiPORCE SECEO-111--n Rv9F1F-2J• AS 09E2 f�L.9N r
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY Al 29
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Croup(s): g'
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA - tij4 — NO C1•)A N6C J
Existing Proposed
No.of Flours/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 13 A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Factory F-I ❑ 12❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-1❑ R-2 X R-3❑ R-4❑
S: Storage SI ❑ S2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as Applicable)
IA Ill IIA ❑ 118 ❑ 1 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SFCTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply I Flood Zone Infomtation: Sewage Disposal: Trench Permit: Debris Removal:
Public A trench ,,J not be 1-,ceme, D"Ip " Sile ❑
C heck it out>rde Th�::d Gmr Indicate mu ,teio YH&IC4
� required otrench ur.peal c:
I'rn ah•❑ ::r indentrfv Lma•; ,rr:m .rte.Y.tem ❑ e /4S 12� firr2t4 permit a cndo• d ❑ W
Railroid right-of-way: Hazards to At .V avigation: \I:N I L.h n, <-.•mmr-nnr R, ir„ I'rr::..:
\:-t .l I•pin.,fdc CY h}Inrctu rc„nhut.0 rpn rt ap),n rdd� ,r,•a' 1.thou' n•a icrc pnnl•IcIcJ' 1
iu 0udd rnd:,,rJ ❑ 1'c.❑ \:+ pi-
SF.CTION 8:CONTENT OF CER rIFICA rE OF OCCUPANCY
L.Lium :d C:•Jr C.c l;r::upt.c _. rR pe:a t lcarpow Ltod per l lu,:r
17• r� the hwlJur.;:,ml.nn.tn Cf,onl.lcr ?pc0el>upul,,no nv _
SECTION 9: PROPERTY OWNER AUTHORIZATION
N.une and Address of Pro, perte Owner
prt)n/�ETon/ iWoArerrc--T ///S w~sr�iro s� G®r�ezS/ rr, o/8Si
Name(Print) No.and Street lilt/Town Lip
Pro pertt 0%,ner Contact Information:
jfi; f iritxT yy 97e .YSb'- e706/3P y_T 8rIS. /oQq /<SA, l fft"T'Acur��c.- rf; cc
Title Telephone No. (buslnas) Telephone No. (cell) e-mad address
If applicable, the pn+pertc nw ner hereby authorizes
�//R t�SN/LL/IV6TD/y i /✓es)rmey Sr Lp WE'G /k,- G/Pft
.Name Street Address Cih'/Town State Zip
to act ern the pro perk owner',behalf, in all matters relatite to work authonzed by this btiddin p permit a + +lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
III buildin•is Icss than 35,00 cu.ft.ut aulosad s pace and/or flat tinder Co..stntdion Control then check here O and skip Section 10,11
10.1 Registered Professional Responsible for Construction Control
CHATS V1tCC4 fo,10 N/.T, z0_ y eS 11?-70 s
Name(Registrant) Telep`,a^_Nu. e-mail address Registration Numbe-
Qe goic 7Yfi an J• f4A 012sr /MK•N.,E
Street AddressCity/Town State Lip Discipline Expiration Date
10.2 General Contractor
�iCaB.4r �E".IQUtCCE� Or�PGN.J��/NC c��io-- G/19,(b492
Company Name: 9sSrgy 1J
.T7lSOu CY✓1 AJ e-4
Name of Person Respnsible for Construction License No. and Type if Applicable
it?�hry ,gm r ta��)/N r!" f-T yNNA.r^ i' 4 017 6'r
Street Address City/Town State Zip
S- 95i_ GAY! Sow-9S/ - 6791 Jason. q4s/tet lan V orz"tmr.coo-
Telephone 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 licationt Yes 9 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and MaterriGials) Total Construction Cost(from Item 6) _$
1. Building 'i $ *-7 O/J I Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ Q appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
S. Mechanical (Other) $ _ Enclose check payable to
6.TnLil Cost $ y2 .(V (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
aBy entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
pplication is true and accurate to the bes of my knowledgeand understanding.
