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9 LINCOLN RD - BUILDING INSPECTION ar _ 7, l'he Commonwealth ofMssachuselts -- i� Board of Building Regulations and Standards CI I')' OF r Massachusetts State Building Code, 7SO C NIR ti,\LG\I 'Ill/ Building Permit Application To Construct, Repair, Renovate -Pegtollsh a Opie-or Tmvt-Family Dwelt itt,�r This Section For 0 'to I Use Only -"I Building Permit Number: JAte Ap lied: Building 011icial(Print Noire) Si lu pat SECTION l: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Aiap& Parcel Numbers I.la Is this an accepted street?yesz no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(Il) 1.3 Building Setbacks(B) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.1.c. 40.§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ outside Flood"Lone? Munici el ❑ On site dis Check it' vs❑ P posal s)stem ❑ 2. n ert of Record: SECTION2: PROPERTY OWNERSHIP' y, g, cA,en S&Cf� A/( A tSati`t b Cit N;une(Print)t) y.State,ZIPq 4.(hcala 1-d 9-7 a- 9oa 6rgry Nu.and Street Telephone Finail Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction ❑ Existing Buildin Owner-Occupied - Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Grief Description of Proposed Work': rd1Ui'*r0 4— wt I£La PZl6,Yl / SECTION 4: ESTIMATED CONSTR(iCTION COSTS Item eEstna :d Official Use Only (Laborand Y 1. Building 1. Building Permit Fee: S Indicate how ree is determined: '. Flectrical ❑Standard City/Town Application Fee ❑Total Project C'osl'(Item 6)x multiplier x 1. Plumbing '. Other Fens: $ J. Mcch;1nical lll\'.1(') List:--i 'Fireiunt rotal .\II Fees: SCheck Nu. C'hcckAnwton: _ C ash ,\mounc m. Total Project Cost: ❑ paid in Full�-- 0 Outstanding Balance Doc: SECTION 5: C'ONSTRUCTION sF.RvicFs 5.1 Construction Supervisor License(CSL) 0 ZZg3 I( Qtylf) ! R'WQI/ License Nuulhwr Pvp ;ni+ lDale © � I ist CSL I)Pe IS" — ---------------------- ---------- 'I)pe Description No. .ntJ Socel S1 �} l I 14vestrided I IIuilJin s ti n+ 1S,U110 cu. Il.l I #A �_ 7 —.._. R Restricted 1l2 Famil Miellin CilYToan,.state./IV %I %lasmiry RC R,iotlng Oncrin ...—. A'S Window and Siding � SF Solid Fact Iluming Appliances • -1 /-3Y7/ �/f/aJS Cud[ Insulation 1'eli hone -11nailaadress D Demolition 5.2 Registered Home Improvement Contractor(HIC) P/6/7 /E4xj U) e'rc-t rp-m il) -C/y c' IIIC Registration Numlxr li pirulit n Uulu IIC C'ompan) Name or 1IIC'Registrant Name No.Cmd ct M O/47� GyI�-7y/,�Y ma .�/ I: iladdress Ci /Town, State,ZIP G "rcic hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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........... O 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 piGN'l� `/ !j ' ,) toalf,in all all matters relative work authorized by this building permit application. 111M�� /O l 9 v Print Owner's Nwnc(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 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 the best of my knowledge and understanding. 4l Prim Qulnr's or:\uthorirc .\gcnt's Nam Iltlectrunie Signuuucl Dutd NOTES: I. An Owner suhu obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor (nut registered in the Hume Improvement Contractor(HIC) Program), will fro have access to the arbitration program or guaranty fund under M.G.L. c. 1 a2A.Other important information on the HIC Program can be found at u\so 111.111 �,,+ ,11.1 information on the Construction Supervisor License can be found at k1+)\y.nlus: a�\ ,Ip, 2. \Then substantial work is planned, provide the infonnatiun bclo\v: rotai Moor area(sq. R.) _ (including garage. finished basement-attics,decks or porch I Gross lk ing area I sy. It.l . . -. Habitable room count Number ol'tiroplaics,_.._ - _._ Number of bedrooms Number kit,hathroonu Numbcrofh:dl'haths _ i I)pc of heating system .. _ - _ .Number ofdccks, porches - .. I f�peol'a+olingsystem 1'.niloscJ . ..Open , 1. ,f onul Proicct Square FooijLtc'111m he Substituted fir-I"'Ii Project Cost- I acrry OF S:UE.Nc, , L`iSSACHL'SETTS BI:ILDING DEPARTMENT i_O \Y/.�SHL�IGTON STREET, 3 FLOOR"IEl_ (978) 745-9595 F-X(978) 7.10-9844 lumBF Ri F.Y DRISCOLL AM& T}IO titAs ST.PiF RRa DIRECTOR OF PUBLIC PROPERTY/BUMCI NG CONLMSSIONER Warkers' Compensation Insurance,%Mdavit: Builders/Contractors/Electricians/Plumbers Altpllcant Information Please Print Legibly ,V;11[1C 10unitxss.UrWtniratinn;lndividu;d); M�f� wY'1e'a rT roc—+ Address: `3 0 Cfr JaZ AV L CityiStatcaip: 541(l Mf 'NI 60Z Phone #: IX�tire you an employer?Check the appropriate box: Type of project(required): am a employer with__4-- 4, 0 I am a general contractor and 1 6. ❑New construction enlployces(full and/or part-time)." have hired the sub-conlractors 2.0 1 con a sole proprietor or partnur- listed on the attached sheet I 1• ❑Remodeling .ship and have no employees These sub-contractors have S. 0 Demolition working for me in any capacity. workers'comp. insurance. q, 0 Building addition (No workers:comp. insurance 5. 0 We are a corporation and its required.) officers have exercised their 10.❑ Electrical repair or addi[iaro ).❑ 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself. (\o workers'comp. C. 152, $1(4),and we have no 12.❑ Roof copal insurance required.] t employees. (No workers' comp. insurance rcyuimJ.J I).DOther VIS'V041U \ny applicam tIW c1ucW box rl mswt also NI uul the suction bylaw aboating thair worken'eompenu ton palmy intbrmmion. r I hvnouwnwe who,uhmii this rtttdnvit indicating they am doing all work and that him oubide Gtnnctas mot$',limit a new affidavit indicting,ach. =f\mtrxwn that vh.ck this boa meet maehod an addiliurud.hesi.hewing the nwne of the subroatneton and Chair workers'comp.policy intomudan. !urn un eurpluyrr that is pruvid/ng workers'compenrarlun brsarunee jar my emp/uyera Below is the policy and job site irrjonnaNan �r�� InAll'U tee Company Name: RKt/e�efS Policy 4 or Srlf-ins. Lie. th rI d _r o f q 7 J + 1 ?^ Expiration Date:f1 �/n 7 ✓7 lob SIIC Address: 1 L! Gp I N City/StatePLip: J /�J� Attach a copy of the workers'eampensatfon policy declaration page(showing the policy numbor and expiration data). Failuru to secure coverage as required under Section 25A oIi`IGL c. 152-can lead to the imposition of criminal penalties of a fine up to S 1,500,00 andior one-year imprisnnmcnt,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to 5250.00 a day against file violator. Ile advised that a copy of this stalument may bu furwarded to the Office of I o vcstigai ions ofthe DIA f'or insurance covcmgc vcri ficat ion. /do hereby reify under the paint and pen allies ujperjury that the/ojuroradtnr provided ubuv i.r true uud correct. rc i� Data: chnne,� �Si • —�q�� 3�l�r 011h iul use only. Du ,of write in tiri.v area, to be cuuspleled by city ur town afriat City nr l'uwn: Permitil.lcense 4 Issuing• toloirily (circle one): -- _ 1. Ilourd of Ilealth 2. Iluildlntl I)cpartutcut 1 Cilyi Town Clerk 4. Electrical Inspcclor 5. Plumbing inspector I G.rhhcr Contact I'crton:_ I Information and Instructiom, >lassachuscus General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this.statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the gio'Wids or building appurtenant thereto shall not because of such employment be deemed to be an employer." NIGL chapter 152, §25C(6)also states that"every state or local Iiceaslng�agency shall withhold the