101 MASON ST - BUILDING INSPECTION Q 2� �
The Commonwealth of Massachusetts CITY OF
�. Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number. ` Date lied;:
Building Official(Print Name) ignature Date
SECTION 1:SITE INFORAIATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
ion .s7,q.to. s le-
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' '
2.10
wner e of�R ord:
oric/ �a vrrs S, !cr �9 D 1
Name(Print) City,State,ZIP
�oirz rso-r soe 7V-6JF-90/1 ?
No. and Street Telephone Email'Address
SECTION 3: DESCRIPTION OF, PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other Specify: v& rr
Brief Description of Proposed Work': ,./ a .A6<ie !6,e--J,0 Z, dr .r rL
L✓.^ ig /4vc�.'oh
D o ✓Gs�.TS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only..,
Labor and iV(aterials
I. Building S 327 7(0 1 Building PermitFee $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical S - -" ❑"Total Project Cosf,(Itein.b)x multiplier x
3. Plumbing 3 2. Other Fees: $
1. �lechnnical (HV;AC) .S List:-
5. Meeh:mical (Fire
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. 'l031 Project Cost: S 3 3Z .7 ❑ Paid in Full ❑Outstanding Bal:yiceDue:
4 g-, 20�1 tie Gc�
SECTION 5: CONSTitucr[ON SERVICES
5A Const/ruction Supervisor License (CSL) 9 Q QZ
License Number Expiration Date
Name of CSL Folder 14
List CSL Type(see below)
-2P Xa Tv Description
No. and Street
� Unrestricted Buildin s up to 35,000 cu. tt.)
.rho P* !4 G /17 p Restricted M2 Family Dwelling
City/town, Sta ,ZIP b( ibfasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2Reegistered Hooune Improvement Contractor(IIIC) YJ•73
4
r4.1eep1 5�i �..SQd n C-,- _— HIC Registration Number Expiration Date
HIC Coi�nJ�any Name or FIIC Rcgi trant Name
N aYnd S reefJ�rf Email address
o
City/Town, S ate, ZIP Telelphone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. t52. § 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 PERMIT
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.
�ai Oil /
Print Owner's Name(Elec onic Signature) Date
SF,CT[ON 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name.below, [ hereby attest under the pains and penalties of perjury that all of the information
contained in this a plica� is true and accurate to the best of my knowledge and understanding. 0
Print wner's or Authorized 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(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. I42A. Other important information on the HIC Program can be found at
wwev.mass.<,ov.oca Information on the Construction Supervisor License can be. found at www.mass.^o�!dL
2. When substantial work is planned, provide the information below:
Total tloor area(sq. ft.)- (including garage, finished basement/attics, decks or porch)
Gross living area(sq. ft.) 1-labitable room count
Number of fireplaces_ Number of bedrooms
Number o[bathrooms Number of half/baths _
Type of heating system Number of decks/ porches
----------- --
type of cooling sysicnt---- -- -- Enclosed—__-----Open _
J, `' total Pnojec[Squnrc Footage" umy be sub,titutcd for';FotA Project Cost" _---
f I
a
ti
f Mf
<r CITY OF S�1 ZI ,L-kSSACHUSETrs
{ A BUILDNIG DEP.1R-r% NT
�
120 WASHING ^s.d'fe TON STREET, 3 FLOOR
TEL (978) 745-9595
KIMBERLEY DRISCOLL F.-A(978) 740-9846
NL-tYOR THons ST.PIERRH
DI.2ECTOR OF PUBLIC PROPERTY/SUIMNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5
Debris, and the provisions of tb1GL c 40, 5 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by VIGL c
111, S 150A.
The debris will be transported by:
(name ot'lmuler)
The debris will be disposed of in
��~zy&:
(name of facility)
Awls 0 Z y� ..
(address of facility)
signature of permit applicant
date
dcbn:u C',I,k
CITY OF &U.E.M, N-Lks&.cHUSETTS
BUILDING DEPALMLEDiT
:= ra 120%VASHL1IGTON STREET, 3'e FLOOR
TEL (978)745-9595
FAX(978) 740.9944
KI\[BERLEY DRISCOLL
�UYOR THOAL►S ST.FIERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMISSIONER
Workers' Compensation insurance AMdavit: Builders/Contractors/ElectriciansiPlumbers
Applicant Information �/� ( / Please Print Legibly
V:Ilna(BasilesvUrganiratiovindividual): f/il✓GiAlfl� 6Hlr4N Z,z
Address:-2.?
