22 SOUTHWICK ST - BUILDING INSPECTION (2) � 6l 041�te_4 /1-0 /y
The Commonwealth of Massachusetts
q1 Board of Building Regulations and Standards CITY
\� Massachusetts State Building Code,780 CMR, 7`"edition OF SALEM
Revised January
/ Building Permit Application To Construct, Repair,Renovate Or Demolish a 1,2008
1 One-o -Family Dwelling
c Use '
Building Permit Number: is Sion For Official ate vial ✓��\
Signature: ]' -
Building Commission /Inspector of Idi Date t'7
SE ON 1:SITE INFORMATION
t 1.1 71.2 Assessors Map&Parcel Numbers
— C 5J-
1.1 a.Is this an accepted street?yes no Map Number Parcel Number
13 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'
2.1 Owner'of Record:
orp-ace Iri4ap, ` 50—�6tlicEt 4i
Name(Print) Address for Service:
P C_3W,e dA)_1 R->k-7Ys-o(23a
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other 001pecify:/�/g,C,'7�(�g
Brief Description of Proposed Work': -A/ r ,�./tv/0fP r
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 $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
fo
J�A - I trr �pnl/'cic�vT
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /�.7/J7� J -Z3`-2
0'(3
.i1 yarrp- License Num_�ber�•! Expiration Date
Name of CSL-Ho er l�
List CSL Type(see below) (�
rT Description
A U Unrestricted(up to 35,000 Cu.Ft
Si ure R Restricted 1&2 Family Dwelling
M Masonry Only
DIP RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R ed Ho Improvement Contractor(H IC)
J a 91M PV M2 t/dT°t f9 7 JJ ff00
HIC Comp�y�'N e�p r HIC R grsuant N Registration Number
29 Hsf2�wS c ✓ ,k�nC:Tc ry ��
Aaar� q /O -Z/-201/
Expiration Date
Signff;t Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 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
1, t_y— P—Q ce C r4 Q R as Owner of the subject property hereby
authorize 1 FF Qp.V /�1�5 O Ze to act on my behalf,in all matters
relative to work authorized by this building permit application.
)o fi(—y — G/
Signature of Owner Date
(SECTION 7b:�O1 WNER'OR AUTHORIZED AGENT DECLARATION
I, S EF9'Qe V%I lY'y� ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
F " ®GTZ.
Print N e /� //
signat r or nt -Date
Gam[
(si th ins and 'es 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 110.R6 and 110.R5,respectively.
-17 When 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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
RThe Commonwealth ofMassachuse is
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
t Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers
Applicant Information Please Print Legibly
Name (B=sines/Orgdnizafion/lndividual): f'f(�t�S��C�'L�10�✓r7 vl/ifo'K"DedJ�' � .LsNSU<�i.7 e0�✓
Address: PC) BOX R
City/Stawap: LVQv✓ A Phone 4: q O7�
Are you an employer. Check the appropriate boa: Type of project(required):
�1 4. I am a general contractor and I
�
1. t 6. ❑New construction
employees(full and/or part-time) * have hired the sob-contractors
2.El I am a sole proprietor or partner- listed on the attached sheet 7. El Remodeling
ship and have no employees These sub-contractors have g. Demolition
employees and haveJ e workers'
working for me in any capacity. 9. .�Building addition
[No workers' camp.incrnaam comp. i a corpora
- S. Q We are a corporation and its 10.❑Electrical repairs or additions
requred.] officers have exercised their I LEI Plumbing repairs or additions
3.❑ I am a homeowner doing all work
right of exemption per MGL
myself [No workers' comp. 12.❑ Roof repa rs
insurance r eel t c. 152, §1(4),and we have no r�,� ,,. � ��....r
�� employees. [No workers' 13.�q ether
comp.insurance required_]
-Any applicant that chocks box it l mustalso fill out the section bclow showing Theis Workers'.compensation policy information
t Homeowners who submit this affidavit indicating they are doing all work and then hire outride contractors must submit a new affidavit indicating such.
tContcectos that check this box most attacbed an additional sheet showing the name of the sub-contractors and state whetl=or not those entities have
employers. Tf the sub-contactors have employees,they most pmride their workcrs'a mp.policy number. ..
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
inform ion j
Insurance Company Name: 4✓�rlp
Policy#or Self-ins.Lic.#: (a s7�(a��' Exp ration Date: — l�
Job Site Address: �2 7o Lilt,W iC ST City/State/Zip: 54 J' M /Mr4
- 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify un e the pains and enald o.perjury that the information provided above is true and correct
Si e: _Date
Phone#: �7 q
Official use only. Do not write in this area, to be completed by city or town offtcial -
City or Town: Permit/License 4
Issuing Authority (circle one):
1. Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
G. Other
Contact Person: - Phone 1": -
I-D- IN I IRAF 1, F
S;QRTIFICATE OF
LIABILITY INSURANCE
"-'Grose lr;svr''1CF, THIS CERTIFICATE CATE IS 4 '2 C
Agency 111C ONLY AND CONFERS NO AS A MATTER
NOT UPON THE (%RTIF!CAfr
HOLDER. THIS CERTIFICATE DOES AMEND EXTEND)I- INFORMATION
MA D1901 ALTER THE CQVFRAGE AF Pa�u E 0 13Y
f3k,-
IN,
1 INSURERS AFFORDING COI,',R�G
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In accordance with the provisions of MGL c 40 & 54, a condition of
Building Pen-nit Number is that the debris
resulting
from this work shall be disposed of in a properly licensed solid waste
disposal facility as defined by MGL c 111, & 150A .
