12A MAY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
- Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or De a
One-or Two-Family Dwelling
This Section For Official e Only
Building Permit Number: I Date A liieedd:
Building Official(Print Name) Signature Date
SECTION l: SITE INFORMATI
1.1 Property Address: 1.2 Assessors tap Parc umbers
1.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Cf1w�0
Zoning District Proposed Use Lot Area(sq R) Frontage(it)
' 1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
6 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: D
U4P_ _ BW�Ps vx/ 5AIeM
v_
Natne(P�/nt�) City,State,ZIP
-
/L /7 �(
No.and Street �� " elephot ey Email Address -
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: Lj/2.y,'71.,, ;`2 ri•oa�
Brief Description of Pro osed Work'':
,, n
a)
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ ` 3 0 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ Cl Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier_ x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees: $
4 ZD a Check No. Check Amount: Cash Amount:
6. To[al Project Cos[: $ J 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 163 q?41 /`Z3" 20,(3
JE&RW M�.Yd'a 9",P License Number Expiration Date
Name of CSL Hold r
List CSL Type(see below) �)
t�)o.and Sveet Ty Description
1._„yCNd✓ ��� �l S� U Unrestricted(Buildings up to 35,000 cu. ft.)
Restricted 1&2 Family Dwelling
CC�own,State,Z P M Masonry
RC Roofing Covering
WS Window and Siding
+�� SF Solid Fuel Burning Appliances
/1Sf 1 I Insulation
Telephone Email address I D Demolition
5.2 ggRegisyt'�ered Home
Improvement Contractor(HIC) ,
.J —r m w y � - C R.Ais ber Ex6rati;AITte
�t7C CR,Qmpany Naffieor HIC Registrant Name
�t'ct 45dJ0 $�2S C"
No.and Street _ ^� Email address
t_utiN
Ci /t owe,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 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf, inall ma�ttters relative to work authorized by this building permit application.
s S /
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
contained in this a placation is true and accurate to the best of my knowledge and understanding.
Print er' o onze A s Name(Electronic Signature) Date
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
Z. 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 Cast"
CITY OF S.U_E:NN , AXSSACHUSETTS
BUILDING DEPART%MNT
' 120 WASHL*IGTON STREET',3sa FLOOR
TEL (978) 745-9595
FAX(978) 740-9946
KI,),tBFRI EEY DRISCOLL
.MAYOR �I4lohus ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BUtIDLNG CO%L%aSSIONER
Workers' Compensation Insurance Affldavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information / Please Print Legibly
Nalne (BusitnnsxOrpnizatiowindividual): �l 7e6iS,yNS (it/FtN6�C A �✓�j(J/CGS J LLC
Address: Cd 670.t7 a-z Zc7
--6
City/State/Zip: LSly ,Lz OM Phone N:._7t�!'Mtf-&bA
t
Are yo .an employer?Cheek the appropriate box: Type of project(required):
d. am a employer with,) 4. ❑ I am a general contractor and 1
6. ❑New construction
employees(full and/or pan-time).• have hired the subcontractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractor have 8. ❑ Demolition
workingfor me in an capacity, workers' comp. insurance.
Ya9. El Building addition
required.]
workers'comp. insurance 5. ❑ We are n corporation and its 10.❑ Electrical repairs or additions
required.] officer have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself[No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof tepaus
insurance required.]t employees. [No workers' )3.0 Other
COMP. insurance required.]
'Any applicant that chucks box xl must alw fill cut the section below showing their wwker'tvmpensuiun policy infurmation.
I Lxmuwrvs who submit this affidavit indicating they are doing all work and then him omsidecontmztora must submit a new affidavit indicating such.
=C. rectors mhot check this box must annelmd on additional sheet showing the name of Ow ub�tmcton and their workor'comp.policy information.
I um an employer that is providing workers'compensadon insurance for my employees. Below Is the policy and Job site
information. )
Insurance Company Name: V.�t/t
Policy H or Self-ins. Lie,il: 417 3 PF4 _ J5_ _I/ Expiration Date:
Job Site Address: 17 69 rh4t/ 5T City/State/Zip: `X—r/FvV, (,es A
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 51,500.00 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. i3e advised that a copy of this statement may be forwarded to the Office of
Investigations ofthc DIA for insurance coverage verification.
