6 SOUTH ST - BUILDING INSPECTION (2) R
The Commonwealth of Massachusetts
r Board of Building Regulations and Standards CITY
n Massachusetts State Building Code,780 CMR,7 h edition OF SALEM
^ Revised January
Y I Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or 7-Wo-Family Dwelling
This Section For Official Use Only
Building Perrr'tNV694 Date Applied: t r rs
Signature: ��M.%,O
BuAling Comm si /Vpector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L l a Is this an accepted street?yes_J,�' 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 Requimd 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❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 wner of Record- `
Name 0Address for Service:
—
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of ProposedWork2:
Pam . ATMCwei� ;' —LVOIZ14--'-0P 5J!z--
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ O 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard CitylTown 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 Amoun
6.Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due:
j?07 0
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r_ ^ f03�►�+� /-23 -20/3
�J E�'�'�GV- TO�e License Number Expiration Date -
Name of CSL- older
a1''1 ►Qrtt�0t..P.alS LrJ r k�.yL4-RTwv rt/ List CSL Type(see below) u
Type Description
U Unrestricted(up to 35,000 Cu.Ft.
S Restricted l&2 FamilyDwelling
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burring Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
9FrFA� Name �dy56y
HICCompan N or HIC Re istrant Registration Number
rn�i s L �stsT I2 i✓Cs-rer. w,�
Expiration Date
S' 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 .......... p ' No...........❑
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Tito 60(„L rya✓ as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this 6uilding permit application.
Signature of Ov�Fer Date
SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
I, JEW nc/ h1&J0 ft as Owner or Authorized Agent hereby declare
that the statements—and rinfo��rmation on tie foregoing application are true and accurate,to the best of my knowledge and
behalf.
, .i-�1�A�r�r�-�
print
S a or u ze Age�n'
t Date
d a sins llies
of
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2.7When substantial work is planned,provide the information below:
'Total floors 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 beating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
1 .
t The Commonwealth of Massachusetts
Department of Industrial Accidents
0Jf1ce Oflnvestigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Apniicant Information y Please Print Leelbly
Name (Business/Orgahizadon/Individual): �Il �et*S&V_ .14V6kk0AV&) VSf11G!
Address2a U2n)p 332.S
City/State/Zip:_s"t 1 014 619-0-tti Phone#: 781 Rqci-W70
Arr�e,yy an employer?Check the appropriate box:
1.6; I am a employer.with 4, Type of project(required):
�_ ❑ I am a general contractor and I 6, New construction
iemployees(Ertl and/or part-time).* have hired the sub-contractors
2.❑ learn a sole proprietoror partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for mein any capacity. workers'comp.insurance.
9. [�Building addition
[No workers' comp. insurance 5. � We.aze a corporation and its
required] officers have exercised their IO.❑Electrical repairs or additions
3. I am a homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees.(No workers'
comp. insurance required.] 13-�ther tJQAYt. i ✓
•Any applicant that checks box ql must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire oulside contraclors mull submit anew affidavit indicatiag such.
iContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
f am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /� ii ..
Insurance Company Name: A 7 N jM f ft a �n 1
Policy#or Self-ins. L`ic. #: V WC (O OO�c�T2 00 r Expiration Date: CJ— / 7 — �O
Job Site Address: (4 1;01 '('`! 5T City/State/Zip:. of MiA01970
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 imprisomnent,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 penalties of perjury than the information provided above is true and correct
Si nature: Date: 1
Phone#: Q
Official use only, Do not write in this area, to be completed by clty or town offlcial
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #;
04/09/2010 22759 17815955820 AMBROSE INSURANCE PAGE 01/02
9ATE(MWO:, VVI
A � N CERTIFICATE OF LIABILITY INSURANCE 10 to
•RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Ambrose Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
56 Central Ave. ALTER AFFORDED BY THE POLICIES BELOW,
Lynn, MA 01901
701-592-8200 !INSURERS AFFORDING COVERAGE NAICO
NSURED Delangia, Thomas C. INSURER A Providence Mutu 1
A11 Seasons Windows & Insulation INSURER B. ,_,balla Protection
P.O. BOX 8229 INSURER& AIM Mut}iA� —�
Lynn, MA 01904 INSURER C!
INSURER E;
".OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEC 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 SY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
R eR➢i POLICY NUMBER I. NE P YEM Ip TO LIMITS
GENERAL LIABILITY EACH OCCURRBNC�F.-----�-S 11 .0 Q.000
''COMMERCIAL GENERAL LIABILITY PREMb^EB Eu acrwunm 7 �5Q�000
CLAIMSMADE Q OCCUR MEO EXP(Anyorb Fer:enJ 3001
A _ CPPOO58607 3/19/10 3/19/11 PERSONALSADVINJURY 3 1 ,000,000
GENERAL AGGREGATE j 2 000 OO
GE.V'L AGGREGATE UMIT APPLIES PER; PRODUCTS-COMP/OP AGO 5 2 Q00 QQ�
I""^ POLICY jE L00
AUTOMOBILE LIABILITY
COMBINED SINGLE LW j 1 QOQ QQQ
ANYAUTO (Eo ut Cenp r ,
ALL0 NSDAVTOS BODILYINJURY S
g SCNEUULEOAUTOS
gI; HIREDAU-05 I37797400001 5115109 5115/10 BODILYINJURY
NON-OWNEOAU705 (PnroeaArril) i'
I I
(PPRR TYOPEERTY DAMAGE I j
GARAGE LIABILITY AUTO ONLY.EAACCIDENT 5
ANYAUTD
OTHER THAN EAAGC F
AUTOONLC AGO S
EXCESBNMBRELLA LIABILI I EACH OCCURRENCE j _
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OCCUR C OWMSMADE 1 AGGREGATE 8
j
I DEDUGISLS I j
0.ETENTION j F
I WORKERSCOMMNSATIONAND 'H'
EL
EMPLOYERS'LIABILITY E.LEACCHH AOOOM NT -Es Q Q
ANY PAIIIMOM"AMIPAII@CUTIi+
C MIeERAreNB anwou" VWC6009502012008 9/17/09 9/17/10 11 11 DISEASE,EA EMPLOYEE j 500,000
If n UeBCNGBNneer
SVE�IAL PROVISION9bs1cw - E.L.DISEASE•POLICY LWIT S 5 000
OTHER
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I
;ESCRIPTION OF OPERATIONS)LOCATIONS rVEHICLESl EXCLLSIONSADDED BY ENDORSEMENT/SPEOAL PROVISIONS
Carpentry 6 Inaulation
i
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TI4E EXPIRAnON
City OP Salem DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAILIO DAYS WRITTF•N
Attn. Building Dept. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 30 SHALL I
City Hall IMPOSE NO OSLIOATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS CR
Salem, MA 01901
REPRESENTATN/ES.
AUTHORIZED REP S A
( w
400RD2S(200YOB) MACORD CORPORATION 1988
'-CAI A sosaa+twcwtzts .
Y B' wse or registration Valid for individl u use onl `018ee of Coawvkr Affs:13& eainex RegulationLic
- y
HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to; ,
R egiytroymr, 18458c Office of Consumer Affairs and Bnainess Regulation
19 Print Plaza-Snite 5170 !
EttDiratlan 19121/201 1 Trill284821 Boston,MA 03116
Type; Individtrel
JEFFREY MAYOTTE i
JEFFREY MAYOTTE
29 ANDREWS LN.
FAST KINGSTON,NH 03827 Uodersecregry *It
id wiMo i
r
:V'Lissachusetls - DCp:u-tment of Public Sal eh
Board of Building RC-ulations ;Ind Standards
Construction Supervisor License
License: CS 103474
Restricted to: 00
i
JEFFREY MAYOTTE
29 ANDREWS LN
EAST KINGSTON, NH 03827
Expiration: 1/23/2013
t'unm t"i.nu'r Trm: 103474
ACTION, INC
47 Washington Street
Gloucester, MA 01930 F .
Tax Fwarnnt
'ApencY CAP • tVQ t PPhcatlon#
PRQGRAM AARAWAP 0
JOB NUMBER. 0
0DOEWorkArdort No
Work Order Date: 01/29/10
Pnmary'Contractor: All Sea son WlndoYvs& Insul4)n
Other'Contractor: NA' . k Bums installed S 0 00
Cost of Bulbs 1"o
Client: Paul Goodwin. 12500 napt$ Max $0.00
Street 6 Sopth Strea! "Other ln'kind o.vo
City; State,7Jp. Salem AAA Oi870� plecircal Work
Telephone: 878444-2539 :, 8 aayowit xeyspaa av vc ;
.. ";$, Am6unt tleftyon6.1 Grid $0,00 :
Blower Door Test RWrs other utiiity 60.00
Inspect Knob&Tube, No
DateJobCnrlipleted 01/)0l00 E®ebndtgditepatrTotal $z17.5o:
Weatherization : Est Act Cyst Est Cost 1 4 Act Cost
Door Kit i 2 437= $74,001
oaor Swe® 2 12, 5 ;!: S24.50'
Auto aw Door Sweep
Air Sealin (per hour 3 "' !" 55 D0 1,65.00
Attic Air 5ealin 2-partfoam: erhour =:$6000 'I'
WeatherstripWindow(per side) $425
Seal Ducts-Maslic $54.00
D 00
$0.00 'v
0 00
$0.00
0 OD
$0 00 _
$0.00
Weatherization Totals. $263.50 --son
Insulation : Est .:: Act Cost Est
. .o . .
Goss Act Coet
The'rinodoine 1 $152:00- i�.' t 2.00 :i x: .....:....
Attic.Flat R30 o en, 1 05 'a
Attic FlabSlo es Rao restricted $1.14
Attic Flatisio s R20 iest(icted ;! $1 08 :I
Attic Kneewal R13 FG
Attic KWeIF:Rt3 Cell w/Membrane $1 33
Attic Kneewall FI or R30 rest
Kneewall'Floar R30 1 14
Sidewalls-vinylR13.Dp . -Aug
Inferior WaB R13-Plaster R13 DP
Test Drill.Sidewalk•4 sides 53 00
Dkt Insuletion R5 8 Seal Seams $2.22
N dmnic'Pi a Insul to 1"RS $2 t39 '
Steam Pie lnsul to 115!R5..., $4-68
DHW Pi a Insustlon R5' 6 $2 05 $12130
Insulate Door $36.50
Insulation Totals: 'i '..; $1.64.30 $0.00.
:Paul Goodwin Pe e 2 ''.DOE D .
ether Measures Est Act =Cast Sst Cost P.
Act Cost
2 6.D0 $732-QO
Roof, nt+smell $7600
Gable VeM
V14 I Re lacement Window•73 ui 312 OD
vn LRe kicement Window-83 ui 3 327 0 003 0981.00
338 d0 :'li! 42.
Vin 1 Re'15cement inflow;93 ui B
Vln I,Re cement Window 101 ui " 3,00
hi
Vln I Re I:6sm4 HS§Oef Window I 1 1200.00 :`:
Fibe`issPre-Hurjg.. ..:boor ."'. ,....1 ..: ,b0 !i. $480.00
Solid Core Door w/Hardware $330 00
Faucet Aerator
15 00
Low Flow Showerhead :$25.00
Blower Door Test " 45 00 .`_ ?
$O 00
Oth6r Totals .,;: :$4 645. 0 . $0 00-
Igne;oy Conservation :. Est Cost IAct Cost
Totals !.Max$10 000:00 '. $g072.80 "..$0 0
Re airs Est 'r. Act ; Cos ± Est Cost :Act Cost
Patch Closet door 2 $20 00 '` ! 340,00
Patch Foundation 1 4 pp
Door Threshold I $33 00
Mir Door Hinge ' ;'`:$2b 00
Bolt
Sash Lock 2 $7 75 1 :i' 15:50
Glass Replacement to 64 ui : •:.. . : $36 50
$D 00 fi
$0 00
0 00
Health'&Safety j
Vent Clothes Drver to Exterior 70 00
Vent Bath Gh--ausf Fan'to Exterior I $70M $70.00
Replace D or Hose 1 $32 00 $32.00
$0 00
0.00
$0 00
Re air Tot;Max 2500.00 217.50 $0.00
r
- u
Work Order Sub Total: $5,280:30 $0 00
Measures' Est >`:' Ad Cost Est Cost Act Cost '.
other .. 0.00
other $0.00
'HeBf n 5 9tom Re ii 0.00 r 0,00
Action approval only :,:
Estirrtated Job
Job mini
Total $5 280 30
Job cannot exceed$10,600 00
mum $200.00 Job Orand Total $0 00
AUDITOR:: ... Woody SWAq
NSCAP
J.
