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17 HERITAGE DR - BUILDING INSPECTION (2) y The Commonwealth of Massachusetts I y'+ Department of Public Safety // 'I �y \la>sachu.vtts State Budding Cade(,-80 CMR)seventh Edition (/hJ City of Salem B uilding Permit A lication for an Buildingother than a I-or 2-FamilyDwelling ly (This�ecuon For Official Use Only) BuildingDate Applied: Building Inspector: SEON (Please indicate Block a and Lot N for locations for which a street address iii not available) 1 - AIEYO Q/q ?J No.and Cite /Town Zip Code dame of Building(if applicable) SECTION 2: PROPOSED WORK ew Construction check here❑or checkall thatapply in the Iwo rows below Existing air❑ Alteration ❑ Addition ❑ Demolition ❑ (Please till out and submit Appendix I) Change of Use ❑ Change of Occupancy ❑ Other Specify: ADDIr)ON OF SOu9✓t ►y10DVGES Are building plans and/or construction documents being supplied as part of this permit application? Yes fr}--No ❑ Is an Independent Structural Engineering Peer Review required? Yes I&— No ❑ Brief Description of Proposed Work: /NSTA41- -70"A t'woAt1L G7 ON ROOF A.t OAR7- eF A Vr/G/rN - r/e-A Cce:crryc. SYs7Sht, RCENPORCE SECEO-71-E-12 9t9F1r72S A r j9C?e P44N-r SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY [Existing eck here if an Existing Building Evaluation is enclosed (See 790 CMR 3402.0) ❑ Use Group(s): Proposed Use Group(s):isting Hazard Index 780 CMR 34: ProposedHazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHTANDAREA - A.I)q — NO C)4 A I✓G�.IExisting Proposed .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 ❑ A4❑ A-5❑ 1 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 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-10 R-2 K R-3❑ R-4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a lieable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ Vol ❑ SECTION 7:S(TE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: I Flood Zone Information: Sewage Disposal: rrench Permit: Debris Removal: Pubhc A trench ,ed nut he Lwun.ed Din +o.a1 Site❑ O� Check tf uut.lde Pluod Lnnr Indicate muniap,rl PI MCKIPAA/ � I ' required tr trench or.prcdc: Private❑ ,•r laden tdc Zunc: ��r tin .ate.%.tern ❑ - perrtut t.unclo.c•d ❑ (�/aJ-7Lr ,TE��ut 4'l- liailmad rightof-way: Hazards to Air Navigation: V:\ IIrh�n, (-.•nun..-u... lie,i,,. Pn• \ n lly•Ito,ldclY 1•}trw lure„ilhu, aopun.tpf,roddi area' htheu re,IV,, nnnplcled' u. lituld ❑ V..❑ "r..\'o(it� 10.❑ \„ fd— SECTION 8: CONTENT OF CERTIFICA rE OF OCCUPANCY dam :d i i-dC C c llr1nifa1r _ f,pe 01 l 1rt,.uuCuon: t CCUI',nt pvr lip-,-r : I) w. the buildup;rml,on.,n til.nnl.ler?, .tem''. ?pvrial?hpul.,uun� .. __ _. SECTION 9: PROPERTY OWNER AUTHORIZATION r and Address of Pr,,prrle Owner IA/ccpA/ P20 (!GS /l/S lvE3�'�a/Zo S� Ger�Ezc� rr,r1 o/BS� (Print) No.and Street L ih/Too.•n Zip riv ON%nrr Contact Inturmation: 47B . Iff- &zoo 9 8_/s- lody /<.A,/A� �'-eOnnccl%/yr� a; co Telephone No.(bu.cmess) Telephone No. (cell) r-maul address If applicable, the property owner herebv authorizes �r/R'!"SN/GG/ryGTDN ///S A167Jr R19 Sr Ga W6? vh,- c//P.Ct Name Street Address City/Town State Zip to aet on the pro+ertc uw ner.behalf, in.dl matters rclatiye lit work authorized by this building permit a p +licatiun. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If buildin•is Iexs thin 35,(xx)nt.fr of:nctosed s pace and/or not under Construction Gntlrul then check here O and Skip Seoiun 10.11 10.1 Registered Professional Responsible for Construction Control CRAIS VREECAWO ' 1 - 2(,4. qel&C 70 S Name(Registrant) Teler'u)--No. e-mail address Registration Numbe- / Rd .sox 7v6 aril �✓IA yt2S7 '"411W.E% c �c Zo16 Street Address City/Town State Zip Discipline Expiration Date r eral Contractor L )9CJBuKCt' aP7)ON-r, IAIC yName: '/SSBy lJ d'od t N G4 r..Person Responsible fur Construction License No. and Type if Applicable o�.ar� Oit r i�� t//v r r f-T xNN -nt"4 Oz76-dress City/Town State Zip f_ (0n/ Sow-9S/ _ 675f lasso. owlet lanceorosola.