I do hereby certify of der the pains cord tenaltles of perjury that the information provided above is true and correc6
Si'>na t re: Date,
Phone U-inoll
Official use only. Do not write in this area,to be completed by city or town onfciat
City or,ruwn: Permit/I.Icense k
Issuing Aut horny(circle one):
1. Board of health 2. Building Departmcat 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person; _._ Phone p:
i
03/13/2012 22: 51 179159558213 AMBROSE INSURANCE PAGE 01/07
OATE(W OVIYYY',
AQR� CERTIFICATE OF LIABILITY INSURANCE3/20/2 -12
o
RDDOCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Ambrose Insurance Agency, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
56 Central Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES_ BELOW. J
Lynn, MA 01901
751_592-8200 _ INSURERS AFFORDING COVERAGE NAICA
NSJRED All Seasons windows 6 Insulation wsuaeRA 5COttsd41e
P.O. Sox 8229 IINsuRFRB A be11a Protection
Lynn, MA 01904 INSURER0 TravelerIS—
IN
INSURER D' ^— �'
6URSR E
:OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE SFEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY RECUIRENIENT, TERM OR CONLATICTN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO`PlHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INOURANCE AFFORDED BY THE POLICIES OESCRIBEO HERF_M IS SUBJECT TO ALI.THE PERMS.EXCLUSIONS AND CONCI(IONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY NAVE 6EEN REDUCED BY PAID CLAEd5. _
POLICY NL'M.bEft ��LY E I ,I`/E PCOAL rY t�A?�SON
�in a v E FINRUPANY � ��� LIMITS
GENERA-LABILITY FACN OCCUP.RENGE S 1 ,000 , 000
X GCMNERCIP.GENEFWL LIABILITY PREIdS- IEF wauvn[C)�, 5 5Q ,000
—,
APASMAOE •'.X OCCUR MED FXP(AnY.'.P.RW).L �C
A CPPOG58607 1 3/19/12 3/19/13 F EPSDNALSADvwluar ': 1 .OLIO 000
IL— GENERAL AGGRE3�TF S?'000 000 '
,:N•_I,GGPEGATF.%IMIT AP;LIES
PER - PROD'JCTB,COM^/OP AGG !3 2 OQ Q
Pcuir jp �,i LOC
AUTOSIDBILEUA 5 9ILTY COMBINED SINGLE LIMIT �
�I ANYAL'TD (BeecclnBPu ___� 1 10001000
ALLOWNF,DAUTOS BOOILYINJURY S
FISCHEOULED T05 Pe!Pe wn7
.
H ; NIREo nLrroS ! 37797400001 5/15/11 T EODILYINJURY IS
5/15/_3 (PoncRlden!I
H NON ON;lEO<U'O$ II ._
PORT'DNAAGE
GaR.AGE•.It9�-DY hVTOONLr.EAnCC EANT 5
r_iAFr AUTO _
OTHER THAN EA_ArC i
AUTCDNLY. A30 9
EZC3SS/LV6RELLA -1ARQTY ! EACH OCCURRENCE 5
j OCCUR _I C:LAI;$MADE ACAC�RF,GATE
_ r 5 —
OEGLCTESLE 5
'; RETENTION 5 ` S
Tb'J0RUCdSCCNPEN9ATiCNAND—�Tj _ fW�VI BAITS % aE
FMR'I.OYERS LIABOUT'
ANY r`R-PeIETJRF.ARTNEADPPC'JTM E.L.EACH ACGIOENT S 500 000
OFf IIElLAIEAt3FB FT0.11JcJ?C 4973P69-5-11 12/15/11 12/15/12 EL DISEASE EnEMPLDYE S $00 000
I'' dn:.vioe u..tlar T
51'-ECW.PROVISI]Nt< e,W '3.L.DISEASE-POLICY LVAP; S 50Q 000
'.' OTHER i
� I I
IJeScr PTION 0--OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BYENDJRSEIAEN'Ti SPCCIAL PROVIEIONS
Carpentry/Insulation/Electrical
i
I
CERTIFICATE HOLDER _ '^ CANCELLATION
City of .Salem SHOULD NAY OF THE AROVG DESCR BED POLICIES BE CANCELLED 9EFORE THE EXPIRATION '
Attn. : Building Dept. DATE THEREOP•T'NE ISAOING INSURER WILL ENDEAVOR TO MAIL20 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NMIBD TO THE LEFT.BUT fAILUP.E TO DO 60+HALL
