3 OUTLOOK HILL - BUILDING INSPECTION (2) dam -
I'he C•011iln011wCalth of Massachusetts
Board Of luilding Regulations ;Ind StutJards CI'I'l OF
st' Mas"c"I'Selts Slate building COJO, 780 C NIR -SALEM
I)uilJing Permit Applicaliun 'fo Construct Repair. Renuvat�Or Dcmulis a Rrrit,•d 16u 'n//
ow- or Tuv:•Piwu(r lJrre//S(y,� .
This Section For OIPc'd Use Only
building Permit Number. Da 4. pp icd:
Iit'Id' g()117,1—il IPrint none)
1)alc
SECTION is ITE IN R31 ION
L I Property Address:,
sots Nlap,fl Parcel Numbers
I.In Is this an acre (CA street? es -�—Itts Nap Nunsher 1'urcel Number
1.3 Zoning InformtsNont 1.4 Property Dimensions:
tuning District 1'ntpused ll.vu Lul Areu(s 11►
y Pronlugu(ill
LS Bulldlns Setbacks(R)
Fran:Yurd Silo Yun4
Rear Yard
Required Fran:
RequiredProvidedReyuircd PnsvideJ
1.6 Water Supply-IM.G.I.c. 40. §54) 1.7 Flood Zone Information: I.a Sewa
ide ge Disposal System:
Rtbllc❑ Private❑ Zone: _ Outs Flood'Lune?
Check if cs0 Municipal Cl on site Jispusul s)stmn ❑
SECTION I: PROPERTYOWNERSHIPI
7.I,QwnerlofRetor s /
Nune(1'nnl) C'iq•.Smtu,l.IP
3 tnJ 0��—too /Jr7 l r1 7�. 7yS/ jL?C Nu.. Slrcul relephone
Emuil Address
SECTION): DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ E.vistiny Buildiny❑ Owner•Occu1: ❑ Repairs(s) ❑ Alleration(l) Cl Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units
O fDescriptionofProposed Work':Z s.. Other
ri Spccily: . 6_ o„�
SECTION I: ESTWI.ATED CONSTRUCTION COSTS
itcin Estimated Costs:
I labor and.\ttteriah) Official Use Only
I Building S Z Of o 1. Building Permit Fee: S Indicate how fee is determined:
'. F:Iatrical S ❑Standard Ciry:Tawn Application Fee
I .1 19mnhinq S (3 Total Project C Cush l ltem 6)x multiplier _
'. Other Fees: S —
J. \Icdt.mic.d ill\ WI S List:
i �n n•ssio'tl S rotal it Fces: S
n Ibtal Project Cast i Z(r�� / ('lied \,). _ .__(-heeA
❑Paid in Full ❑Oulslatdimg II.11.utcc Doc:
ao��
tiF:(`I'lON t: ('t)Ntil'R1�("rlON SF:R�'1('F.S
i.l C'onstrucliml Supcnisor License(C tit.) _ — j:\Bruton Date
I iccn,e Nunlhcr I
Ile
(�
`.uneul'CSL Ibdllcr I is101. I'sNis Yhelaul.__.__
.1.11x Dc;criPliun
No mJ Area U l InrcsricicJ 111tuWi11 s ti to 15,000 al. 11.1
Itc,Iricwd l.l'?f.1111 Ihtcllin
Slasoll
l'ipil'o„n.Stal LII' RC Krnnin lb\erin
µy µ'indow,uld Si. l 111 -
-- SF Soli)I'uYlIlurniny'1PPliuncO
( lostdulion
���• yJy- tort D I)cnullitioo
�� fnlailuJJrc,:1
lblc hunt
3.3 Registered 110 It Improvement Cuntrnclar(HIC) ill: Itc jistrnliun NlunhYr Eq,iruuun Will
1IIC Conlpan) I(agi runt NwnY
Jr H IiIIIYII uJJrest
No atld 5 el ?d/- Y�r-a�Y'S
o„ s 69 O G1lCU
Ci Rown.Slat 21P
rtic hung 25C(6))
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G e. 1l3.
Workers Compensation Insurance affidavit must be completed and submitted with this appliccatat ion. Failure to provide
this atfidavit will result in the denial of the Issuance of the building permit.
Signed Afildavit Attached? Yes ..........
