39 LAFAYETTE PL - BUILDING INSPECTION (2) IP- 2S " * t of zr
The Commonwealth of Massachusetts INSPECTI NALc�Rb/�CES
° Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR 1415 JpN 'SAM
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
1 This Section For Official Use Only
L 1 Building Permit Number: Ito Applied:
Building Official(Print Name) Signature ' ''"�iaie`
SECTION l: SITE INFORMATION
I' 1.1 PProperty Address:
ddress:�l 1.2 Assessors Map&Parcel Numbers
l.a Its tf hts an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(ft)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 fl"O'of Record:
�(`� t 7 2.a [ U lip-tr"M- liM� 1
Name(Print) Ci ,State,ZIP
lc �PE4P el ��
No.and Street �— Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': v Q 1' �5
0�'t11Ct G1,iA S4Elll4Yn-.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Official Use Only
1.Building $ L.t ' ,�V `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:
5.Mechanical (Fire $ b '
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ f 1 I �' q 8 ❑Paid in Full ❑ Outstanding Balance Due:
uaLL- H 'P. v o2.E!s S S-7 Zoa - (D --1 y -7
cam u 111bQ 10; IQA
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1013�Q
,�O-L (][.1n S License Number Expi ti io
Name of CSL Holder
List CSL Type(see below)
W Q�i IkDYI cc�
Noo..and nn d Street ' Type Description-.
yt„y, U Unrestricted(Buildings u to 35,000 cu.ft.
�'y11�]I�( N CRA 1L 1'1lR u(� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
11 'l�J� O� 1 SF Solid Fuel Burning Appliances
,�1"1 'W I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I L9 310u 5 1l I
ft�&�w HIC Registration Number Expiration Date
HIC Company or HIC Registr Name
9 tlr y,Q cabiill�l�latjaddresst�l.(:oi�
No.and Street �" Email
Me oZ► U 1 I 2,n ne
_��
i /Town, State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 ..........Ql� No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
"APPLIES FOR BUILDING'PERMIT `
I,as Owner of the subject property,hereby authorize_ N%J�\s
to act on my behalf,in all matters relative to work authorized by this building permit appp kaation.
lml !ZZ► -0 is
Print Owner's Name(Electronic Signature) ate
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
1A %a 1 l3
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/di)s
2. When substantial work is planned,provide the information below:
Total floor 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
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
IN www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BnsineWOrganintionandividual): American 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.M I am a employer with 5 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
listed on the attached sheet.t 7• ❑Remodeling
2.❑ I am a sole proprietor or partner- .
ship and have no employees These sub-contractors have 8. ❑Demolition !I
working for me in any capacity. workers'comp. insurance. 9. ❑Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
required.] officers have exercised then ]0.❑Electrical repairs or additions
3.❑ I 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 repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.®Other insulation
Any applicant that checks box A I must also fill out the section below showing their workers'comperaation policy information.
t Homeowners who submit this affidavit indicating they are doing all work ar�d then hire outside contractors must submit a new affidavit indicating such,
tContractors that check this box must attached an additional sheet showing the name ofthe subcommctors and their workers'comp.policy information.
I am an employer that is providing workers'compensation Laurance for my employees. Below is the policy and job site
Information,
Insurance Company Name: Hartford
Policy#or Self-ins.Lic.#: 6BO2483-5-13 Expiration Date::����15/29/1hh5 MID
q
Job Site Address: M WG -n\ )k t ! 1 City/State/Zip: III V-,,\ ID
Attach a copy of the workers'mpe satlon 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 de a pains and penalties of perjury that the information provided above is true and correct
Si nature: Date: i �S
Phone#: 7 3 04
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.FAectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-101378
JOSEASANTOS,�
37 W.Mittens Strek
Hyde Park MA I&M
Jam,,,, ,rre`• Expiration
Commissioner 11/2712015
t I
&7& ry'wit WoPeoeollll o�F3'"�ln uic�rue/<j i
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
11 -. ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
_egist2tion: 163106 Type: Office of Consumer Affairs and Business Regulation
Expiration: 511112015 . LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
AMERICAN BUILDING TECHNOLOGIES
JOSE ALVES-SANTOS ,
2 NEPTUNE RD.SUITE 439
BOSTON,MA 02128 L �-
Undersecretary Not valid ithout signature
A�OKbe DATE(MWODIYYYY)
/� CERTIFICATE OF LIABILITY INSURANCE l0/28/2014
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: a the certificate holder Is an ADDITIONAL INSURED,the policy(les)must he endorsed. N SUBROGATION a WANED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A steMment on this certificate does not confer rights to the
certificate holder In Ileu of such endomement(s).