City Hall IMPOSE NO DBLIGATION OR LIARII,T'OF ANY RWO UPON THE INSURER.ITS AGENTS OR
Salem, MA 01970 RE'RESENTAMVED
AUTHORVFD REF TAT
ACORU25(2001105) ---i. 'ACVRD>PtPCRATION 1988
CITY OF S.ULENI, 1NLkss.A cHusETTS
Buu-DLNG DEP1RT%1EE2NT
130 WA+SHNGTON STREET, 3iD FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI,,{BERL EY DRISCOLL
MAYOR THomAs ST.PtERR6
DIRECTOR OF PL:BIIC PROPERTY/BI;tt.DING CMMSSIONER
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 11 L5
Debris, and the provisions of MGL c 40, S 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 MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
D r�,�rL Duo p57op
(address of facility)
s;� a e o p 1 applica
date
Jcbrivfr.d(s
i
Massachusetts - Department of Public Safety
{ Bourg of Building Regulations and Standards
constructjot Supervisor License
". CS ig3}74
.iestricted to 00 0.
JEFFREY MAYOTTEi} 1
`..'I��t l•
29 ANDREWS'LN,�' ,
EAST KINGSTON .NH 03827 !"
� � 1/23/2013--L Ex iration.•
P
('onuniselonrr( - - Tr#: 1,03474
Office o oosumer A airs siaese e u a on i -
HOMEIMPROVEMENTCONTRACTOR
Registration 164564 Type, tt
Expiration 10/2J2013 IndividualNo
F
VEY MAYOTTE
JEFFREY MAYOTTE
' 29 ANDREWS I.N.
�—
EAST KINGSTON NH 03827 `
- Uaderaecretary f'
I 7
� O ,
�ar�t
Roty,-J ,,
t,
WAP Work Order
North Shore Community Action Programs,Inc. Job Number: 100709
98 Main Street Work Order Date: 7/19/2012 a
Peabody,MA 01960 Ownership: Owner
Phone:978-531-8810
All Seasons Windows& Insulation Auditor: Brandon Dorrington
P.O.Box 8229 Email: bdorrington@nscap.org
Lynn MA 01904 Cell: 781-540-8569 _
Email: njmayotte@comcast.net Phone: 978-531-0767 x121 -
Phone: 603-642-4451
Noreen Henderson NGRID-Electric - $4,29436
12 A May St Total $4,294.36
Salem MA 01970 -
978-594-5854
Safety Issue(s):Knob&Tube Wiring/Lead Paint Possible
.,Q,uthorized ; ;; Actual,
Measure Description + Comments :!
Qty, Prtce Total Qty Total
Basement Insulation t _
Sill two-part foam w/fiberglass batt 131 $2.20 $288.20
Doors
Automatic Sweep 1 $23.00� $23.00
Fixed Sweep 3 $15.75 $47.25
Repair/Refit Door 2 $52.00 $104.00
Weatherstrip s/Q-Ion or equal 4 $45.50 $182.00
Health& Safety -+
Clothes dryer vent including 1 $89.00 $89.00
Exhaust Duct
sc Insulation
Duct insulation R-5 360 $3.10 $1,116.00
Date:7/19/2012 Page 1
WAP Work Order: Job Number: 100709
Misc Measures _
-41
Basement sealing with two-part 3 $75.00 $225.00
foam
i
Pe I rmit
Building Permit I $100.00.1$100-00 1 1
Wall Insulation
Wood clapboard/shakes/shings or 1179 $1.79 $2,116.41
vinyl(dense pack)
Top Sash Lock 1 $9.50 $9.50
Total $4,294.36
Contractor Instructions:
Before Starting the Job: During the Job:
1.Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978. Lead safe practices are
2. Obtain required building permit. required.
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 posted? Yes No (Circle One) Attic Inspection form attached? Yes N/A (Circle One)
Where Posted:
Contractor: Date: WAP Auditor: .Date:
Date: 7/19/2012 Page 2