17 A HERITAGE DR - BUILDING INSPECTION o
` The Commonwealth of Massachusetts
Department of Public Safety
` A. 'i' f Sla.,achusvtls titate Budding Code 1780C.\IR)t ' Ith Ediuun
City of Salem
Building Permit ApElication for any Building other than a I- or 2-Family Dwelling
(This Section For Official Use Only)
Budding Perm! Number Date.Applied: Budding Inspector:
SECTION 1: LOCATION (Please indicate Block 0 and Lot M for locations for which a street address is not available)
12A henit4oe_W • -SACEll� Cif q ?c'
\'o.and Street C itv /Too,n Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑ur check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Changeof Use ❑ Change of Occupancy ❑ Other Specify: ADDITION OF SOLAye ry/0DVGO •-r
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0- No ❑
Is an Independent Structural Engineering Peer Review required? n Yes 1� No ❑
Brief Description of Proposed Work: IA-S r�AI LL S'OL,RA Hr/ODvCC,T OA/ FOQF W
QAg7 - or A Vr/c/ry -r/B'A EcEcr/zlc SYS,rFl�A
RE-CA/twcE SECIE Ib'n it?t9F7�2J• A r Af 2 E4,1A,s
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): P
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA - Al — A/O C14 A N GC 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 Cl A-3 ❑ A-4❑ A-5❑ B: Business ❑ Mbebe
E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ I-3❑ I-4 ❑ M: Mercantile❑ R: Residential R-10 R-3❑ R-4 ❑
S: Storage SI ❑ S-2 ❑ U: Utility❑ Special Use❑and please below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 LB ❑ IIA ❑ IIB O IIIA ❑ IIIB ❑ IV ❑ VB ❑SECTION 7: SITE INFORMATION (refer to 780 CMR I ILO for details on eac Trench Pernikebris Removal:Water Su I Flood Zone infom,ition: Sewage Disposal:VP Y \ trench ,vrl nut beed DI. .mal `pile❑PubhC tv .Chcd0 out>ide HI"'d Zone Indic.ov municipal Pffyr rcONILI or trenchcdt':Zone, _ nr un .,tr>,,t,m ❑ ,f_ L!fpermit ocndo.r`I ❑ ____.__
Railroad right-of-waY: Hazards to Air Navigation: �L\ I L.b n. t'••unn,.-e�n IL.. .....
\, t .\11•hr.,betrY LNruri urc,,nhot.urpnn.,pprodch.,rra I. then rut Ic,v c,nn( Ictcd'
• •a( ,.n.rnt i„ Bu,l.l rnilu,t'J O I }..❑ r\'„(J-� Pc. ❑ \„ �
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
L,lu„m :,1 C• J,' _.—_ f-.c l�n n,f,h i'. ._ ftpe,u t_',m.trucn„n: l)CI tlp•utl I I l per I In„r
ILr. �ha l•u,Liu„�;, m.,,n.m til.nnUer}t.Icm': ?pvi ul?upulaWm. .� _ _
SECTION 9: PROPERTY OWNER AUTHORIZATION
N.inw•uid Address of Properly Owner
P✓CllvfETaf\/ P/20AZRGT ///S t1`V6Wr/6'W J7' G®!✓r?� rNJi o/PS/ — --
Name(Print) No.and Street Cih/Town Lip
Pn perh'Owrier Contact Information:
47e .YSbz. e?dd/3P 9�8-/S- /oG9 /<SA ,' f/7�1eiAr r✓✓�I ro c.� tl; cc
Title Telephone No. (busnxss) Telephone No. (cell) e-mad address
If applicable, the properh'om,ner hereby authorizes
�yR'rSH/GG/NGTaav ///.S NE:TY�RO Sr LOWE'L /MF G/PSt
.Name Street Address City/Town State Zip
to acl on the pro prrh pew ner's behalf, m all matters relati%'e to work authorized 6 this building permit a p plicatiun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
Ilf buildin•is less than 35,0%)0cu,ft.of endosvd s pace and/or not under Construction Control then check here O and.kip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
CRRIS Vlt"4AWO 2f13. Z0_ vrcela^467cDmsn.co. Y/7o
Name(Registrant) Telep`o-�No. e-mail address Registration Numbe-
Po 901C -7V0 erns t4A 0t2.S? '4CA). _6/"io
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
�iCoK4.4 L "TOu CCt� aG71 GNJ INC, c4o.- G2e.T4;1492
Company Name: / �6 V y LA_ _A,5,0N Q✓tNGAw
Name of Person Responsible for Construction License No. and Type if Applicable
,- <-ee¢N OiCtcam /N Ir f-T orAi NIPA^ • "4 OX76'
Street Address City/Town State Zip
8 - 9St- Gail Sir--?S/ _ 674r Jason 0 let yro•lutwr.cow
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'S:O_WENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.S 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 9 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =$
1. Building $ 7 (T L/ a n
Building Permit Fee =Total Construction Cost x_(Insert here
2. Electrical $ (7 e 0 Q appropriate municipal factor)_$
3. Plumbing $
4.Mechanical (HVAQ S Note:Minimum fee=$ (contact municipality)
S. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ '2 `3 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv attest under the pains and penalties of perjury that all of the information contained in this
applicaton is true and accurate to the best of my knowledgeand understanding.
