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5 LEMON ST - BUILDING INSPECTION r �25 � v2.��-- ea�cr: /��►� r�gee►s ... 179 -990 '7498 The Commonwealth ©A1aclidE ?g 4`1.1 CITY OF ������,,,,,, Board of Building Regulations and Standards SALEM N J Massachusetts State Buildi fgf*7$Q Cr Revised Mar 2011 In Building Permit Application To Construct, Repair, Renovate Z5r [ gnolish a V J One- or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 5 Lemon St 1.2 Assessors Map& Parcel Numbers I.I a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.O.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 Owner'of Record: George Christodal Salem, MA 01970 Name(Print) City,State,ZIP 5 Lemon St (617) 686-5123 glee 1 I I@hotmail.com No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ AIteration(s) ❑ 1 Addlition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ® Specify: G(/S'/r(.9T/ON Brief Description of Proposed Work: Blown in cellulose to attic and exterior walls, air sealing, affix weather stripping,and door sweeps SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1. Building $ 3,139.69 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical g ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (BVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Su ression Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 3,139.69 ❑Paid in Full ❑ Outstanding Balance Due: NAILS I-p C-ol.YT 511 0� T c -F�� SECTION 5: CONSTRUCTION SERVICES 5.1. Construction Supervisor License(CSL) CS-052576 10/03/2017 James Fortin License Number Expiration Date Name of CST,Holder U List CST,Type(see below) 50 Rundlett Way No.and Street Type Description Middleton. MA 01949 U Unrestricted(Buildings up to 35,000 cu. ftJ R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 978-998-4684 phi]@air-tightweatherization.com I Insulation Telephone Email address D Demolition 5.2 Registered Rome Improvement Contractor(HIC) 165640 3/15/2018 Air-Tight Weatherization, LLC James Fortin HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name 50 Rundlett Way phil@air-tightweatherization.com No.and Street Email address Middleton, MA 01949 978-998-4684 City/Town, State,ZIP 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 .......... EX No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize James Fortin to act on my behalf, in all matters relative to work authorized by this building permit application. George Christodal 6eoQ9e C/x,r dat May 17, 2016 g GeorOe ristotlaI(May 17.2016) Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 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. James Fortin a" 9 5/17/2016 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.tnass.eov/dps 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" may be substituted for"Total Project Cost" Work Order North Shore Community Action Programs, Inc. Job Number: 160211 119 Rear Foster Street,Building 13 Work Order Date: 4/28/2016 Peabody,MA 01960 Ownership: Renter Phone: 978-531-0767 Air-Tight Weatherization Auditor: Brandon Dorrington 50 Rundlett Way Email: bdorrington@nscap.org Middleton MA 01949 Cell: 781-540-8569 Email: inbox@air-tightweatherization.com Phone: 978-531-0767 x121 Phone. 978-998-4684 Alexandra Nowak NGRID Gas $2,102.63 5 Lemon St Apt 1 Total $2,102.63 Salem Ma 01970-3901 617-792-4142 Landlord Name: George Christodal Landlord Phone: 617-686-5123 Safety Issue(s): Asbestos on Pipes - Authorized Actual Measure Description Qty, Price Total Qty Total Comments Basement Insulation 6 ml poly on ground 322 $0.88 $283.36 322 $283.36 CSpace for moitsure control seal edges with 2part too foundation Sill/mudsill seal&insulate to R-19 149 $2.58 $384.42 149 $384.42 includes CS Doors 1" THERMAX or equivalent on 1 $60.00 $60.00 1 $60.00 door Fixed Sweep triple flange 1 $18.52 $18.52 1 $18.52 Weatherstrip s/Q-Ion or equal 2.5 $53.55 $133.88 2.5 $133.88 Misc Measures _ Attic/basement blower door guided 2.5 $88.20 $220.50 2.5 $220.50 basement...includes sealing of 6ml poly sealing with two-part foam Clothes dryer vent including 1 $105.00 $105.00 1 $105.00 Exhaust Duct Seal ducts with mastic or butyl 3 $76.65 $229.95 3 $229.95 backed tape Date: 4/28/2016 Page I Work Order: Job Number: 160211 Other Remove duct tape from ducts 1 $70.00 $70.00 1 $70.00 Work on Ext.Wood BH 2 $70.00 $140.00 2 $140.00 thermal boundry...make tight and shut and close effectively...Prime Permit Building Permit 1 $100.00 $100.00 1 1 $100.00 Wall Insulation - Wood clapboard/shakes/shings or 170 $2.10 $357.00 170 $357.00 front wall empty....scattered insulation vinyl (dense pack) throughout test drill and let me know.. Total $2,102.63 $2,102.63 Contractor Instructions: Before Starting the Job: During the Job: 1. Please notify us 24 hours before starting or scheduling a job. 1. Incorporate lead safe practices as applicable. 