30 WEST AVE - BUILDING INSPECTION r T> - I Lt-
t The Commonwealth of MassachusettRECEIVEU
Board of Building Regulations atithV9 1190AL SERVICES
X
Massachusetts State Building Code, 718,0 CMR��nn /� ��
is
Building Permit Application To Construct, Repair' njl&trPl�r 1le]nU"A5� Revised
One-or Two-Farnily Dwelling August 15, 2013
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/Inspector of Iruildings Date /
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
9O (.Jesr 0411 ei
1.1 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'
2.1 Owner of Record:
Ter-rope ,70 We IT-
Name(P 'n[) Address for Service:
A 9-/7- `/7l- 9a66
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORIeZ(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other X Specify: V
Brief Description of Proposed Work':
OGU/f OaA J ytiV
�G e J C
j 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:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa (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: $ 2Z��r g� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor'(C'SL) 3
// t
f
�t,�,tj,rgtyp PSM License Number Expir do Date
Name of CS -Holder r .r t /f
� �471 tV - Q t _��� r�tl� List CSL Type(see below)
Address ? type Descri tion
MA 6 t f 7d U Unrestricted(up to 35,000 Cu.Ft)
R Restricted 1&2 Family Dwelling
Signature@I �f M Masonry Only
Q�" 7` 13Y1I RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel BurningAppliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contactor(HIC) it, 6
tyl ASS 1AJ*A4*4-0tlza-"d
HIC Company Name or H1Q Registrant Na�itg Registration Number
k C�k �/'t C� `' //J—
(�� g7lD"N -YyV Exlfirat6n Date
Signature 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, &Oee- H6r -)J f l , as Owner of the subject property hereby
authorize R (G14-i+ {J A?i/2-t to act on my behalf, in all matters
relative to work authorize by this building permit application.
' u
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, zw' ,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. 6 ^ f „
Print Name
(�f�r/'�
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of a du )
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.
2. 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 halfibaths
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"
azYnl <
r v DATE(MM/DO'YYVY)
.,. CERTIFICATE OF LIABILITY INSURANCE
- __
7 ,pERTIFICA'TE!` -A M11,AT11 T11 E1711 R O1111 F INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES �.��DOES NOR NEGATIVELY AMEND OT CONSTITUTE A CONTRACTNBETTWEEN THE ISSUIINGOVERI NSURER(SAGE ),AUTHORIZED REPRESENTATIVE
ENTAT VE
THIS CERTIFICATE: III°;CAT O D
cl to
ON
AI
OR RODUCER AN _, ,-...
IMPORTANT•.It the c.��•' i�lrcerta n poDcnONies rn Y e9ulRre and endorsement A statement on this ust ios endorse . if certificate does lnoW con ter rights eto the e
terms and condition ,,I\dorsement s . CONTACT
certificate holder In .. NAME:
PRODUCER =FA '
PHONE
EASTERN lti:"
(A/C,No,E%1):
I55B OTIS ST'Rl. E-MAIL
456 ADDRESS: NAI C Y
\(1RT11R(IFI II INSURER S)AFFORDING COVERAGE
INSURER A: TRAVELERS INDEMNITY CGNIPA.N1 nP1EN`
_.
�-----'--- INSURER 8: --
iNSUREO -- --'—
\.�',titi INSURER C:
INSURER D: _------��--
INSURER E:
AVI _ INSURER F:
S,AI.F,M,M p 1?I"' ' REVISION NDMBER: pNDNG !
I -......•.....,.�... PE N CA7ED
CERTIFICATE NUMBER: p
COVERAGES , hy,.', MAYHAVEBEEN REDUCEDBY
CNV REGU REMEM.TEENMrF,^r.,;;!`NIS'RON OF ANY CONTRACT OR OTHER DOCUMENT WITH REEPECTTO DMONS SCERDFlCATE MAY BE 159JED OR MAY PERT PIN THF.IN
A�FpRDED BV THE POI-IO"- '`-='A'f1,9ED HEREIN IS SUBJECT 70ALL THE TERMS E%d-t610NS AND CONDmO1`I`''�� Ip� LIMT59-7CM'N
M S
PNDCLAN's .. . ............. POUC/FFFDATE POLICY FXP DATE --�
•..-.....'..,.-. ADD SUB - pOLICVNMBER (WWADD,YYYV) (FM'LDD\VVVY)
CH OCCURRI NCE I'i.
INSR TVr I --
.;TR
RENTED
GENERAL LIAN DAMAGE S
t COMML-Hl
'JABILITV PREMISE (Ea occurrent:)
OCCUR. MEO EXP(Any one
CLAIM: ° ..
q.
' -- PERSONAL F AUV INJl1HY
ENERAL ACCREGAI I
v
�� .... .... IES PER: PRODUCI} LOMtvOP A(t _-----
OGN'L AGGHI L�LOC ' 4
PCILIC" ` COMBINEI SINGLL
_..._,_.
