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25-27 LEACH ST - BUILDING INSPECTION (2) ^ _ z,�4 . The Commonwealth of Massachusetts ,;FOIt Board of Building Regulations and Standards MUNICIPALITY Massachusetts State Building Code, 780 CM7'.,editioa USE `1 Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January One-or Two-Family Dwelling 1, 2008 This Sectio ffic at Use Only ` Building Permit Number: Dat pplied: Signature: � I Building Cornmissioner/Inspecto ofBuildiu Date (( S N I: SITE INFORMATION 1.1 Proer�r4�dress: 1.2 Assessors Map.&Parcel Numbers. , I.1 a Is this an accepted sheet?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District ProposedUie '.Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided ,r 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public El Private❑ Check if yes❑ SECT N 2: PROPERTY OR'NERSFIIP' 2.1 Ov er'of R cord: /� �� _ e f S.F fd l Name(Pnt) Address for Service: j� Sig6atTre Telephone _ SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Numberof Units_ I Other ❑ Specify: Brief Description of Proposed Work': ffT . 5 �e �,, 5l�// �io�� ce.flt /pro �✓0./r t -r5— SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item (Labor and Materials) - 1.Building $ - 1. Building Permit Fee:$ _Indicate how fee is determined: ❑Standard City/Fawn Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Total All Fees:$ -Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 3 y 0O. 6(' 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL)- S79 License Number Expiration Date 11 Name of CSL-Holder 3 Fiilta�t$treat- !r List CSL Type(see below) 2 Address - Salem ; ' Type Description - U Unrestricted(up to 35,000 Cu.Ft. Signature R Restricted 1&2 FamilyDwelling M masoml Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) lyaogry" HIC Company WW Al' e LLC Registration Number �1 tF� IS6Hl�VP�Hl4 2 Address Salem MA 01970 R P� -7 9 t/-S/Y 3 Expirauon Date 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 IssuancPof 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 5 as Owner of the subject property hereby authorize A "-k - to act on my behalf,in all matters relative to work authorized by this building permit application. - AV q&y Si nature of Ov Date SECTION 7b: OWW)NEW OR AUTHORIZED AGENT DECLARATION I, _ G �- ,as'Owner or Authorized Agent hereby declare that the statements an information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature drOwner or Autbonzed Agent Date (Signed under the pains and penalties of a u NOTES: I. 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1I O.R6 and 1IO.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" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 UIV www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/oiganination/ludividual): Atlantic WeathaiZBtlon, LLC 611t Jeffma Avestie Address: City/State/Zip: Phone#: 12 5 Are an employer?Check the appropriate box: Type of project(required): 1.F I am a employer with 9� 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.t �• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑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 their 10.❑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 12.0 Roof repairs insurance required,]t employees. [No workers' 13.❑Other comp.insurance required.] 'Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContracton that check this box must attached an additional sheet showing the name of the subcontractors 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: v4 f i Policy#or Self-ins.Lie.#: S i<) 7 Z 1 ( Expiration Date: s [ 3 Job Site Address, ;Z��7 L C- City/State/Zip: Attach a copy.of the workers' compensation policy declaration page(showing the policy number and expiration date). Faifire 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 cer nder the painssaa)nd�penahies of perjury that the information provided above is true and,correct Sienattre� '/. //GAG — Date- Phone#- y Of Jleld use only. Do not write in this area,to be completed by city or town oflwiai City or Town: Permit/l icense# 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#: -= CONTRACT -- - Primed 915n01 - - WoYc:Orderid: S556i9P5e745C299 s, a Atlantic Weatherization Wendy Foss Phone(Eve). 978-825-9073 61R Jefferson Ave 27 Leach St Phtine(Day);. 50/F932-2348 Salem,MA:01870 Salem;MAg1976 4312 Site lU: 500002o558i9 Fin -y .r. i eSrs' :S TOte�'i S e+��p Bae�j eS ,'•C ft r•.r- 'r rF'' a r•i .,.z K .Ax._.ass..^ -xa..a'1'!.,. .�•�uucuu'Yys�'++. x -.�: �a•..� : -2'; v . Location Description Quantity Unit TOtat S Ltving Space InsuldId Rim 4016t With 6.25'fibergless Batting 44 $2.09 Living Space Insulate Wall From Interiorwlh 4'Dense Pack 1 558 $2.1i $3;287;. Living Space: Perform Air Sealing at EstimatedS2.5 CFM50 1 $77,06 $77t00 , installed Measures Total $3,460 34- vsr.