This debris %vill be disposed of in which City or Town
OFt�S,rYe- DuwP0 T S� a57P�LS T-�c
Street Address
-1 )'P(c ol' contLliner for
Transportation S
X
+gPennit Applicant
`SGi Q SMO�NhC�4n5
-\ Ofr><r of Cnesumcr.V&ir..4 Rovwc.a Rgdnno+ (.ittuse r.r rrgistrx io,:valid for indiridot fur.only
.. HOME"APROVEMENT CONTRACTOP. Ware the ezpbatioo date. if found refu:lt w: -
Repiatrntlt 1u581 ()Mee of Consumer ATysirs and Ausiacsr Reglatidn
Exptratbsn i0i2tf20t 1 TN 289821 It Parli Plaza-$trite 5170
Typo: Indivryoal i Smtoa•Mr 02116
JEF F REY MAY OTTE
JEFFREY MAYOT-m
29 ANDREWS IN.
FAST KI nIGSTCIN,NH 03827 ❑odrstctmr --�j -F---�—L __
id wiry,odt poaturt
\la�•arhu.vll. - Ut'p:rrlmcnl ..I i'uhli� �.rl It
� � Rrra rJ ref liuihlin" Hr,ulari��n. ;rn.I �r:rndara.
CS 103474
Rr$Icn ru: 00
JEFFREY MAYOTTE _ -
29 ANDREWS LN r
EAST KINGSTON, NH 03827 - r
T E.pi .vi,m 1123/ 13
fr-- 103474 '
ACTION, INC y
47 Washington Street
Gloucester, MA 01930
Agency: NSCAP NGRID Application #:
PROGRAM: AARAWAP 0
JOB NUMBER: 0
DOE Work Order#EAII
0 E.S.C. performed? Nc
Work Order Date: 03/30/11
Primary Contractor: on Windows & Insulation
Other Contractor: NA # Bulbs installed o.010
Cost of Bulbs ss0.00
Client: Grace Carr nspt$125.00 Max $0.00
Street: 22 Southwick Street Other In Kind oo.Cc
City: State, Zip: Salem, Ma 01970 Electrical Work i0.00
Telephone: 978-745-0632 S amount Keyspan so.;>0
$ Amount National Grid $0.00
Blower Door Test: No Other utility U.oc
Inspect Knob & Tube: Yes
Date Job Completed: Estimated Repair Total $2,498 00
Actual Repair Total $0.00
Weatherization Est Act Cost Est Cost Act Cost
Door Kit 2 $43.00 $86.00
Door Sweep 2 $15.00 $30.00
Automatic Door Sweep $22.00
Air Sealing 2- art foam (per hour 5 $75.00 $375.00
Attic Air Sealing 2-part foam (per hour 2 $75.00 $150.00
Weatherstn Window(per side) $5.00
Seal Ducts- Mastic $62.00
W/S & Insul. Attic Hatch R30 FBI 1 $32.00 $32.00
Seal Fireplace d Damper w/FB 1 $30.00 $30.00
$0.00
$0.00
$0.00
$0.00
$0.00
Weatherization Totals: $703.00 $0.00
Insulation Est Act Cost Est Cost Act Cost
Attic Flat R20 open 506 $1.23 $622.38
1" Pol iso Foil Faced Foamboard 102 $1.85 $188.70
Attic Flat/Slopes R30 restricted $1.41
Attic Flat/Slopes R20 restricted $1.35
Attic Kneewal R13 FG $1.25
Attic KWall R13 Cell w/Membrane $1.65
Attic Kneewall Floor R30 rest. $1.41
Insulate Attic Stairs&Walls $130.00
Sidewalls-Vinyl R15 DP 588 1 1 $1.70 $999.60
Interior Wall R13 - Plaster R13 DP $1.81
Test Drill Sidewalls-4 sides $60.00
Duct Insulation R5 &Seal Seams $2.95
H dronic Pie Insul to 1" R5 $3.25
Steam Pie Insul to 1.25" R5 $5.25
DHW Pipe Insuation R5 1 6 $2.50 $15.00
Insulate Door 1 $44,00 $44.00
Sill 2-part foam w/FG Batt R19 138 $2.00 $276.00
Insulation Totals: $2,145,68 1 $0.00
Grace Carr Page 2 DOE 0
Otht<r Measures Est Act Cost Est Cost Act Cost
16 ml Poly On Ground 72 $0.75 $54.00
IGableVent- Rectan ular 2 $88.00 $176.00
IVin I Replacement Window-73 w $390.00 `
IVin I Replacement Window-83 ui $400.00
Vinyl Replacement Window-93 ui $410.00
V�2Re cement Window- 101 ui $425.00
I Re I. Bsm't Hopper Window $325.00
ISteel Pre-HungDoorw/Life $610.00
I Solid Core Door w/Hardware $350,00
Faucet Aerator $15.00
Low Flow Showerhead $25.00
Blower Door Test $45.00
