0020 STATION ROAD - BPA-12-675 lj�I The Commonwealth of Massachusetts
W� � p Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official se Only
Building Permit Number: Date plied:
Building Official(Print Name)c "' Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.l a Is this an accepted street?yes JK no - Map Number - Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) 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 Ow er'of Am�t 1 Record•
f F<I�rb�tJ Sal e►�a o ����
Name(Print) City,State,ZIP
S;�t� =��✓ 2�P q)0 s6—-/u rs
No.an et Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition O-
Demolition ❑ Accessory Bldg.❑ Number of Units Other @Specify: (,tlp�„G.p12,Lg7Gb✓
Brief Description of Proposed Work': glow,u i., Cel/vl&',e or A'v2scslr_5
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 11' Official Use Only , . °
Labor and Materials 's�
1. Building Permit Fee:$ Indicate how fee is determined:
1. Building $ I
2.Electrical $ ❑Standard City/Town Application Fee , +�
drat
❑Total Project Cost'(Item 6)x multiplier x x
3.Plumbing $ 2. Other Fees: $ ( N
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1 XQQ 0 Paid in Full 11 Outstanding Balance Due:
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Con,_1++stru(cctiion Supervisor License(CSL) /0.34-744 f — 23-ZO/3
-FPI' / /Q1/(7(-fie. License Number Expiration Date
Name of CSL HoI
List CSL Type(see below)
;Le-) Aw&we f;Ni
No.and Street Type Description
r U Unrestricted(Buildings u to 35.000 cu.ft.
�yST K:NCsI�>-•' Restricted 1&2 FamilyDwelling
Cny/Fown,State, IP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
��1 `dr T'7'�7� • aLCr y, f6,� I Insulation
Tele hone Email address C D Demolition
5.2 Registeered Home
Improvement Contractor(HIC) /67 5G41 f0-Z/n&
EFe� /"{+ f7Lti'� HIC Registration Number Expiration Date
FI�C�Com any Nam CReg e or Mistrant Name
Noo..andStreete F-6i d c�wd t co ca,
a Email address
E05 K:.sue w Al 7 7$j-g�U-815o
Ci /Town,Stat ,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 Issuancp of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize U EFFaw Mv4V0-r-TP
to act on my behalf,in ail matters relative to work authorized by this building permit application.
lot o,AI KuPsbcJ a—>y- 12
Print Owner's Name(Electronic Signature) V 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.
Print Owner's or Auth�Agent ame(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. oe v/oca Information on the Construction Supervisor License can be found at www.mass..Pov/dns
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"
t t
CITY OF S.UX.M, IN'IASSACHUSETTS
BUILDING DEPARTmE.NT
• 120 WASHNGTON STREET,3m FLOOR
TEL. (978)745-9595
FAX(978) 740-9846
Klbi$ERIBY DPISCOLL
MAYOR THoN AS ST.PwjutB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Legibly
Name(Busitxr,Organization/Individual): O S&"5at S 'GL`:ar AW g TcYSU/gTic^d LLe
G _
Address: D SOk _
City/State/Zip:LV6W 141A D1 rra t/ Phone#: '-781 - R!(q-ed O
Are you an employer?Check the appropriate box-. Type of project(required):
1.Ist am a employer with_1 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
7-❑ I am a sole proprietor nr partner- listed on the attached sheet: 7• ❑Remodeling
ship and have nu empluyees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] otTicen have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers comp, c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t cmployces. [No workers' IJ.00therlJPE.TL+e.2`L��
comp.insurance required.]