City/5tatcMp:� Phone✓E: 71/• t171 90
Are ou an employer?Check the appropriate boss 'type of project(required):
1.)W1 am a employer with 3 4. 0 I am a general contractor and 1 6. ❑New construction
employees(fLll and/or part-lima).• have hired the subcontractors
2.0 I am a sole proprietor or partner. listed on the attached.sheet t 1• ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
workingfur me in an capacity. workers'comp.insurance.
Y a ty• S. 0 We are a corporation and its 9. ❑ Building addition
required.]
workers'camp.insurance a10.0 Electrical repairs or additions
reyuircJ.j officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employces.LNo workers' 13.0 Other
comp.insurance required.]
;Any applicant Na chwka box el must alto rill out IN umiw below showing tholr warkeo'Mmpemadun pulluy inrurmali"
t I r.wwuwnos who submit this affidavit indicating they am doing all Wiliam!then him ouiside'cantractan mug submit s new aMdavit indlaing such
:Gmtmutom Ihet ch,%it this box must anachad an addillunol sheet shuwing the name of the tubeamradors sod their wurkmo ramp.policy infomurioa.
i um an employer that Is providing workers'compensadon hrsurance jar my employees Below/s the policy and Job site
information. /
insurance Company Name: Char �S
Policy 4 or Self-itts.Lic, d: COS SZ Expiration Date: Cr r t
Job Site Address: !o / s.t ,V-zr .V Sf City/State/Zip: SJL Gs.r oe 70
.\nauh a cupy of the workers'compensation policy declaration page(showing the policy number Sind expiration date).
Failure to secure coverage as required under Suction25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and aline
of up to 5250.00 a Jay against the violator. lie advised that a copy of this statement may be forwarded to the Orrica of
Investigations ofthe DIA fur insurance coverage verilicalion.
i do hereby c errify ru de rh pules m d puru111 of perJury that r/re hrfunnalon provided abuve is iru a and correct
iienuure; 7 /J( Date: I f//� o r Z
Phoned: 7,f I • `C'7S� 2o5s' - ''
IOfficial use mrly. Do not write in Mir urea,to be completed by city or town offlcla!
cityurTuwn: Permful.lcenseq
Issuing.lulhorily(circle one):
I. Board of liealth 2.nuilding Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Persnn: ._._ „ _ ___ __ Phoneth
l ® DATE,4coRo , CERTIFICATE OF LIABILITY INSURANCE 29 14 1
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 poficy(jes) must be endorsed. H 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 endorsemen
PRocucrn CONTACT
NAME: Paul T Murphy
Paul T. Murphy Insurance Agenc PHONE FAX
628 Broadway HONE 781 321-9700 NI: (781) 324-4253
-6 R
Malden, MA 02148 Ess: paul@ptainsurance.com
INSURE SAFFORDING COVERAGE NAICe
INsu RERA:First Financial Ins Company
INSURED INSURER B:Safety
Advanced Energy Solutions LLC INSURERC:Chartis
28 Hamilton St INSURER D:
Peabody, MA 01960 INSURER E•
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES 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.
CY
TR TYPEOFINSURANCE AED UBR POLICY NUMBER PMAID/Y FF gMIDM'Y�YY UNITS
A GENERAL LIABILITY 807F000697 5/7/12 5/7/13 EACH OCCURRENCE s 1,000,000
X COMERCIAL GENERAL UABIUTY DAMAGE TO RENTED $ 50,000
CLAIMS41ADE aOCCUR ME D EXP(AM one peso,) $ 5,000
PERSONAL&ADVINJURY $ 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER -PRODUCTS-COMPIOP AGE S 2,009,000
POLICY PRO- LOG $
B AUTOMO&LE UA&UTY 6217151 3/19/12 3/19/13 CONIBINEUSiNGLELIMIT
as=ldent $ 1,000,000
ANYAUTO BODILY INJURY(Pw person) S
ALLOWED SCHEDULED
AUTOS X AUTOS BODILY INJURY(Per eccidenl) $
X HIRED AUTOS X AUTOSVVWED PROPP=DAMAGE $
UMSRELIALIAS OCCUR EACH OCCURRENCE S
EXCESS LUIB CLAIMS-NWDE AGGREGATE S
DED RETENTION
L. VARKERS COMPENSATION WC005690446 5/14/12 5/14/13 X 11 WC STATU- OTH-
Me EMPLOYERS'LIABILITY
ANY PROPREMRIPAJTNEMEXECUTIVE YIN EL.EACH ACO DENT 1,000,000
OFFICE RIMEMBER EXCLUDED? N/A
(Mand tMInNH) E.L.DISEASE-EA E1,IPLOYEE S 1,000,000
Byyeess d—lbe wder
DESCRIPTO NOFOPERATIONSDMow E.L.DISEASE-POLICYLIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEKICLES (Aftmh ACORD 101,Addleonal Ra.a Schedule,If nwre apace Is Mqd red)
Insulation-Coverage is subject to policy terms conditions and exclusions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Lowell ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR®REPRESENTATIVE
`t2A
®1 8-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
)hone: Fax: E-Mail:
t Massachusetts -Department of Nbiic Safety
Board of Building Regulations and Standards
-Construction Supenisor
s
License: CS-090902
RICHARD B BOR¢sES ,
28 HAMILTON ROAD
Peabody MA 019a0 I,
ration
11 0Expi112014
Commissioner
i �'/re �aoo,�monu�e d "
Office of Consumer Affairs&B sinessL soon
HOME IMPROVEMENT CONTRACTOR Types..
