5 NURSE WAY - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
�� al Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CIviR SALEM dMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
- This Section For'Official Use Only
Building Permit Number:. Date Applied.- '
Building Official(Print Name) - '.'.'Signature Date
SECTION 1: SITE INFORMATION -`
1.1 Property A dress:ff 1.2 Assessors Map& Parcel Numbers
Q?id < .f. .-kD l" 07- 0331 — 0
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 Wate Supply: (M.O.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public l� Private❑ Check if yes❑ Municipal Von site disposal system ❑
SECTION 2:, PROPERTY'OWNERSHIPt.'
2.1 Owner'of Record: Q
750 le v. too v.c �.t Ao�s a LI—G 1�e.uc�0.� Vk 01`1 1 S
Name(Print) �•1 r. City,State,ZIP
� t}ollo/�nCnn,/1[x,�nrfS •f
No.and Street Telephone Email Address
SE TION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 21Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': P e w µo n-p
SECTION 4: ESTIMATED CONSTRUCTION COSTSs
Item Estimated Costs: Official Use Only--,,,
Labor and Nfaterials y'`
1. Building $ 1. Building•PermitFee $ Indicate how fee is determined:
❑ Standard City/Coven Application Fee
2. Electrical $ .Cl Total Project CosY,(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
1. Mechanical (HVAC) S List:
5. Mechanical (Fire $
Su ression) "total All Fees: S
Check No. Check Amount: Cash Amount:
6, Total Project Cost: S �U Paid t _� OUv 0 I au! in Full ❑.Outstanding Balance Due:________
SECTION 5: CONSTRUCTION SERVICES
S.1 Construction Supervisor License(CSL) -76-79 ,6s I ) a0l 3
Si 0.!� License Number E.e iration Date
Name of CSL Holder K
List CSL Type(sae below)
sq Sv L�,_ S+ F1uy� `�
No. and Street Type _ Description
L�U VAN
N tea, S � U Unrestricted2 Family
(Buildings u el ing cu. tt.
/ 1"\ R Restricted 13e?Famil Dwellin
City/Town, State, ZIP NI Nlasonr
RC Rooting Covering
WS Window and Sidin�
SF Solid Fuel Burning Appliances
-1W _08aa I Insulation
'1'ele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(1IIC)
MC Registration Number Expiration Date
HIC Company Name or l-IIC Registrant Name
No. and Street Email addressli
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 ..........N4 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.
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 A.-ent'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.aovoca Information on the Construction Supervisor License can be found at www.mass.co�';'dL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _(including garage, finished basementlattics, decks or porch)
Gross living area (sq. R.) _ habitable room count
Number of fireplaces_ Number of bedrooms
Number of bathroours Number of half/baths _
1'vpe Of treating system --_-- -- Number of decks/porches
1'ypeofcoolingsystem-----___--- Enclosed--- _Open _
3. `' focal Project Square Footage" finny be Substituted for"fntrl Project Cost"
a
CITY OF S.u.E11 INLAjS&. CHCSEM
BUILDING DEPAR.MNT
7' 120%VASHLNGTON STREET, 3'FLOOR
TEL (978)745-9595
Rue(978) 740-9846
KIJ[BFRT R.Y DRISCOLL -
MAYOR THOMAs ST.PtERM
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COSCMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Avolicant information Please Print Leeibir
Name(Busitxsyorgtniratiorulndividuagl: 1 1 P _[..�ora.n-4 R\), ,As /c� . L(-Cr
Address: ` Q00
City/State/Zip: CAP,J ZA J. V\N 01 G 1 s Phone#: 910 �, - a5 4 q
Are you an employer?Check the appropriate box: Type of project(required):
I.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. New construction
employees(MI and/or part-time).* 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 sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp. Insurance. 9, 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself. [No workers'cump. c. 152,11(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.0Olher
cump,insurance required.)
