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11 ROCKDALE AVE - BUILDING INSPECTION (2) cK 2N �g �zg � The Commonwealth of Massachusetts 'NSPE Rp'� PVi Board of Building Regulations and Standards P15� ES % Massachusetts State Building Code,780 CMR o Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demoli ' UL 21 A ": One-or Two-Family Dwelling 3 This:Section For Official Use Only ' 1_ Building Permit Number: Da Applied: Building Official(Print Name) Signature - Date N^\ SECTION 1.SITE INFORMATION 'c'� 1.1 Property Addre s: 1.2 Assessors Map& Parcel Numbers Lla Is this an accepted street?yes V 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(it) 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: Zone: _ Outside Flood Zone? Public❑ Private[I Zone: ElOn site disposal system ❑ Check if yes❑ '.SECTION-2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: S.wt rv�, 11 A 6 Vq tb StnN Name(Print)ao City,State,ZIP \ AUi._ti-&-4 ftV{ ale ta4 cn .lar M. w No.and Street a ne Email Address 1� SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) N New Construction❑ Existing Building Owner-Occupied 131 Repairs(s) Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work',: S S Sw0. t t-%LA kYA sd &- &Y $-f4i .e.•• G SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: - Item Official Use Only Labor and Materials 1.Building $ i %LA. ot '3 1 Budding Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ; ❑Total Project Cost"(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 3 H 3 ❑Paid in Full ❑Outstanding Balance Due: rn,a\ 1 tJ s(as e. SECTION 5:4CONSTRUCTION SERVICES' 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL older Lis[ESE Type(see below) Flo Q QA 34 No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) ct a�lXl l� o t g 3 8 R Restricted 1&2 Family Dwelling City own,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances q AN H1�t(tr�d�W I Insulation Telephone Email address D I Demolition 51.'2-R`e/gistered Home Improvement Contractor(HIC) I—VI N( l7 l,V�I �Cl W K\er HIC Registration Number Expi at n Date ►�%C Co pang Name or HIC Registrant Name f pan ?u4 g (.>Jh��ti�hbJ�uhan `I % uv -- No.and Street Email address Ivy"ft n 1`1 u I I CMAJ-,o• 19 3 Ct /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 Issu ce of the building permit. Signed Affidavit Attached? Yes ..........16 No...........❑ SECTION lac-OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize aN ' Men�7`br &-ISI�-�-'� 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: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 understanding. J I- (1wimitp- -Id Lu It Owner's or Authorized Agent'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.=ot v/oca Information on the Construction Supervisor License can be found at%Nww.nrass.gov/dVs 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.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" CITY OF S.uFm, TNLkSSACHUSETTS BUII.DIING DEP\RTNt&%%-r 120 W.NsH1NGTON STREET,3'a FLOOR o� TF-L (978) 745-9595 FAX(978) 740-9846 KlxjBE t FY DRISCOLL MAYOR THomAs ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUUMNG COND(ISSIONER 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 wi 11 be transported by: (name of h cr) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant -T� date a�n.�safr.auc V��casgtr yti PARTICIPATING mass save CONTRACTOR Sw�agys«nato v m,uy&Weney PERMIT AUTHORIZATION FORM I, SEN NGO owner of the property located at: (owner's Name,printed) 11 Rockdale Ave 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 Owners Signature r 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: Participating Contractor -Date a. For otnce use onty Rev. 12132011 CONTRACT FOR Conner atlon 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 Son Ngo 11 Rockdale Ave - Conservation Services Group.