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4 LARKIN LN - BUILDING INSPECTION (2)
The Commonwealth of Massachusetts FOR V\ Board of Building Regulations and Standards MUNICIPALITY i Massachusetts State Building Code, 780 CMR T°edAp�n,a� USE Building Permit Application To Construct,Repair,Renovate Or Delnd�ish;a Revised January One-or Two-Family Dwelling 1.2008 This Section For Official Use Only Building Permit Number: Date Applied: Signature: . Building Commissioner/lnspeV of Buildings Daze SECTION 1:SITE INFORMATION - - 1.1 Property Address: 1.2 Assessors.Map l&Pa Lcgl tV.4oultersr tlii;,i,,. I.1 a is this an accepted street?yes_ no_ Map Numbcr .. Parcel Number 13,Zoning Information: 1.4 Property Dimeusious: Zoning District Proposed Use •-Lot Area(sq ft) Frontage(R) - 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.Gi-c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ heck ifyes❑ SECTION 2: PROPERTY OWNERSFIW 2.1 Ownert of Record: ' I _ '4 Cw] f ' C eV . Ia1��, � N� VC Name(Print) Address for Service: / Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Otxupied ❑ Re ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ I Accessory Bldg:❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work : 1 In w 1 Ce (ft, I dam_`{/1 S 4 /{— SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials - L Building - $ I 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: (`\e 5.Mechanical (Fire $ Total All Fees:$ Suppression) + Check No. Check Amount t: Cash Amount 6.Total Project Cost: $ /72C 0 Paid in Full 0 Outstanding Balance Due: . n SECTION 5: CONSTRUCTION SERVICES .. $.I Licensed Construction Supervisor(CSL) License N lumber Expiation Date Name of CSL-Holder NWW I Shwt t List CSL Type(see below) Address Salem MA 01470 Type Description U Unrestricted(up m 35,000 Co"Ft) Signature e. R Restricted I&2-Family Dwelling M Masmay Only Telephone RC RmideutialRooBn Covering �/ WS Residential Window and Siding 9-7 Y 7 y y— b y� SF Residential Solid Fuel Burning Ak2pliance Installation D Residential Demolition - 5.2 Registered Home Improvement Contractor(MC) HIC Companl Registration Number R:� 12 Tr{ 'Pm(1H-QlVf'iAl� Address Salem MA 01970 o P lZb (Y3 Expi.[ion Dale - Signature Telephone - - 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 .......... No...........❑ _ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, r/ l b of r 1/` ( ( as Owner of the subject property hereby authorize n, �. ( 'a,( rtq to act on my behalf,in all matters relative to work authorized by this building permit application- - - Si nature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION as'Owner 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 Nam - Signature of Owneror Authorized Agent - Date - (Signed under the pains and penalties of - 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 underM.G.L.c.142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IOR6 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 - - - - 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"may be substituted-for"Total Project Cost" RigihtFax C2-2 3/26/2012 7 : 26 : 52 AM PAGE 6/027 Fax Server IS SUE DATE WANO 3nii=12 N X THIS CERTIFICATE IS ISSUED AS A14ATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOTAFFIRI&ATIEVELY OR NEGATIVELY AhIEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THIS CERTIFICATE OFINSURANCE DOES NOT CONSTITUTE A CONTILACTI)EINVEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRUBUCER,AND THE CERTIFICATE HOLDER.. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ics)must be endorsed.If 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 CONTACT EASTERN INS GROUP LLC NAMEPHONE FAX 233 W CENTRAL ST (Ac P4,E.tI: Aq no NATICK,MA 01760 E-MAIL ADDRESS: PRODUCER CVIMIAER tDO: INSURED INSURERS)AFFORDING COVERAGE NAIC 9 ,,TL,.JJTIC WHATHERIZATION UC INSURER A AMERICAN ZURICH INSURANCE COMPANY 61 REARJEFFERSON AVE INSURER B FALERI.MA 01970 INSURER C INSURER 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 REQUIREUENT,TERM OR C014DITIC14 OF A14Y CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 'ERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUE= TO ALL THE TERMS, =LUqIOITS AM CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, -UTS—R TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY ERE POLICY EXP LUMTS LTR INSR NVVD (MM)T)D/YYY DNVYV) GENERAL LIABILITY FACH OCCII&BFNCF $ ➢A ZETOT.Enm $ 0 CTO, tzD,BE 0 occDG ISED.FXPFDYE(Ay am g $ D PEODIIC I"OQUrPrS 0 F=y a PYGIPCl 0 LTC P.GG &UTOI.TOBILE LIABILITY CCVdBHrPD T"'"I 0 Panlplulo $ $ RxAcciL D MR11xviog $ ❑ $ $ %VORkMRS-CO7.1PENSATION AC A AND EMPLOYERS LIABILITY YIN PENcPU1ff=1MUFP=1=- N/A 7PTUB-511270121 03l20f1 2 0320113 FL FACH F.CCIDFtrIsmo,000 H=LOOPDI Z00,000 (�TORY Ta UE) ............. CITY OF SALFIVI SHOULD A14 e OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 93 WASHINGTON ST BEFORE THE EXPIRATION DATE THEREOF, 140TICE WILL BE DELIVERED SAUNI,MA 01970 IN ACCORDANCE WITH THE POLICY PROVISIONS. 1]i6 i488li9"Abb 1 CERTIFICATE OF LIABILITY INSURANCE 3/19/2012' 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:, I(tHeticate holder Is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condlTiblls 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 E.B. (SOB)651-7700 FAX No: 233 West Central Street ADDRESS: PRODUCER D0029397 Natick_ MA 01760 INSURERS AFFORDING COVERAGE _NAIC# _ INSURED INSURER A:Arbella Protection Ins. Co. 41360 INSURER B Arbella Indemiaity Ins Co. 10017 _ Atlantic Weatherization INSURER.C:Zurich—American Group 61 Rear Jefferson Avenue INSURERDBeacon Hill Associates Inc INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFIOATE-N 6MBER:MASTER'-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. INSR 7ypE OFIN9URANCE O POLICY NUMBER MMIDDYEFF MMLIDT'E%P. LIMITS R GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES E. occunence $ 50,000 A _ CUIMS-MADE �X OCCUR 8500042816 /20/2012 3/20/2013 MED EXP lAny one arson $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 G 1 AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGO S 2,000,000 POLICY X PRO- LOC $ "CTAUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ALL AUTO $ ED AUTOS 938274'00003 3/20/2012 /20/2013 BODILY INJURY(Per person) $ X SCHEDULED BODILY INJURY(Per accident) $SCHEDULED AUTOS '"' `a' PROPERTY DAMAGE $ X HIRED AUTOS Y (Per accident) X NON-OWNED AUTOS Uninsured molonst Bl split limit S ' gEACHACCIDENT otodsl 8l spin S X UMBRELLA LIAB X OCCUR ENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE $ 1,000,000 DEDUCTIBLE - $ A RETENTION $ 600047820 /20/2012 /20/2013 $ C WORKERS COMPENSATION U- OTHANDEMPLOYERS'LIABILITY YINANY PROPRIETORMARTNER/EXECUTIVE NIA IDENT $ OFFICER/MEMSER EXCLUDED? ERTIFICATE9 TO eE I39VED(Mandatory In NH) . . -EA EMPLOYE $ I Yes,descnde under DIRECTLY BY CARRIER E.L.DISEASE-POLICY LIMIT $ IDE Cgs, OF OPERATIONS Del. D POLLUTION LIABILITY PL200378600 10/1/2011 10/1/2012 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES lAnach ACORD 101,Addltlonal Remarks Schedule,It more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY. OF SALEM 93 WASHINGTON STREET AUTHORIZED REPRESENTATIVE sALEM, MA 01970 Rosemary Fulham/PMA ACORD.25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD The Commonweakh ofMassachusetis Department of Industrial Accidertts Offwe oflnvestigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electx iciaus/Plumbers ApOcant Information1. Please Print Legibly Name(Bvs]ncastOtganiu -on/Ind vidaal): Atlmltie Wea6terization I I C Gl t IttitefspttAvtte Address: City/State/Zip: Phone#: 12$ Are an employer?Check the appTnprlate boz Type ofproject{regalored): 1. I am a employer with 4. I am`a general c4ontrackorand I 6 0 New donsOcfion employees(fall and/or part-time). have hired the sub-contracturs 2.❑ I am a sole proprietor or partner- listed on`tho attached sheet: 8. ❑Remo ship and have no employees These sub-conuacwrs have . 