�.coe No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152.§ 25C(6)) A Workers'Compensatton 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 19 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) =$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ I 3,nO appropriate municipal factor)=$ 3. Plumbing $ 4. Mechanical (HVAC) I Note:Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6. Total Cost $ '� &';3,Qe,9 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my namv below, I herebv attest Cinder the pains and penalties of perjury that all of the information contained in this .tpplicaoun is true and accurate to the best of my knowledge and understanding. D/4✓f ✓� 7zl cN.4✓U�lOw� %EGr. IAAA+VAo-er- FVZ I'Ic,o.c pant and n.tme fitie Telephone\n. Date 60-,S'._� N D2 f t E', (//yr r f� T ,vNA✓r. B404 O Z l ?fret WJIV.> � C th';Tim it tat zip ` Municipal Inspector to fill out this section upon application approval: i \,one 1 l,t to PC The Conanonweahh of Massachusetts t'! ._ I Department of Indast'ia1 Accidents Q11ice oflnvestigatioms 600 Washington Street Boston, MA 0211.1 e www.nutss.gav/din f n: Workers' Compensation Insurance Affidavit: Builders/Contractors/.Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organi7a6on/Indivi(laal):(teats,4L %C-TOUtt$�` Op�lon/f A`VC. c��F G4G SO". 4 Address:_/O/ aL0 RIV6"7L 2D SU /7i:3 -- City/State/Zip: 41#17Z,ell/ Phone #: R00 174d G/4/9 y Are you an employer? Check the appropriate box: Type or project(required): - - 4. f am a general contractor and I I.L�J I p o employer with r p rt S ❑ 6. ❑ New consn'uction employees(full and/or part-time).* have hired the sub-conhactors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition and have workers' working for me in any capacity. employees ,. 9. ❑ Building addition [No workers' comp. insurance comp. insurance. ` required.] 5. ❑ We are a corporation and its MF1 Electrical repairs or additions 3.❑ 1 ant a homeowner doing all work officers have exercised their 11.0 Plumbing repairs of 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' 3.�Other SdU9t2 QAN�LS comp. insurance required.] 'Any applicant that checks box 81 nmet also fill out the section below showing their workers'compensation policy infonnalioll. t llomeownm,who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such. .conlPacans that check this bon must atlached an additional shecrshowing thGnnnne of the sub-colaractols and state whether or not those entities have employees. If the sub-contractors have ennployecs,they must provide ntcir workers'comp.policy mantel. I atu att etttldoyer that is providing tvorlcets'cotttpetisation irtsttrattce for my cntployces. Below is the policy mat job.site iglortnatiou. Insurance Company Name;.. C.�✓0�� N'lO.�Y�n/.f(7N.J iNS; Policy#or Self-ins. Lic.#:_ �J9 �� LJO Expiration Date:_ Job Site Address: 7 HC?% TRGC nn City/State/Zip: SAeeIY Y►tA olg7u 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 told 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 Of-Flee of Investikations of the DIA for insurance coverage verification. l do hereby certify under floe ns and penalties ty'Imijurp that the lttjorntation provided above is trite and correct. S',natum S/ Date: Phone#: 8a z 2�i9 -SP�r 01,"Wal use only. Do not write in this area, to be completed hV citp or town of/icial. City or Town:— Permit/License# . Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Cleric 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: _ Phone#: tFilC4,dRD.I CERTRICATE OF LIAB TY WSURANCE DATE M/DD/Yl'YVj _ 7/31/]/2009 PRODUCER Phone: 603-352-21.21 Fax: G03-357-13991 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Clark - Mortensen Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 606 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Keene NFI 03437. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC it INSURED _wsuRERA:American Inter-nat:ional_Special T GroSol.ar INSURERB:The Hartford Global Resource Options, Inc. DBA INsuRERc:Nati.onal Union Fire Ins. of P 601 Old River. Rd. ; Suite 3 --- White River Junct-i.on VT 05001 INSURER D:Liberty Mutual Middle Market_ _ INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUCD TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 'PERM 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 'PO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DOt POLICY EFFECTIVE POLICY EXPIRATION LTR IN RO' Iyp�q[-�ygljEpFS{CL— POLICY NUMBER UATE !/MML0Dp' Dg1R_IMM/0D/YYI LIMITS C GENERAL LIABILITY 493020 8/l/2009 8/l/2010 EACH OCCURRENCE S 1,-Q� QO0 —_ DAV1VGE`TC_RPATE6------ X COMMERCIAL GENERAL LIABILITY _PREMISES IEnaccurernc)_ $1 00_, 000 _I CLAIMS MADE C_1OCCUR NED EXP(Any min person) §10 OQO PERSONAL&AOV INJURY_ S 1, 000 000 _ GENERALAGGREGATE_ $2, 00 _000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS_C_OMP/OP AGG $2 Q� 00, 000 X POLICY D PR 1 JEC'O-r I LOG -Project Aaq 'S _000 000 B AUTOMOBILE LIABILITY 492997 8/l/2009 8/1/2010 COMBINED SINGLE LIMIT 13 X ANYAUTO 493000 8/l/2009 8/1/2010 (Eaaccmem) $ 1, 000, 000 _ ALLOWNEOAUTOS (P.... .IN) $ SCHEDULED AUTOS (P°I P°rsp^) X HIRED AUTOS BODILY INJURY $ flcc X NON OWNED AUTOS (Peritlen0 —_— PROPERTY DAMAGE $ (Peraccidenl) GARAGE LIABILITY AUTOONLY-eA AGGIUErvT S ANY AU FO OTHERTHAN EAACC__S_ _ AUTO ONLV: AGG $ A EXCESS/UMBRELLA LIABILITY 492930 8/l/2009 8/1/2010 EACHOCCURRENCE— $ S, 0001 000 �XL1 OCCUR El CLAIMS MACS AGGREGATE S=, 000, 000 DEDUCTIBLE $ X RETENTION S10 o0Q WCSTATU- 01111- D WORKERS COMPENSATION AND 491640 8/1/2009 9/1/2010 TORV IMITS SEER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 1, 0-0-0, 000 OFFICEWMEMDER EXCLUDEXCLUDED4 yes E.L.DISEASE-EA EMPLOYEE § 1 QQQ, QQQ SPECIAL PROVISIONS SPECIAL PROVISIONS helaw E.L.UI$C-ASE-POI ICY LIMIT S 1 000 000 II OTHER 493126 8/l/2009 8/1/2010 Limit $2,224,000 Install,,Ll On DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS general Liability Per Project Aggregate is $5,000,000 dorkers Compensation Coverage Part A Applies to the Workers Compensation Laws in the States Listed Here: CA, CO, MD, dA, MT, NH, NO, NY, OR, VT Excluded Officers: Jaynes Resor, CFO, Jim Merriam, COO, Wayne St Jacquest,CIO, Dorothy M I^olfs,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. DHA WILL ENDEAVOR TO MAIL N/A DAYS WEITrE1J NOTICE TO THE GrOSo lay CERTIFICATE HOLDER NAMED TO 'T14E LEFT, BUT FAILURE TO DO SO 601 Old River Rd. ; Suite 3 SHALL IMPOSE NO OBLIGATION OR LIABILITY O' ANY KIND UPON White River Junction VT 05001 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE -V-dj.4b,%Q ACORD 25(2001108) ©ACORD CORPORATION 1988 v �/ �09)UIN.N)1XI1�4 O�✓(/(.QIW?C/G((W'/A.o Board of Building Regulations and Standards Construction SupPmsor LlCense - - Lice nse:=CSI 95884 • . ,� ` - Birthdate: 121211977 , ` Expiration: 12/2/2010 Tr# 95884 hee i � Restriction: 00 JASON QUINLAN - 180MAIN STREET#B42 BRIDGEWATER,MA 02324 Commissioner Bmu d of Baddmb Rrga i a tunas itd s(Ifla d5 �� i�r HOME IMPROVEMENT CONTRACTOR is 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 Adntinlstrafnr