96-6, I;IANACft1 go2 .2�i9SSB� -
I'Ic.u�a.print 'and.ignmanic fill, lblcphon, \',i. Datc
Dreher-- UjVIr 112'4 /A4, ` A114 oz767.-
1 >t sect \Jdrx•.. Cl()/Town Mate L p RR
� Municipal htsprcnr to till out this section upon application approval: _
tV
\ame [1), to
' - plx The Commonwealth of'Massachusetts
De artment o Industrial Accidents
p OfficegfInvestigatiotts
s..
600 Washitigtott Street
g>; Boston, MA 027 LI
3 www.nmss.gov/dig
VVm•kers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /J/ ' /� Please Pr/ilnt Legibly
Name (nosiness/Organirntion/Individual):ty (�1,44 &(-fQVAM' O��IUr✓s �/V rya (J6O So 44
Address:/O/ aL21!?tV6 Z /1®. SV /1C 3 --
City/State/Zip: MP17Z ,ot/EYfj(/NGrtGF/ Phone #: gV0 F-2q
Are you an employer?Cheelt the appropriate box: Type of project(required):
I. is t am a ern ilo 205 4. ❑ I am a general cone actor and 1
I Yer with�---- have hired the sub-contractors 6. ❑ New construction
employees(flop and/or'part-time).* 7. Remodeling
Z.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ 6
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.,
required.]
5. We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I tun a homeowner doing all work officers have exercised their 1 I.❑ 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 ANC-:1S
employees. [No workers' 13.R'Other S'd44te
comp. insurance required.]
'Any applicant that cheeks box NI must also fill out the section below showing their workers'compensation policy information.
'nonreowners mho submit this affidavit indicaing they m'c doing all work and then hire outside cononc o s nuIst submit a new affidavit indicating such.
'Conlractnrs that check this box must attached an additional shectshowing tile alone of the sub-contractors and state whether or not those entities have
employees. Ifthe sub-conu.wtors have employees,they most provide their workers'comp.policy number.
/art an employer that is providing tvorlcers'conrpettsatimt insuranceJiir rtty employees. Below is the policy anal job site
intortnation.
lnsurance Company Name;:. C'. �� tj'lO aeT�NJ'bN /NS;
policy#or Self-ins. Lic.it: 1/9 /6 L/O Expiration Date:_
Job Site Address: 1 7A Hen MA'C On. City/State/Zip: .SRLE�""t YN/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 anti/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER anti 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.
/do hereby certify under the ins and penalties oJ'petjtay that the hnjormation provided above is true(aid correct.
Si nature: Date: t
Phone#: -2
O% a!ase only Do not write in this area,to be canpleteel by cig,or larva of lim
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: Phone#:
AC®R®,, CERTIFICATE OF LABILITY INSURANCE /DATE
3l/MIDD/YYYY)
_ 3]. 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 NId 034.31 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC it
IN911REO INSuRERA:Alnerican Tnternatiorlal_Jpecial. ___.__
GroSolar INSURERB:The Hartford
Global Resource Options, Inc. DBA 601 Old River Rd. ; Suite 3 wsURERcNational Union Fire Ins. of P
White River Junction VT 05001 INSURER D:Liberty MutuaL Middle Market
INSURER E'
COVERAGES — '
THE POLICIES OF INSURANCE LISPED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD TNDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICII THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERRIN IS SUBJECT TO ALL THE
'GERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDI POLICYEPFECTIVE POLICY EXPIRATION
T NL TYPE-4EIHSLBA T- POLICY NUMBER DATEIRMLODry D TE 1M DD Y LIMITS
[; GENERAL LIABILITY 493020 8/1/2009 8/1/2010 EACHOCCURRENCE $ 1 -p 00_Q JO
-DF�AGE"TbFFEI T�6 --
$ COMMERCIAL GENERAL LIABILITY cp)_ $10Q-,000 _
]CLAIMS MADE k]OCCUR MEDEXP(Anyoneperson) SS1D 000
PERSONAL&ADV INJURY_ S 1 000, 000 _
GENERALAGGREGATE 5 2, OOO-, OOO
G EN.L AGGREGATE LIMI I'APPLIES PER: PRODUCTS-COMP/OP AGO_ S 2, 000,000
�xPOTICY PRoi El LOC --Project Agg SS 000, 000
3 AUTOMOBILE LIABILITY 492997 8/1/2009 8/1/2010 COMBINED SINGLE LIMIT
D X ANVAUTO 493000 8/1/2009 8/1/2010 (Ea a.6mm) $ 1, 000, 000
ALL OWNED AUTOS
— BnDII.V IN,111RY $
SCHEDULEDAUTOS (Pal parson)
i X HIRED AUTOS
BODILYAIdeffl) $
X NON-OWN[U AUTOS (Perracciaen0
PROPERTY DAMAGE S
(Par accitlenl)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT g
ANYAIITO EA ACC .$__
AUTO ONLY: AGG _$
A EXCESSIUMBRELLA LIABILITY 492930 8/1/2009 8/1/2010 EACHOCCURRENCE $5 000, 000
X OCCUR n CLAIMS MAC' AGGREGATE -- �$ j, 000 Ooo
DEDUCTIBLE $
X RETENTION S1Q 000 _ Is _
D WORKERS COMPENSATION AND 491640 8/l/2009 8/1/2010 _ 1WRVT PU- TH-
EMPLOYERS'LIABILITY
ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.I-.EACH ACCIDENT SS 000
OFFICER/MEMBER EXCLUDED?Yes E.L.DISEASE-EA EMPLOYEE S 1 000, 000
UYoe,IAL PROVISIONS
, '
GPECIM.PROVISIONS UeImv E.L.DISEASE-POLICY UMI'r $1 000 000
3 OTHER 493126 8/1/2009 B/1/2010 Limit $2,224,000
Installation
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I 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, MIT, NH, NJ, NY, OF, VT
Excluded Officers: James Resor, CFO, Jim Merriam, COO, Wayne St Jacquest,C:O, Dorothy M 1-1o1fe,PresidenL, 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 MIA (JAYS WRITTEN NOTICE TO THE
Gr.OSol.ar 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) OACORD CORPORATION 1988
ry ✓/2C �O'I/NtNY)JAI/¢6GUA .CHAl4C6 .I
Board of Building Re'gelnhons and Standards
V'0 Construction Sup9rgrsor License
rr License: CS, 95884 • - `�{
o Birthdate 12/2/1977
k Expiration 12/2/2010 Tr# 95884
Restriction:. 00 .f
JASON QUINLAN
180 MAIN STREET#642
BRIDGEWATER, MA 02324 Commissioner
139mdof uildin Iteg�//! r� lfr,;.r rc�rosl/,I .
6 r CO and standards
ds
HOME. IMPROVEMENT
CONTRACTOR
TRACTOR
�+ Registration: 159879
Expiration: Tr# 269363
TYPe: Private Corporation
GLOBAL RESOURCE OPTIONS dba GRO SOLAR
DAVID RICHARDSON
601 OLD RIVER RD SUITE 3
W RJ, VT o5001
i
Ad mirrixl rarer