(CSG) Salem,MA 01970-1048 Attile RCS 60 Washington Street, Suite 3000 Site ID:800002024512 _ Westborough,MA 01651 Project ID:P00000027460 Reg.No. 173484 CustomerED:C00000034525 Federal ID No.222467170 Contract ID:20150522 ASEAL (Mail completed contract to address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contactor will perform or cause to be perforated the following work on these"Premises"in a pro.essional manner and in arconhaice with the Loans of this Contract,including the attached recor nnendatlonshvork order describing the work in detail(the"Work")wtdch are incorporated herein by reference: Description Quantity Location Perform Air Sealing_at Estimated 62_5 CFM50 Per Hour__ 10Living Space.___. _ $843.2D.y,. .... N/A ___.. . .... ...... ...__.______$6954......... Exterior Door Weather Stopping ..3. .....__. NlA _ $82.77__ Sub Total: $995.61 Utility Incentive Share $995.51 Customer Contribution $0.00 For office use only Printed:=2/2015 - Page 1 of 2 11. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Snare of the Contract Price as follows:Payment 41;$ 0,00 as a Deposit payable to CSG upon signing the Contract(not to exceed 1,13 of the total retail costs).Mail check&contract to CSG,Attru RCS,50 Washington St.,Ste. 3000,Westborough,MA 01681.Final Payment:$ 0.00 as the linal payment.for the Work shall be payable to the Independent Installation Contractor("RC")upon satisfactory completion of the Work.Customer understands that h0she will not be required to pay the Utility Incentive Share of the Contract price in the smavnt of$ 995.51 .Changcs to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share. III. DISPUTE RESOLUTION The IIC and Customerlimeby mutually agree in advance that m the eveatthat the RC has a dispute concemhrg this Contract,the 1IC may submit such diywte to aprivate arbitration service which hasbeen approved bythe Office of ConsumerAffaits and Business;Regulation stud Customer shall be required to subrmtto such arbitration as provided in KUL c 142A. 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 posted, by telegram sent or by delivery, not later than midnight of the third bus! Ilowing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Cu mar Signature Date Indicate your selected RC here,if applicable (oR) Initial here if you want FthanSeaman 5/22/15 FthanCeaman the Program to assign a CSG Signature Date Naanc of CSG Representative(Printed) Participating Contractor TERMS AND CONDITIONS APPEAR ON THE REVERSE. NA CONTRACT FOR Conner atlon PRODUCTS / SERVICE WORK Services Group This service is brought to you through support from your local utility This Agreement is made by and among and San Ngo 11 Rockdale Ave - - Conservation Services Group(CSG) Salem,MA 01970-1048 Attnt RCS 50 Washington Street,Suite 3000 Site 11D:S00002024512 Westborough,MA 01681 Project ID:P00000027460 Reg.No. 173484 Customer ID:C00000034525 Contract ID:20150522 WORK Federal Ile contract t to 22o a 0 — (DS.ail completed c address above) I. DESCRIPTION OF WORK TO BE PERFORMED Contractor will perform or cause to be performed the following work no these"Premises"bh a processional numnc:and in accordance with Oho terns of this Contract,nmluding the attached necomtu malationshvork order describing the work in detail(the"Work")which are Incorporated herein by reference: Description Quantity Location Attic Floor Open Blow Cellulose 6..,._ „._,q_. ,_ _ 1,144 _ LrvinU Space ___, $1�681.68 Damming._— _ _ _ 14_.... ..WA .....