•Any applicant that checks box r I must atso fill cut Ow u.lioo below thawing Choir Wooten'compenudon policy infl mnallan
'I Lvnuuwm"who rubmil this,fllMvit indicaing They am doing all work and then hire outside contractor mmt submit a mate ahidavit indicating such
�Cuntractun that Oct;k this box must attached an atUdunal,hoot showing the nano of the rubaunlruWn and their workers'comp.put icy infomneon.
l um an employer that Is provldbof Ivorkers'compeasaton Insurance for my empluyees Below is the policy and/ob slt8
iujonnurion. (-� i M 11
Insurance Company Name: vf4'A4 T ` C_CCV'f(t31y r S�)(anfP C `�
Policy 4 ur Sclf--itsii.Lic. d:,w]c_ aC)a. 000 I t 7 Expiration Date: I b6 o _
job Silts Address: L-V— aj3 ) 6Goa Cs f f CitylSlate/2ip:. '0 r� ! MrT oi 9 7�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
1•Aure to sucuru coverage as required under Suction 23A of MGL e. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a line
of up to S'_30.00 a day against the violator. lie advixed that a copy of this statement may be forwarded to the Orrice of
Investigatio s of the DIA for insurance coverage verification.
l du hereby certify under the polns and pdnu/rler ujperya hat the fajorinurlon provided above is true and correct.
�i,,nanurcj Data' aly 113
P n ,'l• 1 ctv - Sy
FC,:,tyior*ruwn.-___
cialuseuniy. Do not write in this urea,to be completed by city ur townaIJlciab- Permit/f.lconse# 71nipector
I.ssuing,lulilorily(circle one):
1. Dourd of Health 2. Building Department J.City/fown Clerk 4. Electrical inspector 5. Plu
B.Othcr _
Contact Person: Phone it:
' I
L
1gg
C
r
CITY OF S.1L E\i, -LkSSACHUSETTS
UL.ILONG DEPART.L&NT
120 WASNINGTON STREET, 3'FLOOR
TEL (978) 745-9595
Kl.NtBERLEY DRISCOLL FMX(978) 744O-9846
bL�YOR T io.%w ST.PiEm
DI.RECTOR OF PLBLIC PROPERTY/8L1MDzG COS3IISSIONER
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 111.5
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 transporttcd by:
JcLou
(name uler)
The debris will be disposed of in
--. (name of facility)
-- (address of facility
r`
signature of permi applicant
date
Jabns.ill'J.w
CITY OF SALEM
ROUTING SLIP
New Construction `Z
Certificate of Occupancy
07
LOCATION LPl- 7 )v DAT $
ASSESSORS DATE w l�
93 Washington t.
CITY CLERK DATE I ✓I
93 Washington St. ff
PUBLIC SERVICES_,DDATE lj
120 Washington St. lye 11
WATER DATE I• l
120 Washington St.
CROSS CONNECTION DATE tik L; "'� Ifr�t C r'•
5 Jefferson Ave J
PLANNING - ' DATE
120 Washington t.
CONSERVATION TE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH If— DATE ( Z Z
120 Washington
BUILDING INSPECTOR DATE
120 Washington St.
'qGo CERTIFICATE OF LIABILITY INSURANCE DATE IMM/DO/VVVYI02I01/2013
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 pollcy(les) 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
92GERALD
NOR?T MCCARTHY INSURANCE AGENCY,INC PHONE 978 744 6433 F"'I 8)744-3575
_(97____-__
92 NORTH ST _fNO_No.Ex11;_�. �
E-MAIL debbiet@gtmccarthy.com
P O BOX 839 ACORE$S:.—-------------...----_..---- .. .-------.._— ------------
SALEM MA 01970 PRODUCER 537 -...----
_— _ INSURER(S) AFFORDING COVERAGE NAIC Y..__...