PRODUCER
CUNTAOUI
Ambrose Insurance Agency, Inc. NAME:E: 781-592-8200 6CNo:781-595-5820
56 Central Ave. S
Lynn, MA 01901 wsuRsale) ArroRnao coveaAoe Noce
INSURER A:AtlantiC Casualty
INSURED American Building Technologies Inc INSURERB:Torus Specialty
INSURER C:Hartford
2 Neptune Rd. , #439 eSURER D:
Boston, NA 02128 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 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 POLICY NUMBER MM UPLIMITS
GENERAL LIABILITY r�NEA
RENCE S 1,020,000
X COMMERCIAL GENERAL LIABILITY am=l t oe S l00 000
CLAIMS-MADE OOCCUR one Perwn) 8 5 000
A L035-011660 10/17/14 l0/17/lsDVINJURY a 1,000,000
GREGATE s 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: COMPIOP AGO S 1,000,000
POLICY PRO- LOC S
AUTOMOBILE LIABILITY IS.ecdderd
ANYAUTO BODILY INJURY(Per Perwn) S
x AALL UTOS OWNED �OSULED BODILY INJURY(Per aeddW) S
�� ED
HIRED AUTOS AUTOS Per eaoldm $
S
UMBRELLA LIAB OCCUR 8331OH141AL 10/17/14 10/17/15 EACH OCCURRENCE s 1,000,000
B X EXCESSLMB CLAIMS-MADE AGGREGATE $ 1,000 000
DEC) J I RETENTION$ $
WORKERS COMPENSATION R _
AND EMPLOYERS'LIABILITY
VIN S
C ar a EXCLUDED?
eCUTI.2 NIA E.L.EACH ACCIDENT 1 00.0 000
IMendMory In NMI 6BO2483-5-14 5/29/145/29/15 E.1-DISEASE-EA EMPLOYES 1,000,000
M yeti,deauTeIPTION uMer
DESCR OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Ahach ACORD 101,Additional Remarks Shcedule,1f more space is regWred)
Insulation Contractor
Community Teamwork, Inc. , NGrid Corporate Services, LLC, dba National Grid, dba
Boston Gas Co. , dba Colonial Gas Co. , dba Essex Gas Co. , Action, Inc. , NStar, and
ASCII, Inc. as additional insured general liability, excess liability, auto liability
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
NSCAP THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
98 Main St. ACCORDANCE WITH THE POLICY PROVISIONS.
Peabody, MA 01960 AGTHORZEo RE ESENTgTNE�
Fax: 978-53531-1012 s''RR((``
01988-2010ACORD CORPORATION. All rights reserved.
