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LEE FORT TERRRACE, COMM. BLDG., BPA-14-1903 C,iL I z � I $SOS TO — 1L4 -- Iq © 3 RFCFIVED �s The Commonwealth d%W"9M se s Department of Public Safety A 4 4 Massachusetts State Building I {� C ) Building Permit Application for any Building othefthan as One-or Two-Family Dwelling ('Phis Section For Official Use Only) MBuilding Permit Number: Date Applied: Building Official: ® SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) CT No. Marc.-r�wc�tr,� . SAt-a✓ 9 M Nk. 01 _7o Lge. lipiyT -T�c, 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 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Existing Building 0 Repair 0 Change of Use ❑ Change of Occupancy ❑ 1 Other g Specify: FA-D WO 11J UA. 4LAGS re. 195 LA--1'1 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 19 Brief Desc tionrip of Proposed Work: g(-.Olclls I I`SJI.A-11O 6 (U.{-yl.�, &:I'T(G 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ 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 ❑ UB ❑ IUA ❑ 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 t?4wsm A-gustLLq Au-t1to�1-r Street a ST EM . M4. 01970 Name(Print) No. d City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes AIIL-1keA07T LLCL. �Y�O�s Name Street Address ity/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) building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 17 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control WA- Name(Registrant) 1 (� Telephone No. e-mail address Regis WA Number I\I f�. Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor A1r- -TE6tWT t-L -TEA.IZ4"no),J LL(, Company Name ,UMP-4, OS L-710 Name of Person Responsible for Construction License No. and Type ,if ApIplicable lD 11I 4c kJ.101.(� 17dt . �EtIE(LL`( . ��Q.. 1 uI Clef Street Address t, q �q� Gty/ own State Zip =tg8-4(0%+ t�-J.1[1 CCP O 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 a suance of the building permit. Is a signed Affidavit submitted with this application? Yes No 13 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ t 27 3.74 1.Building $ 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 $ ,t,r� Enclose check payable to 6.Total Cost $ T� Z7 5.74 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 a be of m owledge and understanding. Wtt,t 14M Ceet,�t�r lk J/i wt o tEc-t Manr4c tote —� ?"Title print and sign name Title Telephone No. Date I51cIZ1f . AVV, . MA. 0I9(?50 Street Address 0 L of (S City/Town State Zip Municipal Inspector to fill out this section upon application approval: "''t 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 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) 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 Incomplete Not Re uired 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas atural,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 Energv Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Com ensa 'on Insurance , 19 Hazardous Material Mitigation Documentation 20 Other S ec' 21 Other(Specify) 22 1 Other Sec' "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. Wd Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date K14- 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 Discipline Expiration Date Street Address City/Town State Zip The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: General Businesses Applicant Information 1 ` Please PrintLe¢ibly Business/Organization Name: \�\_�l t�`-(c�.t\`, �— \o �C'C�t>LQ V \ c�ly�­, Address: City/State/Zip:_3Li Q-'11-\ `—,QW Phone#: ('y� Are you an employer? Check the appropriate box: Business Type(required): IA I am a employer with employees (full and/ 5. ❑ Retail orpart-time).• 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate, auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] g. ❑Non-profit 3.❑ We arc a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have I0.❑ Manufacturing no employees. [No workers' comp. insurance required)** I 1 ❑ Health Care 4.❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] I2.