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10 LYNNE ST - BUILDING INSPECTION The Commonwealth of Massachusetts } , Board of Building.Regulations and Standards CITY t Massachusetts State Building Code, 780 CMR,, m}dtlI OF SALEM + a' lon . tq '1;1 i Revised January Building Permit Application To Construct..Repair, Renpv4ly OFP,5molish.a /. :008 One-or Two-Family Dwelling ; This Section fariqlficial Use Only- Building Permit Number: I D - pplie 2. Signature: Building comunissiTVOrnspectoror u m Date SECTIO :SITE INFORMATION 1.1 Property Address: I 1.2 Assessor Map dt Parcel Number lO C�( nrl I.la Is this.an acce ted street?yes no Map Number PaO Number: 1.3 Zoning Information: 1.4 Property Dimenslolas , Zuning District Proposed Use Lot Area(sq 11) Frontage(11) 1.3 Building Setbacks(R) 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: 11 Sewage DVposalSystem: Zone: Outside Flood Zone?Rutilir0 . Private❑ 'Check it es❑ - Municipal 0 Onsitedisposal system O SECTION 2: PROPERTY OWNERSHIP' 2A Owner'of Record: r7J annc_ r)')Orrl S�►1 IQ 6� - Name(Print) i .Addteu.fo $ignau Telephone SECTION 3: DESCRIPTION OF PROPOSED WQRIts(cbeck;61 11011'Apply) New Construction❑ EkiSting Building O Owner-Occupied O 'Repatrs(s),�`' ;Altera_tion(s) l] , Addition ❑ Demolition ❑ Accessory Bid g.❑ Number of Un[b Olher 4, Specify: Brief Description of Proposed Woik':_—riJ g 14/( c O SECTION 4: ESTIMATED CONSTRUCT101�((^^OST,S 4x�.d Item Estimated C osti: - Ofllelal i1se:Only Laborand Materials I. Building S I. Building PermiPFee:S. ' Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost "(item 6)x multiplier x 3. Plumbing 5 2. Other Fees: S 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire S Su ression) Total All Fees:S Check No._Check Amount: Cash Amount:_ 6. Total Project Cost: S a3yf OO- ❑Paid in Full ❑Outstanding Balance Due: r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) q'� -� a 3 Z u4'0''+W. .?9611 _ License Number - Iirpira//tiJ�un time Name of CSI.• Ilulder 3 List C'SLTypr(see below) V. /?n =WSRoidcmial Ikscri -ion :WJrry d u to 35,000 Cu.:Ft. IR2 Family Dwrllin signature /�, ` nl-Roulin Covrrinfcfcphunc Window and Sidina (?-)"6 ,7 y y _s /y 3 SF Residential Solid Fuel"Bum n in A`i liaa Installation D Residential Demolition. L5. Registered Home improvemeenntt Co�ntractor(HIC) V�0 Cums ' '�" egismuion Number ress MA01970 g�S y y, jji V"� E.rpiration Date ature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.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 thc,lssuanceArthe building permit. Signed Affidavit Attached? Yes .......... No...........O SECTION7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT. 1, VI O.//n e as Owner of the subject property hereby authorize e- to act on my,behalf,in all matters relative to work authorized by this building permit application. r urc of Owner - Date SECTION 74:OWNEW OR AUTHORIZED AGENT;DEC,LARATION as Owner or Authorized Agent hereby declare e statements and information on the foregoing application arc true and accurale,:to the'best of my knowledge and ame ,�/,� _ 2 Signat�)wner or Authorized Agent DL-- Dale Si ed under the sins md: . nalties of 'u NOTES: I An-Owner who obf tins s building permit to do hiSRtctown work,or an owner who hires anunregi'slered contractor (not registered in the Home Improvement Contractor(MC)Program), will gli.have access to the arbitration program or guaranty fund under M.G:L.c. I J2A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115. respectively. 2. When substantial work is planned,provide the information below: Toal floors area(Sq. FL) (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 healing system- Number of decks/porches Type of cooling system Enclosed Open 1. "Total Project Square Footage"may be substituted for"Total Project Cost" The Commortfveahli of Massachusetts ' _ Department of Industrial Accidents d, 'V (:6 Office of Investigations Fd 600 Washington Street Boston, MA 02111 :,r�rt�'b www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): AllaM1Q WEAtht'_ri7hfit%L 1 C 6 f 1k Jdfinen Avoue Address: City/State/Zip: Phone #: -7 Are y/oam u an employer?Check the appropriate box: Type of project(require Ed): 1. 