No...........❑
SECTION Tat OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNCRIS AGENT ORCONTRACTOR APPLIES FOR BU ILDING PERMIT
1, as Owner of the Subject Property,hereby authorize Ilcatlon.
to act on my behalf•in all matters relative to work authorized by this bullding pe It opp
Pr Ife /'-P2/
Print U\tncr's Nunle(Elcc --c Slgnumrc)
SECTION 7b:OWNEW OR AUTtIORIZED 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°nd accurate to he best of kno eISe It understanding ep !� /
Pfllll t)ltlkr ilR:\Illltllrl/cd,\gelll''li hilly tl`.IC\lr"'lie. Igll:IlUfY)
NO'rESt
1 t n Oregisrcred in the a a Improvement ing permitto do Cuntr Contractor l HlCl Programl.n�llLur(have access tohires an lthe arbitration registered nractur
pr` g am or guar n Iylnformtion on the
m+soon on he Conistruction Supers for Lie tnse can be found at
C Pruyram•can lbaltfound at
+, \\-htn substantial,wrk is Planned• Prot iJe the infuI including
garngt• finished bascn ent allies.Jocks or Porch)
Total floor area 1 W• 111 thbitablt room count -- -.
Urosi li\ing area 1 sy. It ..... . .. .... . .. \unlber of hcdrounls . . -
\unlhcrol'lircPlaees .. .. _ --- NkIlnberol'hall'hNhi
\unlhcrafhadrpulni . . - \unhcrol'Jceks. ponhes
I'\pe of hc.uulg s),Icnl llPcn
i I'nclo.cJ
t "fLll 1'nIccl Squ;ut I'aaLlye" nre) bc,uh,IindcJ l'tq Modal Project Ca,l.'
CITY OF StU_F_1tI, l'L1SSACHLSETTS
{, BUIMING DEPARTM&NT
� . 120 %VASHLNGTON STREET, 3aa FLOOR
TEL (978) 745-9595
FA.X(978) 740-9846
Kl\[SF_RI.EY DRISCOLL
AAYOR THoNlAs ST.PiExim
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG COSLMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant information // Please Print Le )bly
Naitle(BusitwssOrganizaiiam individual): 41.1e,
Address: Z P / ow-r,, •"/ Arm
Cityistatelzip: e / G Phone ✓E: 2V/• YJ.I'% L aft_
Are you an employer'!Check the appropriate box: 'type of project(required):
lyel am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hind the sub•conlractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sub-contractors have N. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing ail work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers'comp, C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) f employees.[Aro workers' 13.0 Other
comp, insurance required.)
•Any appiic:mt that chucks box e I must also till out the soctioo blow showing their workers'compensation polity information.
r I Neneowners who submit this affidavit indicating they are doing all work and then him outside conlmettxs must submit a new amdavit indicting such.
=Gmtrasaun thal cheek Ibis box must a0achcd an additional sheet showing the name ofthb sulfcamndon and thelrworkers'ramp,polity information.
l um an employer that Is providing workers'co pettsatlon hlsurance for my employers. Below Is the policy and Jab site
iufonnmlon. /
Insurance Company Name: •� {�/v�,yi�y
r e
Policy 4 or SeIF-hu, Lie,0: L//�l Expiration Date: . //s- ' Y
lob Site Address: 3 D✓T O it /f/ City/State/Zip: >Sa�t.4. t "i AG L117.7e
Attacb a copy of the workers'curnpensatlon policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invcstigwimts ol'the DIA fur insurance coverage verification.
Ida hereby certify raider th alns r peno tlrs o' fprrjury that the irrfuratudon provided above is true and c'arrect.
5i.,rial lrc, Daro: !O . /9• /
p m e,1' 7Pi Y7f zdf�
OQicial use only. Oa not write in rhis area,to be completed by city ae town gjzcia[
(
City or Town: PermitiT.iceme f!
Issuing Authority(circle une): --_-
1. Board of health 2.Building Department 3.Cily(rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Outer
Contact Person: .._.._.._.._ Phone 4:
(
CITY OF SAL,ENl, -AxsSACHUSETrS
BUILDING DEPARTMENT
3 N + 120 WASHINGTON STREET, 3" FLOOA
TEL (978) 745-9595
Fns(978) 740-9846
lel.NtBERLEY DRISCOLL
IN LAYOR THOSL s ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LNIISSIONER
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 l 1.5
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 transported by:
/sat �►< < /<
(name of hauler)
The debris will be disposed of in
(name of facility)
G —, L�y r MR /►. /*f# OZ/ yv
(address of fhcility)
signature ofpermit app icant
date
y - l
WAP Work Order
North Shore Community Action Programs, Inc. Job Number: 29445
98 Main Street Work Order Date: 10/10/2012
Peabody,MA 01960 Ownership: Owner
Phone: 978-531-8810
Advanced Energy Solutions Auditor: Brandon Dorrington
28 Hamilton Road Email: bdorrington@nscap.org
Peabody MA 01960 Cell: 781-540-8569
Email: rborges95@comcast.net Phone: 978-531-0767 xl21
Phone: 781-475-2095
Domenic A Petronio NGRID Gas $6,268.01
3 Outlook HI Total $6,268.01
Salem MA 01970
978-744-5626
Safety Issue(s): Lead Paint Possible
.�y - T •" Authorized .