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ••Ifdic corporate onfcers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organimion should check box#I. I am an employer that is providing w�oorr+kers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: r� \�i l C-0 Insurer's Address: ����x V\" , p City/State/Zip: W� � �,5-� Policy#or Self-ins. Lic. # RILIC 5-7Cs Expiration Date: 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 S1,500.00 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, under the pains and penalties ofperjury that the information provided above is true and correct Signature: 0 l am, Date 1 C% ( I C-1 Signature: e Phone#: �a ��. (j(A- Y Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/Liccnse # Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia A��® CERTIFICATE OF LIABILITY INSURANCE °A;z;D5/2014"' 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 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 endorsements. PRODUCER CONTACT Jacqueline Marie Melanson,CLCS MassPay Insurance Services,LLC NAME PHONE g7g 77q�338 x105 FAx (978)774-1318 27 Garden Street, Unit 1 B W. a E. ( ) ac No Danvers, MA 01923 E-MAIL Iackie@l hilrichardinsurance.com ADDRESS: jackie@philrichardinsurance.com AFFORDING COVERAGE NAIC# INSURERA: AmGUARD Insurance Company 42390 INSURED Air-Tight Weatherization,LLC INSURER B: 9 Story Ave INSURER C: Beverly, MA 01915 INSURER D: INSURER E NSURER 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY OFF POLICY D(P LIMITS LTR POLICY NUMBER MM/DDIYYYY MMIDDM'YV GENERAL LIABILITY EACH OCCURRENCE $ AMA ET RENTED COM MERCIAL GENERAL LIABILITY PREMISES Ea Occurred.) ccurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL S ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea a.sm ANY AUTO BODI LY I NJU RY(Per person) $ ALLOWNED SCHEDULED BODI LY I NJURY(Per accident) $ AUTOS AUTOS HIREOAUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ E%CESS LIAB CLAIMS-MADE AGGREGATE $ DID RETENTION$ $ A WORKERS COMPENSATION AIWC576437 07/01/2014 07/01/2015 WC STATU- OTH- AND EMPLOYERS'LIABILITY IN IQRY LIMITS ER ANY PROPRIETOR)PARTNERIEXECUTIVE YNIA EL.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDEDi (Mandatary in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Proof of Workers Compensation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Salem Inspectional Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington St.,3rd Floor ACCORDANCE WITH THE POLICY PROVISIONS. Salem,MA 01970 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD To Whom It May Concern, I, James Fortin, do authorize William M. Crowley to act as my agent in the process of applying for building permits and other necessary documentation pursuant to the conduct of my business by Air-Tight Weatherizaiton LLC. ignature State of Massachusetts County On this \c:j— day of �`�J , 2014, before me personally appeared Ck=c..i kAjO/) C/CI k� , to me known to the person (or persons) described in and who executed the foregoing instrument, and acknowledgement that he/she/they executed the same as his/her/their free act and deed. 444 OBERT A. MONAHAN Notary Public , NOV Public COMMONWEALcommission Expires S My Commlesion Expires Print Name: September 17� 2021 My commission expires: I _ I s� Office of Consumer Affairs and Business Regulation 1 Park Plaza - Suite 5170 Bo ton, Massachusetts 02116 Home I I r rovement Contractor Registration I Registration: 165640 . Type: LLC Expiration: 3/15/2016 Tr# 248557 AIR - TIGHT LLC. WEATHER ZATION JAMES FORTIN 10 PINE KNOLL DR. BEVERLY, MA 01915 Update Address and return card.Mark reason for change. scat G ao%a ast+ .. Address I Renewal - Employment Lost Gard fi - + License or registration valid for individul use only Offce ofConsumer:Affairs K business Rcgulati a $ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: t �Reglstmtion: 165640 Typ : Office of Consumer Affairs and Business Regulation +') c 10 Park Plaza-Suite 5170 �,_' ,?