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11 MAY ST - BUILDING INSPECTION Gl� I Ll s� The Commonwealth of Massachusetts a Board of Building Regulations and Standards CITY Massachusetts State Buildin g5551i'E SALEM IMP&MO MES Revised Mar2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Faq#lvlli 9 This Section r tcial Use Only AA Building Permit Number: Date Applied: �1 Building Official(Print Name) Signature Date 1 SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers I I N A `( ST Lacer OrJ Pf 51 1.1a 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: "ge V ISAt't2lM I AA.t4 Name(Print) City,State,ZIP It MAg s-W—f—f UNIT sJ- 60Ay-Z-9D No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work : /AISDI.4 (V 5 d V 1. S! ' pffiuvai SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materi s 1.Building $ l4,1 R_ e 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ e ❑Total Project Cost (Item 6)x multiplier�. 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ F D� Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ l� ❑Paid in Full ❑ Outstanding Balance Due: aara011� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) a_(AaOp v epft e License Number Expirati n Date Name of CSL Holder 66 n I I ` �� List CSL Type(see below) No.and street Type�I Type Description o m U Unrestricted2 Family (Buildings u el ing cu.ft. R Restricted 1&2 Famil Dwelling City/Town,State,ZIP �— M Masonry RC Roofing Covering WS Window and Siding ��) �� _ �� l/��jej� SF Solid Fuel Burning Appliances r� Nqt vial wvki, I IInsulation ele hone email address D Demolition 55..2 Registered to Improvement Contractor(HIC)Pn IV I , 1 1, HIC Registration Number EI pir ion Date C C mpan sine or HIC Re istran Name HIf �b nnin� �S 1 &sib 10aM411. co. No. S et �� Email d ess . I AAA Qn 12T -73- ago 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 ..........'3%, 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 SQQ to act on my behalf,in all matters relative to work authorized by this building permit application. Q Print Owner's Name(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 understandin . g a 1s PrinOwner's or Alithorized 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 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.Qov/dns 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 half/baths 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" IL4Dq V test## ter ITT r7r- mass save pCCN NIACCMR Sn'n¢ctrouQh.wrpy steleney PERMIT AUTHORIZATION FORM I, KAREN CUSHING owner of the property located at: (Owner's Name,printed) 11 May 5t Unit S1 SALEM (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. X � Owner's Signature C9-G-ZO15 Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: e- PF T :::�-1 2//5 Participating Contractor Date af�a oil For Office Use Only Rev. 12132011 r CONTRACT FOR Conner anion PRODUCTS I SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among and Karen Cushing Conservation Services Group(CSG) 11 May St Unit S 1 Salem,MA 01970-2149 6 RCS 0 Washington Street,Suite 3000 Site ID:S00050032903 Westborough,MA 01681 Project ID:P00050037852 Reg.No. 173484 Customer ID:C00050033214 Federal ID No.222457170 Contract ID:20150703_WORK (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner mid in accordance with the terms of this Contract,including the attached remmmendations/work order describing the work in detail(the"Work")which are incorporated herein by reference: Description Quantity Location Insulate Rim Joist with 6.25"Fiberglass Batting 54 Living Space $129.60 Insulate Vinyl Sided Wall With 4"Dense Pack Cellulose 504 Living Spam $1,214.64 Blower Door Test Only(Diagnostic Testing Part). _ „ . ..1 ., N/A $65.70 Sub Total: $1,409.94 1.1111ily Incentive Share $1,05T46 Customer Contribution $352.48 Pre-Weatherizatlon Incentive $125.00 Remaining Customer Contribution $227.48 For office use only Printed:7IN2015 Page 2 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1;$ 70.00 as a Deposit payable to CSG upon signing the Contract(not Tg, cGgd 1/3 of the total retail costa).Mail check✓$contract to CSG,Attn:RCS,00 Washington St.,Ste. 8000,Westboroullb,MA 01581.Final Payment$ 1y/•45 as the final payment for the Work shall be payable to the Independent Installation Contractor("IIC")upon satisfactory completion of the Work.Customer understands that helshe will not be required to pay the Utility Incentive Share of the Contract price in the amount of$1,057.46 .Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III.DISPUTE RESOLUTION The HCand Qrstumalierebyriummly agree In advance that in the event that the ilC bass drsputerWrccmity,this Contract,the gC mqy submitsuch dispute to a private arbitration service which has been approved by the Vice of Corm aAffaksand Baaness Regulatim=dQisamershagberegrlhedtosubn&tosuchadritradm asprovidedhi M.GLe 1421L 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 ported, by telegram sent or by delivery, not later than midnight of the third bulir>ssclayfollpwing a si,ning of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. X yL� &L4 _ X �° iS� X Customer Sign a Date Indicate your seleeteil IIC here,if applicable (OR) Initiallnitial here want aiLl catty 7/3/15 TOf e Herrin the I rograrn to assign a CSG Signature Date Name of CSG Rcpres�n[ative(Printed) Participating Contractor TERMS AND CONDr1TONS AVATAR ON THE REVERSE. 8/14 RCS PLANVIEW DIAGRAM �j' �.n Customer. Home Phone: ( /-7 L- - 9-!3 1 yy L1� q Address:�L/�J A"Y r5f / Work Phone: ( t- - Town: Cell Phone: C )- Any amitata for access by large truck? No_ Ytt / nyes,describo: 0-'f+ Arty specific dlrectkmsd landmarks? No ✓ yes__ If Yes,di wdb(.. Site ID:5 003 210j Energy Specialist: xohr, A / Reviewed by: © �J " r (� la-wr— tor' —I -- /D 3 as �24 alb For Office use Only 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=Wail S=Sheathing Temp Unless Noted Otherwlse =Vents Note in Triangle R=8"Roof S=Soffit G=Gable M=12"Mushroom For Access Rev 1/14