/A✓l y _TZl C1-1A16>J OIJ - g6-(j._/"N,46Er- _ ?b
11m.i.e pr'mt'and.,Wi n.ime [file f0cphune.N,,. Dale
�rS__� .14 N!�R f 6E'f Un/r r f'� _�.'fiV. '�A✓/•x O
?Wean lJJrc�r 0t); Toflee1 to )p
�-Municipal Inspector to till out this section upon application approval:
\di Uale
The Commonwealth of Massachusetts
? Department gJ'lndusU•inl Accidents
Office oflnvestigations
��•
� 600 YYnslaington Sheet
Boston, MA 02111
E
www.ntnss.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Legibly
(13usiness/organizntion/hidividual):e44&,4L /eF7'QUaV` 0/l RUA1S'ZIV C• ��� ��✓O��'
Address:_/p/ OLD /2t!/E7L 2D .S'U ITS 3 --
City/State/Zip: A/Nt7z�- )ywrno✓ Phone#: R"00 ,7741 '/4V95'
Are you an employer?Check the appropriate box: Type of project(required):
I.Plain am a co to er o S 4. ❑ t am a general contractor and 1
P Y with
employees(full and/or part-time).'K have hired the sub-contractors 6. _❑ New construction
7. Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet ❑ b
ship and have no employees These sub-conk actors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurauce comp. insurance.T
required.]
5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I ant a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees-. [No workers' 13.�Other S 49R Q
comp. insurance required]
*Any applicant that checks box#1 must also fill out the section below showing their workers'contpensaIlot,policy information.
610mcowners who submit this affidavit indicating thcY arc doing all work and then hire outside contractors most submit a new of fulavii indicating such.
'ConYFactois that check this box must attached an additional shectshowing the.name of the sub-contractors and state whether or not those cooties have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy nunther.
l am aft eurptoyer that is provielbtg rvor(cer:v'contpetesatiott ittsrnrtttce for trty eutployees. Retail,is the policy rind job site
igfortnation.
Insurance Company an Name:.. C•C,i4rc� Yr90Ael'"G NJ'd!V /lVJ,
Policy 8 of Selt=ins. Lic.tt:_ /j� �� �✓O Expiration Date:_ _-
i
Job Site Address: 5 fiea,'re 6e pa City/State/zip: sACt7rt YM.4 of 9'7u
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Paiture 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 imprisur nnent,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 eertiJj,under the 1w.its and penalties qJ peijiny that the inJarination provider!above A true and correct.
Si mahtrc: Date' /(&V/d S —
Phone At: jft 2 2CK
OJJdcinl use only. Do not write in this area, to be completed!)V city or town official.
City or Town:_ Permit/License#_
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.CitylTovn Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other _
Contact Person: Phone#:
ACORDP, CERTIFICATE OF (LIABILITY INSURANCE DATE(MMIDD/YYYY)
7 37. 2009
PRODUCER Phone: 603-352-2121^ Fax: 603-357-8491 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
Keene NIT 03431 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE --_I NAIC/R
INSI11iE1I INSURERA:American International_Special ___._.__
GroSol.ar wsURERB:The Hartford
Global. Resource Options, Inc. DBA msuRERc:Nati.onal Union Fire Ins. of P
601 Old River. Rd. ; Suite 3 —
White River Junction VT 05001 INSURER O:Liberty Mutual Middle Market
_ INSURERE:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE; BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWIT115'PANDING ANY REQUIREMENT, 'PERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY HE 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 REDUCED BY PAID CLAIMS.
