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7 LEAVITT CT - BUILDING INSPECTION
14 - 139 *q ZS I eCommonwealthofMassachusetts RE1.4EIVED Boaz J of Building Regulations and Standards INSPECTIONAL6IEMEES Mass ichusetts State Building Code,780 CMR ft SALEM Building Permit Ap lication To Construct,Repair,Renovate Or De'ndIkAG 2 I�tsgd ar�q(1 One-or Two-Family Dwelling A ti This Section For Official Use Only Building Permit Number:) Da Applied: Building Official(Print Ndme) Signature Date - SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers CQ L la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Informations 1.4 Property Dimensions: Zoning District Proposed Us Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard I Side Yards Rear Yard Required Provided Required Provided Required Provided l.6 Water Supply:(M.G.'L c.40,§ 4) 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 wner'of Recordr Name(Print) City,State,ZIP LeaV (21 No.and Street Telephone Email Address SECTION 3:E ESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing B jilding❑ Owner-Occupied ❑ Repairs(s) ❑ eration(s) ❑ Addition ❑ Demolition ❑ accessory Bldg.❑ 1 Number of Units_ Other Specify: Brief Description of Proposed Wo k2: '614cr L/ I I SECTION 4:ESTIMATED CONSTRUCTION COSTS Item I Est mated Costs: Official Use Only Labo and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee ❑ 2.Electrical I $ Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC)I $ List: o 5. Mechanical (Fire Suression) $ Total All Fees:$ Check No. ' Check Amount: Cash Amount: 6.Total Project Cost: $ ! -7 q � tp / /S ❑Paid in Full ❑Outstanding Balance Due: lr�- 1 Jew I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Sui ervisor License(CSL) License Number j Name of CSL Holder Ei1C W.Palm Expiration Date Hilton Street List CSL Type(see below) L& No.and Street lent MA 01970 WDemolition Description - -tricted uildin s u to 35,000 cu.ft.City/town,State,ZIP cted 1&2 Famil Dwellinn Coveriow and SidinTyy_�il Fuel Burning AppliancestionTele hone Email address lition 5.2 Registered Home'Improv meat Contractor(HIC) lLl.� d�9 / �� HIC Company Name or HIC e e HIC Registration Number Expirazion Date I � Stm Avenue No.and.Sheet I glCM 01970 Email address �y 8/�[ 3 EAffidavit e,ZIP Tele hone 6: ORKE IRS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c 152.§25C(6)) nsation Insurance affidavit must be completed and submitted with this application. Failure to provide ll result in the denial of the Issuan of the building permit. t Attached? es.......... No...........❑ --------------------- SEtfi rION 7 :OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subj Ict prope ,hereby authorize ` r t G r Ct/V✓r n to act on my behalf,in all matte relative to work authorized by this building permit application. Print Owner's Name(Electronic Sig azure) / I Date =myname TION b:OWNER'OR AUTHORIZED AGENT DECLARATION , b I low,I h eby attest under the pains and penalties of perjury that all of the information ation is a and accurate to the best of my knowledge and understandingized Agent' Name(Electronic Signature Date NOTES: 1. An Owner who obtains a bui ding permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in th Home I nprovement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund un let M.G.L.c. 142A.Other important information on the HIC Program can be found at www.illass-voy/oca(Informal on on the Construction Supervisor License can be found at www.inass.gov/di)s 2. When substantial work is pla tried,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.j 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 Footag "maybe substituted for"Total Project Cost" CA:08 Weatheiftag8TIM 61 R Jefferson Avenue Salem, MA 01970 • (978) 744-8143 May 15, 2014 PROPOSAL SUBMITTED TO: NSCAP Attn: Chuck JOB SITE: Roxann Lemarco 7 Leavitt Court Salem, MA We hereby submit specifications and estimates for: Roof(Approx 14SQ) 1. Pull building permit 2. Remove and dispose of existing shingles 3. Install up to 100SF of sheathing as needed 4. Install ice/water shield 5. Install flashing and dripedge 6. Install roof paper 7. Install 30-year architectural shingle WE PROPOSE HEREBY TO FURNISH MATERIAL AND LABOR COMPLE IN ACCORDANCE WITH ABOVE SPECIFICATIONS FOR THE SUM OF: $6,49511W (0 7 *Notes: Access is tight and neighbors will have to be notified J Option: Install Two Rubber Roofs(small flats)—Approx.3SQ—Additional Cost: $1,s95;8B /7-00 . . ......................:........................................................................................................................................................... All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents,or delays are beyond our control. Our workers are fully covered by Workman's Compensation Insurance. ...............................................................................................................................:............ The above specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made upon completion of work as BPI Certified • EPA and Mass. Lead-Safe Certified Authorized Honeywell and NGRID/NSTAR Contractor The Commonwealth oflllassachusetts Department of dndustrialAccidents Rr nt Form. Office ofdnvestfgations 1 Congress Streets Spite 100 .Boston, '�M 02114-2017 Min Workers' Compensation Insurance Affidavit. Builde s/Contractors/Electricians A licant Information /Plumbers Please Print Lea Name (Business/Orga11 zation/Individual): =�I!a11tiC th'sBU ri s .ulu0i? Address: 61 _ ,efiersofi zvertue 5a.. er ivi 0 '7 --` City/Statgl- Are n employer? Check the a Phone#: q7&' 7 y1/i-girl 1•L�J I am a employer with 2�appropriate box: employees(full and/or I am a general contractor and] TYPe of project(required): 2• I am a sole proprietor opt-time).= have hired the sub-contractors partner- listed on the attach Xsheet 6' New construction ship and have no employees These sub-contractors have �' ED Remodeling working for me in any capacity. employees and have workers' [No workers' comp. ' $- ❑Demolition required.) P insurance comp, insurance.- 9. 0 Building addition 5• ❑ We area corporation and its 10.0 Electrical repairs or additions •❑ I am a homeowner doing a1]work officers have exercised their myself[No workers'comp, ti right of exempon per MGL 11'0 Plumbing re insurance required.]t g Pars or additions c. 152, §1(4), and we have no 12.0 Roo airs employees.,[No workers' 13. E 'Any applicant that checks box#1 must also fill out the section below showing required.) t Homeowners who submit this affidavit indicating the are i doing g their workers'comnausation Contractors that check this box Y ail work and then hire outside contractors Policy information. _ employees. must attached an additional sheet showing the name of the sub. con Yes. If the subcontractor,have employees, g contractors and state whether or not those entities indicating P Yes,they mustpmvide their workers'com I am an employer that GS rovfdinoWorkers, P-policy number. information p e workers compensation insurance for my employees Below rs the policy and job site Insurance Company]Jame. - Policy or Self-ins.Lic.#:_ 13a7 o 01 1 Job Site Address: Expiration Date: LC Cjl (� Attach a copy of the workers compensation policy declaration Page City/State/Zip: _� Xc t fineu p to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a P e (showing the policy number and expiration date). fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WO Of up to$250.00 a day against the violator. Be advised that a co of Investigations of the DIA for insurance coverage verification. ORDER and a fine COPY this statement may be forwazded to the Office of r do I:ereby certi u re a Tries of erjury that the information iienature: provided above is true and correct - 'hone Date. . / 4-1 Offlcia1 use only. Do not write in this area,to be completed by city or town official City or Town: Issuing AuthorityPermit/License n 1.Board (circle one): Of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbino 1. Board Contact Person: a Inspector Phone�: +t16+a 1.16A 1\J-1 J/1L/ LV1Y ! ;Ll ;V( HI.1 YHV1:. OV/ VVO C6A OGS VGI a CERTIFICATE OF LIABILITY INSURANCE U312-2014 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: If the certificate holder is an ADDITIONAL INSURED,the polrcy(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 an this certificate does not confer rights to the certificate holder in lleu of such endorsemem(s). PRODUCER ` CONTACT NNAE: EASTERN INS GROUP LLC I PHONE FAX 233 WEST CENTRAL ST 1 Art NA Ext: No: NATICK,MA 01760 1 E-MAIL 1 - INSURER(S)AFFORDPIG COVERAGE NAICX INSURER A:AHERICAN IDflICH INSURANCE COMPANY INSURED I I INSURERS: ATLANTIC WEATHERIZATION LLC INSURER C: 61 REAR JEFFERSON AVE SALEM,MA 01970 INSURER c: INSURERE: INSURER P: 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. INSR ADO SUB POUCYEFF POLICY EXP LTR TYPE OFINSURANCE INSR WWD POLICYNUMBER MMIOOI'/YYYj MM/DDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY I DAMAGE TO RENTED S CLAIMSMADE❑ OCCUR 1 MEOEXPWIrymepe—) S 1 PERSONALSADVIN.IURY 5 GENERALAGGREGATE 5 GENLAGGREGATE LIMIT APPUESPER: ! PRODUCTS-COMP,OP AGO S PRO- JEC POLICY T LOL I i 5 AUTOMOBILE LIABILITY i I CEQMe211N GSNGLEUMIT S ANY AUTO I a adenl SCHEDULED BODILY IWURY(Pei petition) 5 ALL OWNED AUTOS BODILY IWURY(Fe,a¢i4nq 5 A UTOS NON-OWNED MIRED AUTOS AUTOS ( I A W AMAGE 5 S UMBRELLA LUIB OCCUR I EACH OCCURRENCE S EXCESS UAB CMUS MADE AGGREGATE 5 DEVI I RETENTIONS ` S WORKERS COMPENSATION x VIOSTAT.0 OTH- ANDEMPLOYERS•LIABILITY YM TORYLWITS ER ANYPROPRIETOR/PARTNER/ XECUTN�NfA I E.L.EACH ACCIDENT $500,000 (MitridOFFICERAIEMBER EXCLUDED? CN 622U6 03.20-2014 03-20-2015 It yet, lmyin NH) j 1 58270121 E.L.DISEASE-EA EM PLOYEE $500,000 DESCRIPTION OESCflIPTI OF OPERATIONS txbx � � E.I.DISEASE-POLICY LIMB $500,000 1 ; DESCRIPTION OF OPERATIONS/LOCATIONSI VEHICLES(Attach ACORD 101,Addillenal Hematite Schedule,H more spars is required) I CERTIFICATE HOLDER CITY OF SALEM - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 93 WASHINGTONST CANCELLED BEFORE THE EXPIRATION DATE THEREOF, SALEM,MA01970 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE @ 1988.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2019106) The ACORD name and logo are registered marks of ACORD I f1C®68�® CERTIMCATE ®F LIABILITY INSURANCE DATE(M6VDDM yy) THIS CERTIFICATE IS ISSUED iqg q MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT E F IIgSUTIV NOR NEGATIVELY AMfiND, EXTEND OR ALTER THE COVERAGE AFFORDED ElyTE THE/PO(THIS BELOW- THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(iesust be endorsed.If SUBROGATIONE ISSUING IIg WgSV subject AUTHORIZED the terms and conditions of the Polley,eertaIn policies may require an endorsement q statement on this certificate does not confer rights to the Eastern I C ACT assurance Group IS,C M . Construction 233 West Central Street PHONE (503)651-7700 Fax A'MAIL C No Natick Mil 01760 INS. S AFFORDING COVERAGE INSURED INSURERA- lla Pro . Ction Ins, Co. RAIC9 Atlantic Weatherizatiol INSUREReArbella Ind 1360 61 Rear Jefferson Avenue wsuRERcNautilus Insuraace2Ca Co 0017 INSURER D: Salem I INSURER E: COVERAGES MA' 01971 ICERT)FICATENUMBER3aaster 201gs. RF: THIS IS TO CERTIFY THAT rHE PANY RE of INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO REVISION NUMBER: CERTIFICATE MAY O ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, STANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED SY Pg10 CLAIMS. 1NSR LTR TYPEOFINSURANCE GENERALUABIUTY POUCYNUMBER MM/U EFF OUCY P UMRS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 11000,000 A CWMSJAADE a OCCUR 500042816 /20/2014 /20/2015 P I IE -aill S 50,000 MEDEXP(AnYanep ,li S 5,000 i PERSONAL S ADV INJURY S 11000,DOD GENI AGGREGATE LIMIT APPLIES PER:i GENERAL AGGREGATE S 2,000,000 000 POLICY X PRO- LOC { PRODUCTS-COMPiOP AGG S AUTOMOBILE uaBlLm 2,000,000 S B ANY AUTO CO aSIN� INGIE UMR ALL OWNED �� S 1 000 000 AUTOS X gUVOESDULEO' 02 0 015 8 71 BODILY INJURY(PeTPerson) S X HIREDAUTOS X ALTOpS'AREDj /20/2014 /20/2015 BODILY INJURY(PerecciCel S PROPER DAMAGE P'al enl S X UMBRELLA UAB X OCCUR I PIP- Basic S B 000 p IXCE$8 LIgB CLAIMS-MADE EACH OCCURRENCE S 1,000,000 DED RETENTIONS 600058654 AGGREGATE S 1,000,000 WORKERS COMPENSATION /20/2014 /20/2015 ANDEMPLOYERE-LyudLnY I S ANY PROPRIETORrygRTNER/v(ECUnVE YIN WC STATU- TH.OFFICER/MEMSER EXCLUDED? N/A(f YclI d ery in NMI EL EACH ACCIDENT U Yes,¢esaNeNMI S DESCRIPTION OF OPERATIONS below E.L.DISEASE-EA EMPLOYE S ` C POLLUTION LIABILITYEL OISEASE-POLICY UMT $ >.200378602 0/1/2013 0/1/2014 GENERAL AGGREGATE EA POLLUTION CONDRION $1,000,000 DESCRIPTION Op DpERATIONS I LOCATIONS!VEHICLES(Affieh ACORO,e,,gyyyony Rerrul Schedule,Rmore apace Ia re4ol $1,000,000 i i I i i CERTIFICATE HOLDER ; CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LL: ��Hj OFTFM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN i ACCORDANCE WITH THE POLICY PROVISIONS. TON 3TREET�01970 AUTHORIZED REPRESENTATIVE 1 ACORD25 Ronald Cleaves/Sty (2010/05) INSB25nn,nn5 m Tho ACrTRn name and ©1988-2010ACORDCORPORATION. All rights reserved. f innn aro roniafarod malbc of ACARn SW Massachusetts-Department-ef Public Safety Board of Building Regulations and Standards Construction Superri+or License: CS-087977 n. ERIC W PALM Lv - 3 TONST Salem 01m MA 01970= Expiration Commissioner 04/23/2016 Ofrice of Cousumer Affairs&Business Regulation vp ME1MPROVEMENT CONTRACTOR n istration: 142089 Type: f ' Iration: j311212016 Ltd Liabifty Colpw i ATLANTIC WEATHERIZATION L.L.C. ERIC PALM 61 R JEFFERSON AVE SALEM,MA 01970. - .Undersecretary .i i