15 MALL ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations.and Standards CITY OF
V /D Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OfficialNse Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature
SECTION 1:SITE INFORM TIO
1.1 Property Address: � 1.2 Assesso s Ma Parcel Numbers
r � I'V�1�c--t- FP'e� .,�,.
1.1 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 Recor lGUSZ
e�I (Z f'rd� �U�e SAZ �►�n , ty1A
Name(Print) City,State,ZIP
i "s- MAL,_ snzez► q-gL-�b
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check a6 that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ �\
4. Mechanical (HVAC) $ List: }
5. Mechanical (Fire $
Su ression) Total All Fees:$
3 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $
f f SFc1 ❑Paid in Full ❑Outstanding Balance Due:
9
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
' �V U/ � S• �'"'�2� License Number Expiration Da e
Name of CSL Holder
}tv _ List CSL Type(see below)
--
No.and Street Y100Ic 2 (0) Type - - - Description _.
Int pp U Unrestricted(Buildings up to 35,000 cu.ft.)
�c R Restricted 1&2 Family Dwelling
City/Town,State,ZIP - M . Masonry
RC Roofing Covering
c-. lJ � C�� _ WS Window and Siding
SF Solid Fuel Burning Appliances
®0 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) � -? 'f _W 6 ? ((D I 0�
Ed r K +�® HIC Registration Number Expi at tion Date
HIC Comp y Name or HIC Re istrar t '
No.and St e Email address
Ci /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 CONTRAC_TOKKR APPLIES FOR_B_U_ILDIN_G PERMIT _
1,as Owner of the subject property,hereby authorizeG•�.ULvIJg: S ' G P0, U�
to act on my behalf,in all matters relative to work authorized by this building permit application.
C 14 e) C- A fed li- ►�c��Z
Print Owner's Name(Electronic Signature) - Date
SECTION 7b:OWNERr 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.
Print Owner's or Au boozed Agent's Name(Electronic Signature) Date
---'— — ------'` - -- -- NOTES:
I. 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(H IC)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.mass.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 halfibaths
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"
�p nationalgdd
V The power of action
conservation Services Group This service is brought to you through support from your local utility
This Agreement is made by and among N /�
and
MassSAVE
CHRISTIAN ARRIETA-RODRIGUEZ Conservation Services Group (CSG)
15 MALL ST 40 Washington Street, Suite 3000
SALEM MA 01970,3815 Westborough,MA 01581
• Customer ID: S10004018555 Conti-act IDc 1462011C
I. DESCRIPTION Of WORK TO BE PERFORMED
CSG will perform or cause to be performed the following work on the'Premises" known as 6 J �w l� �T, ,m a
professional manner and in accordance with the terms of this Contract,including the attached recommendations/work order
describing the work in detail(the"Work")which are incorporated herein by reference:
•
Description Quantity Location
Wall Ins.Clapboard Siding 4"Cellulose 2270 EXTERIOR $4,358.40
Sub Total: $4,358.40
Energy Efficiency Incentive -$2,000.00
Net Sales Tax After Incentive $0.00
Total $2,358A0
1.CUSTOMER affirms that they have received no incentives during the past 12 months.Initial here "Individ
• 2.The incentive Is dependent upon the package purchased andlor prior Incentive utilization. Changes
line items and/or previous incentives may increase or decrease the size of the in ' e
• 3.CUSTOMER affirms that their electric provider is National Grid.Initial here
•
•
• 11. PAYMENT -
CUSTOMER agrees t�o-1 pay
/CSG for the Work as follows:
Printed 06/23/2011 Page 1 of 1
Payment#1: $ 1 . 1 3
-Deposit upon signing the Contract(Not to exceed''
1/3 of the total retail costs or actual costs of special orders,whichever is greater)
' Additional Payments and Final Invoice: $ l J ,2, ;L 7
-Additional payments for the Work shall be due 30 days from the date shown on the Invoice. Final payment for the Work shall be
due 30 days from the date shown on the Final Invoice.
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the
seller, which may be his main office or a branch thereof, provided you notify the seller in writing at his main
office or branch 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 S1P3N T 91S rONTRACT IF THERE ARE ANY L NK SPACES.