1 a employer with�r 4. ❑ I am a general contractor an 6.6 ❑ New construction. employees(full and/or part time - , _ have hired he vab-contractors 2:❑ I am a sole proprietor or partner listed 6n the attached sheet. 7. [� Remodeling ship and have no employees These sub-contractors have g, Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp, insurance romp. insurance.t 1 am red.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.) t c. 152, §1(4),and we have no q ] employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compenswion policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-wntractors and state whether or not those entities have employees. If the sub-cootrnetors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site - information. ^ Insurance Company Name: 1'1�'�f r Gr..%/r..ZT r r c- ��+ . CL o ! . Policy#or Self-ins Ltc. Expiration Date:. 10 [13 -- Job Site Address: i0 Y n/)e:_J f City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder 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 Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature �— Phone#- -2 f t Official use only. Do not write in this area, to be completed by city or tows:official . City or Town: ,__ Permit/License# _. Issuing Authority(circle one)': 1. Board of Health 2.Building Department 3. City/Powu Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Ila o ® CERTIFICATE OF LIABILITY INSURANCE U (MM,DDIY `�I 3/1/19/2012 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 endomement(s). PRODUCER CONTACT ConstructionNAME: FAX Eastern Insurance Group LLC PHONE (508)651-7700 INC.No: 233 West Central Street q DD RESS: PRODUCERCUSTOMER to 00024397 Natick MA 01760 INSURERS AFFORDING COVERAGE NAICN INSURED INSURERAArbella Protection Ins. Co. 41360 INSURER B Arbella Indedanalty Ins Co. 10017 Atlantic Weatherization wsuRBR.c:Zuriah-American Group 61 Rear Jefferson Avenue INSURER D Beacon Hill Associates Inc INSURER E Salem MA 01970 INSURER F: COVERAGES CERTIFIGATENUMBER3q+STEP'2012 REVISION'NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO 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. INS. TYPE OF INSURANCE AWL POUCYNUMBER MWD�EFF MMI pY EXP. LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occu arcs $ 50,000 A _ CLAIMS-MADE 7x OCCUR B500042816 /20/2012 /20/2013 MED EXP(Any one arson $ 5,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 G 1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2,000,000 POLICY }L PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT It 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED AUTOS 938274'00003 /20/2012 /20/2013 X _ BODILY INJURY(Par accident) $ SCHEDULED AUTOS PROPERTY DAMAGE }[ $ HIRED AUTOS (Peraccident) % NON-OWNED AUTOS Uninsured motadst Bl split limn $ Undednsured motorist BI split $ • UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DEDUCTIBLE $ A RETENTION It 600047820 /20/2012 /20/2013 $ L. WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERB LIABILITY - YIN ANY OFFICER 11 PRiETOERmEXCLUER]E ECUTIVE ::] ORYN/A E.L.EACH ACCIDENT $ (Mandate,In NH) CERTIFICATES TO BE ISSUED - EL.DISEASE-EA EMPLOYE E If es scribe under IRECTLY BY CARRIER E.L.DISEASE-POLICY LIMIT E DESCRIPTION OF OPERATIONS below D POLLUTION LIABILITY PL200378600 0/1/2011 10/1/2012 GENERALAGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional RemaHcs Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SALEM ACCORDANCE WITH THE POLICY PROVISIONS. 93 WASHINGTON STREET SALEM, MA 01970 AUTHORIZED REPRESENTATIVE Rosemary Fulham/PMA ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD RightFax N1-2 3/21/2012 6 : 26 : 51 AM PAGE 3/003 Fax Server z p `/Y `s a ISSUE DATE �-1' :lr x ..aM ' 3/21/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOR1,1ATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT,AFFIRMATIYELY 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 INSDRER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(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 CONTACT EASTERN INS GROUP LLC NAME: PHONE FAX 233 W CENTRAL ST (A/C,No,Ea): (AC,No): NATICK, MA 01760 E-MAIL ADDRESS: PRODUCER CUSTOMER ID is INSIr D INSURER(S)AFFORDING COVERAGE NAIC tl ATLANTIC WEATHERIZATION LLC INSURER A AMERICAN ZURICH INSURANCE 61 REAR JEFFERSON AVE COMPANY SAL.EM,MA 01970 INSURER INSURER C INSURER D INSURER E . INSURER . COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO=INSURED NAMED ABOVE FOR THE POLICY PERIOD WDICATED. NO'I-%l R1.STANDING AM'REQUIREMENT,TERM OR'CONDFITON OF ANY CONTRACT OR OTHER DOCUMENT WRTI RESPECT TO WHICH THIS CERTIICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDTRONS OF SUCH POLICIES.LMOTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. HJSR TYPE OF INSURANCE ADDL SUBR POLICYNUMBER POLICY EFF POLICY EXP LIMITS LRt INSR WVD D D GENERAL LIABILITY EACH OCCURRENCE S D�GETORR COMMERCIN,OEFIERAL LIABEd]'Y REMI ES(EacNTED 3 h . urrenae) MED.EXPENSE(My on 3 CLARdS MADE 0 OCCUR. arson O PERSON &ADV. S INJURYAL O GENERAL AGGREGATE S GEN'L AGGREGATE LI.47 APPLIES PER'. PRODL1=COMP/OP $ O POLICY ❑PROTECT 0 LOC AGO AUTOMOBILE LIARMITY COMBINED SDTGLE S LQAT (Each accident) 0 AYIY A�JTO BODILY IUURY S ✓ "Parson) CI ALL OWNED AlITOE BODILY INJURY S r Accident) PROPERTY DAMAGE S D SCHEDULED AUTOS (Per accident S H D AUTOS S O NON.OWNEDAUTOS O LW[ RELLALIA 0 OCCUR EACH OCCURRENCE S 0 EXC&:S LIAR ❑CLAIMS-MADE AGGREGATE S O DEDUCITBLE S S C) R£TENl]ONS WORKERS'COMPENSATION - WC A AND EMPLOYERS LIABILITY N/A STATUTORY LRATS Y/N AN)FROPMTOMARTUIE E.L.EACH ACCIDENT $500,000 EXECLTNE OFFICER✓MEMBER Y N/A 7PR1B-$R27U12I 03/20/12 03/20/I3 ECG?r=' E L.DISEASE—EACH (NLANDATORY IN NH) E1.fPLOYEE 000,000 E.L.DISEPSE POLICY Ify±:,Aescrib±wder DESCRIPTION OF $$00,0011 JF'ERATfO1JS below DESCRIPTION OF OPERAT ONS/LOCATIONSNEHICLES(A tach ACORD 101,Additional Remarks Schedule,irmore space is required) THIS REPLACES ANY PRIOR CEIYnFICATR ISSUED TO THE CERTIFICATE HOLDER AFFECTING.WORKERS CONH'COVERAGE '� 'TT�I@0t)AOLUM t o° P ' 'Ct i t1Tc7 .,..xom. CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 WASHINGTON ST THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SAI.F..M.MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUIHORIMD RFPRFSFMATI VE Brcau Ma.cLet _ .. . Weatherization fAtlantmic 1 61 R Jefferson Avenue Salem, MA 01970 • (978) 744-8143 March 1, 2012 PROPOSAL SUBMITTED TO: Diane Morrison 10 Lynne Street Saiern;MA (978)745-1723 We hereby submit specifications and estimates for: Attic/Wall Insulation ATTIC INSULATION 1. Add R30 cellulose—ceiling 2. Dense pack slope areas 3. Weatherstrip/insulate hatch COST: $750.00 WALL INSULATION 1. Dense pack Class I blown cellulose—walls COST: $1,500.00 Optional Measures: Weatherstrip rear door—Additional Cost:. $65.00 Weatherstrip/insulate cellar door—Additional Cost:-$95.00- .......................................................................................................................................................................... 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 outlined above. BPI Certified • EPA and Mass. Lead-Safe Certified Authorized Honeywell and NGRID/NSTAR Contractor Please sign and return one copy to the above address. ATLA WEAT, RIZ TION, LLC ACCEPTED: DL - l� B= /� �( � Eric Palm DATE: J r ? Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Unrestricted-Buildings of any use group which License: CS-087977 contain less than 35,000 cubic feet(991tn )of r rS oR: enclosed space. ERIC W PALM- �p . 3 HILTON ST " y SALEM MA-01970 r r Expiration Failure to possess a current edition of the Massachusetts Commissioner 0 4/2 312 0 1 4 State Building Code is cause for revocation of this license. For DIPS licensing information visit: w .Mass.Gov/DPS Office orf'& m Ae. - HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only Registration: ,F142089 Type: , before the expiration date. If found return to: Expiration: 3l1212014 Ltd Liability Corpor Office of Consumer Affairs and Business Regulation F WEATHERIZATION L liC. 10 Park Plaza-Suite 5170 A IC Boston,MA 02116 ERIC PALM 61 R JEFFERSON SALEM,MA 01970 ' Undersecretary I Not valid without signs ure .`�.........._. .__.�_...." J It