ACORD25(2010105) The ACORD name and logo are registered marks of ACORD
Work Order
North Shore Community Action Programs,Inc. Job Number: 110801
119 Rear Foster Street,Building 13 Work Order Date: IM2015
Peabody, MA 01960 Ownership:Renter
Phone:97ft-531-0767
American Building Technologies Auditor: Brandon llnrrington
263 Western Avenue Email: bdorrington@nscap.org
Lynn MA 01904 Cell:781-5404569
Email: rostrecker@gmail.com Pbone: 978-531-0767%121
Phone;781-598-7125
James Seybold lii NGRID Electric $4,481.98
39 Lafayette PI 'Total $4,481.98
Apt.2
Salem MA 01970
978-744-9273
Landlord Name:Nancy bpi
Landlord Phone:978-766-7407
Safety Issue(s):lend Paint Possible
a t • A utBot9e_d Actual_
COmmcnts y f
Measure Descrlp6un t ,
e Qty Price Total Qt} Tom-
ow r
Attic Insulation
Attic/Kneewall Floor Transition 70 $2.82 $197.40 70 $197.40
Dense Pack w/cellttlosc
Kneew•alls R-12 cellulose behind 200 SL94 $388.00 200 S388.00 Rear large KW
permeable membrane
R-I I FGB in open rafterslwallsi 90 S1.47 $132-10 90 $132-10 r13 KW @ smaller KW 2'
kneewalls
R-18-20 restricted-slopes/floored 460 $1.55 S713.00 460 S713.00
fill wlcellulose
R-30 restricted -slopes/fioored fill 500 SL59 $795.00 500 S795.00 flat rear
wlcellulosc
R-30 restricted-slopesi loored fill 150 S1.59 $238.50 150 $238.50 kwf
w1cellulose
R-38 unrestricted-settled cellulose 330 $1.6S S544.50 330 '$544,50
'T ' Attic Ventilation > -t w r r,y , . i s i, 'a ,� »;fi «.� ^ _ -
Roof vent 865(A sq it NFV)small his
90.00 S.540.011 6 $540.00
Automatic Sweep I $26.40 S26.00 1 $26.00
Fixed Sweep 2 S17.64 $35.28 2 S35.28
Date: IM2015 Page I
worx Vraer: ,lob Number: 110801
R-5 Ductwrop or R-max on door 1 $57.00 $57,00 1 $57.00
3 tw Heallh`&4afet}':_` s ' w.,rise' r a '"?$r'3' ` x.,r' ':• Y-.., t ..:
Clothes dryer vent including I 5100.00 $1WOO I $10070
Exhaust Duct
` 9r: v li'IiSC.Men StLL'C9: .,f}
Attic sealing with two-part foam 3 $84.00 5252.00 _ 3 $252.011
Shcetroek no tape @ attic slope 100 53.63 $363.00 100 $363.00
4
Building Permit I $100.00 $100.00 1 $10111
0
Total $4,481.98 $4,481.98
Contractor Instructions:
Before Stanip t e J : u m t o Jab:
. Please notify its 24 hours before starting or sc)teduling a job. I:"this residence was built.before 1978. I.tad sate nrrclice5 are
2. Obtain required building permit: required.
2. Total for I leath&Safety and Repairs cannot exceed$2500.00.
3. Davis Bacon time sheets required for ARRA work on US
Deparunent of Labor Certified Payroll Report Form WH-347.
Additional Contractor Instructions:
Attic Inspection form attached? Ycs NIA (Circle One)
Certificate of Insulation posted? Yes No (Circle Me)
Date: 1/70-015 Page 2
worx urger: Job Number: 110801
American Building Technologies herehy certifies that this job was supervised and completed in compliance with all Department
of Labor Standards and Lead RRI'regulations.
Contractor Signature: pate: RRP License ti:
i hereby acknowlege that all work has been completed and inspected.
Customer Signature: Date:
Energy Director: Date: Fiscal C)FGcer: Date:
FOR ACE',N_CY U$P t
Pre Post Language Other than linglish needed? Yes No (Circle On(f)
Dryer CO 0.000 II'yes,indicate language: _
Stove CO 0.000 Occupany change in last 18 months? Yes No (Circle One)
1-120'I'ankCO 0.000 Comments:
Fleating System CO 0.000 Number of windows
Ambient CO 0.000 Number of rooms
Blower Door fl.00
Date: 117/2015 Page 3