INSft ADDT POLICY EFFECTIVE POLICY EXPIRATION
LIE WSR TYPE OF INSURANCE POLICY NUMBER _ U T MMIDDIYY DATEIMMIDDIYYI __LIMITS
G GENERAL LIABILITY 493020 8/l/2009 0/l/2010 EACH OCCURRENCE _ $ 1,_000 000 _DAM-Ac`E'T6RrfnrO
X COMMERCIAL GENERAL I IIABILITY PREMISES(E.,xrdenve)_ $100,, 000
CLAIMS MADE u OCCUR MED EXP(Any one Person) $ 3-0,�QQ
_ PERSONAL B ADV INJURY $ 1, QQQ pQQ _
GENERAL AGGREGATE S 2 OOO, 000
GENT AGGREGATE LIMI r APPLIES PER: PRODUCT S-COMPIOP AGG $2,000, 000
g POLICY jRO- LOG YYO ECt A99 '---- S GOO, OOO —
—_ 3 '
B AUTOMOBILE LIABILITY 492997 8/1/2009 8/1/2010 COMBINED SINGLE LIMIT
B X ANYAUTO 493000 8/l/2009 8/l/2010 (Eaooaidenl) $1, 000� 000
ALLOWNEDAUTOS
— BODILY IN,DRY
5
SCHEDULED AUTOS (Per person)
X HIREDAUTOS BODILY INJURY
X NON OWNED AUTOS (Per arxidenQ S
PROPERTY DAMAGE S
(Poramitlenn
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
_ ANY AUTO --- _
EA AC_C .$ ---
OTHERTHAN _
AUTO ONLY: qGG $
A EXCESSIUMBRELLA LIABILITY 492930 8/1/2009 8/.1./2010 EACH OCCURRENCE _ SS, 000 000
OCCUR CLAIMS MACS AGGREGATE S S,_OQO, OOO
S
DEDUCTIBLE 5
`RETENTION S10, opp_ S
WC STKfU- OTH-
D WORKERS COMPENSATIONON AND 49).640 8/1/2009 8/1/2Q10
EMPLOYERS'
IETOWPART EL.EACH ACCIDENT 51, 000, 000
ANYPEWMEM ORIPARTNDED XECUi'IVE --
OFFICER/MEMkinderBER EXCLUDED?Yes E.L.DISEASE-EA EMPLOYEE 51, GOO, OOO
If SPECIAL
IALdmicAffirkPRO antler
SPECIAL PROVISIONS belmv E.LDISEASE-POLICYLIMIT 51`00 OQO
B OTHER 493126 8/.L/2009 8/l/2010 Limit $2,229,000
Installation
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/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,
A, 1,1T, NH, NJ, NY, OR, VT
Excluded Officers: James Resor, CFO, Jim Merriam, COO, Wayne St JaC9Uest,CTO, Dorothy M IJolfe,President, Jeffery Wolfe,
EO
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE 'THEREOF, THE ISSUING INSURER
Global Resource Options, Inc. DBA WILL ENDEAVOR TO MAIL N/A DAYS WRIT" I-,N NOTICE TO 'L'HE
GTOSOlar CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 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
ACORD 25(2001/08) OACORD CORPORATION 1980
U �. �x ✓/[Q t704Nn1ilYlLl/�Q�!/L O�✓r�GC�lOQ4'/E<! x�'
Board-ofBuilding Regulations and Standards
Construction:Supervisor License -
License:<CS 95884
Birthdate: 1.2/2/1977
Expiration: 1i212/2010 Tr# 95884
`k..' Restriction: 00
JASON QUINLAN
180'MAIN STREET#B42 -
BRIDGEWATER, MA 02324 Commissioner
._..........
\ Bow�f n l0?ldm l"l"riC//X 0� �Icr.0 it�r��i LLri
6 Regu4rt+mn m+d StIndal ds
HOME IMPROVEMENT CONTRACTOR
l�\ Vlj r+ _/ Registration: 159879
->,-: Expiration: 6/9/2010 Tr# 269363
Type: Private Corporation
GLOBAL RESOURCE OPTIONS dba GRO SOLAR
DAVID RICHARDSON
601 OLD RIVER RD SUITE 3
WRJ, VT 05001
AdministraM1n-