*Any applicatd that checks box#1 must also till out the section below showing then wmirm,eompmrattua policy information.
t I Inmeownets who submit this affidavit indicating they are doing all work and than hire amid.mmractom rant submit a new affidavit indicating such
:Cammatms that cheek ibis box must anacmd an aklitimral sheet showing the name of Ihn aub•eontmtamx and their workws'comp,put icy information.
l am an employer that Is providing workers'compensation Insurance for my employees. Below Is the policy and joh site
information. —r7� I
Insurance Company Name:_ / f<<%l u-e.1�_ -j
Policy#or SedFins.Lic.#: 'NriLco Expiration Date: iG
Job Sire Address: ;?o rj't-g77'0� �o� _City/State/Zip: sc lees —A
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 S 1,500.00 and/or one-year imprisonmen4 as wall as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. He advised that a copy Of this statement may be forwarded to the Office of
Invostigetiuns of the DIA for insurance coverage verification.
Ida hereby certify der the pains and penaldes of perjury that the information provided above/s true and correct.
jwfl ire• ' Z
Data.
O1f&ial use only. Do not write in rh&area,lobe completed by city or town oJ�ciaL
City or Town: Permit/License# _
Issuing Authority(circle one): _
1.Board of Ilealth 2.Building Department 3.Cily/town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Of her
Contact Pcrsun: _ Phone#:
1
,< CITY OF S.U.E.M, NIASSACHUSETTS
BuiLDLNG DEPARTNLE1NT
• f 130 WASHINGTON STREET, 310 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
IU,%IBERLEY DRISCOLL
.MAYOR THoniAs ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMISSIONER
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 will be transported by:
� TP'-A5 L' W. 5a� .7VCT
(name of hauler)
The
(debris will be disposed of in
(name of facility)
(address of facility)
OV
g. fur f ermit a> scant
date
dcbrisaff.dm
01/d6/2d12 02: 27 17815955820 AMBROSE INSURANCE PAGE 02/08
AC-ORD- CERTIFICATE OF LIABILITY INSURANCE DA/6/2D 12
I✓<;lDlif:EH i
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
_�B Arose Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
56 Central Ave. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
j t.y:1n, MA 01901 ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOw, I
9,1 5.92-H2OO _ INSURERS AFFORDING COVERAGE I NAICB
All, Seasons Windows & Insulation INEURERA —I
P.O. Box 6229 �---
Lynn, MA 01�04 !NSURERB be Protection _
INS
NsuReR C' Trav®leza —
' URER
COVERAGES ---~—` I INsQRkR E'
Fi 'OLICiES CF INSJRA^ICE U T:.'pF!-OIN HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
'N1 REQUIREMENT, TEPM OR C Nul IONII OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
I.V\y PERTAIN,THE INSLRANCf Af CR-IED BY THE POLICIES DESCR1SE0 HEREIN IS SUBJECT TO N.L THE TERMS• EXCLUSIONS AND CONDITIONS OP SUCH
JL ICIFS AGGREGATE LIMIT S z k-ro`A.�Mlny HAVE SEEN REDUCED BY PAID CLAIMS. j POLICY NUMDGP X I POTCY EFF TIVF--, LIC ERATION
NMYDO!YY LIMITS
IUEp. L LOAD fiY --
EACH OCCURRENCE $ 1 000 000
X]WA.ME7CIN-G2NEF l.:VDIUI I °
r ! PREMISES 'Ea we PC
S I
C.NMG NInDE g I,r,'pC'.JN, O OOO
MFO ExPtAnv onepvbon) a 5L000
CBP0058607 3/19/11 13/19/12 IPFRBONALSAOVIN:URI' ;9 1 000 000
GENERAL AGGREGATB rs ^„�1000 ,000_
�NI.AGG],EGhTE LIAtlT M4'LIiiS�'CR';
pRt. PRODUCTS AGO S
POLICY r X- T I I:% ! --- — �1 DO D00_I
,MYAUTO COMBINEb SINGLE LIMIT
FpxNtlprnl j000,000
' nu-OVJNECAUTDS
r—
C( iSC4_C RrJLED BODILYINJURY
' P1iT0'n (Pa Rgtxm)
wREOAUTos 137797400001 I5/15/11 5/15/12 w —1
BODILYINJURY
_I NONOWNFD/,b'09 I (Pa•pbcmmq b
-li --- i -
PROPERTY DnuApE !$
-- (PxecemonL)
i _I,RArE L!PBII,iN I
I--- ANYALITO LAUTO ONLY.F•q ACCIDENT $
OTkRRTHAN EA ACC 9 _
j AUTOONLY'. AGO t C%CFSSNMSREILA LNill i.,. I - p r __,.A
CV EACH OOCURRENCE
OC R �I p..unn5l.nL'r
AOGREGATG Is —
DEDUCTIBLE I 3 !
