56 SALEM ST - BUILDING INSPECTION \Lk The Commonwealth of Massachusetts
CITYOF
Board of Building Regulations and Standards SAL M
t�� ® Massachusetts Revised Mar State Building Code, 780 CMR Revised
\ 20]/
Building Permit Application To Construct, Repair, Renovate Or Demolish a "
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D e Applied:
-ba
Building Official(Print Name) Signamr Date
SECTION 1: SITE INFORMATION
1.2 Assessors Map&Parcel Numbers
L 1 a 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 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'
29
1 Owner'of cord:
Name(P t) City,State,ZIP
No.and Street Telepho to Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) '
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': t_1CU.a.V.r,](�Lc�uC(�yx � 9�•�,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building 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 $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ , a, ❑Paid in Full ❑Outstanding Balance Due:
S • O / lti `� b (p 14,/O6r t2 /
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
!�N-�5"1 b t
F'�.� .�V License Number Expiration Date
Time `CSL Holder
( (� List CSL Type(see below) \�
Type Description
No.and Street
U� Unrestricted(Buildings a to 35,000 cu.ft)
R Restricted 1&2 Family Dwelling
C1 /Town, t M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
lion I I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) .1
X4-i, ,4\oi� HIC egis[ration umber Expiration Date
HIC Company Nam or HIQ Registrant Name
No.and Street Email address
0-)-7�-k I
i /Town, St ,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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject prope ,hereby authorize
to act on my behalf, in all matt rs elative to work authorized by this building permit application.
Print Owner's Na (Elec tunic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my time below,1 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.
riot wner'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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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
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"
WAP Work Order
North Shore Community Action Programs,Inc. Job Number:980545
98 Main Street Work Order Date: 7/23/2013
Peabody,MA 01960 Ownership: Owner
Phone:978-531-8810
Air-Tight Weatherization Auditor:Brandon Dorrington
9 Story Avenue Email: bdorrington@nscap.org
Beverly MA 01915 Cell: 781-540-8569
Email: airtightlle@gmail.com Phone: 978-531-0767 x121
Phone: 978-998-4684
Raymond St Pierre NGRID Gas $1,482.38
56 Salem St Total $1,482.38
Apt.2
Salem MA 01970 cA 1 6 33 —�
978-337-6004, 6 J
CQcc? LA
u i z e, ifs r �y7,'�",Haa>EG, lji i:i'�•a'e"x'ty'4fi` y-y"c�k.�' v�h.7 aat ,r`�",.�,.E A" ut tsth'ronie,d iea Thf P[ �Aw, w ¢ ( t
E+ik styk. -
nu
"
E Measure.Descnphon t � +er^ Ta > of �> ,r t ri kcc�,t Comments b ..� `•l,
Pnce 'y T(Otal. '.� Qt3'r lTota�rlj� g xi F'•vm i r, � G �y.+�,�i �!
to , 4r § m'6n
Basement V6 'tRii r 8 -^,.a „}' , a qi z n >t„t.y n 54I.
"NI _*1
_s t
��3ia"f£r�e1iwi ,w h �. w"�` `,a7a �i� ,,, t1eh ?cr_,.`'x-',.* rw"I"*';.r9, f Yn,
Sill two-part foam w/fiberglass halt 128 $2.20 $281.60 128 $281.60
y�ra 5 1 W ifi CY fF�
E'ti ^ � DOOrS'� '�" itij. f� a r
,' � -.qua CI`- ti' "L
.$ s+y ,u'�`rlm+r•�-*rF' vvrAPF3i. ,,tl,.n7 eiG .n.,i< .es a-6H..E., Ic� mAl _
Automatic Sweep 1 $23.00 $23.00 1 1 $23.00
Basement/outside door-door only 1 $367.50 $367.50. 1 $367.50 Solid core LUAN w/hardware
Fixed Sweep 2 _ $15.75 $31.50 2 $31.50
Lockset/Seblage or equal - 1 $73.00 $73.00 1 $73.00
R-5 Ductwrap or R-max on door 1 $51.00 $51.00 . 1 $51.00
Repair/Refit Door 1. $52A0 $52.00 1 $52.00
Weatherstrip s/Q-Ion or equal 2 $45.50 $91.00 2 , $91.00
B tit
a .,�,°*'> u' $ti F,t z �e^ k'aNby�,..t,arks a uw:. cl 'e"'�, 5-.K C* toy_. .cam „
Healtb&$afe -,Rey, e �^ 1,a"'�' x �^ -+kL"' r .
3ikn' 4zY� n,Sk(rf'.+.R.. I� ', +` I,Y'.rtR.
Clothes dryer vent including x 1 $89.00 $89.00 1 $89.00
Exhaust Duct
Date: 7/23/2013 Page 1
WAP Work Order: Job Number: 980545
f -1' s iu'v'+�-�;,c' .� *�+ +u� � i e .w3 s� ' "�,71„ .,~. a sd' w
u' tscInsrrahon. z.. `'tr.'...+ -:e;s .mr�. ». s: �. .,�. ,.+ 'rt� ,
.M;flkb�srn=;i}:Gi; 'aw.;uk nf,Tu�s.:. .air-...t u. <a.A0.1
Domestic water pipe wrap 6 $2.63 $15.78 6 $15 78
x+ MIsr r z 4P ,�* a. i ..nor}, s
{.- r .tld d -�+""vy
tik,'f MrscMeasures ,� .yt` ARK _,� sty '�i-# ,4-k .`,` i, •s'I.�'r.•;d e,
w-
Basement sealing with two-part 3 $75.00 $225.00 3, - $225.00
foam
lstn
`+L
Building Permit - 1 $100.00 $100.00 1 $100.00
i�'f+� "XF`1 -d4 C i� �•{ My�t `§ J` ro -,a��:qn,�s,7, r+, kiF Y 'i - + a il_,:� tmcn J ' ., d Y"� (Rrt+✓v. °i �5"Ili "-'�.
rca�i` �k in SWhz'.,i' �..ti'iJ
Glass replacement to 64 ui 1 $44.00 $44.00 1 $44.00
Top Sash Lock 4 $9.50 $38.00 4 $38.00
Total $1,482.38 $1,482.38
Contractor Instructions:
Before Starting the Job: During the Job:
1.Please notify us 24 hours b ore starting or scheduling a job. 1.Incorporate lead safe practices as applicable.
2.Obtain required building it. 2.Total for Heath&Safety and Repairs cannot exceed$2500.00.
3.Davis Bacon time sheets required for R work on US
Department of Labor Certified Payrolll 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:
Date: 7/23/2013 Page 2
` Office of Consumer Affairs ane. Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165640
Type: LLC
Expiration: 3/15/2014 Tr# 222331
AIR - TIGHT LLC. WEATHERAZATION
JAMES FORTIN
10 PINE KNOLL DR. - - - -
BEVERLY, MA 01915 - - --- ----
Update Address and return card.Mark reason for change.
_DPS'-CAi is 5OM-04,04-G101216 Address 1 Renewal i - Employment ;] Lost Card
Z/74e '&apes......:elr✓/� rf. lfRa:err'�rrleldt
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
-.HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
—t' Registration: 165640 Type: Office of Consumer Affairs and Business Regulation
Expiration: 3/15/2014 LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
AIR-TIGHT LLC.WEATHERAZATION
JAMES FORTIN
10 PINE KNOLL
BEVERLY, MA 0191191 5 Undersecretary � Not valid without signature
\L1�•ai hlPcft. 1)C".,Cillcnl •d I'b!+Ifi �.dil�
1 3•',;r,! '.I Huf!�Nu_ K.'_I'i.,ti„In .mJ �t.,nd.u-,1.. =
J^Si'._Ct Cr
UCense .:i 52576 _
fl
s
JAMES E FORTIN
10 PINEKNOLL DR
BEVERLY, MA 01915
=_;wr.'wofi 10/3/2013
The Commonwealth of Massachusetts
PrintForm ,
Department of Industrial Accidents
r f Office of Investigations
I Congress Street, Suite 100.
Boston, MA 021I4-2017
� y ' www.mass.gov/dia -
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print I.eeib�
Business/Organization Name: L --
Address:
City/State/Zip: C)\q 1S Phone #:
Are you an employer?Check the appropriate box: Business Type(required):
t am a employer with k'57 employees(full and/
5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate, auto, etc.)
employees working for me in any capacity. g ❑Non-profit
[No workers' comp. insurance required]
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption.per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.®Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box 91.
I am an employer that is providing workers'compensation insurance.for my employees. Below is the policy information.
Insurance Company Name: V^%Uru-w�-'°•
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lie.
Expiration Date: `'-1 I ILA
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$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$250.00 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.
I do hereby certify,under the pains and pena •es ofperjury that the information provided above is true and correct.
Stanature �C.3. —' Date
Phone#:
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia ,