18 LINCOLN RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts st'il
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SAl'
r �IG NOV �d,,s�tr z�071
M Building Permit Application To Construct,Repair, Renovate Or Demo1 ish a
One-or Two-Family Dwelling
This Section For Official Use Only
,9 Building Permit Number: Date Applied:
Building Official(Print Name) Signature - Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
I n lirtc 'Jy &A
l.l 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.G.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:
Roland &AA+h"eK Sol , µA Win
Name(Print) City,State,ZIP
IY untolvt IA (410 tMi-220%
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other id Specify:WtaF4tbv(2e-h'et.
Brief Description of Proposed Work : jnStr,l&k1_ [AC,• do."; insbw Su roof ycuk
It' nuuhrwn., vte d�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 3 .51 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee
' ❑Total Project Cost'(Item 6)x multiplier x _
3.Plumbing $ 2. Other Fees: $
4.Mechanical (FfVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3 Z$ g1 ❑paid in Full ❑Outstanding Balance Due:
I1I28 MG-4tU-ED io G .C . t0 S�§�
✓ C-SSL.� IcJo035 —. CoN . S �PR ' S�LG
" — 1rJs
SECTION 5: CONSTRUCTION SERVICES COAT
5.1 Construction Supervisor License(CSL)
II DG41 7 Iolq
�. QAMA 'Say License Number Expiration Date
Name of CSL Holder
Boy �11 List CSL Type(see below) (A
No.and Street " Type Description `
Mctt�clnt s4v t- NN D31(% U Unrestricted(Buildings u to 35,000 cu.ft.
City/Town,State, IP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
( '✓��-�� tn�Qn"+II Ghbb14rgM.cory -- I 1 Insulation
Telephone Email addres D Demolition
5.2 Registered Home Improvement Contractor(HIC)
kidAMA J,y 182792 7 �at
HIC Company Name r HIC Registrant Name HIC Registration Number Exp rat on Daze
M 80X U-til tdgYp�{MIIIG4NlHu � CON^
No.and Street Ent 'I add,
MWGk4A,5�Wt W D3kaK (5D8�3Y2-2o�1
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 .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERWIF
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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.
&*V-Larsbv\ &n, 1.,— II 23 Zola _
Print Owner's or Authorized Agent's Name(Electronic Signature) IJatc
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.gov/oca Information on the Construction Supervisor License can be found at www.mass. ov/dQs
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost"
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Permit Authorization ..►'' `
mass save Form ®
sr.•rf 0•r•It•svY•Ilydnoi CONfRAC10R
v
Site ID: S00050246869 Customer: ROLAND GAUTHIER
I, ROLAND GAUTHIER owner of the property located at:
(Owner's Name,printed)
18 Lincoln Rd SALEM
(Property street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
`j below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
1 Owner's Signature:
Date:
p�Oiai••rJ•A••!rA♦iA•it♦arrrl•A•MA�NraAarH 3Ar•r ArrAar♦•AA•1A••f rr AA
FOR CLEAResult OFFICE USE ONLY
CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Ki
Iwll Cif F,y�nra�� ►► 1 231 2-0a,
Participati g Contract&V I Date
tS
oF•o
CLEAResult • 50 Washington Street,suite 3000 • Westborough,MA 01581 . 1800-480-7472 Q
For Office Use only
Rev. 102015
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compeasation Insurance Affidavit:General:Businesses.
TO BE FILED WITH THE PERMYFTTNG AUTHORITY. _
,Applicant Information Please Print LeeibiY
Business/Organization Name:Mill City Energy
Address:PO Box 6411
City/State/Zip:Manchester, NH 03108 Phone#:603-391-7923
Are you an employer?Check the appropriate box; Business Type(required):
1.[]✓ I am a employer with 12 employees(full and/ 5. ❑Retail
orpart-time).* 6. RestauranUBar/EatingEstablishment
2.0 1 am a sole proprietor or partnership and have no 7, Q Office and/or Sales(incl.real estate,auto,etc_)
employees working for me in any capacity.
[No workers'comp.insurance required) 3. ❑Non-profit
3.0 We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees.[No workers'comp.insurance required]* I7 ❑Health Care
4.❑ We.area non-profit organization,staffed by volunteers,
with no employees.[No workers'comp.insurance req.j. 12.p Other VAt&kW A L7 10
*Any aoplicant.thatchecks box Xl must also fill out the section below showing their workers'compensation policy infonnatioa
"If the corporate officers have exempted themxlves,but the corporation has other employees,a workers'eomperlstaim policy is required and such an
organization should check box ell.
I am an employer that is providing workers'compeasaBon insurancefor my employees. Below is the policy information.
Insurance Company Name:Clark Insurance
Insurer's Address:.One Sundial Avenue Suite 302N
City/State/Zip: Manchester, NH 03102
Policy#or Self-ins.Lic.#MIWC791896 Expiration Date:4/2912017
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$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.
1 do hereby certify,u his and penalties of perjury that the information provided above is true and correct
Signature; Date:
Phone#:603-396 7520
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.CityfTown Clerk 4.Licensing Board S.Selectmen's Office
6.Other
Contact Person: Phone#:
wtnv.mass.govldia
Massachusetts Department of Public Safety Construction Supervisor
Board of Building Regulations and Standards Restricted to:
Unrestricted-.Buildings of any use group which contain
Licenser CS410041 less than 35,000 cubic feet(991 cubic meters)of
Construction Supervisor enclosed.space.
MICHAEL JOY -
106 JOSEPH STREET
MANCHESTER NH 03102 j
l� Failure to possess a current edition of the Massachusetts
Expiration: State Butldirg Code is cause for revocation ofthis license.
Commissioner 08/07/2019 DPS Licensing information.visit:WWW.MASS.00VMM
�-.`Farem<ar {/d ti/�as.arXwA License or tration valid for individut use on
'' ;. Office gf(CgqsqmerARqirs 8;6o' ess Rsggydoa re8b only
OMER4PROVEMENT CONTRACTOR before the expiration dare. If found return to:.
trabon; 782782 Type: (1f0etof Consumer Affairand Business ReguiaAon
piration:_7r271411, LLC 10 Pant PIs7A-Suite.5170
- Roston,AIA 02116
MILL �M ENERGY,LLC.r -
ig
MICHAEL JOY
106 JCSEPH STREET ,,
MANCHESTER,NH.031021 Voda rrerary
Mill City
ENERGY
To Whom it may concern:
Please accept this letter as authorization for Rene Larson,an employee of Mill City Energy, to apply for
and receive permits on behalf of Mill City Energy,owner Michael Joy.
If you need anything further,please do not hesitate to contact us at 603-391-7923.
Thank you for your help and cooperation regarding this matter.
Sincerely,
4k
Michael Joy
CLEAResult®
t
t
CONTRACT FOR PRODUCTS / SERVICE WORK s
i
This service is brought to you through support from your local utility
I; This Agreement is made by and among
Roland Gauthier and.
_ 18 Lincoln Rd CLEAResult
Salem,MA 01970-4457 Attn:HES
Site ID:S00050246869 50 Washington Street,Suite 3000
Project ID:P00050283318 Westborough,MA 01681
Customer ID:000050248570 FederalED No.222457170
Contract 1D:20161018-1_WORK (Mail completed contract to address above)
I
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3 1. DESCRIPTION OF WORK TO BE PERFORMED i
k Contractor will perform or cause to be performed the following work on these"Premises"m a professional manner and to accordance with the terms of
this Contract,including the attached recommendations/work order describing the work in detail(Iha"Nark')which are incorporated herein by reference: 1
rfff
Description Quantity Location
Attic Floor Enclosed Cellulose Dense Pack 10" 952 Living Space $2,779.04
12"Mushroom Vent 2 Attic $275.94
;i Install 8"Roof Vent_ __ 1 Attic $99.65 I
Sheathing Access 2 WA $72.28 i
'fl Damming 14 WA $30.66
Sub Total: $3.258.37
Utility Incentive Share $2,000.00
Customer Contribution $1,258.37
F� I
❑� fr�
i For office use only Printed:10/1812016 Page 1 of 1
I
II. PAYMENT
Customer agrees to pay Contactor for the Work,the Customer Share of the Contract Price as follows:Payment 81:$ 419.00 as a Deposit payable
`{ to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs).Mail check&contract to CLEAResult,Attn:11ES,50 Washington St.,
�a Ste.3000,Westborough,MA 01681.Final Payment:$ 839.37 as the final payment for the Work shag be payable to the Independent j
,I Installation Contractor("IIC")upon satisfactory completion of the Work Customer maknuurds that he/she will not be rexryired to pay the Utility Incentive
Share of the Conhact price in the amotmt.of$ 2.000.00 .Changes to individual line items and/or previous incentives may increase or decrease the siyx of the Utility
Incentive Shore. .
Ill.DISPUTE RESOLUTION i
'the nC and Customer hereby mutually agree in adwhce that in the event t hatthe RC has a dispute ennerming this Contract,We RC may submitsuch dispute to a private arbitiahan
•� seMce which has been approved by the Office ofCmrswurr ARdn and Bushey Reindation mah Custamershaa be allured tosubmittosuch arbitration as provided in 41G.t.c 142A.
`' You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
business day following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
�� 6
OR
Cisa Unte Indicate your selected RC hem if a licabk: Initial here if ou want
II �
Y PP Y
the Program to assign a
_ Scot Regnier 10 18 16 Scot Re ier Participating Contractor
CLEARmailt Signature Date Name of C We Representative(Printed)
I
TERUS AND COMMONS APPEAR ON THE REVERSE. 2200-2,Rl.16
I
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RCS PLANVIEW DIAGRAM
Customer: , ,I� Home Phone:
+ .Address: Work Phone:
Town: Cell Phoney (9 , ?fir- _
Any Ilmllatlons for access by large track? No i Yes IY yes,describe:
Any specilic directions or landmarks? - No Yes _ IF y¢s,describe:
Vte.ID:_ .,5(�Zsy /. Energy Specialist:: _ ✓ Reviewed by:
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For Office Use Only t
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Bushes Ladder Neighbor Proximity Pocket Doors Insert Radiators Fence(s)
Existing Conditions X=Access ❑=Vents Note Inside Square R= Roof S=Soffit G=Gable
RV=Ridge Vent CS=Continuous Soffit CDE=Continuous Drip Edge T=Triangle
Install O=New Access Note in Circle C=Ceiling W=Wall S=Sheathing Temp Unless Noted Otherwise
Q=Vents Note in Triangle R=8"Roof 5=Soffit G=Gable M=12"Mushroom For Access