- ' I RETEN'ION
':I:DIi RS CDLkS LI^-F,TIONANJ ---��"— s
L
A1P,OvFRS LIAR TY GbI AI V- Iw
oaRrrRR.rARTVEvcarsvr,rr TpNY LIb11TF I
C -I..EwNcr.RRn .xa I EL EACHACCIDF,NT Soo-L000 1
II n m. eounol Binder 12/15/11 112/15/12 EL.DISEACE-EAEMPLOVR x 500,000
.- .r.nCIAL PFOVIEION9 beIw,
0!HC9 E.L.DISEASE-POLICY LIMIT $ 50Q,000
I I
'!°T''CE'CF DFERATIDN"P ILGCAIIOuti,v!ippl�SE.tCLU910N9 AGDFD9V FADORSERIFNT/FPECIAL FROVI3i0N5 '
Carpentry/insulation/?leatrical
I
_ I
c FRTiFI^nTE HOLDER -
CANCEL TION
City OE Salem SHOULD ANY OFTHE ABOVE,DESCRIOCO POLICIES 8E CANCELLED SEPICRE THE E%PTATION I
Attn. : Building Dept'. DATC THEREOF, THE 138UING INSURER WILL ENDEAVOR TO MAIL20 tT..,i
DAYS 1VR. M
City Hall NOTICE TO THE CERTIFICATE MOLDER MANED TO THE,LEFT,BUT PAII•LpE TO DO 10 SIWLL.
Salem, I4A 019]D IMPOSE NO OBLIGATION OdLIA81I,IT'Y Y KIND UPON THE INSURER, ITS vENTS G
9LPRF8ENTAT S,
AUTHORRBO T
:CORD 25120U1/GS) I I
Q ACORD CORPORATION 1988
Office of Consumer A atrs B smess egu anon
�, -- HOME IMPROVEMENT CONTRACTOR Type.
Registration: 164564
Expiration: 10/21/2013 Individual
REY MAYOTTE -
JEFFREY MAYOTTE -- _
29 ANDREWS LN.
EAST KINGSTON,NH 03827 Undersecretary
Jlassachusctts- De
pM-tment of Public satetc
Boilgj of Buildin Regulations and Standards
Construction Supervisor License
1_imise:. cs 103474
Restricted to: 00
P
JEFFREY MAYOTTE fr+<
29 ANDREWS LN
EAST KINGSTON, NH 03827
Expiration: 1/23/2013
('onunissimicr Tr,9: 103474
ACTION INC ^ .+t��T�:1���+./������y ��` A�-�< +
o, �'3' °
47 Washington Street
Gloucester, MA 01930 w` r
t ;,a
Agency: NSCAP NGRID Application#:
PROGRAM: DOE/11 0
JOB NUMBER: 0
DOE Work Order # 0 ` 6.S.C.performed? No
Work Order Date: 02/02/12.,.
Primary Contractor: All Season Windows_&Insulation's
Other Contractor: NA #Bulbs installed 0 .,
- Cost of Bulbs S0.00
Client: Jamal Kurbaj, Inspt.$175.00 Max $0.00
Street: 20 Station Road ther In Kind $0.00
City; State;Zip: Salem,Ma '01970 - Electrical Work $0.00
Telephone: 978-594-1475/Manah 339-532-8533 $Amount KeySpan $0.00
- $Amount National Grid $0.00
Blower Door Test: yes .,_ Other Utility $Il.a(1
Inspect Knob&Tube: No
Date Job Completed: Estimated Repair Total $870.00
Actual Repair Total $0.00
Weatherization Estimated Actual I Cost I Est Cost Act Cost
Door kit 3 $43.00 $129.00
Re ular door swee 3 $15.00 $45.00
Automatic door swee $22.00
Air sealing 2-pan foam(per hour) 3 $75.00 $225.00
Attic air searng 2-pan roam(,«ho 75.00 $225.00
Weatherstrip window(per side) $5.00
Seal ducts-mastic $62.00
Seal duct returns-mastic $62.00
W/S&insulate attic hatch R30 1 $30.00 $30.00
$0.00
$0.00
$0.00.
$0.00
$0.00
Weatherization Total: $654.00 $0.00
Insulation Estimated Actual' Cost Est Cost Act Cost
Rear overhang blow cavity fill 98 $2.00 - $196.00
Attic Flat R20 o en 630 $1.23 $774.90
Attic Flat/slo e R30 restricted
Thermodome $175.00
Attic kneewal Rl3 FG $125 .
Attic kneewall R l5 cellulose w/Fcamboard 350 $1.73 $605.50
Attic kneewall Floor R30 restricted 588 $1.41 $829.08
Insulate artic stairs&walls $130.00:
Sidewalls--.Aluminum R15 DP 616 _ - ''.$2.20 $1,355.20 Interior wall-plaaster R1)DP +. $1.81
I"rigid foam board((D KW 350 $1:85 i$647.50
Duct insulation R5&seal seams $2.95. .
H dronic pipe insul to I" R5 $3.25" -
Steam pipe insul to 1.25"R5 ``.$5,25
DH1V 2ipeinsuationRS 6 .' 15
Insulate door- I" $2.50 $15.00
rigid board R7 ] i $$2. 0 .'.$ .00
Sill 2-pan foam wl FG bat[R 19 - $2.00 ..
Insulation Total - - $4,467.18 $0.00
DOE
Other.Measures Estimatedrulal ..Cost .' '"'Est Cost Act Cost
vnt-small „::'',`$7600 Gablevenrectaneular - -i'- $88 00
Recessed can cover $30.00
CuVfinlsh anidkneewell access $10000
$60.00
blower door test I $45.00 $45.00
Vinyl replacement tr-iindow- IOlui 2 $350.00 $700.00
Faucet aerator $15.00
Low Flow showerhead $25.00
$0.00
$0.00
$0,00
$o.00
$0,00
Other Total: $745.00 S0.00
Energy Conservation Est Cost Act Cost
"Focal: (iVlax S 10,000,-0) _ $5,866.18 SO.00
NAdij,",t
s Estimated Actual Cost Est Cost Act Cost
efiI door $50.00
oor vilx-i Lite $20.00
Door entry lockset $70.00
Re air door hin_ee $25.00
Slide boll $20.00
Sash lock $9 25
Steel 2-hung door white I $610.00 $610,00
Solid core door%/hardware $350.00
Gla s replacement- to 64 ui $42.00
Sa1 Ah,n $415.00
Clean:utters(per hour) ? $60.00 $120.00
Building pernut i'ee I $100.00 $100.00
Health S Safety
Vent clothes dryer tv exterior $85.00
Vent bath exhaust tan to exterior $85.00
a�,m<rinenwudow�.ad.;zievramres 2 $20.00 $40.00
RepaidHRS Total:(Max S2500.00) $870.00 $Q00
\York Order Sub Toqa1:1 1 $6,736.18 50.00
Measures Estimated Actual Cost Est Cost Act Cost
Other $0.00
Other $0.00
"Heating Svstem Repair $0.00 $0.00
Action appro,al only
Estimated Job Total: $6,736,18
Job cannot exceed S10,000.00 -
Job minimum =S500.00 Job Grand Total: $0.00
AUDITOR: Doug Cranford
d _ >u�k�Jp..;v,Y�"ahcl {>�'.IF".++i.i4�F14�q �td✓a�4�}iV+�i�__ � k _
NSCAP
Kos?jiP"t yti,W�53 �t vt 5 n frit y- f
98 Main street ':A I �a y;,, I
Peabody, MA 01960
Tax Exempt#: 042-385-280
Agency: NSCAP t ..