2. Obtain required building permit. 2. Total for Heath&Safety and Repairs cannot exceed$2500.00. 3. Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH347. Additional Contractor Instructions: Attic Inspection form attached? Yes N/A (Circle One) Certificate of Insulation posted? Yes No (Circle One) Air-Tight Weatberization hereby certifies that this job was supervised and completed in compliance with all Department of Labor Standards and Lead RRP regulations. Contractor Signature: Date: RRP License #: I hereby acknowlege that all work has been completed and inspected. Customer Signature: Date: Date: 4/28/2016 Page 2 Work Order North Shore Community Action Programs, Inc. Job Number: 160185 119 Rear Foster Street,Building 13 Work Order Date: 4/28/2016 Peabody,MA 01960 Ownership: Owner Phone: 978-531-0767 Air-Tight Weatherization Auditor: Brandon Dorrington 50 Rundlett Way Email: bdorrington@nscap.org Middleton MA 01949 Cell: 781-540-8569 Email: inbox n;air-tightweatherization.com Phone: 978-531-0767 x121 Phone: 978-998-4684 George Christodal NGRID Gas $1,037.06 5 Lemon St FI Total $1,037.06 Salem Ma 01970-3901 617-686-5123 Safety issue(s): Asbestos on Pipes/Lead Paint Possible Authorized Actual Measure Description Q� price Total Qty Total Comments Attic Insulation R-18-20 unrestricted -settled 42 $1.51 $63.42 42 $63.42 roof vent Access can discuss all measures on cellulose site for changes Doors Automatic Sweep single flange ] $27.30 $27.30 1 $27.30 Fixed Sweep triple flange 2 $18.52 S37.04 2 $37.04 Weatherstrip s/Q-Ion or equal 3 $53.55 $160.65 3 $160.65 Misc Measures Attic/basement blower door guided 1 $88.20 $88.20 1 $88.20 sealing with two-part foam Wall Insulation Wood clapboard/shakes/shings or 290 $2.10 $609.00 290 $609.00 front wall empty....scattered insulation vinyl(dense pack) throughout test drill and let me know Windows Glass replacement to 64 ui 1 $51.45 $51.45 1 $51.45 3rd fl.window Date: 4/28/2016 Page I Work Order: Job Number: 160185 Total $1,037.06 $1,037.06 Air-Tight Weatherization �4Jirr�T'ight 50 Rundlett Way Middleton, MA 01949 978.998.4684 CONTRACTOWNER AUTHORIZATIONFOR CONTRACTOR TO PERFORM WORK I as owner/authorized agent of the subject property, hereby authorize James Fortin to act on my behalf, in all matters relative to work authorized by the building permit. Owner/Authorized Agent (Print): George Chrristodal Date: May 17, 2016 Geo.PAe l,f�.frSTOa�RL Owner/Authorized Agent Signature: yn� ceo.ea 't.'sl(Mey 17,2016) Contractor Signature: Contractor:James Fortin V Construction Supervisor License: CS-052576 Exp: 10/03/2017 Date: 4/28/2016 Page 2 . i Salem Building Permit App - 5 Lemon St Adobe Sign Document History 05/17/2016 X=y Created: 05/17/2016 — — By: Phil Morris(phil@air-tightweatherization.com) 8 Status: SIGNED s� Transaction ID: CBJCHBCAABAAkgda9gZNzgzeFaDggjKPtuo6qlDs_gzi I "Salem Building Permit App - 5 Lemon St" History Document uploaded by Phil Morris (phil@air-tightweatherization.com)from Reader 05/17/2016- 12:09:44 PDT-IP address:24.34.162.250 tM Document emailed to George Christodal (gmc111 @hotmail.com)for signature 05/17/2016- 12:09:46 PDT Document viewed by George Christodal (gmc111 @hotmail.com) 05/17/2016-1:07:54 PDT-IP address:71.232.164.187 .� Document e-signed by George Christodal (gmc111 @hotmail.com) Signature Date:05/17/2016-1:25:01 PDT-Time Source:server-IP address:71.232.164.187 O Signed document emailed to Phil Morris (phil@air-tightweatherization.com) and George Christodal (gmc111 @hotmail.com) 05/17/2016- 1:25:01 PDT Adobe Sign (MMIDDIYYY A� CERTIFICATE OF LIABILITY INSURANCE DATE g/g/ZOl6 Y 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 have ADDITIONAL INSURED provisions or 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). CONTACT PRODUCER TGA Cross Insurance, Inc. NAME, TGA Cross Insurance Inc. 401 Edgewater Place, SUIYe ZZO PHONE FAX Wakefield, MA 01880 E OANo t: 781-914-1000 Ac No: 781-246-2601 IL ADDRESS: switchboard @t across.com INSURERS AFFORDING COVERAGE NAIC# www.tgacross.com INSURERA: Arbella Protection 41360 INSURED INSURER B: Air-Tight Weatherization, LLC 50 Rundlett Way INSURERC: Middleton MA 01949 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 28898957 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 ADDXP L SUBR POLICY NUMBER MMIDDPOLICYIYYYV MMIDDIYEFF EVYY LIMITS ILTR A � COMMERCIALGENERALLIASILITY 