3 NURSE WAY - BUILDING INSPECTION (2) The Commonwealth of NlassachuSettS CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CN[R Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
Chis Section F6rOfficial Use Only
Building Permit Number: Date Applied ,
Building Official(Print Name)
. 'Signature ,_ , Date.
SECTION 1:SITE INFORtNIATION '
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
Map Number Parcel Number
l.Ia Is this an accepted street?yes_ no
p
1.3 Zoning Information: 1.4 Property Dimensions:
Lot Area s Frontage(ft)
Zoning District Proposed Use ( q ft)
1.5 Building Setbacks(ft)
Rear Yard
Front Yard Side Yards -
Required Provided Required Provided Required Provided
1.6 Waat Supply: (NI.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage/pisposal System:
Zone: Outside Flood Zone? Nlunicipal® On site disposal system ❑
Public Private ❑ Check if yes❑
SECTION 2:1'PROPERTY'OWNERSHIPj'
2.1 OwnertofRecord: O, 1�
C \ r'�tor.Q �,t 1ae/Sy l-LC,
Name(Print) City,State,Z P
4, � arc¢{ �40al�1o2.' d5ut1 Sew Iloilo/cv Cc>r �s ;�dr
A(,-0 �C _�No. and Street Telephone Email Address
-
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteratien(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2: �a,.0 �tn n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only,
Item Labor and Materials
I Budding Permit Fee $ Indicate how fee is determined:
1. Building $ ,
❑ Standard City/Town Application Fee l act )
2. Electrical S ❑Total Project Cost''(Item 6)x multiplier x
3. Plumbing $ 2 ,Other Fees: $
4. Mechanical (FIVAC) $
List:
5. Mechanical (Fire $ Total All Fees: S
Snppression) .
Check No, Cheek Amount:. Cash r\mount
6. Tutal Project Cost: $ ���QQd ❑ Paid in Full _ [IOutstaitiling Balance Due __
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Sup(errviissor License(CSL) lb 1q b 5 t4 aOl
S \1 0.(� _ License Number Expiration Date
Name of CSL (ladder
List CSL'iypz(see below)
6q 5SDA \ Sk ntoe- 4- 1
No. and Street Type Description
c' M+'� Oa,SS U Unrestricted(Buildings u to 35,000 cu. 11.)
2 ear R Restricted 1&2 Family Dwellin
City/Town, State, ZIP NI Nlasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Ih6o-oaaa I Insulation
pelt hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
FIIC Registration Number Expiration Date
FIIC Company Name or I-IIC Registrant Name
No.and Street Email address
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 ..........IN( No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNHT
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' 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 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 fund under NI.G.L. c. I42A. Other important information on the HIC Program can be found at
www.mass.�'ov oca Information on the Construction Supervisor License can be found at www.ntass.sovrdos
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
fype of heating system— --- Number of decks/ porches "
1'}'peOfc001ingsy;iaut_-- Enclosed . ..__-------Open _
3. `'IbCal Project tiqu:vc Footage' may 6e substinned for''fnfal Project CoA"
CITY OF SALEM, AxsSACHL'SETTS
BumiNG DEP. IMW—NT
3 1 r 120 WASHINGTON STREET,3iD FLOOR
TEL (978)745-9595
Rix(978) 740.9846
KI\(BEnelf DRISCOLL
MAYOR. TrtOSL►s ST.FtEQRti
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aimlicant information 1 Q 1 1 Please Print Leeibtx
Ntlfne(BmiiwsyOrgtniratiorvindividual): LL-C
Address: 100 Cu���- -< - CA+
City/State/Zip: (gyp .)r,r (q . M O I Cl l5 Phone hi: bin q O xs,A y
Are you an employer?Cheek the appropriate bogs 'rype of project(required):
1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. New construction
employees(full and/or part-time).' have hind the subs:onractors
2.0 1 am a sole proprietor or partner- listed on the attached shcut t Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp.Insurance. 9. 0 Building addition
(No workers comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their to.0 Electrical repairs or additions
3.0 1 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 12.0 Roof repairs
insumncerequired.]t employees.INTO workers, 13.0Other
camp,insurance required.)
•Any applle:ml that chsxks box rl must also till out the uctioe below showing their woekars'evmpenomlon poaey inrurmation,
'I h. ,vawm"who submit We affidavit indicating they am doing all work and then hors outride contact n most submit a new aminvil indicating such.
:Gmorncton that check This box must anaehod an additional sheet showing the name or the subs nmaelon and Ihotr workers'eamp.put icy infonnttion.
lam an employer that fs providing workers'compensadon larurance for my employe" Below If the pollcy and Jab site
iafortnarion.
Insurance Company Name: bo,"U �• 1"�C.1 cJ-t'��t SV fit`CR, t"T �C y
a
Policy 4 or Self-ins. Lic, d: W L^Cga. (X 1-�i�- — Expiration Date: 1l U6 1�_ '
lob Site Address: UN- aYJ K) .1 t SL �� Cityistate/Zip:Se 1R v\ Wr v1970
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Suction 25A of N IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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$230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Oflice of
Investigutions of the DIA for insurance coverage verification
/do hereby certify ender the pules and penuldes of peryu that the Ltfunnurlon provided above is true and cornet
iicn;tture: t✓&/ Duto: a 14 � ) 3
P_ n ,i &9 b) o - asp 4 LI
U/)iriul use unly. Du not wrile in this area,to be completed by city ut town,,JJ7cJoJ
City or Town: __... _ Permit/1.lcense k _ 71axpector
Issuln{tAulhorily(circle uric):
1. Bourdof Health 2. Building;0upartntent 3.City/fotvn Clerk 4. Electrical Inspector 5. Plumbi
5.O1her
Contact Person:—, . . _.__._. _. Phone 8:
s •
Lk a3y
t
Yf,
<r CITY OF S�U.E,%I, 1'LuSACHUSETTS
{ BU'MC�'G DEPAR-ME,IiT
C. 120 %V-kSHLNGTON STREET, '
' TEL (978) 745--9595 FtiooR
(978) 740 9346
KINMERT Y DRISCOLL �.{'�
NLWOR T HOMAS ST.PIERA2
DnucTOR OF PUBLIC PROPERTY/BI:IL0mG 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 l t 1.5
Debris, and the provisions of iMGL c 40, S 54;
Building Permit i# 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;
kc.
(nama of hau
The debris will be disposed of in
--- (name of facility)
(address of Yacilay)---
N
signature of Pero t applicant
date
t.
1
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
Lvt
LOCATION 3 ) P f,t&'V DATE 6 ZZS
ASSESSORS DATE
93 Washington S U.
CITY CLERK DATE " R
93 Washington St.
PUBLIC SERVICES DATE
120 Washington St.
WATER DATE ��
120 Washington St.
CROSS CONNECTION DATE ' f« lVB
5 Jefferson Ave
PLANNING (, 4
—� DATE
120 Washington I
t.
CONSERVATION E-_1
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH ?_ 1N36� DATE t 2�
120 Washington St.
BUILDING INSPECTOR DATE
120 Washington St.
ACOR�O CERTIFICATE OF LIABILITY INSURANCE DATE IM12GOVI Y)
02/01/2073
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 endorsement(s).
PRODUCER Phone: (978)7446433 Fax: (978)744-3575 CONTACT Deb Tournas
.N _.
GERALD T MCCARTHY INSURANCE AGENCY, INC PME:—
- PHONE --
92 NORTH ST .Wc.No-EaIG_-(978)744-6433__-,__-__._- FA" (978)744-3575
E-MAIL
debbiet@gtmccarthy.com
POBOX 839 Ao0RE55:_
PRODUCER 637
SALEM MA 01970
INSURER(S) AFFORDING COVERAGE NAIC p
INSURED HOLLORAN DEVELOPMENT LLC INSUREflA Acadia Insurance Company
C/O JEFFREY HOLLORAN INSURER B
41 FAIRMOUNT STREET - INSURER
SALEM MA 01970
INSURER D:
INSURER E
INSURERF ;
COVERAGES CERTIFICATE NUMBER: 22728 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 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 WIN MAY HAVE PAPIP UCED BY PAID CLAIMS
INSR ADD'L SUBR POLICY EFF POLICY EXP
LTEL TYPE OF INSURANCE POLICY NUMBER LIMITS
----- IMMlD04CKp_ (MM@DtY10'Y)_ — __ ____._.
GENERAL LIASIDTY
EACH OCCURRENCE_ $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
PREMISE5_fEe
CLAIMS-MADE I7OCCUR MED.EXP(Any one person) $
PERSONAL 8 ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCT$-COMP/OP AGG $
—I PRO- — L$ --
$POLICYLIEGL.�LOCAuioMoelLE LMe1llTY COMBINED SINGLE LIMIT
ANYAUTOIEa accidenqALL OWNEDAUTOSBODILY INJURY(Per person)BODILY INJURY(Per accident)SCHEDULED AUTOSPROPERTY DAMAGE
HIRED AUTOS (Per accident)
NON-OWNED AUTOS $
$
UMBRELLA LMB _ OCCUR —_ ----- --�----__------ — --------- EACH OCCURRENCE — $ —_—__----_—
ExCESS uae CLAIMS-MADE AGGREGATE
DEDUCTIBLE _ $ -
ftETENTION $ $
A WORKERS COMPENSATION r I WC STATIL —r pTH AND EMPLOYERS' LIABIUTY YIN WC2020001688 11I06I12 11/D6/13 SORYL1ata5_�_—J_ I
ANY VROPRIETORIPARTNEIVEXECUTNE E.L.EACH ACCIDENT $ 100,000
OFFICERIMEMBER EXCLUDED? 71 NIA
(Ntandetery In NH) E.L.DISEASE-EA EMPLOYEE $ 100.000
DESCRIPTION OF OPERATIONS W. E.L.DISEASE-POLICYLIM1 $ 500.000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 107,Adtllllonal Remarks Schedule,If more space is required)
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
93 WASHINGTON STREET I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
SALEM,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Attention: / T�
�ah T�l rights reserved.
The ACORD name and logo are registered marks of ACORD
1 � l
o
To Salem Building Inspectors:
Holloran Company has secured me as their HERS rater for building on Nurse Way and
suroundings as of 1/1/2013.
I am currently processing the Projected HERS scores for these homes.
Thank you,,////►
Ian Rem!
��3/ 1.3
i .-
Dominic Pezzulo
Fwd:Holloran Companies
' January 31,2013, 11:47 AM
Jeff Holloran
Sent from my iPhone
Begin forwarded message:
s ,
Ian Rex
Energy Efficiency Analyst & HERS Rater
978-578-1782
11 Broadway, # 3, Beverly, MA 01915
The -- -
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OM
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.Ji1'i;Ji .. , .�i ii 4 ;L;! ,1,.:f t:fJ111t 4� .Iful 4:
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r ,_ ,, � .. ,y' �, .-n _ii 1 ar�y [gin , �u r r�
ftem/Cost Namepermits
^,
city water and sewer hook up fee $� _.,.250.� pull Permits based on 145k=$1595. $11 per$1000+$5=1600
architechtect $ 1,000.00
engineering $ 2,000.00
windows $ 4,368.00
utility water and sewer
final grade rough loam
perimiter and basement stone
excavation,backfill,rough grade
excavate for foundation
tree clearing and stump removal
foundation $ 850000
foundation coating $ 400.00
concreate floor $ 2,50000
framing labor S 9.000.00 8k usher
framing lumber $ 16,000.00
decks $ 1.500.00 -
trash removal $ 1,000.00
hvac $ 8,675.00
plumbing $ 917500
pump sewer $ 3,500.00
bath vanitys and tops $ 1,000.00
water heater $ 650.00
fire place $ 1,400.00
fire place mantel $ 500.00
electrical $ 10,370.00
insulation $ 4,000.00
sheetrock $ 9,149.00
kitchen cabinets $ 2,500.00
finish floors $ 6,400.00 hard wood carpet vinyl
light fixtures $ 500.00
trim and stock $ 3,000.00 doors trim stair parts
finish carpentry $ 3,000.00 install all doors,trim,kftchen and bath cabinets and van itys and microwaves stairs
painting $ 2,400.00
appliances $ 2.500.00
cleaning $ 40000
ley John $ 200.00
mailboxs $ 10000
siding labor $ 3,500.00
siding $ 3,200.00 3200 labor tucci
roof $ 3,700.00 18.5 square
garage doors $ 2,000 00
counter top $ 2.300.00
landscape $ 3,000.00
drive way $ 2,500.00
mist labor $ 300000
contingencies $ 4,728.00
$ 145,000.00
Subtotal Subtotal
Real Estate Taxes
Light/Electric
insurance
Total
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Construction Su�3 pertrisor License
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' sg License: CS 76746if
r ' �,i "THOMAS J„'BRYAN a = 4
` $4, SOUTH''ST 'FLOOR #1
MEDFORDa MA 02155 ,: A
5/1412013
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