-a *. 't ----^ n .,� r `-i✓' e{> emu. . +rt. i.�-,c :+ s'4 f t .y„'> type Status Notes' Asbestos. UNKNOWN Knob 8 Tube Wiring FIXED Mt claaredforali areas license#11044 6/14/12 jk Owner �rt,-- Atlantic i e �45-r "� . uxs• �..°:- r ..,; "1`'.- -�.. --� ,.P -.-.` 11e9n J�J ��P$ Incentive Paymer#ts Air Sealingincentive $7T.00 weatheria0_0n Incentive $2,000.00 Tota)Incentive payments 52,077.Q0 a Customer Share Total customerShate $1,379.34. Less Deposit Af $0.00' Customer share Balance iDue Contractor) $1,379:34 Conseroafion ServicesrGroup-:5U Washington Street Suite 3000-Westborough,MA 01581-(504)016-9500 —Ri-gITtFaX—C-2 2 3/26/2012 7 : 28 : 52 AM PAGE 6/027 Fax Server THIS CERTIFICATE IS ISSUE➢AS A MATTBA OF INFORMATION ONLY AN➢ CONFERS NO RIGHTS UPON T}iE CBRTIFICATH HOLDER. THIS BEL O\\r. THIS CBRTIFICATH OF INSURANCE DOHS NOT CONS TITUTH A CONTRACT BBTWHBN THH IS SUING INSURHR(SJ,AUTHORIZE➢ REPRESENTATINT OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)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 enclorsement(s). PRODUCER CONTACT NAME FASTEf,N INS GROUP LLC PHONE FAX 2133W CENTRAL ST (A 'J.,Ed Aq P40 EMAIL NATICK,IVAA 01760 ADDRESS: PRODUCER CUSTOMER ON INSURED INI;URM(S)AFFORDING COVERAGE NAIL 4 ,�TLATITIC V717—kTHERIZATIOV LLC —INSURER A kMUUCAN ZMCH INSURANCE CONEPANY 61 REAR JEFFERSON AVE INSURER B S-AI-al,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 DTDY-ATE).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 SUBTECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICYEXP LUMTS LTR 1NSR 'LVVI) D D/YYYY) GENER.f i.LIABILITY —fp E�10=m 0 C'ADdSIdAE� 0 crcuiL. 0 G I n FL h Lm A I—ELTLD I KFPELR S P M DF=Y 0PLGSEC1 OUDC hGG UCKMIXO=01GLE AUTOMOBILE LIABILITY 0 $ 0 PIT CWOODANT09 Rzfwcilc Q A`aFDIILEDAVlos Rzeccilc 0 s� kulot 0 --0 EACH Ccc�WH 0 M�LAUAB 0,Ccc� D 0 0 DE=IMLE 0 LETEIT1101is 4;�.IUICKYc ANIORIZERS' COLIPENSATION AND EMPLOYERS LIABILITY T=9 Y/N EN N/A 7PJUB-5B270121 03f207I2 03120113 E1.BACHPXC=T1 $500,000 EXCLU= $5100,000 (LSAffMToxy LR ffa) EfdQflJYEE $500,000 T.1 OPFLA1=9 B- DZSC8 OP OF OPzitAn ACcILD 101. w-'ad) 0, G, =�Cn 7 :. 7 77�7-777.7.7�7�7777777,77.71777717.7. ...... 7 . ...cu'lvi Jj?KK CITY OF SALYAVI SHOULD ANY.OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 93 WASHINGTON ST BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED �ALEJVI, MA 01971-1 IN ACCORDANCE WITH THE POLIC.' PROVISIONS. DATE AC�® 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: It thei rS't�ficate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condino'rls 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 t. (508)651-7700 ftftl nlc No: 233 West Central Street ADDRESS: PRODUCERcusToMER 00029397 Natick MA 01760 INSURERS AFFORDING COVERAGE NAICp _ INSURED INSURER A:Arbella Protection Ins. Co. 41360 INSURER B Arbella Indemn-ity Ins Co. 10017 Atlantic Weatherization INSURER_C:Zurich-American Group 61 Rear Jefferson-Avenue INs B uREROeacon Hill Associates Inc NSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFIOATE`NUMBERJMAST> R"2012 - REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES AF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE 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. ADDLINSR TYPE OF INSURANCE INSR POLICY NUMBER MMIDCYEFF MMIDDIYYY CY EXP LTR LIMITS GENERAL LIABILITY EACH OCCURRENCE g 1,000,000 DAMAGE X COMMERCIAL GENERAL LIABILITY PREMISES -RENTrrence $ 50,000 A CLAIMS-MADE ❑X OCCUR 8500042816 /20/2012 3/20/2013 MED EXP lAnyone personi S 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 G 1 AGGREGATE LIMIT APPLIES PER: _ PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY FX jpERGOT F LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Es accident) ANY AUTO BODILY INJURY(Per person) $ $ ALL OWNED AUTOS 9382741D0003 /20/2012 /20/2013 BODILY INJURY(Per accident) b X SCHEDULED AUTOS '9 PROPERTY DAMAGE $ X HIRED AUTOS Y (Peraccident) X NON-0WNED AUTOS Uninsured motonsl BI split limit $ Undennsured motorist BI split $ x UMBRELIJI UAB X OCCUR EACH OCCURRENCE 8 1,000,000 EXCESS LUM CLAIMS-MADE AGGREGATE $ 1,000,000 DEDUCTIBLE - $ A RETENTION $ 600041820 /20/2012 /20/2013 $ `. WORKERS COMPENSATION VvC STATU- OTH- AND EMPLOYERS'UABILITY - ANY PROPRIETOR/PARTNERIEXECUTIVE YI❑ NIA E.L.EACH ACCIDENT S OFFICE(Mandatory In H)EXCLUDED] I RTIFICATES TO BE ISSUl E.L.DISEASE-EA EMPLOYE $ (Mandatory In NH) If yes.desrnUeunder IRECTLY BY CARRIER EL.DISEpBE-POLICY LIMIT E DESCRIPTION OF OPERATIONS 0alme D POLLUTION LIABILITY PL200378600 0/1/2011 0/1/2012 GENERALAGGREGATE $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(2009m) The ACORD name and logo are registered marks of ACORD