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15 HOLLY ST - BUILDING INSPECTION The Commonwealth of Massachusetts ® Department of Public ilf"Cl 12 P 12- 35 Massachusetts State Building Code(780 CMR) `Q Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 15 Holly St Salem 01970 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ® Specify: Insulation Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: 6 ml poly on ground, 90 sq ft;3 door sweeps & 1 weatherstrip;2 hours air sealing;vent clothes dgxr to exhaust dart&hath fan; 1 in T-max foam heard, 194 s i ft SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.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-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ 1H: High 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❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ ItB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner MarIlyu Costa 15 Holly St Salem 01970 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Marilyn, Owner 978 _744 _6920 Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes lose Santos 263 Western Ave Lynn MA 01904 Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control lose Santos _M- 598-7125 jobs@abtisulation.com 101378 Name(Registrant) Telephone No. e-mail address Registration Number 37 W Milton St Apt 1 Hyde Park MA 02136 11/97/9,017 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor American Building Technologies Company Name lose Santos 163106 - HIC Name of Person Responsible for Construction License No. and Type if Applicable 2 Neptune Rd. Ste 439 Boston MA 02128 Street Address City/Town State Zip 781.59& 7125 617 -233 -8704 lobs@abtinsulation.com Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 application? Yes M No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 1 815.19 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ J/V Enclose check payable to CL 6.Total Cost $ 1 815.19 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By enter' m ame below,I hereby attest under the pains and penalties of perjury that all of the information contained in this applicat f e accurate to the best of my knowledge and understanding. lose Santos Owner,ABT 781-598 - 7125 Pleas ' t audsign name Title Telephone No. Date 2631YVestern Ave Lynn MA 01904 Street Address City/Town ,S,taate Zip / Municipal Inspector to fill out this section upon application approval: V / -"'y'�"'" y /�!^ Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit e PP g application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot #for locations for which a street address is not available) 15 Holly St Salem MA No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incom lete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 1 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan(Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State 1p Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Date Street Address City/Town State Zi Rightfax C1-1 11/5/2015 8 : 46: 52 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE IATE(MM/D D/YYYY) T1111114ENTIFICATE 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 ORPRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to he certificate holder In lieu of such andorsemen s. PRODUCER CONTACT NAME: AMBROSE INS AGCY INC PHONE FAX 70 MUNROE ST STE 5 (A/C,No,Ext): (A/C,No): LYNN,MA 02101 E-MAIL ADDRESS: 237LY INSURER(S)AFFORDING COVERAGE NAICD INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY AMERICAN BUILDING TECHNOLOGIES INC INSURER B: INSURER C: NSURER O: 263 WESTERN INSURER E: LYNN,MA 01904 04 INSURER F: COVERAGES - CERTIFICATE NUMBER: REVISION NUMBER: IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERpD INDICATED. NOTWITHSTANONO ANY REOUIREMENT,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 HEREN EI SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITB SHOWN MAY HAVE REM REDUCED BY PAID CLAIMS. NSR ADD SUB POUCYEFFOATE POLCYEXPDATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MM MYYYY) (MM=WYYY) UNITS GENERAL LIABILITY ACH OCCURRENCE Is COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS MADE a OCCUR. PREMISES(Ea occunence) $ ED EXP(Any one person) $ GEN'L AGGREGATE LIMB APPLIES PER: PERSONAL A ADV INJURY $ ENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMPIOP AGO $ AUTOMOBILE LIABILITY COMBINED SINGLE $ AU'r LIMIT(Ea