0•DemoMen Remodeling liti workers'Comp.insurance. q. addition working forme in any capacity. �Building o worl=s'comp. insurance We area corporation and Its 10 Electrical repairs oradditions required.] officers have exercised their 3 I am a homeowner doing all work right of exemption per MM 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' 13.0 Otber comp.insurance required.] 'Any applicant that eheola box#1 must also fill out8w section belowshowing their wo&aera'compensation poUey B&NU12tien t l39mw"ms who submit this affidavit indlosting they me doing an work and thm biro oobide eonnaetow must subunit a tww affidavit indicating sueh. tCoauamm tbw check this box mvst attached a n*Witionel sheet showing lheaame of a+a mbcaahaetotsand1heirwortoW comp..policy int'ormsdea. I am an Gtiplayer that is providing workers'compensoNon tnsumnce for my employees Below is the policy and job she information. y Instuauce Company Name; Policy#or Self-ins.Lie.#: �� e�//� i ( Expiration Job Site Address: y ✓` n City/ShatelZip: eJ�i GPI �`� Attachacopy.o£the workers'compensation policy dedaration page(showing the policy number and expiration date). Pailnte w..secura coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$I,500.M and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to MOM a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of tho DIA for insurance coverage verification. l do hereby certify under the pains and penahles ofperjury that the information provided above iv true and Courser J 2 Sigpatiae �`✓ Date: //,7t // l P_hone#- q -2 SY Y. /Y 22 OfJieW ass only Do not write in this area,to he completed by city or town ofjrcidi City:or Town: PermlVUcensei# Issaing Authority(circle one): 1.Board of Health 2.Building Department 3.city/Town Clerk 4.9"trgealinspector 5;Plumbing Inspector y G Other Contact Person, Phone CONTRACT( Printed: 1/17/2013 Work Order Id: S9058SP9378OC203 t ontractoY 'f w f«y* iistom /Site�De aUslt"tU r N !n ottgation ._. . .._ _. ..,._._.........� . r 4 ' .d. Atlantic Insulation Albert Hill Phone(Eve):+ 978-744-3910 61 R Jefferson Ave 4 Larkin Ln Phone(Day): Salem,MA 01970 Salem,MA 01970-5624 Site ID: S00002090583 w; rr�+�l HiA�'2,f�, ^��,r�+ �y 7". �.,'v,T�s,�• A�'y 'Sp' vnn�rry .cR'uc lv Yamaar.' a mnY" .., r 4 Location Description Quantity Unit$ Total$ Blower Door Test Only 1 $60.00 $60.00 Living Space Insulate Wood Shingle S pd Wall With 3'Den 485 $1.82 $882.70 Living Space Insulate Asphalt Sided Wall With V Dense Pao 285 $2.75 $783.75 Installed Measures Total $1,726.45 „,�h �7X1^��*�3 KY °»f'fr9�}»�°7b`�y�cF tl'`�'9�b's�1- '�k'. s�'". g-�mry �� rs u�w rhr. r 'i•,; � : 'it4:A�+r,. ,8°�G�,'.�l�lii�',i-r?.'Ynwr�.£5fs w'S'ti�.f�,,.'� -��'�',� �•r+�`�F�bsc�n.,,%ri!vOrkO�er�tr0 .si;ll_.+�... is w.l.r� ..Q�'�1�.r -:r��'r.1��1 � xi . Owner Atlantic km-, Incentive Payments W,eatherization Incentive $1,294.84 Total Incentive Payments $1,294.84 Customer Share Total Customer Share $431.61 Less Deposit Of $142.43 Customer Share Balance(Due Contractor) $289.18 Conservation Services Group-50 Washington Street Suite 3000-Westborough, MA 01581 -(508)836.9500 Massachusetts-Department of Public Safety Board of Building Regulations and Standards r - Unrestricted-Buildings of any use group which Construction Supcnisu License:CS-087977a contain less than 35,000 cubic feet(991in )of is ni• 1 '� enclosed space. -ERIC W PALM .r+�_ 3 HII,TON SALEM MA-01970 si*`'` Expiration Failure to possess a current edition of the Massachusetts Commissioner 04/23/2014 - - State.Building Code is cause for revocationofthislicense. - For OPS ticeminginformation visit: www.Mms.Gov/DP5 Offce 0At�m°'e'r'� i�{a n�c Ba�ind egu anon - - •� --- — _ =a !.. V .,HOME IMPROVEMENT CONTRACTOR � i wLicense or registration valid for individul use only, ` ! Registration 142009 Type: 0 Expiration• 3/12(20t4 Ltd Liability before the expiration date. If found return to: . s Office of Consumer Affairs and Business Regalation r- 10 Park Playa-Suite 5170 C WEATHERTLATtON L L_C. 7 ; Boston,:117A 02116 ERIC PALM - II 61R JEFFERSON AVE i SALEM,MA 01970 - undersecrctary � Not valid-without signs are i