INSURED INSURER Acadia Insurance Company
HOLLORAN DEVELOPMENT LLC
C/O JEFFREY HOLLORAN INSURER B
41 FAIRMOUNT STREET INSURERC
SALEM MA 01970
INSURER D:
INSURER
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,
EXrLIJSInNS AND-GONDITIONS OF SUCH VITS SHOWN MAY HAVE BEEN REDUCED BY PAID Q.1 AIMS
INSR A0LIR 6R SUBS POLICYEFF POLICYEXP
TYPE OF INSURANCE POLICY NUMBER LIMITS
SB._W.Vo '.YYYI IMMlDOttYYYI—
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO DAMAGESGa RENTED
CLAIMS-MADE I7 OCCUR MED.EXP Any one person) $
PERSONAL S ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO Is
PRO. --
POLICY ILOC
$
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
(Ea accitlanp
ANY AUTO --- - -----
ALL OWNED AUTOS BODILY INJURY(Per person)
BODILY INJURY(Per accident) $
SCHEDULED AUTOS -
PROPERTY DAMAGE
HIREDAUTOS (Per accident) $
NON-OWNED AUTOS $
$
UMBRELLA LMB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE _ $
DEDUCTIBLE _—
RETENTION $ $
A VroRKERD COMPENaAYON WC2020001688 11IO6112 11/06113 WC srAru. I—r OTHI$
AND EMPLOYERS' LIABILITY YIN ---
ANY PROPRIETORIPARTNE (EXECUTIVE E,I I.EACH ACCIDENT $ 100,000
OFRCERIMEMBER EXCLUDED? NIA
(Mandatory In NH) — E.L.DISEASE-EA EMPLOYEE $ 100,000
IIw XxXibe urn
I I
DESCRIPTION OF OPERATIONS below l E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
SALEM,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS.
- AUTHORIZED PEPRESENTATNE
Attention: !` ,' / u
c �- �ah . All rlrrig s reserved.
The ACORD name and logo are registered marks of ACORD
Ho d'
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 Rex
Dominic Peuulo
Fwd:Holloran Companies
' January 31,2013, 11:47 AM
Jeff Holloran
Sent from myiPhone
Begin forwarded message:
i y
i
Ian Rex
Energy Efficiency Analyst & HERS Rater
978-578-1782
11 Broadway, # 3, Beverly, MA 01915
The
Ho d
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`a tl`75 t ,'i1.F1_,[i r, •7ii ,. .�`�. ;._a 8i.0 .! ! d4;i.31 i .,r.!?i$
�r'._lu JI-?Y.rfF,.i. ]i ,fnl J ';iJli - t1*. i i,• ; Ci ItJ V tir? 'on( , il,i!
�•`.lL'ci i P,14 (..�:�L c 4 '� ,-`i.� r� t,n icy ,•! ) ,:41ti i � � ,i( -IT '� .1 ,� k- _lt I ...i � 1C' a-h
ltem/Cost Name
permits ' $' m �1,135.00 pull permits based on 145k=$1595. $llper$1000+$5=1600
city water and sewer hook up feE $ 250.00
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 $ 8,500.00
foundation coating $ 400.00
concreate floor $ 2 500 00
framing labor $ 9.000.00 8k usher
framing lumber $ 16,000.00
decks $ 1,500.00
trash removal $ 1,000.00
hvac $ 8,675.00
plumbing $ 9,175.00
Pump sewer $ 3,500.00
bath vanitys and tops $ 1,000.00
water heater $ 650.00
fire place $ 1,400.00
fire place mantel $ 50000
electrical $ 10,370.00
insulation $ 400000
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,kitchen and bath cabinets and vanitys and microwaves stairs
painting $ 2,400.00
appliances $ 2,500.00
cleaning $ 400.00
jiffy john $ 20000
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
misc labor $ 3,000_00
contingencies $ 4,728.00
$ 145,000.00
_ Subtotal Subtotal
Real Estate Taxes
Light/Electric
insurance
Total
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7 yy•
+d(iard of Building Rvoulat.tions :iiic!
Construction Supervisor License
License: CS 76746
THOMAS J �BRYAN "
84 SOUTH".ST; FLOOR #1.
, ' ` ` MEDFORD, aMIA 2155
Expiration. 5/1M2013
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