Registration 164893-
Co
i oration
kVADANCEED
Expiration_ 1 113 012 013 rp ENERGYL`UTIONSrw LC.
,4 RICHARD 80RGE�$. ------------
�. 28 HXMILTON
i PEABODY MA 01966;� y �� Undersecretary
WAP Work Order
North Shore Community Action Programs, Inc. Job Number:Not Feul Eligible
Pe body NIA Work Order Date: 1/7/2013
Peabody,NIA 1-880 Ownership: Renter
Phone: 97S-531-SS10
Advanced Energy Solutions Auditor: Brandon Dorrington
28 Hamilton Road Email: bdorrington@nscap.org
Peabody MA O1960 Cell: 781-540-8569
Email: rborges95@comcast.net Phone: 978-531-0767 x 121
Phone: 781-475-2095
Alyssa Warren NCRID Gas
101 Mason St Total $1,788.78
Apt.2/Floor 2 $1,788.78
Salem MA 01970 5377
978-818-3752
Landlord Name: David Byors 3
Landlord Phone: 781-639-9019
rur 9 '.I .� y, a, Ida e4 k ux a '1 " pr-,ykaF ,hV
"4 Measure Descry twn ��'
l{ c�ta P n�rRn�bl r :n�E•,P 4 i�^,4, 7 S :: v ^te � : �!'+.. +• �; .
L Y sAthc Insulation J1�...-' yr L ''NN ,
� .' _ ...31 d..,�ds•b+.'k'.I f d.0 .. 1.1+.. �y p:.:i'v.l': ai. AT-- ::,hd'Ai.. Kea y�L ;4{n1.yl Sy'. Yf
4 ..._ 1 a t.1 „Y,i.ti� ti x..r .•ef
R-30 unrestricted-settled cellulose 660 $1.37 $904.20 660 $904.20
a *w 'Attic Ventllattonh
.a Lr. dr •via. '. v y �tti.•:3. .i.`^l•Y.., "�kr ��- 1 4r^.. ,s� �a� 1.# { !H+ ai 7a x R Pi t ro ' a"l� i'4.. � S 4 '�Rectangular gable vent 2 $92.00 $184.00 2 $184.00
tHoofvent5(A sq RNFV)small 2. $.80.00 $160.00 2 $160.00
Doorsa F :` S. s'K. .r :v� L.�z n`;. '. Y t i,'.+ A : .��> K " f: � , • r�Y, � ;`� 3 k �' '?
Fixed Sweep 2 _ '"• r
$15.75 $31.50 2 $31.50
Weatherstrip s/Q-Ion or equal 2 $45.50 $91.00 2 $91.00
Misc Insulation :'` r K
Domestic water pipe wrap 6 $2 63 $15.78 6 $15.78
Hydronic pipe insulation to 1 in. 30 $3.41 $102.30 30 $102.30
copper pipe R-5
Date: 1/7/2013
Page I
WAP Work Order: Job Number: Not Feul Eligible
:Measures
Attic sealing with two-part foam 3 ''' " ` s-
$75.00 $225.00 3 $225.00 t
Basement sealing with two-part 1 %75.00 $75.0o foam 1 $75.00
Total
$1,788.78 $1,788.78
Contractor Instructions:
Before Starting the Job:
1.Please notify us 24 hours before starting or scheduling a job. 11.. Incorpora eblead 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 ARP work on US
Department of Labor Certified Payroll Report Form WH-347.