�Expiration: 3/15/2016 LLC Boston,MA 02116 AIR-TIGHT LLC-WEATHERAZATION 10 PINE KNOLL DR. BEVERLY.MA 01915 `Unders'ecreb rr Not va Id,,,(lout signature I I t'i t;nl +T U]Y 1I*_ class tC n + tIG - i IRo:vrt tl r +luny f Iu1Jbu t J ,; i. ,• CS-052576 a .ZANIES E pORTIN � lit PIN IiKNOI,I.t)R Bevcrlr MA 01915 1010312015 Weatherization Work Order Fac0ltylD:o Work OrderOate - Act/an Energy 47 Washington St.,Gloucester,MA 01930 Auditor&Email: Brian Beote,bbeote@actioninc.crg i Project Name Lee Fort Terrace Auditor Phone(s)i. - O 978-283-2131 x240,C.978-879-9896 I. Address Lee Fort Terrace,Salem,MA 01970 - Wx Contractor Owner/Sponsor Salem Housing Authority. - Contractor Phone: Primary Contact Diane Boulay,0,978-744-4432,0 - Other Contact 0 aldgs,Apts 8 Area:0 Bld(s),.Units,0 SFt. Lead and Confect Notes: Facility Notes: ConsWcton Type(s) Foundation Type - r 0 'LMnP - Ene Camery Meeeuree e. - - - Ener Conserving Measures - ' Deecnptw or LocationUnil -Esf Aetual UnIl Cost -Ell Cost - ' Act CPet' 'Ge Wall Insulation 16 Wes Consfrucvon a Seevpn l: Wan Type Sect 2: - ie Eboard/shakestehin les orvin I dense ack s ft �1.79 17 led asbestos/as hall dense Pack) s q ft $2.21 1a iled asbestos/aluminum dense '-Pack) ft-. 2.31. es laster tch or.finish wood lu dense ft. 1.82 zar asbestos dense Pack - 's ft - - - $2.31- - - m4 sides Flat mte $60.00 1 zs f . . . . .$2.50 m i CcnimabMWftr KaT _ Knob&Tube Wiring - 'FhMi,Ns aik kceuan 34 Door Measures Weatherstrip w/Q-Ion orequal as $45.50 ze , Fixed S"s _ ea $15.75 27 Automatic Sweep ea $23.00 ae i MDuctwaporrt-max ore ulvalenl on door - ea $51.ODor ea $52.00ures33 ndow/ScNe lore uivalent - - er side $6.00 as ent to 64 ui as -$44.00 -34- Top Sash Look - - - as - $9.50 - 36 Miscellaneous Insulation - 9] D/atr/buvon lypa Seconds 8 LHydrordc insulation R-5 s ft $3.10 ae stic water I wra s ar tank In ft 48 - $2.63 $126.24 40 nic Pi Pe Insulation to-.1'eo eR-5 In ft $3.41 41 pipe insulation 1.25'-1.5-copper Pipe R - In ft $3.86 - - 4z Steam insulation to t5'-2'iron pipe R-5 In ft - $6.35 - 43 Steam ' e insulation 3'iron pipe R-5 In it E4E $7.61 4a 4e Water Conserving Measures - 4e Spa 2000 shawerhead or eaulvaient as $30.00 47 Aerator 0.5 GPM bathrodm - - as $15.00 4a Aerator 2.0'GPM kitchen swivel/dualspray - as $21.00 Auditor Notes-.Page 1 . Heating Energy Semlce sz t 63 Lee-Fon WX WO xt-Pp byP Leeptarnttion E My 1114QO14 i . r. unac . fzre cein'n M—una ` En¢f CDn$¢tviR 117eaSUf¢S Descriptor or Location Unit Est Actual UnN Cost Est Cost Act Cost �e Attic Insulation sa R 36 unrestdcted-settled cellulose It '..', $1.47 ss RJO unresWetted-settled celulose $1.37 $34,318.50 se R-18-20 unrestricted-sealetl cellulose sq ry1 $1.29 67 R48-20 unesticted-settled cellulose 1 $1.29 - se R-10-12 unrestricted-settled cellulose fl $1.27 1 sv - R-30 restricted-slo esftored fill w/cellulose ft $1.48 1 ea -R-78-20 restdded-slopes/soored fill w/cellulose ft $1.42 er R-10-12mstdded-slo es/floored611w/mUtdose saft 1 $1.301 1ez Thennodome or Magneto pull down stalrwa boz ea 1 $180.00 as Alfieyn a0 Floor Transition Dense Pack w/ce0(Ml a dense uaw. fend bap In fl $2.52 ea - 66 Attic Ventilation ea Rectangular gable vent ea $92.001 1 w Roof vent 135 1 sq N NFV large ea $95.00 ee Rectangular solid vent ea $27.00 - s4n.O. e. $4.00 7Pro a vent e0v 7r Miscellaneous Measures >z Wealhersm U-Ion or eqmo 8 R-30 attic hatch ea 24 $33.50 $804.00 73 Blom,doorset-u wsh a esthete ea I $45.00 7a ANic/basemem rearm with two- foam agn maMhr 98 $75.00 $7350.00 >a Atfic/basementsealin withtwo- foam man/hr 49 $75.00 $3675.00 76 Seal ducts with mastleor but backed a hf $65.00 n E CuVf.nish Mic-kneewall access ea. $105.00 7e ff Vent killbalh fan ea $89.00 76 3 1 Clothes d r vent includin Exhaust Duct: ea $89.00 as Labor onl cha e � man/hr $60.00 - er e2 Basement Insulation Gana a call. cavity 611etl so It $2.10 ae Sill two- an foam w/urrfaced 6be lass baft In R $2.20 ¢s Perimeter Wr R-5 reinforced foil or vi faced tl ft 1.91 ea Perimeter Y T-max or uivalent foam board ft $0.752.50 m 6 ml I on round - g ry $ ee ure of Owner Date Printe me Company Iz5- l� Signature of Contractor(A*nt)lr Date 91UKiALI Am -ricityT Wrra-T►4rg.jz.a-rio4 ��cr Printed Name Company completion Date: $46,273.74 <Estimated Total Costs $0.00 jAct Total 1.1 - Lee Fort WX WO AL P bY0..Lepp/erAe6on Energy 1114MO14