__. _.....___...... . . ........... .. .......$30:66,.,.,, Vent bath fan to roof flapper .,......._ ._ ---------------- I Attic Hatch Thermal Barrier Polyiso 2 mch_NTT $41.71 Dense Pack 6 Cellulme_In Garage Ceiling312 _ Liwng Space $836,16 Sub Total: $2,719.42 Utility Incentive Share $2,000.00 Customer Contribution $719.42 For office use only Printed:5/22/2015 Page 2 of 2 II. PAYMENT Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Rice as follows:Payment 41:$ 249.80 as a Deposit payable to CSG upon signing the Contract(not to exceed 1/3 of the total retail costs).Mall check&contract to CSG,Attn:RCS,50 Washington Sc,Ste. 3000,Westborough,MA 01681.Final Payment:$ 479.62 as the final payment for the Work shall he payable W the Independent Installation Contractor("IIC")upon satisfactory completion of the Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of$ 2,000.00 .Changes to individual line items and/or previous incentives may increase or decrease the size of the utility Incentive Slone. III. DISPUTE RESOLUTION The IIC:ad Custonxsbemby inuhailty ugase in advance ttwt m de event that the IIC has adispute concerning this Coidruc,the llCmay subrottsuch dispute to aprivate arbivation service which has been approved by the office of Cauamher Affairs mid Business Regulator and Costumer shall be required to subrnitto Mich arbitration as provided in M.G.L.c 142A 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 posted, by telegram sent or by delivery, not later than midnight of the third business y-f I] wing the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. s"ad rS om S�J Custol 51 .lure are indicate your selected IIC here,if applicable Initial here if you want Ethan Seaman 1 115 Rthan Seaman theProatinggram C Contrassignactor a CSG Signature Date — Name of CSG Representative(Printed) Participating Contractor TERMS AND CONDITIONS APPEAR ON THE REVERSE. N14 RCS PLANVIEW DIAGRAM Customer: Sen N90 Home Phone: - Address: 11 Rockdale Ave Work Phone: - Town: Salem Cell Phone: Any limitations for access by large truck? No X Yes If yes,describe: Any specific directions or landmarks? No X Yes If yes,describe: Site ID: 2024512 Energy Specialist: Seaman 303 , Reviewed by: A/S- 10 hours air-sealing attic penetrations: 3 door kits and sweeps (1) -Attic floor open blow cellulose 6" - 1,144 S.F. (2) - Damming- 14' (3) -Vent bath fan to roof flapper (4) - Hatch:2"polyiso thermal board (S) - Dense pack garage ceiling 8"- 312 SY Garage Ceiling 12' 44' CSV BF (1) (2),(3) (5) CRV 2 26' 6' 2' (1) (1) (2),(4) 2' (S) CSV 44' 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=Wall S-Sheathing Temp Unless Noted Otherwise =Vents Note in Triangle R=8"Roof S=Soffit G=Gable M=12"Mushroom For Access Rev 1/14 Attic 26'x 44'= 1,144 S.F. 1,144 S.F. Damming 6' + 8' = 14' 14' Garage Ceiling 12'x 26' = 312 S.F. 312 S.F. Recommended Ventilation Calculation 1,144/300=3.81 over Recommended Ventilation Calculation 44(0.13) + 88(0.12)= 16.28 Air Sealing Work Hour Calculation 1,144 S.F. Work Hours 4 6 8 , 10 12 14 16 (+2) Attic Sq.Footage <500 501-800 801-1100 1101-1400 1401-1700 1701-2000 2001-2300 Every 300' Exceptional AFL Hours Primarily Floored Attics Chimney or BF=1 Hour Multiple Chimney/BF=2 Hours Prefab/Modular Hours No Chimney=4 Hours Chimney=6 Hours Exceptional KW Hours X<20 feet=1 Hour 20 ft<X<40 ft=2 Hours X>40 ft=4 Hours Rim Joist Only Hours RJ<150 it=1 Hour RJ>150 ft=2 Hours BMT Ceiling Only Hours Ceiling Area<2,000 sq ft=1 Hour Ceiling Area>2,000 sq ft=2 Hours "`NOTE:You MUST be INSULATING RJ or Basement Ceiling to specify RJ or BMT Ceiling ONLY Air Sealing Hours— Q >6"Loose Insulation Cross )it Insulation Multipliers B >6"Mix Batt&Loose Insulation Truss Construction low- For Office Use Only The Commonwealth of Massachusetts Department of IndustriatAcciderro' Office of Investigations I Congress Sdtet,Suite 100 Boston,MA 02I14-2017 www.mass govJdia Workers'Compensation Insurance Affidavit.Builders/ContractorsflilectricionstPlumbers Aun[icant Information Please Print Legilfly Name f_ Address: p a 5 3�t4 r Ci lstatelzi (} 3$ Phone it: 3 2 Are you an eniptoy . Cha*then approprfatebotc: Type of project.