PROGRAM National Grid/2012
Job Number: 0 f .NGR1D Application 9: 0
Work Otte
0
Work Order Date: 02/02/12
Primary•Contractor: All Season Windows&.In Per.Unit$4500,00 -
Other Con[rac[or: NA
Client: Jamal Kurbaj. &+T Yes=1 No 0.
Street 20 Station Road `";,K&T: _0
City; State; Zip: Salem,Ma _
Telephone: 978-594-14,75/Manal: 33 Stand Alone: No
Fee Code: 0
Blower Door Test Yes -- �StandAlane Yes=1 No=O
MO
nspect Knob& Tube: No Elec—Contractor:
lation Estimated Actual' Cost Est Cost Act Cost
49 o on('lee heat only) $I 53
38 o en
-0 o en $L40
20 o en - .$1.30
l Oo cn $123
AtticFl $1.1541
flat/slope e R30 restricted .�$1
Attic flaL/slope R20 restricted - $1.35
41
Auto fladsl0 e Rio restricted . "$1 24
Attic l:neewall R 13 - $1.25
Attic Ueewall floor R30 restricted - $E41
Attic/kneewall floor transition DP 45 $2.40 $108.00
Finished attic access ;Tem orary attic access .00
$.$100100.00
Crawl space R19 /poly vapor barrier $2 53
Gara e ceiling/floor R30 576 2 , .
Thermadome $ .00 $115200
ReRo $1 .00
a"In .
Roof vent-large .00
$$7766.00
Pro pa vent 6 $3.75 $22.50
Gable vent-all sizesSaff `°
Auto train 6
Anic slope R30 cellulose Iv/,,,,b.... $26.00 $156.00
embrane + $L.95..
Anic slope R20 cellulose w/membrane
Attic kneewall RI_i eellulosc w/membrane -
Attic air seating 2. art foam
Vent drverPoath exhaust fan
Rage 2 National Grid/2012
Ltst i an I a I cc] Actual Cost I Cost
"Vall Insul'ition
�Sioe!r railed usbcso>;a9phullKL UP $2.10
atS V 13,5 0 $2 20 $2,970.00
Rrn:V/stucco R 15 DP ---$2.75
I tmcrwr ,id)blow DLIS[Cr R15 DP
I R 15 M, $1,70
Tar drill 4 sides $60M
ISill 2-Pan foam :6 hmi F(19 $2.00
J C 10 $1.50
$1.82
l:Air Stalin"
Ima
Door kit $43.00
Re-uldr door sweep $15,00
dour sweep $22.00
:Air scafm_e 2-part 10,1111 $75.00
Sash lock $9 25
lGlass rcpktcemant $42.00
aiBlu,,cr Dour Soup $45.00
Tutal Air Stalin" Cost:
I u"�'-'r'S
�DLJCfle"Itill, systeul !Measures
I 11SUIZItiOn L sciil scams(sq. 1.)
... ..1 $2,95
HI'L%oronic pip"=insulaimnta I R5 20 $3,25 S65"00
H',dF011IC I)1j)C ITISLIflatiOn 1.25 - R $3 50
lslcrinl pipe Insulation to I 27R, $5.25
Isicam Pipe 111tLLurn, I ) 2 R) $6.05
[8011er/furnace%placvinew $000
Progarn repair V)M
Actual Total does not include $175,00 K &T charge. S4,473.30 Est Total
I I I I
I S10.00 I JAC(1 otal
AUDITOR Doug Cranford