Window Grids- per sash $20.00
$100.00
Other Totals. $230.00 $0.00
Energy Conservation Est Cost Act Cost
Totals: Max $10,000.00) $3,078.68 $0,00
Repairs Est Act Cost Est Cost Act Cost
Building Permit Fee 1 $100.00 $100.00
(Electrical Permit Fee 1 $50.00 $50.00
K + T Inspection 1 $175,00 $175.00
Install Bathfan no light) 1 $440,00 $440,00
Site Built TG Door Z Brace 1 $350,00 $350.00
Sheetrock Attic Ceiling no toe 461 $3.00 $1,383.00
Glass Replacement-to 64 ui $42.00
$0.00
$0,00
$0.00
Health & Safety
I Vent Clothes Dryer to Exterior $85.00
Vent Bath Exhaust Fan to Exterior $85.00
Re lace Dryer Hose $38.00
$0,00
$0.00
$0.00
Repair Tot: Max $2500.00 $2,498.00 $0,00
Work Order Sub Total $5,576.68
Measures Est Act Cost Est Cost Act cost
Ocher $0.00
Other $0.00
-Heating System Repair $0.00
"Action approval only
Estimated Job Total: $5,576.68
Job cannot exceed $10,000.00
Job minimum = $200.00 Job Grand Total: $0.00
AUDITOR: Brandon Dorrington
NSCAP
98 Main Street
Peabody, MA 01960
Agency: NSCAP Client Application #:
PROGRAM: Keyspan/2011 100616
30B NUMBER: 0
Work Order# 0
Work Order Date: 03/30/1 l Job Limit:
Primary Contractor: All Season Windows & Insulation Per Unit $4500.00
Other Contractor: NA
Client: Grace Carr K+T Yes=1 No=O
Street: 22 Southwick Street K&T: 0
City; State; Zip: Salem, Ma 01970
Telephone: 978-745-0632 Stand Alone: No
Fee Code: 2
Blower Door Test: No Yes=1, No=2
Inspect Knob & Tube: No Elec. Contractor:
Attic Insulation Est Act Cost Est Cost Act Cost
Attic Flat R38 open $1.40
Attic Flat R30 open $1.30
Attic Flat R20 open $1.23
Attic Flat RIO open $1.15
Attic Flat/Slope R30 restricted $1.41
Attic Flat/Slope R20 restricted $1.35
Attic Flat/Slope R10 restricted $1.24
Attic Kneewall R13 $1.25
Kneewall Floor R30 restricted $1.41
Finished Attic Access $100.00
Temporary Attic Access $75.00
Crawl Space R19 w/Poly Vapor Barrier $2.53
Garage Ceiling/Floor R30 (with approval) $2.00
Thermad ome $175.00
Roof Vent large $95.00
Roof Vent small $76.00
Turbine Vent $160.00
12" Stack Vent $145.00
Pro pa Vent $3.75
Gable Vent(all sizes) $88.00
Soffit Vent $26.00
Ridge Vent(per In. ft.) $22.00
Attic Air Sealing 2-part foam (2 hours max) $75.00
Vent Dryer/Bath Fan 2 $85.00 $170.00
Knot`& Tube W irina Inspection $125.00
Page 2
Grace Carr
Est Act Cost Est Cost Act Cost
Wall Insulation
Single Nailed Asbestos / Asphalt DP $2.10
Double Nailed Asbestos/Aluminum DP $2.20
Brick / Stucco $2.75
Interior Wall Blow - Plaster DP $1.81
Clapboard/ Wood Shingle/ Vinyl DP 1429 $1.70 $2,429.30
Test Drill 4 sides $60.00
Air Sealing Limit:
Single Familv w/Blower Door= $400
All Others = $200
Door Kit 543.00
Door Sweep $15.00
Automatic Door Sweep $22.00
Air Sealing (3 hours max.) $75.00
Sash Lock $9.25
Glass Replacement $42.00
Blower Door Setup $45.00
Total Air Sealing Cost:
Heating Svstem Measures
Duct Insulation & Seal Seams (sq. ft.) 52.95
Hvdronic Pie Insulation to V R5 $3.25
Hvdronic Pie Insulation 1.25" + R5 $3.50
Steam Pipe Insulation to 125" R5 $5.25
Steam Pipe Insulation 1.5" -2" R5 $6.05
Boiler/ Furnace Replacement $0.00
Program Repair**** $0.00
***Action approval needed: Max 5500 _
Actual Total does not include $125.00 K & T chg. $2,599.30 Est Total
$0.00 Act Total