3A WILLOW AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIVED
dE�
Massachusetts State Building Code, 780 CMR INSPECTION L SE���
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or DIMliO I A % 51
One- or Two-Family Dwelling
This Section For Official Use Only
` Building Permit Number: Date,Applie
(/j
Building Official(Print Name) Signature Date
1 SECTION 1:SITE INFORMATION
1.1 Property Address:A e 1.2 Assessors Map&Parcel Numbers
Ito
1.1a 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Prin City,State,ZIP
' jCk L. ;WOW kyt q 8•Z'� S•21gy �1rGwarkQS&U. o.VLa
-
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Er Repairs(s) Alteration(s)`Er Addition ❑
Demolition 1 ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': "S SL L '�• t o
V of is b I- r
i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Zo W .10^L 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total:Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
�-I � Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ W ,�p 2 ❑Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) `Q-L �- 01, ' 1' Z�
kw" rR " +, .i fir- License Number Expvat" ion Date
Name of CSL Holder ^-t-
� (��� ,3�� List CSL Type(see below) 1
Type Description
No.and Street
��a 3 U Unrestricted(Buildings u to 35,000 cu. ft.)
SW R Restricted 1&2 Family Dwelling
Ciiy/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
of 3$�c 3y 1- SF Solid Fuel Burning Appliances
r1 RLJ��y-t �1 I insulation
Tele hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) ' 13 y I D lO
0JJ«1t f HIC Registration Number Ex nation Date
HIC Company ame or HIC Registrant Name , r�
D box TAN 61WJtKICrtr>5Lt �iornOcii'DA�
No.and,SSttreet n , 3 3 rlD 3�4 Cb'7 Email address
i /Town,State,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 Issua ce of the building permit.
Signed Affidavit Attached? Yes ..........�6 No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative tp work authorized by this building permit application.
I
Print Owner's Name(Electronic Signature) Date
SECTION 7bi OWNER' 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.
V u e i— Gwikh,te— S
Print Owner's or Authorized Agent's Name(Electronic Signature) i Date
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 can be found at
www.inass.6ov/oca Information on the Construction Supervisor License can be found at www.mass.gov.2lps
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 balf/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"
Docu$ign Envelope ID:6448A7FF-OBF5-4FD2-BDA5-7B4195ADA96C
CONTRACT FOR
�onser atlon PRODUCTS J SERVICE WORK
Services Group This service is brought to you through support from your local utility
fins Agreement Is made by and among�,
q sand .
}
Amy SfewaXt s Qorkservataon Service-5 Group(CSG)'
`3a[�✓iltow Ave= �, Atttt:RCS
Salem MA e100.5407 I '. 50 Washington Street, Suite 3000
SitrIDi500002206596'. k Vestborough;'MAQ1581- .
Project 1D:P00000211830 ; iteg.NI 174484
Ci stamecID.COQO00�166fii Fgderi ID No:22245i170
ID:.20,-150507_AS�"EA�+ . 4 " ,f' ' ` C PM Yin
eonraart to address above) .
1. DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to be performed the following work on these"Premises'in a professional manner and in accordance with the terms of
ds CeniraCL,including the attachedrecommendations/work order describing the work in detail(the"Work")which are incorporated herein by reference:
Description Quantity Location
Perform Air Sealing at Estimated 62.5 CFM50 Per Hour - 6 Liv_'ung ice $616.00
6mm Pdy Vapor Bamer 216 WA $177 12
3 WA «. $63.51__
Exterior Door Weather Stopping ...._....__-. _.3 NIA ...:_.__...._.______.� ._.. .60
. _ $75--- -
Sub Total: $932.23
Utility incentive Share $932.23
Customer Contribution WOO
For office use only Printed:517I2015 Page 1 of 2.
II. PAYMENT
Customer a pay es to a Contractor for the Work the Customer Share,of the Contract Price as follows:Payment fil:$ 0 -as a Deposit
payable Co CS6 upon signing the Contract(not to exceed 1/3 of the wtnt read cxxstal.Mail check&contract to CSG,Alan:RCS,50 Washington St.,Ste.