'I` ....,... `LIMIT(Ea 2rcitlent
AUT'OMORIL E I l y
I BODILY INJURY
ANY Al!K. leer Person) _-y-----'���
I
ALL OYVIu BODILY IN.IURY
f r,
Ir DAMAGE
(Rer SCFIELWI• PROPERT\'PERI Y,l I,Y
y I IIRLD A''11 -
(Per accidraY; •I
f NON ON'N;
EACH OCCURRENCE
AGGREGATE Iti,
UM3RC'J..%
.
EXC '._AIMS-MADE
IS
h
L tin;'..- _. ...._
UflU, ' I.i, .. \NC 6TATIJTORY Cl-.1ER, j
RLTLNIK . JMITS
09)032013 09/0&20f4 I,5 500,000I
+I AND YM UB-584493RA-13 rE
EACH ACCIDENT
A WORKERS ti(i'i< MPLOYLLiIT 11OO
EMPLOYER ,I-:�,IpIVE pt/A DISEASC-LA E
ANY PROPER]OEl R IS 500,000
9EI .-t' DISLASG POLICY llMll'
(Rksd,tM IOFFICEFVM�ly*I, .
II es.d,,n11101 ..iu'n
C&RIPI'IONr _
OCgTI ONS/VEHICLES/RESTRICTI ONSISPECIAL ITEM
DESCRIPTION OF I ' .,)CATF NS/VF TO THECFRTIRCATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CANCELLATION
CERTIFICATE HO'-11= , �.„,.. NOTICE WILL BE DELIVERED
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLE
BEFORE THE EXPIRATION DATE THEREOF,
C-Sl" IN ACCORDANCE WITH THE POLICY PROVISIONS.
40 W'ASV'IL\':' AUTHORIZED REPRESEM9PVE ;; 1- ee.-(.. �.-°Lx.•. ._.....,....
?)I .. v
...................
bV L'>ti7B111 \
�':. -•--^' lggg-2016 ACORD CORPORATION. Ail nghts reserved.
aCOR `��-� :` � �ORD name and logo are registered marks of ACOR
-4�' Office of Consumer Affairs&Busifiess Regulation
ME IMPROVEMENT CONTRACTOR
I egisteation: 111617 Type:
xpiiation: 1/12/2015 Private Corporafir
MASS WEATHERIZATION, INC
RICHARD LAMBY
3 OCEAN AVE
SALEM, MA 01970 Undersecretary
c
Massachusetts - Department of Public Safety
jWf Board of Building Regulations and Standards
Construction Super%isnr Specialh - 3
License: CSSL-102293
RICHARD LAMBY.
3 OCEAN AVENUE
SALEM MA 01970
1 i" Expiration
Commissioner 05/03/2016
Work Order
Noah �iu.r, ( onununity Action Programs, Inc. Job Number: Griffth (1)
I]It lieu I ewer Street. Building 13 Work Order Date: 7/17/2014
PenbodN. tl A 01960 Ownership: Renter
D1ass AA catll� I Izatio❑ Auditor: Brandon Dorrington
3Occrlo Acome Email: bdorrington(�..nscap.og
Salon; ]1.1 61970 Cell: 781-540-8569
Email: rnasswxG%comcast,net Phone: 978-531-0767 z121
Phoncto78-741-3471
Eriu (.:011l, NGRID Gas $2,262.88
30 Ax cs! :A e Total $2,262.88
Saicm \i 001 0
Safety Issue(s): Lead Paint Possible
Authorized I I Actual
Measure Description Qty Price Total Qty Total Comments
Attic Insulation
R-30 unrestricted -settled cellulose 798 $1.53 $1,220.94 798 $1,220.94
Doors
Fixed Sweep I $17.64 S17.64 1 $17.64
R-5 Duct)rall or R-max oil door 1 $57.00 $57.00 1 $57.00
Repair/Refit Door 1 $58.00 $58.00 1 $58.00
\N'catherstrip sl(3�-iou or equal 1 $51.00 $51.00 1 $51.00
Health &Sat'ety
Clothes drper ccm including 1 $100.00 S100.00 1 $100.00
Exhaust Duct
4ent kit'/bath Gall 1 $100.00 $100.00 1 $100.00
Mist Insulation
Domestic water pipe wrap 6 $2.95 $17.70 6 $17.70
Hydronic pipe larion to I in. 80 $3.82 $305.60 80 $305.60
copper pipe 12-c
Page
bete. ii -;.'l,; i
Work order: Job Number: Griffth (.I)
Mile Measures
Attic scaling��'ith n+i, par: loam 2 $84.00 $168.00 2 $168.00
Basement scaling woh ("o-part 1 $84.00 $84.00 1 $84.00
roam
Weatherstrip (Q-luu or vyual) attic I S35.00 $35.00 1 S35.00
hatch
Other
C;Hdc bolt 2 $24.00 S48.00 2 $48.00
$2,262.88 $2,262.88
Contractor lnsiruet:on,.
l3cfolc St .trio: it
During the Job:
I. Please norilr ' ",:� :ctorc starting or scheduling a job. l This residence was built before 19 r6- L�:d sah nracuces are
equ ed.
