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7 HILLSIDE AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts FOR 4 Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code, 780 CMR,7 edf 0c 11 } .. USE Building Permit Application To Construct,Repair,Renovate Or Delnottsh<a Revised January One-or May Dwelling 1,2008 is Section or Official Use Only Building Permit Number: Date Applied: - Signature: Building Commissioner erect Fof' gs Date E ON 1:SITE INFORMATION 1.1 PTerH ty AdS �1 dress• 12 AssessorsrsMap,&rPa 11t,rTlgna�e"141ii . Ii At1e M Number Parcel Number - Lla Is this an accepted street?yes_ no_ � - 1-3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use - :Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) - Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.OL c.40,§54) L7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ — Cbedt ifyes❑ SECTION 2: PROPERTY OVVNERSHIP' 2.1 Ownertof Record: 1�o. 11�I�e�I �Au"os Name(Print) Address for Service: �, Alzr�. 9�� _ � ys -sy7 � Signature Telephone - SECTION 3:DESCRIPTION OF PROPOSED WORK''(c)[Reck aB that apply) EDemolition onstruction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altemtion(s) ❑ Addition ❑ - - ❑ Accessory Bldg.❑ Number of Units_. Other ❑ Specify: Brief Description of Proposed Work2: tee- S(st r f�S� 54. � Cc1)wl SECTION 4: ESTTMATED CONSTRUCTION COSTS Estimated Costs: - Official Use Only Item Labor and Materials)- - L Building $ 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (HVAC) $ List: �7 r 5.Mechanical (Fire $ Total All Fees:$ Suppression) Check No. Check Amount: Cash Amount: F. 6.Total Project Cost: $ a6D6, o D 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES r r 5.1 Licensed Construction Supervisor(CSL) Q n71 �3 J License Number Expiration Date Name of CSL-Holder Ek List CSL Type(see below) Address Salem MA 01970 Type Description U Unrestricted(up to 35,000 Cu-FL) Signature R Restricted M Family Dwelling M Masoury Only Telephone RC Residential RoofingCovering Y WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation- - Residential Demolition - 5.2 Registered Home Improvement Contractor(HIC) I M� HIC Companl Regisr'7ation Number fill R Ieffersoll AlrgMue Address Salem MA 01970 9 air �y`/�lY� Expirlition Date Signature Telephone - SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e-152.§ 25C(6)) . Workers Compensation Insurance affidavit 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. Signed Affidavit Attached? Yes .......... No......... ❑ - SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S tAl!GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, P �I �k ke- 5 as Owner of the subject property hereby authorize P, r_ la J ,g.l to act on my behalf,in all matters relative to work authorized by this building permit application. - - Signature of Owner - Daze SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION - 1, • r. �u-�''�J asrOwner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and• " behalf. - Print Name Signature of OOmer or Authorized Agent Date (Signed under the pains and penalties of 'u NOTES: - - 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor - (not registered in the Home Improvement Contractor(MC)Program),will not have access to the arbitration . program or guaranty fund under M.G.L.c.142A.Other important information on the MC Program and - Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5,respectively. - 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms - - Numberofbathrooms Number ofhalf/baths - Type of heating system - Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted-for"Total Project Cost" The Commonwealth ofMassachusetts , Department of Industrial Accidertts O,fce oflnvestigations 600 Washington Sired - Dosion,MA 02II1 www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/ContractorsWec&icians/Plumbers Applicant Information Please Print Ledbly Name(Bvsmawoiganimtion/Individtml): A*AWe Weadimi afion- TLC C Gj�t Jefft�tAve�ne Address: City/State/Zip: Phone#: h -M6 7 Are an employer?Check the appinpriate box Type of project{retprLtetT): 1. I am a employer with '�. 4. I am a general contractorand T 6.,0 New comtr chttn employees(f dl and/or part-time).* have hired the sub-contrac6ers 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7' Remodeling ship and have no employees These sub-contractors have 8. [].Demolition working for me in any capacity, w 'comp.insurance. 4 Building addition [No wodwW comp.insurance 5. We are a corporation and its 10.F]Mectrical repairs or additions required.) officers have exercised their C1 I am a homeowner doing all work right of exemption Per MQ 11.0 Phmmbingrepaus or additions myselL(No workers'camp. e.152,§1(4),and we have no 12.0 Roof repass insurance retllur«L)t employees.[No workers' 13.0 Other comp.insurance required.) 'Any appliemtihat otmola box#1 mast also fill oatthe section belowslurwi tg thmurmlma'wmPeozeaoa poficy infmmsiioa t Homeowners wbo submit fib affidavit indiastma shay are doing ellwmkmd thm bim oamida contactors must submit tutu affidwAtlndieatiag such. tCoaua=a that duck this box mustattachedm additional sbcdshowurg du name oftbombc hndm wglbdrworkm'comp.policymfomsdon. I am an employer awl rs protddfng workers'eompensaffon haurancefor my eWloyeet Belowis the poky and job site fnformadon. insurance Company Name: Policy#or Serf ins.Lic.#:_ ?//� ! 3 t EXpiration Date: 31'� 13 Job Site Address: � f1J /l Sc 4✓e- �i tii GSty/Statclzip.: /a/���/ Attachaaopy.of the workers'compensation policy declaration page(showing the policy number and ecpiration date). Pailore tosecure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.0p.and/or one-year impriQonmen4 as well as civil Penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day 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 certify under pains andpenaltles ofperjatythatthe information provided above is true andcorred. Date- L 2, ( //72 •- Phone#. a 7 V y EC /Y OrwTd use only. Do not write in dds area,to be completed 4 e ty or town OPTC&L City.or Town. Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cltyrrown Clerk 4.E.lechmeal Inspector S.Plumbing Inspector 6.Other Contact Person: Phone# RightFax C2-2 ry ATE 7��3//266/2,C012 7 : 26 : 5c2rjA�M � �PAGE 6/027 Fax Server ISSIIIEU i'C 33>GYit.Yl-L7{:::T.+ .; 3126tlO12 .: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES B HL OTdr. THIS CERTIFICATE OF INSURANCE DOHS NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.N SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER COIITACT EASTEF'DI INS GROUP LLC: 181ME: PHONE FA% 233 W CENTR .O,4L ST A Im.Ed: ar.Iw EMAIL I"TATICV,NIP. 01760 ADDRESV PRODUCER CUSTOMER IDtl: ' INSURED INSURERS AFFORDING COVERAGE NAIC:4 ATLANTIC WEATHERIZATION LLC INSURER A AMERIC.AN ZUPICH INSURANCE COA-P.SNY 61 REAR JEFFE.RSON AVE INSURER B 'SALENI,MA 01970 INSURER C INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER - REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUTIZEAUNT,TERM OR CONDIT1014 OF ANY CONTRACT OR OTHER DOCULIENT WITH RESPECT TO'WHICH THIS CERTIFICATE LtAY BE ISSUED OR 1 AY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED H=N IS SUB JEGT TD ALL THE TERMS, E>XLUSIOITS AND CONDITIONS OF SUCH POLICIES.LUMTS SHOWN MAY HAVE SEEN REDUCED BY PAID CLA S. INSR TYPE OF INSURANCE ADM SUDR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR \VVD DIYY" D GENERAL LIABILITY EAC$OCCIIEBFNCF $ DP.LIf GE IO BFFIIFD g �,Cprg,@BCIAL GEHESAL LH.HIIISY FBPIB SYf(FecL ' L>F.D.F$T'FIISE(Afy om $ ❑ CLAiLIE IdADE occvk anen ITB9JIIf.LAAW. ❑ EIN&Y CFlrFEAL ACfiPFCh IE $ D CFa'L F.GG&EGAFE LD.DI hPPLIEi PFZ PPCSNCf LCOLIPl�P $ ❑X]LICY ❑PEL�IECI ❑ Loc F.GC: AUTOTAURELE LIABILITY CLV.SSTJmD>'BICLE g CDM F EYJDMyuII.YIIrNkY g 0 F.11YF.QIO zc=YnRY $ ❑ fN.FSLiIL F20PFEIYDF.ldACE $ ', ❑ V:HFDIILFD ARIDS F9:mciL. ' ❑ $$FD AIItOi $ 1iO11-O'L1iED ADIOS❑ D ❑ IIIIETFLLF.LIP3 ❑O:CII& EPJ:H CCCIIISEIICF ❑ EXCESS LU.B OCLA$dSFG.L'F - AGGBFGAIE $ i,. $ I ❑ DPLIICIBS.E ❑ uIEDlroirf u,c $ I WORKERS' C014PENSATION Un, iIh IIIiOE.'i A AND EMPLOYERS LIABILITY LDSIIe YB F.ErY F'EOPPIEIOE�Fh.P.IlIFE/, Ei.EACH F.CCSSDI $500,000 ExecollvE osneFrn^4 N' N/A 7P1UB-5B270121 03.2U112 03720/13 EIU:LUDEDi Fz.marr.xE�-EAca $500,000 (1fAaN.'IOEY 1R f!a) PIdPIDYFF liye�,de,cvTe mLz DESCAEPIE]H CIF E LIEIIL.T EAP&POLICY $500,$500,000 OPIIA[INIS tobw —7 DES CetpF'IOD UE OPEEA310fi8lLO CH'LIOaSNlffiCLIS (AfnctACO&D 301,AdAID+m1Lm+,k 3cbdJ,dmon,Face i aq®dI - TIDE RLPLACIS AaY P=O$CTJMT$IICATE M3=Td T8C CT&TEPICATT$OLTaa APPLCTI$G WOB-ETk3 COMP C O VIICAGE :;6�£ftTkTfcS'ISZ:�h. (`I:�1 ...... CITYOF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Q3 V7AS'HINGTON ST BEFORE THE E�PIRATION DATE THEREOF, NOTICE WILL BE DELIVERED S'ALEN1,NIA 0197U IIJ ACCORDANCE WITH THE FOLIC I' PRO"✓ISIONS. , ' APlHO b1 IDD F8lI�..S' r'1'A9 VF .. .. .. :.::i. .;< ij 398�2409;��f,bX'I1�Cf,YRPI31:iY1T�G7H,Alln' 't9'reseive3:�:� Alm o�® CERTIFICATE OF LIABILITY INSURANCE s�i2oi2' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If tfi� ficate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and coritlin rs of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Construction NAME: Eastern Insurance Group LLC PHONE (508)651-7700 AC No: _ 233 West Central Street ADDRIESS: PRODUCER 00024397 Natick MA 01760 INSURERJSJ AFFORDING COVERAGE NAICN INSURED INSURERAArbella Protection Ins. Co. 41360 INSURERBArbella Indeadinnity Ins Co. 10017 Atlantic Weatherization INSURER.C:Zurich-American Group 61 Rear Jefferson Avenue IrIsuRERDBeacon Hill Associates Inc INSURER E Salem MA 01970 1INSURER F: COVERAGES CERTIFIGRTENUMBER a^TER'-2012 REVISION NUMBER: ' THIS IS TO CERTIFY THAT THE 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 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I TYPE OF INSURANCE MMN POLICY NUMBER MMI Y EFF POLICY ESP LTR . LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DAMAGE TO RENTED X COMMERCIALGENERAL LIABILITY PREMISES aocuen $ 50,000 A _ _ CLAIMS-MADE �X OCCUR B500042816 /20/2012 /20/2013 MED EXP Anyone arson $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGAI E LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGO $ 2,000,000 POLICY FX PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO 938274*00003 /20/2012 /20/2013 BODILY INJURY(Per person) E B ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULEDAUTOS PROPERTY DAMAGE X (Per accident) $ HIRED AUTOS X NON-OWNED AUTOS Uninsured motorist Bl split limit $ 4 Undednsured motorist Bt split $ X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE 5 1,000,000 DEDUCTIBLE $ A RETENTION $ 4600047820 /20/2012 /20/2013 $ L. WORKERS COMPENSATION VvC STATU- OTH- AND EMPLOYERS'DASIUIY - YIN ANY PROPRIETOR/PARTNEIVEXECUTIVE❑ N/A E.L.EACH ACCIDENT $ O(MandatoMBERry NMI EXCLUDED? ERTIFICATES TO BE ISSUED E.L.DISEASE-EA EMPLOYE $ (Mandatory In NH) If vas,desmbe under IRECTLY BY CARRIER E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below If D POLLUTION LIABILITY PL200378600 10/1/2011 10/1/2012 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) ' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF SALEM 93 WASHINGTON STREET AUTHORIZED REPRESENTATIVE SALEM, MA 01970 Rosemary Fulham/PMA ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2009N) The ACORD name and logo are registered marks of ACORD CONTRACT Printed: 12/18/2012 Work Order Id: 889431 P92595C299 :Contractor Information Customer/SitejDetaiis. Atlantic Weatherization Kathleen Makros Phone(Eve): 978 7455478 61 R Jefferson Ave 7 Hillside Ave Phone(Day): 508-M-8271 Salem , MA 01970 Salem, MA 01970-1905 Site ID: SM002089431 Total`instal led'Measures Location Description Quantity Unit$ Total$ Exterior Door Weather Stripping 3 $25.20 $75.60 Living Space Perform Air Sealing at Estimated 62.5 CFM50 1 $77.00 $77.00 Door Sweep .. 3 $21.17 $63.51 Livinn.Space Insulate Vinyl Sided Wall With 4"Dense Pack 968 $2.20 . $2,129.60 Blower Door Test Only 1 $60.00 $60.00 Living Space Insulate Rim Joist with 6.25"Fiberglass Battin 80 $2.09 $167.20 Installed Measures Total $2,572.91 1AIorkOrderNotes Owner rf „� Atlantic P fln ei;ts7. Incentive Payments Air Sealing Incentive $216.11 ' Weatherization Incentive $1 767.60 Total Incentive Payments $1,983.71 Customer Share ` Total Customer Share $589.20 Less Deposit Of $194.43 Customer Share Balance(Due Contractor) $394.77 c i '/% Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836-9500 Massachusetts-Department:of Public Safety. _ Board of Budding Regulations and Standards $: Cuactrutiwri Superv;kur ' Unrestricted-Buildings of any use group.which License:CS4087977' contain less than 35,000 cubic feet(991 m')of w+� S enclosed space. 4�y ERIC W PAL11f .• r. '��'.. 3 RMTON ST' y4 a + 1 SAUM NIA.1970 ... r i ^P+ 3 Expiration. Failureto possess a wnentedition of the Massachusetts `,Commissioner 04/23/2014.. a State Building Code is cause for revocation of this licenie:. for OPSlkeminginfohnationvisit: ~v.Mms.Gov/OPS' tlice o� > m°m""Rmgoess Regulate �"�.w"e."`".""""..: »,.e.,. ..,.,.�.,...t,—•M HOME IMPROVEMENT CONRiACTOR License or registration valid for individul use only 7 .. - Registration:.s,142089-. - Type: - ! f ! Expiration: 3(_t�(2A44 - Ltd Liability Corpoi, before the expiration date if found to - Were Office of Consumer Affairs and Business Regulation { ' 10 Park Plaza-Suite 5170 ° A IC WEATHERY,� IOC+!---u- C: . i 'Boston,MA 02I16 ntl" i -ERIC PALM t�" �"�. e� t OR JEFFERSON - SALEM,MA 01970 lFnderseere ry J Not:vand withootsigna ore d {