3000,Westborough,MA 01581.Final Payment$ �� as the fmal paynient for the Work shall be payable to the Independent Iruitallation
Contractor("IIC")upon satisfactory completion of the Work.Customer understands that petshe will not be required w pay the Utility Incentive Share of the
Contract price in the amount of$-!4 13__-----Changes to individual line items and'or previous incentives may increase or decrease the size of the Utility Incentive
Share,
Ill. DISPUTE RESOLUTION
71re IIC and Customer hereby mutually ogre*a advailceihatin the eventtitatthe IIC has,a dispute concerning this Contract theltG may submit such dispute to aprhvtue acbihmion
service wlucil has beeti abpmbcd by the Office of Consumer Abates mid Business Rngrdailun and Customer adtail be tequired to submit to such whibabon as provided in NIG.L.c 142:k
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
business,tjA,,t fn)',,gwing the signing of this agreement. Do NOT SIGN THIS CONTRACT IF THERE AKA-NY BLANK SPACES.
,It 6UaV{ 5/14/2015 Il\
Custo eer S;gni-.rw Date indicate our selected ll.0 here,if applicable (OR)
y pp Initial here if you want
the,Program to assign a
Participating Contractor
CSC Signature, - Date. Name of CSG Representative(Printed)
.TEEMS AND GONDMONS APPEAR ON TIIE REVERSE t'id
DocuSign Envelope ID:6448A7FF-OBF5-4FD2-BDA5-7B4195ADA96C
CONTRACT FOR
.onser atlon PRODUCTS I SERVICE WORK
Services Group This service is brought to you through support from your local utility
This Agieemeh Is made by and'arnoilg
aaad -
_
Amy Stewart ,< Cmiservataolt Serrires Group (CSG)
34 Willow Ave"zT >M "' Atla< RCVS
Salem,.MA-,01970 5407 < � ; � { - � � " '50 Washington Street,Sgite;3000
SIteID:500002xp654b .'`" � ' �" � ` �. WeStbaxough,MA'01o81
P>ajecf Tll±POOOt1U211830: � Reg Na 17:3.184
c3Oustoin&10:COOOOO216661 fe eral-MIi($:2224 7170
Contract 10 20150567 WORK (Mal completed contract W addressabove) ._
,
11
y .
L DESCRIPTION OF WORK TO BE PERFORMED
Contractor will perform or cause to he performed the following work on these"Premises"in a professional farmer and in accordance,with the terms of
this Contract,including the attached recommendations/work order describing the work in detail(tire"Worke')which are hicorporawd herein by reference:
Description - Quantity Location
AtticFborOpen&IowCellulose6w _._ _.___ 645 _LiAng_Spaca ___.._.�.__ _. . , ._._., $864.30._.
__
Dammirtg._�._.. ._y.,.,.. 34
Verlt bath fan to roof tlapyer _,._...�_...�...._..__,__._..;:._.._ 1 -Attic ._... $119 00
...---- . . ._ .. .w.__ ._...........
Hatch Thermal Bamer Polyiso 2 inch(Attic}, .._-, .__. t.. .,w �ivmg Space-_.,, . . __.,.. _ ._._ $38 09__,
. . Sub Total: $1,088.39
Utility Incentive Share $816.29
Customer Contribution $272.10
For office use only Printed:5ft12015 Pago 2 of 2
It. PAYMENT 9 0.—)O`
Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment 41:$._ _ as a Deposit
payable to CSG open signing the Contract(not to exceed W of the total retail costs).Mail check&contract to CSG,Attn:RCS,50 Washington St.,Ste.
3000,Westborough,MA 01581.Final Payment,S ( $1 i'�_._-._._.as the final payment for the,Work shall be payable to the Independent Installation
Contractor(I`IIC")upon satisfactory completion of the"Work.Customer understands that he/she will not be required to pay the Ohllty Incentive Sham of the
Cuntraet price in the amount i f$ $1&•z 4 .Changes to individuat line items anther previous incentives may increase or decrease the size of the Utility lncesrtice
Share
III. DISPUTE RESOLUTION
ThcIIC and Gstorner'hereby tnuuu3lly agree in advance that ht the eveniilwt the IiC fns a dtspuu concarragg air Contract,-tire RC nary subndt such d>SPatc to a priv:Ae arbitration
service which Ives been approvedby dre()Bice of Consumer Affa6s and Fsusiness Itegilation and Costumer sluall he rerarired to srrbmitto sru h arbiYrafion as provided ht:47.G L.c 14?,1
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller, provided
you notify the seller in writing by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third
y„following the signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE "RE ANY BLANK SPACES.
11Mt? I'l7I)VaO 5/14/2015
astelil@I,JUMP-7; Date Indicate your selected HC here,if applicable (ilk) lnilial here if you want
the Program to:sign a
CSG Signature Date :Name of CSG Represeinative(Printed) Participating Contractor
TERMS AND CONDMONS APPEAR ON THE REVERSE. 31Lt
RCS PLANVIEW DIAGRAM
astomer. ar^N `J "+ y Home Phone: 2-13
idress: Work Phone:
)wn: Cell Phone: C )-
ry limitations for access by large tmtk? No �_ Yes If yes,describe:
ry specific directions or landmarks? No Yes If yes,describe:
to ID: �,b bS-9, Energy Specialist: ��� — Reviewed by: — `—
1 ����� �Y� 1 O�N ��O{.J �jJ '� V• /���Y g GAY\ 3.
3 "' cU Cam. !'4rc-u
It
C �2- 3u r�a4
0
L z s- --�
aisting Conditions X =Access =Vents Note Inside Square^- R= Roof S= Soffit G=Gable
RV=Ridge Vent CS=Continuous Soffit COE =:Continuous Drip Edge T=Triangle
stall O=New Access Note in Circle C=Ceiling W=Wall S= Sheathing Temp Unless Noted Otherwise
=Vents Note in Triangle R=8" Roof 5=Soffit G=Gable M=12"Mushroom For Access
Doi,nt
DocuSign Envelope ID:93594F27-DA16-4C17-B5CA-B794952CCA31
"WW
i iQ. r iiY GI KTRACM
1 mern e0kyancy
PERMIT AUTHORIZATION FORM
I, Amy Stewart owner of the property located at:
(Owner's Name,printed)
3A Willow Ave Salem
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
E�n Sy dby:
µ&4 Sff,wayl
(�ovnenls;Y grarrbmwin,.i
5/15/2015
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
O$+0
01 �'-
For ate Use Only
Rev.12132011
f CITY OF S��LEM, TMASSACHUSEM
• BUMDLNG DEPART�tE.\T
130 WASr NGTON STRM,3'°FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJtBERL.EY DRISCOLL
MAYOR THOMAS ST.PtEM
DIRECTOR OF PUBLIC PROPERTY/BUUMING COSMQSSIO,iER
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:
—G.W1+11Lf s� 'Uv� b0 }MLA'-
(name of hauler)
The debris will be disposed of in :
- ' Pnt ( LOe- �k1J' Stful
(n me of facilif
►CA-�J-Ujo(address of facility)
signature of permit applicant
date
dehrimITAK
VePartmentry"IndustrialAcridents
Orice of Investigations
I Congress Street,Suite 100
8osurn,MA 02114.2017
www.mass gov(dia
Workers'Compensation Insurance Affidavit: BuddersfContractorslEElectriciansiPlumbers
Applicant Information 1` Lease Print,Lmiltly
Name(Busittesstgrganirrt' tvidua4}; tAx1Y#tt C Y l Y1 Sa3 Lf t itt P Y'
Address:
City}State/zi . 3 . 3(a Phone,#: 151e hi 3 M.. m..
Are you an employerI Check the appropriate box: Type of project trequinut}_
I.H 1 am a employer with 'S 4, f am a general contraeoer and i
employees(full antler part-time).* have hired the sub-contractors fi. ®New construction
2,[3 1 am a sole proprietor or partner- listed on the attached sheet, 9. ®R eii%,
ship and have no employees These sub-contractors have S. Demolition
working for try in any capacity. employees and have workers' 9, ®Building addition
[No workers` comp.insurance cmrp.i ce"
required.] 5. We are a corporation and its I0® Electrical repairs or additions
3-® 1 am a homeowmer doing;all work officers have exerciscxl their i I.®plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 1213 Roof repairs
insurance required.] ± c- 152,§I(4),and we have no
employees. [No workers' 13-C]Other,
comp. gisura=required.]
"Aim V0k:antihat cheeks b"*l .also fig oat the swoon tnt st ing tbcit worherx'u tapr pdicy int
ill who sutnug this affdaveit atirsthegaredaing all wz k andthen hire MWdoeoulmu tMVsuhmiianewaffidavieindicaougstuh.
tConuwain that clw&this bac mw arse as add iinoli azd sho%in the Raftw orthe wb- atxtskaw wtxtbcr not dx)w trams hate
tafip$0y4,{�, itt}ke $aSe.Blrtp y diryamstprobideteir wwkM'cmp,pa nutuber-
I am an employer that iv praviding war#ers'compensators insurance,for my emptope4m Below is then policy and job seta �—
infotmntina-
Instaance Company Nam: (I i tt l ,t 1 LL. CO
Policy#or Self-ins. Lis.4:W C 10 Z,+U_ 001 to Lt i O ko W f zlnTatiun Date_ � CS��Dw�l-•�•,.,•-
Job Site Address; 3 a W 1 i V W Vtye City.'Stateizip. S__ X� P"�✓} o i 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 2M of MGL c. 152 can lead to the imposition of cximmid penalties of a
line up to$1,50"ll aruir"nr one-year impris end, as*AvU as civil penalties in the form of a STOP WORK ORDER and a file
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI for insurance coverage verification.
I do hereby certify under the painss and penalties" of perjury that the information provided above is trae and correct.
SLe_=grit C "'s' Dst l 01
OTicfat use a*. Do not write in this area,to be completed by city or town gftiat.
City or Town permit/License f:
Issuing Authority(Circle one)-
1.Board of health 2.Building Department 3.City/Town Clerk 4.Mectrieal Inspector S.Plumbing Inspector
b.t3tbcr
G ontact Persons Phone#s
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Conhractor Registration
Registration: 173410
Type: Individual
"7 Expiration: 1011(2018 Trlt 257812
KURT GAUTHIER
KURT GAUTHIER - --- __
P.O. BOX 344
IPSWICH, MA 01938 m j t.f _ __-____ - .----- -
10
Update Address and return card.Mark reason for change.
- ---' L] Address f_j Renewal C) Employment f_'j Lost Carc
SCA 1 0 20M W11
��ia tgmne nrhizduZr�l�-a�CwFLrsLa¢e�erUc•l/i , � - _
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
.o-° OME IMPROVEMENT CONTRACTOR
before the expiration date. if found return toi
eillstration 173410 Type; t?ffice of Consumer Affairs and Business Regulation
xpiration.� 10l112016' Individual i 10 Park Plaza-Suite 5170
Boston,MA 02116
KURT GAUTHIER : _
X.
KURT GAUTHIER `-} �'
44 ESSEX RD Ll .{-(—j-/— __._.
IPSWICH,MA 01938 ,i, lindersecretnryN�"*Not valid 4wi ,uresignature
ssacdu e #rtment*I poblle fin[
oty
d of i4uild Rogue 302 201d Stanaara
c,33naeraclj3rn „ s
mqhjtv
Licen":
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