accident) - rOWNEDAUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKER'S COMPENSATION AND x wC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-2ES18445-15 10202015 1020/2016 LIMITS ANY PROPERITOWPARTNEWEXECUUVE N/A E.L.EACH ACCIDENT $OFFICEIVMEMBER EXCLUDED? © 1,000000 (Mandoory In NH) E.L.DIS EASE EA EMPLOYEE $ 1,000,000 I7 yes,dasOlae-ac DESCRIPTION OF OPERATIONS W1. E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESMESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTTNG WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION NSCAP SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 11SIR FOSTER ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DELIV ED BLDG 13 IN ACCORDANCE WITH THE POLICY PROI/J W PEABODY,MA 01960 AUTHORIZED REPRESENTATIVE ACORD 25(2D10/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP R r g is reserved. .#e9IstratIori:,,-,'163106 � 'Cons �ONryNQr&Bu O//J�`�R:iJRC�[lTPf'l ice of Consumer ARaira&Busidess Regulation OME IMPROVEMENT CONTRACTOR Type:xpiration -6AU2017 Corporation ^.m-^•------^— •_mow..._.--.-----.,--- _ . AMERICAN BUILDING'TE�CH C GIES,INC. License or registration valid for individual use only JOSE SANTOS �^ �.^ before the expiration date. If found return to: a Office of Consumer Affairs and Business Regulation 2 NEPTUNE RD.SUITE:439� , ' 10 Park Plaza-Suite 5170 BOSTON.MA 02128 �- l'. Boston,MA'02116 Undersecretary r Notv d*oiglattme a Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-101378 Construction Supervisor Construction Supervisor JOSE ASANTOS Restricted to: 37 W.MILTON STREET APT-1,f Unrestricted than 35-00 cubic of any Use group which contain less than 35,000 cubic feet(991 cubic meters)of HYDE PARK MA 02136 enclosed space. i Expiration: Commissioner 1112712017 Failure to possess a current edition ofthe Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit:W W W.MASS.GOVIDPS i o°v ABT American Building Technologies Energy Savings Is Our Specialty 263 Western Avenue- Lynn-MA 01904 Phone-781-598-7125/Fax-781-479-0727 www.americanbuildingtechnologies.com Authorization Letter 1,Jose Santos,HIC 163106 and CS-101378 holder hereby give my authorization to Stephanie DeTomasi to act on my behalf regarding the Building Permit Application 15 Holly St. Salem, MA 01970 Jose Santos 10/6/2016 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 If www,mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organiaationnndividmi):Amer ic an Building Technologies — Jose Santos Address: 2 Neptune RD #439 City/State/Zip:Boston MA 02128 Phone#: 617 233 8704 Are you an employer?Check the appropriate box: Type of project(required): 1.[3 I am a employer with 5 4. ❑ I am a general contractor and 1 .6. ❑New construction employees(full and/or pan-time)." have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑We are a corporation and its required] officers have exercised them ]0.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself[No workers'comp. c.152,§1(4),and we have no 12.❑Roof insurance required.]t employees.[No workers' comp.insurance required.] 13.[ Othe ldtiOn r 1riSll •Any applicant that checks box#1 must also fill out the section blow showing their workers'compensation policy information. r Homeawnere who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub�connactors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Ace American Insurance Policy#or Self-ins.Lic.#: 2E918445 Expiration Date: 10/2 ON/�16 1 p Job Site Address:1� &W I- City/Statc/Zip:mlt IVt 0L"1� 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 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, n pa out nobles of perjury that the informadon provided ct d above is true and corre Si nature: Date: VU Phone#: 61 7D 3 87 4 Official use or . Do not write in this area,to be completed by city or town official 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#: A�® (617) 752 157O Contract for Products/Service Work This Agreement is made by and among Marilyn Costa 15 Holly St Salem, MA 01970 American Building Technologies(ABT) 2 Neptune Rd, Suite 439 Boston, MA 02128 I. DESCRIPTION OF WORK TO BE PERFORMED 1- 6 ml poly on ground,90 sq ft 2- 3 door sweeps& 1 weatherstrip 3-Air sealing- 3 hours 4-Vent clothes dryer to exhaust duct&bath fan 5- lin T-max foam board, 154 sq ft Total: $1,815.19 Customer Signature: �f�< Customer Name: M r Date: 1 aAn Contractor Signature: Contractor Name: Date: loi(`y15)o i(o