8500046432 3/5/2016 3/5/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE 10 RENTED CLAIMS-MADE 1Z OCCUR PREMISES ILA occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ✓� JE0 LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER S A AUTOMOBILE LIABILITY 1020015286 3/8/2016 3/8/2017 Ca arced DINGLE LIMIT $ Ea BINEntl 1000000 VI ANYAUTO BODILY I NJ URY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOSONLV ✓ AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ ✓ AUTOS ONLY ✓ AUTOS ONLY Per accident S B ✓ UMBRELLALIAB GCCUR 4600052930 3/5/2016 3/5/2017 EACH OCCURRENCE $ 4000000 EXCESS LIAR ✓ CLAIMS-MADE AGGREGATE S 4,000,000 DED ✓ RETENTION$10,000 $ OTH 11 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETORIPARTNERIEXEOUTIVE E.L EACHACCIDENT S OFFICERIMEMBER EXCLUDED9 ❑ NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cl ty of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington Street, 3rd FIT ACCORDANCE WITH THE POLICY PROVISIONS. Salem MA 01970 AUTHORIZED REPRESENTATIVE n /1 �AytAyVll/_'�— Thomas I Gregory ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 28898957 1223720 116-17 GL, AUTO, Jill DeHetre 13/9/2016 8:32:51 AM (EST) I Page 1 of 1 The Commonwealth of Mnssrrcliusetts Department of ludustrial Aceitleuts I Congress Street, Suite 100 Boston, MA 02114-2017 t rvtvBt mass.gov/dia - Workers' Compensation Insurance Affidavit: General Businesses. TO BE PILED W1T11 THE PERMITTING AU'I'IIORI'I'Y. Applicant Information Please Print Legibly 13usiness/Organization Name:Air-Tight Weatherization, LLC Address: 50 Rundlett Way City/State/Zip: Middleton MA 01949 Phonc ##:978-998-4684 Are you an employer? Check the appropriate hox: Business Type(required): I.❑✓ I am a employer with 30 employees(full and/ 5. ❑ Retail or part-time).* 6. ❑Restaurant/Bar/Baling Establishment 2.❑ I am a sole proprietor or partnership and have no 7. Off ice and/or Sales (incl. real estate, auto,etc) employees working for me in any capacity, jNo workers' comp. insurance required 8. Non-profit 3.❑ We are it corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workcrs' comp. insurance requirecl)' I I.❑ Health Care 4.❑ We are a non-profit oiganiuilion,staffed by volunteers, with no employees. [No workers' comp. insurance ral.J 12.❑� Other Insulation/Electrical •Any;tpplie:mt that checks hos it t must also fal out the section below showing their workers'compeusalinu policy inlimwninn. "it'the corr,wate ofncen have exempted Themselves,but the cugx.raliau has usher nnployccs,a workcrs'canipcnsal ion pill icy is inquired and such M, organw lion should check bps 01. /am an engrh{per that is pro vit irrg workers'compensation instmolcefor or etrip/gyees. Relnnv is!/re pn!/cy in%unrrnlinn. Insur:ulce Company Name: Guard Ins. Co. Insurer's Address: P.O. Box AH / 16 S River Street City/State/Zip: Wilkes Barre PA 18703 1301icy It 01.Self ins. Lic. H AIWC 693663 Expiration Date:7/1/2016 Attach a copy of file workers' compensation policy declaration page(showing,the policy norther and expiration (1ale). Failure to secure coverage as required under Section 25A of MG1. c. 152 can lead to the imposition of-criminal penalties ol'a fine up to$1,500,00 and/or one-year imprisonment, as well its civil penalties in the form of a STOP WORK ORDER and a line 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. /do herehy eerlifp, under the pains ar )ens/lies of perjury that the ir(%rnrnnon provider/shove is trite and correct. Simnatin'e 0----�^ Date: Phone ff. 978-998-4684 Of%icin/n.ce ands. Do nor write in Uria area. ur he cuntp/ered/iv cirp ar lawn r�%/icio% City or Town: Ile rntit/Licelose # Issuing Authority(circle olc): 1. Board of Health 2. Building Department 3. City/7bw•n Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Conhrct Person: Phone il: www.nrxss.gov/d is �1 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165640 "r- Tvpe: LLC Expiration: 3/15/2018 Tr# 419291 AIR TIGHT WEATHERIZATION, LLG=j�-- JAMES FORTINt _ I=} - 50 RUNDLETT WAY MIDDLETON, MA 01949 � e/Update Address and return card.Mark reason for change. ❑ Address I] Renewal Employment [ Lost Card SCA i 6 2eM-Owi I !?/�� uuuMmncvi�//.o�C/L!fa1N+C�t�N(/3 i Massachusetts Department of Public Safety Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards OME IMPROVEMENT CONTRACTOR License: CS452576 Re gistration: 4165640 Type: Construction Supervisor 31152018 LLC AIR TIGHT WEATHERIZATI LLCM JAMES E FORTIN-, fi0 RUNDLETT WAYS MIDDLETONMAA01 JAMES FORTIN _ — 50 RUNDLETT WAY _ - 1.N MIDDIETON,MA 01949 Undersecretary •,� (--jZn . Expiration: Commissioner 101032017 c �