Additional Contractor Instructions:
Certificate of Insulation posted? Yes o (Circle One Attic Inspection form attached? Yes N/A (Circle One)
Where Posted:-_e/ y/„
Contractor: rD'e+ Date:
WAP Auditor:
Date:
Energy Director:
Date: Fiscal Officer:
Date:
Date: 1/7/2013
Page 2
WAP Work Order: Job Number: Not Feul Eligible
FOR AGENCY USE ONLY
EC036.000
re Post _ Language Other than English needed? Yes No (Circle One)
0.000 If Yes, indicate language:
36.000 Occupany change in last 18 months? Yes No (CircleOne)
5.000 Comments:
em CO 190.000 Number of windows
0.000 Number of rooms
0.00 -
Date: 1/7/2013
Page 3
WAP Work Order
North Shore Community Action Programs,Inc.
98 Main Street Job Number: 120468
Peabody,MA 01960 Work Order Date: 1/7/2013
Phone: 978-531-8810 Ownership: Renter
Advanced Energy Solutions
28 Hamilton Road Auditor:Brandon Dorrington
Peabody MA 01960 Email: bdorrington@nscap.org
Email: rborges95@comcast.net Cell: 781-540-8569
Phone: 781-475-2095 Phone: 978-531-0767 x121
Kerri Collins
101 Mason St NGRID Gas $1,538.98
Apt. 1 Total $1,538.98 .
Salem MA 01970
Landlord Name:David Boyers
Landlord Phone: 781-639-9019
r+AUthorlZed
Via.
+,bMeasureDescrlphon
7�`4- , ,� ,rvr Qty PrICe"
i ^''k �' nfxi k a +" r r�s .Qty 3 TOYaI yy2 � a Frly Y� COmmenf5 h uy
x *Ba'sement Insulation*� t'• _ � - ,, s x w-r �
4.i,
Sill two-part foam w/fiberglass bait 108 %2.20
$237.60 ]08 V217.An Unfaced FG
-
f
Adjust striker late
P 1 $20.00 $20.00
1 $20.00
Fixed Sweep 4 $15.75 $63.00 4 $63.00
R-5 Ductwrap or R-max on door 1 $51.00 $51.00
1 $51.00 w/FB
Weatherstrip s/Q-Ion or equal 5 $45.50 $227.50 5 $227.50
lIeelth&Safety*`
u Clothes dryer vent including 1 •_ .�tr + ';„i x. ,��yw„ , s Ya' 'k
Exhaust Duct $89.00 $89.00 1 $89.00
M1 ulation , # -
q
Ins
Domestic water pipe wrap 6 $2.63
Hydronic pipe insulation to 1 in. 110 $3.41 $375.70 ll0
copper pipe R-5 $375.10
Date: l/7/2013
Page 1 _�'
Ysnl
WAP Work Order: Job Number: 120468
Mts ,c'Measare k' i
,- fir; Q
Basement sealing with two q •-.,;a, r ,,,� �,�,+ .� -e,Fp.szYtf� ? 5,Y
foam $75.00 $300.00 4 $300.00 I hr-FB @ front steps/1 hr-mortar
drafty hsmn't foundation @
erm
Building Permit - '<•` r��s :Fws'�.u> �h" :.N .
I $100.00 $100.00
$100.00
Insulatton , `' t
k.G
� 4
Test drill 4 sides ,
1 $60.00 $60.001 $ 0.00 `
Total
$1,538.98 $1,538.98
Contractor Instructions:
Before Startin the Job: the1. Please notify us 24 hours before starting or scheduling a job. 11.. ng Injcorpora eblead 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 WH-347.
Additional Contractor Instructions:
Certificate of Insulation postedZ>No (Circle One
Attic Inspection form attached? Yes N/A (Circle One)
Where Posted: j p, � q
- Contractor:
Date: i i WAP Auditor:
Date:
Energy Director:
Date: Fiscal Officer:
Date:
Date: 1/7/2013
Page 2r-
f�
WAP Work Order: Job Number: 120468
FOR AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
Dryer CO 0.000
If Yes,indicate language:
Stove CO 2.000
Occupany change in last 18 months? Yes No (Circle One)
H2O Tank CO 1.000
Comments:
Heating System CO 36.000
Number of windows
Ambient CO 0.000
Number of rooms
Blower Door 0.00
,r
Date: 1/7/2013
Page 3