(required) 1.® 1 am a employer with 'S 4- 0 L am a general contractor and 1 _ b. [ New construction employees(full andior part-there}: have hired the sub-contracfum 2.© 1 am a sole proprietor or partner- listed on the attached sheot. 7. Remodeling ship mad have no emldoyacs Those sub-contractors have g, 13 Demolition working for me in any capacity. employees and have workers' ]No workers'comp.insurance comp.insurance." 4. Building addition required.] S. ® We are a co "on and its 10-0 klectricai repairs or additions 3_[Z I am a homeowner doing all work officers have exercixed their i f.®Plumbing repairs or additions myself. (No workers'comp_ right of exemption per ME 12-0 Roof repairs insurance required]+ - c. 152,§1(4),and we have no employees.[No workers' 13.13 Other-- c mp.insurance required:] •Auvapphcamthatcheckatxiai+l masaW Ali Wa tht rxtida Prelots got n atron.PolicP ctfumutimt, rllrnsr mwtowbntit thin ";mdicmagtFby are damg as wmk sultt n hireoatvda eaatrectwa nut subtttitaaew eradaviti - saeh. tCanaecwrsaem clra3cihia baz must attaetxdmt adatwuat area atowi�ftc same arthesub-conttaetprs aM a'tate v.7+etfirmnot dose enjoins have eavty' tfaxe havu ..thcvttua Pmidcl & uut vouip.poteytwuhm I am an eniptaper ohm is pxrsidf waNuers'ord iaa insurarar jar cry empteyees. :Blow is the patrry and job site info . lnsumnce Company Narric:'—ftli Policy#orSetf-ins.Lic.#:�7t_..'l.s?Zu hiylitatt..lt)ta Expira.tionDate� � ',3D is !ob Silc Address: �(J � I lw CiiytStatelzip::tits.+ +rn It Ut at ivo Attach a copy of the workers'compensation;policy declaration page(showing the pelieti•number and expiration date). Failure to sceure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimirsd penalties of a fine up to S1,500.00 an ikir one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine o£up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, t do hereby certify under Ike Pinar and pena`ltieLs.gf perjury dliat the information provided abuse is Owe and correct. Si�natt .. h-. "r-".✓' (..�.A-r-'""` Date Piaac#: !1" 331a 3`tta3 E only, Do not write in dJs am,so be compkied by city orrown avicialin: Permit/Licensehority(circle one}: Health 2Building 3.Citytt'owv C9erk 4.»ectrirat inspector 5:Plurrdtiaig t�pector son• PhoneO: II �I I MaasxAuseits. rtm at Ptt#1ie Satq#y.�'.. IdJ 4`N�earuetixnfS }� ntrti..¢ u, is1 rdat 63cM ;CSSL.10 a tY♦ Y� ky '�xna f7 i f m_ ...... Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement ContraetorRegistration Repistratlon: 173410 ' x _ Type: Individual Expiration: 1 0/112 01 6 Trk 257812 KURT GAUTHIER x KURT GAUTHIER P.Q. BOX 344 - IPSWICH, MA 01938 t 11,E Update Address and return card.Mark reason for change. ate -Address Renewal ; Employment Fl Lost Card scn i G �aosa as Itt ONE)* OB7ee otCansn & nRegulation License nr reglstratioa valid forindividul useaaly OME IM oZVEMENTI-ONTRACTOR before the eFpiratioo dsta'If found return ta:73p10'3Typo Office oTCaosumer ATTairs and Business Regulation xpbathw 10Ah81♦# " IndividualIO Park Plazn-Suite St78 CM Boston,MA 02116 KURT GAUTHIER ' Vs KURT GAUTHIER 44 ESSEX RD IPSWICH,MA 6193E Undersecretary M1it valid I outsignnture , I I