-
YT,
Measure Description k Comments '<
�. Qty Prtce, Total ' Qiy �y ,
Attic lusulahon
Dense pack small roof cavity R30 35 $1.48 $51.80
restr.
R-38 unrestricted-settled cellulose 1053 $1.47 $1,547.91
' AthcVeritilahon ,
Propa Vent 8 $4.00 $32.00
Rectangular soffit vent 8 $27.00 $216.00 4 in front/4 in rear
Roof vent 865(A sq ft NFV)small 2 $80.00 $160.00
Basement Insulation.. .:: ' • - _ -
Sill two-part foam w/fiberglass Batt 60 $2.20 $132.00
Doors
Fixed Sweep 3 $15.75 $47.25
Lockset/Schlage or equal 2 $73.00 $146.00 Int. BH & front door
R-5 Ductwrap or R-max on door 1 $51.00 $51.00 Foam board @ backside of door
Date: 10/10/2012 Page I
WAP Work Order: Job Number: 29445
Repair[Reflt Door 1 $52.00 $52.00
Weatherstrip s/Q-Ion or equal 3 $45.50 $136.50
ea th&S fc
a. ty
Repl.exterior dryer vent wall cap 1 $45.00 $45.00
io
Front overhang dense pack blow 28 1$2.10 $58.80
Membrane/dense pack floor/ 35 $2.05 $71.75
overhead @ small bump out
R13 FG @ open basement wall 160 $1.31 $209.60
isc Measures e
Attic sealing with two-part foam 4 $75.00 $300.00
Basement sealing with two-part 2 $75.00 $150.00
foam
Blower door set-up with pre&post 1 $45.00 $45.00
tests
Labor only charge 1 $60.00 $60.00 Remove old ineffective FG @ heated bsmn't
I I wall
Weatherstrip(Q-Ion or equal)attic 1 $31.50 I$31. 0
hatch
Pe
rmit: :
Building Permit 1 1$100.00 I$100.00 I
Date: 10/10/2012 Page 2
WAP Work Order: Job Number: 29445
Wall lnsulahon ,
Wood clap board/shakes/shings or 1160 $1.79 $2,076.40 Vinyl
vinyl(dense pack)
oo Window& Dr:Rep lace
ments '• _ w - ` w _�a }'��'� F ` " ,� .s m,.'-
Solid Core Door w/hardware 1 $367.50 $367.50 Interior bulkhead door
Windows
Wentherstrip Window/Schlegal or 30 $6.00 $180.00
equivalent
Total $6,268.01
Contractor Instructions:
Before Starting the Job: During the Job:
I. 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:
Energy Director: Date: Fiscal Officer: Date:
Date: 10/10/2012 Page 3
a
WAP Work Order: Job Number: 29445
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 251.000 Occupany change in last 18 months? Yes No (Circle One)
H2O Tank CO 2.000 Comments:
Heating System CO 0.000 Number of windows
Ambient CO 0.000 Number of rooms
Blower Door 0.00
Date: 10/10/2012 Page 4
T
Office of Consumer Affairs& Busine�RhuQ as
§ _ - HOME IMPROVEMENT CONTRACTOR K
-' Registration 164893 '
' € ( Expiration 11/30/2013 Type
_ Corporation
€ y
3( AD NCED ENERGYSOL`UFTIONSµ LC:
Er 1
i RICHARD -BORGES�
` } 28 HAMILTON RD. 7s
f PEABODY, MA 01960�
Undersecretary -
• ,4a ,t":.,:��•'.w—., ....._,._,ems __.__ __ _"� :� ,
Vtass.l - Derlcrtui
Boa nst ai 6
chrnctts St ld irds
of Bu ,
rd ild Rc u
int, ervisr+t License _
Construction Sup
License: CS 909112 '
w
RICHARD B BORGES'`.
28 HAMILTON ROAD'
PEABODY, MA 01960
Expiration: 1111/2012
Tr#: 5481