Issuance or renewal of a license or permit to operate a business or to construct buildings In;the commonwealth for any applicant who has not produced acceptable evidence of compliance with the Insurance coverage'requlreel." Additionally. MGL chapter 152, 325C(7)states"Neither the commonwealth nor any of its'political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)nume(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies anies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. if an LLC or LLP does have to the Department of Industrial t this affidavit may be submitted employees,a policy is required. Be advised that s yp of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should Accidents for confirmation B g he returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accident's: Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Sclf-insured companies should enter their self-insurance license number on the appropriate line. City or'rown Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom Of the affidavit for you to fill out in the event the Office of Investigations has to contact yowregarding the applicant. Please be sure to till in the permiUlicense number which will be used as a reference_number. In addition,an applicant that must submit multiple permit/license applications in any given year,net:d only sutimit one'aftidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by'the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A now affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves cte.)said person is NOT required to complete this affidavit. The Gflice of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: ' 'The Commonwealth of Massachusetts #t Department of Industrial Accidents: ? OMce of Investigations 600 Washington Street Boston, MA 02 11 l Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 ;teviscd 5-26-05 svww.mass.gov/dia �' ♦ � DATE(MMiODIVVVV) CERTIFICATE OF LIABILITY INSURANCE 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(les)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 NAME: Eastern Insurance Group LLC - Main PHONE FAX ac No 233 West Central Street E-MAIL Natick MA 01760 ADDRESS: er c INSURERS AFFORDING COVERAGE NAICa INSURER A:Western World InSUr CO INSURED 37667 INSURER B:HarleySVill Mass Weatherization Inc INSURER C:SCOftSdale Insurance an 3 Ocean Avenue INSURER D:Travelers 935 Salem MA 01970 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:636791424 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. POLICY EFF POLICY EXP rEOF INSURANCE $ POLICY NUMBER MM/DDIYYVV MMIDD/VVYV LIMITS Y PP8085980 /28/2012 /28/2013 EACH OCCURRENCE $1,000,000 DAMAGEIO L GENERAL UABILITY PREMISES Eaoccanence $100000 MADE OCCUR MED EXP(Anyona .noon) $5,000 PERSONAL 8 ADV INJURY $1 000000 GENERAL AGGREGATE $2,000000 E LIMIT APPLIES PER. PRODUCTS-COMP/OPAGG $2,000,000 PRO IFCTLOC $ B AUTOMOBILE LIABILITY BA 00000024700P 10/4/2012 10/4/2013 Eaaccltlem 1,000,000 BODILY INJURY(Per person) $ ANY AUTO ALL OWNED X SCHEDULED BODILY INJURY(Per accident $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ Ix HR�ED AUTOS X AUTOS Peraaitlenl C X UMBRELLA LIAB OCCUR XBS0022678 /28/2012 /26/2013 EACH OCCURRENCE $1,OOQ000 EXCESS LIAB CLANAS-MADE AGGREGATE $ LIED RETENTION$ $ p WORKERS COMPENSATON UB5B44938Ai2 /3/2012 /3/2013 X WC STATI" OTH- ANDEMPLOVERS'UABILITY YIN ANY PROPRIETORIPARTNER,EXECUTIVE❑ N/4 E L EACH ACCIDENT MI $500000 OFFICEREMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE EA EMPLOYEE $500000 It yes tlesalb.under E.L.DISEASE-POLICY LMrr $500000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Romance Schedule,It more space is required) National Grid Corporate Services, LLC, dba/National Grid,dba/Boston Gas Action Inc are listed as Additional Insured with regards to General Liability where required by written or contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Menotomy Weatherization Program ACCORDANCE WITH THE POLICY PROVISIONS. 