96 Main Street '
Peabody;MA,01%9
„ 'Tar Exem t 0:042J95-'280
l
.Agency I,VSCAP �, :,
PROGRAM ati0nal GrW4610 -7777I! '
JOB 14(jtwSB1R 0 ..
7iOM kabdn b:, b
Work Order#0 '.
iWorkOrderData D1/29/10 doA tolt
1?nmary Contractor All Seayon Windows&Fganl Per1Ja8 $4500d10
Other Contactor NA
.Clicm.Paul Goodwm K+T Yea�1 NomO
'.Strect 6 South Street kd,T �0
Crlq.etate7�p„Salem MA 01070 ...• . .
S' "f olephone:.'976-744.2539.. .. .i'' '.. qa AldtHl; No ,
Fee Cods.= 0
.:Blawcr Door Tas*Vt,e�+
la ct'Knob&.Tube: N0 $Iec.:Contractor: !'' zi
td31 �d. ost :!' "'Mgt Coal :.'. . 'Act Cost
Attic Flat R49 aa ;,,: .. ..,, . .
Attic,Flat.R38
AnicFlatR30open:
..: 403 ''d ..:. :;'" El.bS! :,.:..5423.15
AW6 Flat R20 o 50:99:.
EO',41'^
AtticR4adSIti eA30reamictad :' :-':i 31::??A -
Ati c Flat SI0 R20.reatiiaad $1.0,
MAtfldF1oV51' RlOrestricted '.: 310 : ::'"
til �'WF1eorTraQ9ltidnDp ,; „ $a :b .....; 777
AtticKncewa11R13
gmaK;,eewallEloo[R30rest, : ri v!'4 ... ! .... .
Fir6 ied Attic Access '' :. . .'.;: ! I, ). ::$94.0U
Trim oi'. Attic AccosO'..::: '�:� '::r�:.. '.'. $62.00 .,'. .: .. .
:. ... ...
Crawl Spite'wRol V . 'sorrier
... . ... .
G �Ceilf lour R30 with � vel)
Vaoti) or/Bath Fan 57Q.0U
Thcia+;;doVne ' : :,' ..' '.: .� � ' � 152: .....:..EM
RoofVent 2010Pro a V qtv^«5Oati1e VenC
SoflitVeaC::� .. .. � :: : , ; a$23'.00
Atria Air Seeltn 2- tt foam 2 brs max) 2 ';' :$60.00 '; $120.00
Paid Poodwm. P 2 '.::::Ndtzonef .' Oi0 . ... ...
t .: .
Win lssulatfti ..:.
Sifigle Naded'Ast, s" AspbaltDP.
Doubl¢NeiledAsbcsloel Aluaunuin DP .
Brick C stucco AP .,. .. .
Lttotior wall-Blew-Pl z,5P 'S1 AO.
ClahaatdIwoods leltdi 1DP 1774 $t,35.: $2465.86
Test A1171 A s des 553''IICI:.
AfrSssline Limit
Sin 7e P'arnil w/BlowerlDoor=S400
AD Others.-5200
Door: 4 $12:25 .. ..y.,..
Automaiic:Door sw "'$X4::2S^
Air Sealvi' 3 hours MAX) ... 3 ':7: $55':00` '',:S16$.00
Sash lock: F $1.75
Glass Re lacemeut
$a5:00'
BlOwel'DoorS¢tU' ' f ; � . .. ...
Taml Afr'S'ealio Ceatt
Un
Ayct Insu]ation .$2';22;. :.' ' . . ....
'H dmnic pi a Insulatmi to t"..RS .. $2.89.'. ........
H:dronic P' Insulation„1.23"*AS ... I'$3.53'. .
Steiiin Pi Insulation i:5"to2'.S".AS 215 :;,r.,'. 'ai :+ .68 $1,006.20
St-nii nsulation 2.5"+RS r '( `' :S5 4,6,' .. ... .
. . ......
Boiler/Painace R tacesncnt ': . . ... ..�..
••Pw rate Re Alr. ';:; .. � :. ::'; : '::�.` $1.00 .. �::.. . ',: ,. ..:..:.....
`A¢tso4Mpproval needed:Maz.S500.00
Actual Total don not include$125 00 K&T:,ch '!, `, ;:: 54,407.11 Eat Tots
7777
AUDITOR WaOd. 50:00 Act To
.T .y