C ignature Date
fir; 12U
� a3 li 07rcy �iy�YD
CSG Signature Date Name of Repres tative
The Terms of this Agreement are contained on both sides of this page
Conservation Services Group-40 Washington Street•Westborough, IVIA 01581- 800-480-7472 oven
I
CONTRACTOR WORK ORDER
Conservation Services Group Printed: W1812011
ContractbK0 rmation, 10u tomer/Site Details
Dave Boettcher CHRISTIAN &CARRIE ARRIETA-RODRIGUEZ Phone(eve): (781)576-9781
NEXT STEP LIVING 15 MALL ST Phone(day):
25 Boston
MA 0221 Ave 0 SALEM MA 01970 3815
Boston MA Site ID: S10004018555
B O
-
z. A o'intment.Detatls �< >-`
Completion Deadline:
Location':, Vescri tion Quantlt Unit$ Total$ ';Notes/Revisions'
Work Order : NXTSTP 20110818
EXTERIOR Wall Ins. Clapboard Siding 4"Cellulose 2270 1.92 4358.40
Total for Work Order NXTSTP_20110818 : $4,358.40
Grand Total:- $4,358.40
Road-Blocks
Asbestos Possible Asbestos Containing Material Observed
ASSUMED IT WAS PREVIOSLYON OLD STEAM PIPES IN BASEMENT
Conservation Services Group- 40 Washington Street-Westborough, MA 01581 -800-480-7472
i
CERT ICATE OF UQBUTY DATE(MM/DD/NryY)
William Gallagher Associates INFORMATIONInsharanre Brokers,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CEO�TIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND, E7tT
470 Atlantic Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIE END OR
S BELOW.
Bost®ua,-MA-0229D .. _.. -- -- --- --------- — —
NsuRED INSURERS AFFORDING COVERAGE
Next Step Loving,Inc. INSURER A: Federal Insurance Company NAIL#
281
25 Drydock Avenue INSURER B: Great Northern Insurance COmpan 20303 2003
5th Floor INSURER C: Safety insurance Company
Boston, MA 02210.2600 INSURER D: 39454
COVERAGES wsuRER E:
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 MAYBE ISSUED TA
MAY PERTAIN,7HE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MM HAVE BEEN REDUCED BY PAID CLAIMS. OR
SIR 0
LTR NSR TYPE OF INSURANCE
POLICY NUMBER POLICY EFFECTIVE POLIC YEXPI TION
RA
A GENERAL LIABILITY ATE MMIDO OAT MM/DD LIMITS
35904463 1 EACH OCCURRENCE
X COMMERCIAL GENERAL LIABILITY 11/11/2010 11/11/201 $1 OOOOOO
DAMAGE TO RENTED CLAIMS MADE a $' QQO OOO -
®OCCUR
MED EXP(Any one person) $10000-
PERSONAL$ADV INJURY $1 000 000
GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $2000000
POLICY ECT LOC PRODUCTS-COMP/OP AGG $2000600
C AUTOMOBILE LIABILITY - TBD94446 -
ANYAUTO 91/11/2010 11/9112019
COMBINED SINGLE LIMIT
ALL OWNED AUTOS (Ea accident) $9,000,000
X SCHEDULED AUTOS BODILY INJURY
X HIRED AUTOS (Per person) $
X NON-OWNED AUTOS BODILY INJURY
(Peraccident) $
PROPERTY DAMAGE
GARAGE LIABILITY (Per accident) $
ANY AUTO AUTO ONLY EAACCIDENT $
OTHER THAN EA ACC $
EXCESS/UMBRELLA LIABILITY 79870050 AUTO ONLY:
EACH OCCURRENCE AGO $
11/11/2010 11/11/2011
X OCCUR �CLAIMS MADE $3 OOO OOO
AGGREGATE $3 OOO OOO
DEDUCTIBLE
RETENTION g $
{ WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY 71733288 19/99/2090 19/1912019 wcsrgru $
ANY PROPRIETORIpARTNER/EXECUTIVE X OTH-
OpPFICER/MEMggEEREXCLUDED?
( Yes,describe
Nq) N - EL.EACH ACCIOENr $SOD QOO
ER
If Yes,tlascribe antler
SPECIAL PROVISIONS below E.L.DISEASE-EA EMPLOYEE $SOO,000 OTHER
E.L.DISEASE POLICY LIMIT $500,000
:SCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Star Gas Company is included Be an additional insured on general
sbility as their intersts may appear per written Contract.
'.RTIFICATE HOLDER
:,7CANELATIONEFI NStaP Gas RBSidential Y OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
EOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _ DAYS WRITTEN
Weatheriaation Rebate Program40 Washingt0 St.SUlte 2000 HE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SMALL
Westborough, MA 01581 ATIVE ATION OR LIABILITY OF qNY KIND UPON THE INSURER,ITS AGENTS OR
ATIVES.REPRESENTATIVE
DRD 25(2009/01)1 of 2 #S185635/M9 Alml i _ -
---------------------------
31022
GEORGES GARWOOD
Box 0-mf29 RODMAN ROD ...
MA 0 1585
E 7116120 13
TrL,, 19091
HOME IMPROVEMENTC
ONTRACaoR
Req
istratior:
" Type:
36253
E .6!2612072 ind; iduai:V
Gc
GE S. GARANd D.
GEORGEE GARWOOD
29 R0C-fVAN R�-.
101. BRO(DKFIELD. MA.0417585
+\k
11/18/06, TAU 17:04 FAX 617 393 2415 ¢j005
Y'he Corraaoatvealth of MassachaseYts
Department oflnAutrialAoddeats
Q/jice ofXuKFiFyations
t 600 Washingma Street
��. Boston,MA 02I11
el 'v wwKsaras& ov/aia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Blectricians/Plumbers
AP 1�rcant Information ft 1 �C Plcasc Print Luvpi6ly
Name(Business/Organization/lndividual), "J Q,X .54 C 1 'vac
Address:— a., ry o c k^_"
City/State/Zip: oS ��;1 Vh t OZ-L I O Phone
Are you an employer?Check the ap riate bar. Type of project(required):
1.�)am a employer attic _- �� 4. [] 1 artt a general wntrartor and i 6. New construction
amploye�s(01 and/or part-time).* have hired the sub-contractors
2. !am a sole proprietor or p umerr listed ens the ariadled sheet t 7. Q Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
we
for mein any capacity. workers'comp,insu mce• 9. ❑Bulldog addition
(No wooers'comp,insurance S. ❑ We area corporation and its
mluhd•) officers have exercised their I O.Q Electrical repairs or additions
3•❑ 1 am a homeowner doing all work right afexamption per MGi. I LEJ Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4�and we have no 12.[]Roof repairs 1
insurance requred_]t employees_[No workers' 13®�yar ZhSu k i w.
comp.insurance required.]
'Any appliatn thin nue&s box 9I must niso tat out the action below showing Weir wadreta'ormtpasation polici•Informadon.
r Homawners who submh thisafrrdovia indicating they me doing an work and then hire oulsido cwhaaors mutt submit a new affidavit i diming such.
1Ceaaaeton that chmk.this bo:must aftwhed an additional about stowing We name ofthe subamuoims and Web workers'camp.polity Ilrkmatiur.
Iota an aWoyrr tbat is providing workrrr'comprnsotlon imwreneefor my emWoy= Below is rbep &y mud job site
iafomroBan II11
tnsruanceCompatty Name:_ a-ke,rc
Polity#or Self-ems.Lic.#: ENluatiou Date: I b 4 ho l Z
Job Site Address: Chy/Stue/Ztp;
Attach a copy of the workers'compensation policy declaration page(showing the policy number and el mden date).
Failure to secure coverage as required under Section 25A ofMGL c_ 152 can lead to the imposition ofa odual penalties of a
fate UP to$000.00 and/or one-year imnprisonmaoy as well as civil penalties in the than of STOP WORK ORDER and a fine
of up to$250.00 a day against the viol Be advised that a COPY ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance v erifrcation.
I do heritby care under the ofpedwy that theWerawaos prowdrd above a tine and comrcd
tahne;
c� I
Phone#:
Q dfil are only_ Da not write in this area,ro be complded by eky orfewn offldat
City or Town: Permia is nc#
fssaingAuthority(cirele one)_
_rBaard of Ffealtia Z.8aildWg 1?eparrwrent 3_Cily/Town Clerk 4- Clec ai-cal lnspecior S.Phambing Inspector
G.Other
Costa e