20 Academy Street Arlington MA 02476 AUTHORIZED REPRESENTATIVE ® 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 1 � Massachusetts - Department of Public Satiety V0 Board of Building Reg ul a[ions and Standards Camuruction super%isut spuialh License. CSSL-102293 ._ RICHARD LAMBY 3 OCEAN AVENUE 0k ' SALEM MA 01970 ?{'� ;'ase d X p!f ario r Commissioner 05/03/2014 Office of Consumer Affairs&Bdsiness Regulation HOME IMPROVEMENT CONTRACTOR Wm Registration. 111617 Type: Expiration 1/1.212013 Private Corporation / MASS WEATHERIZATIONI�INC RICHARD LAMBY 3 OCEAN AVE ryes — SALEM, MA 01970 Undersecretary WAP Work Order North Shore Community Action Programs,Inc. Job Number: 092812 98 Main Street Work Order Date: 10/l/2012 Peabody, MA 01960 Ownership: Owner Phone: 978-531-8810 Mass Weatherization Auditor: Doug Cranford 3 Ocean Avenue Email: dcranford@nscap.org Salem MA 01970 Cell: 978-335-7154- Email: masswx@comcast.net Phone: 978-531-0767 x135 Phone: 978-741-3471 Patricia Stokes NGRID Electric $7,446.82 9 Lincoln Rd Total $7,446.82 SALEM MA 01970 978-902-0142 Safety Issue(s): Lead Paint Possible -. Authorized '^ !Actual .Measure Description Nrice Total 'yTotal .� ' " ,�Cortiments QtY'" ,Qty .' Attic Insulation R-30 restricted -slopes/floored fill 180 $1.48 $266.40 w/cellulose R-38 unrestricted-settled cellulose 812 $1.47 $1,193.64 Thermodome or Magnetic pull 1 $180.00 $180.00 down stairway box Attic Ventilation` Prop Vent 16 $4.00 $64.00 Rectangular gable vent 2 $92.00 $184.00 Rectangular soffit vent 8 $27.00 $216.00 / Roof vent 865(A sq It NFV)small 1 $80.00 $80.00 FT Basement Insulation - - Sill two-part foam w/fiberglass ball 166 $2.20 $365.20 Doors Basement/outside door- w/jambs 1 $435.75 $435.75 Date: 10/l/2012 Page 1 WAP Work Order: Job Number: 092812 Fixed Sweep 3 $15.75 $47.25 Locksct/Schlagc or equal 1 $73.00 $73.00 R-5 Ductwrap or R-max on door 1 $51.00 $51.00 Weatherstrip s/Q-Ion or equal 3 $45.50 $136.50 'Health&Safety r Clothes dryer vent including I $89.00 $89.00 Exhaust Duct Vent kit/bath fan 1 $89.00 $89.00 Misc Insulation Domestic water pipe wrap 6 $2.63 $15.78 Duct insulation R-5 280 $3.10 $868.00 .: Misr Measures Attic sealing with two-part foam 3 $75.00 $225.00 Basement sealing with two-part 3 foam $75.00 $225.00 Blower door set-up with pre&post 1 tests $45.00 $45.00 Cut/close attic-kneewall access 1 $78.75 $78.75 Labor only charge I $60.00 $60.00 Labor to remove FG in attic. Seal ducts with mastic or butyl 2 $65.00 $130.00 backed tape Date: 10/l/2012 Page 2 WAP Work Order: Job Number: 092812 Permit Building Permit 1 $100.00 $100.00 Wall Insulation Wood clapboard/shakes/shings or 1245 $1.79 $2,228.55 vinyl(dense pack) - Total $7,446.82 Contractor Instructions: Before Starting the Job: During the Job: 1.Please notify us 24 hours before starting or scheduling ajob. 1. This residence was built before 1978. Lead safe practices are 2. Obtain required building permit- required. 2. Total for Heath& Safety and Repairs cannot exceed S2500.00. 3.Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH-347. Additional Contractor Instructions: Certificate of Insulation posted? Yes No (Circle One) Attic Inspection form attached? Yes N/A (Circle One) Where Posted: Contractor: Date: WAP Auditor: Date:_ Energy Director: Date: Fiscal Officer: Date: Date: 10/1/2012 Page 3