Obtain tcgwtc.. l ' i.'�. t�c'rmit. 2,Total for Heath &Safety and Repairs cniina c�cced ti2�00.00.
3. Davis Bacon time sheets recpnted for ARRA Mork on I S
Department of Labor Certified Pavroll Report Form
Additional COW:'Ic;IH Instructions:
Inspection farm attached° Yes [�'1A (Cl:cic One)
Certificate of Ltsula@an posted'. Yes No (Circle One)
Mass Weathc t t ai n " tr' certil5cs that this'job was supervised and completed in compliance with all Department of Labor
Standards and 1 c,o :Ill C,�ulations.
Contractor Signal:n," -- _. --
Date:__,_RRP License
I hereby ackn,-I,�c 'ant rll work has been completed and inspected.
Customer titgnahu r -_----- ._._-.—_.----
Uatc:
1'age '-
Date: 7117"!.I
i he r—ommonweatrn of massacnayelits
Department of Industrial Accidents
Office of Investigations
600 TYashington Street
Boston, MA 02111
mKw.mass.gov1dia
Work-cr.N' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.kpphcant information Please Print Leziblv
Name (Rtism,s,: 7auon!]nd i vii dual): MASS WFAI11FRITATION INC.-
3 OCEAN AVE
Address:
Cirv/State'Zipi 978-Mbg4p.
Are you all employ er? Check the appropriate box: Type of project (required):
am I crripinv�.' '�ith 4. E] I am a general contractor and 1 6. [:] New construction
have hired the sub-contractors
employees amd/or part-time).
listed on the attached sheet. 7. ❑ Remodeling
am a s(Ac 'F(,-)-i"!o-- or Parmer- These sub contractors have S. ❑ Demolition
T 6
Type
of project
J ec' 'r
El N 0 s
e of pr c' (required):
6 0,,.,,I,'r n
oJe equ e
'p 're
ENew c 13 tJ"tJ
l an
d)
7 7 Remodelm"
crao elm"
8 Demolition
Inoll
ship and e 11�1,MPIO)IeCS employees and have workers' 9 Building
I I
working 'For ni,, in any capacity. 9. ❑ Building addition
comp. insurance., L
[No \v,:)Tku;Y comp. insurance 10.E] Electrical repairs or additions
5. ❑ We are a corporation and its
mg rep it;01 additions
um
equ,iud.l 1.[] PI bingo a
3 EJ It am a doing all work officers have exercised their I repairs or additions
right of exempt per MGL 'of rep urs
le J_Nt w()i l�-']S' comp. 12.E] Robf repairs
c+ 152� §1(4),and we have no 13.
3 K Other
_ ( ,
0 eT 4 L�
_;ILW�,d Other ;GJ_�0 wr Q
employees. [No workers' IL
comp. insurance required.]
x AnN applicant thin 91 must also fill out the section below showing their workers'compensation policy information.
Homeowners who solm, !his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
'Contracnoi s that cited:iill,110\ must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. it the s,l,cwa,,4iors have emplovecs,they mush provide their workers'comp.policy number.
I am an etnploj,e' than is providing workers'compensation insurance far mil employees. Below is the policy and job site
information.
lnsuranceComp ;'' 1"AT11c: N\A ty-�s
Policy F or Sch'_-in' LJC.
Expiration Date:
.lob Site Add3c."S__'� ---- City/State/Zip:
Attach a cop
y of the tc orkers, Compensation policy declaration page(showing the policy number and expiration date).
Failure to sectl!( c as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to er" and,or one-year imprisonment, as well as civil penalties in the form of a STOP WORK IORK ORDER and a Fine
t
of up to S-250 00 �-, dad a-ainst the violator. Be advised that a copy of this statement may be forwarded to he Office of
Investigations of M,_ D!A for insurance coverage verification.
I do hercbr ccr under the pat pains and penalties ofperjury that the information provided above is true and correct.
Date
Official u�c (mit. Do not write in this area, to be completed by city or town officiaL
"c'n"
Cite or I OWII: Permit/License#
r I k'"'a it o
t
iss"din,g,Atilbortiv (circle One): r cal Inspector 5 Inspector
5 Plumbing
s f if /Town Clerk 4.Electrical Inspector Plumbing
Boa
rd'd
FIB Lon r d o f ifu�tlth 2. Building Department 3. City
he Other
6. Other
Phone
Contact in ne c
Contact Nrsfm: