8 WOODSIDE ST - BUILDING INSPECTION i156Z
The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised
One-or Two-Family Dwelling March 2011
This Section For Official Use Only
Building Permit Number: Date plied:
a
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Add 1.2 Assessors Map& Parcel Numbers
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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner'of Reco d:
,1 n� � �3 ��J�o�, Scr�ev�n v�nA t� �aal
Nta�me(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ S cify:
Brief Description of Proposed Work': �—
C..\\v��S�-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ C_! � 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 (14VAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �� C� ❑Paid in Full ❑ Outstanding Balance Due:
A(� I?
SECTION 5: CONSTRUCTION SERVICES'
5.1 Construction Supervisor License(CSL)
V^c h �O`��b License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) t�
No.and Street Type Description
U. Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwellin
City own, M Mason
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
'\ _ Ct\� I Insulation
Tele hone T Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) l kzzlS bA`�)
n t Ir^ 1 ;\ l��w a.(`r Z, J(�Z'av/l HIC Registration Number Expiration Date
HIC Company N or HIC Registrant Name
4d
No.and Street ,., _a�� Email address
City/Town, S t ZIP �,.� q�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 ..........`St 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 to work authorized by this builAg permit application.
Sign
Print Owner's Name(Electronic Signature) nor ` - Date
SECTION 7b: 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.
-", t R-a-1--�h
Nat ner's or Authorized Agent's Name(Electronic Signature) 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.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/das
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 halfibaths
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"
, °- Office of Consumer Affairs and. Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165640
Type: LLC
Expiration: 3/15/2014 Trp 222331
AIR - TIGHT LLC. WEATHERAZATION
JAMES FORTIN - ---
10 PINE KNOLL DR. — -
BEVERLY, MA 01915
Update Address and return card.Mark reason for change.
OPs,cAr 0 sOM-04.04-r;101216 _ Address -7 Renewal _ Employment Lost Card
✓k ,!, llajxer1j.zleM
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
- •"-' Registration: 165640 Type: Office of Consumer Affairs and Business Regulation
' Expiration: 3/15/2014 LLC 10 Park Plaza-Suite 5170
AIR-TIGHT LLC.WEATHERAZATION Boston,MA 02116
JAMES FORTIN
10 PINE KNOLL
BEVERLY, MA 0191191 5 Undersecretary o a d witkout signature
.111sus. Ilk•.jr-'111cnl •4 Vuhfik 1.IIC('
MW3•.,;1' ! ••[ HuiL!^u_ k:_ui.,ti.nn ,uni 1.u1 Llr'J. _
L�ter,3e .:.i 52576
�k
JAMES E FORTIN
10 PINEKNOLL OR
BEVERLY, MA 01915
o—
The Commonwealth of Massachusetts Prir t Form
Department of Industrial Accidents
_ p 8 Office of Investigations
�- I Congress Street, Suite 100
Boston, MA 02114-2017
\ www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: xY
Address: Q S-t- ,
City/State/Zip: C�) \q S Phone #: Q
Are you an employer? Check the appropriate box: Business Type(required):
I.®- I am a employer with k S- employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (me]. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* I I.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 1 12.®Other
*Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
orgmii7wion should check box#I.
l am an employer that is providing workers'compensation insurance.for my employees. Below is the policy information.
Insurance Company Name: ��Vr'*Jr•eA a/\SL1Yer..y�..ea. �-o>
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lie. # `A y,W C—"U-,;L T- ,U Expiration Date:
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.
l do hereby certify, under the pains and pena 'es of perjury that the information provided above is true and correct.
Signature !'O ,-r-/-'� �y Date
Phone#: C�lk__V�6
Of use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office .
6.Other
Contact Person: Phone#:
wwwiiias.s.gov/dia
WAP Work Order
North Shore Community Action Programs,Inc. Job Number:26468-1
98 Main Street Work Order Date: 7/3/2013
Peabody,MA 01960 Ownership:Renter
Phone: 978-531-8810
Air-Tight Weatherization Auditor: Doug Cranford -
9 Story Avenue Email: deranford@nscap.org
Beverly MA 01915 Cell: 978-335-7154
Email: afrtightllc@gmail.com Phone: 978-531-0767 x135
Phone: 978-9984684
Dulce Sepulveda NGRID Electric $3,245.92
8 Woodside St Total $3,245.92
Salem MA 01970
Safety Issue(s): Lead Paint Possible
;:1� i; at , xf?`r; , Ly'tWFf .:S 7f' .er'1k 28Qi T� Y� is �} +"l�p,`�'+.3` W 'Y"� a,'r`n•S�i' tr Rb+i a,rt�,tt
$yr
aTq P^ aR' •,
.fi$h3k �/' 'AA1S, .y i"-a $� •'�2" `.r�C rXue�T i� 1c LF�F1'dF
put�tti6cHi d �O rtgP T 1� '
4f d. .P.'6f i t'�,.ry,.µ r�y �,-a"q �`��lxrYfi
Ysat k.a+a• 2u' ' � t'"` i't�'3e�dld ' ' �Ss'S"�`T, r �--yafn g'as{Ar,^si' °gs ' a ,
�Y !.'.
Attic/Kneewall Floor Transition 88 $2.52 $221.76 88 $221.76
Dense Pack w/cellulose
Kneewalls R-12 cellulose behind 285 $1.73 $493.05 285 $493.05
permeable membrane
R-30 restricted-slopes/floored fill 626 $1.48 $926.48 626 $926.48
w/cellulose
R-38 unrestricted-settled cellulose 230 $1.47 $338.10 230 $338.10
{nr 2M� rr• 7iN ti= n b v ax s•a ws h +,. °.".5 x€{r i,v`a+r ms �,a ..; s-� '� r
a. .erk xe a DnoCS.. a ? m a-�1,: xq
. ,(' u.��rirk
r � ..`��ttL� I �b .`�..�- 4? •� ���a4��x.r s��.r���rY.��.'�ir�'f'� �fRV.'�P
4v to_AT§+_^.S.&-. ' fsFirl. �...f•.uv.., Vw¢. � � Yt A C rt...�+r"T 'N
Fixed Sweep 3 $15.75 $47.25 3 $47.25
Weatherstrip s/Q-Ion or equal 3 $45.50 $136.50 3 $136.50
.-k.i. ;t' kr *t,
+,vi:7.'a 'rv2r.."pw.fr,:'�- , . Z t
r.• r xzl � � ;yW..ckxrk�'" ,ar�5-A
Vent kit/bath fan 1 $89.00 $89.00 1 $89.00
Mtsc lnsunsulahon,C11911?fi2�*r.47sy°:=F @;R?%rti"6P 'h+�.- �.fx,.�'_3�_+uiez� it��'�'�'„'.�. "� � �^rae•� vrt�'-i�'31t71'�.�?&� E`F�:�i�
Domestic water pipe wrap 6 $2.63 $15.78 6 $15.78
Duct insulation R-5 140 $3.10 $434A0 140 $434.00
Date: 7/3/2013 Pagel
R
WAP Work Order: Job Number: 26468-I
ak ": , -ira r
_ AR�?;.11 'Tss�E . .-.&..�., fr v rf, ` 1w�."3..•nv}' .
Attic sealing with two-part foam 3 $75.00 $225.00 3 $225.00
Cut/close attic-kneewall access 2 $78.75 $157.50 2 $157.50
Seal ducts with mastic or butyl 2 $65.00 $130.00 2 $130.00
backed tape
Weatherstrip(Q-Ion or equal) attic 1 $31.50 $31.50 1 $31.50
hatch
Total $3,245.92 $3,245.92
Contractor Instructions:
Before Starting the Job: During the Job:
1.Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978.Lead safe practices are
2.Obtain required building permit. required.
2.Total for Heath&Safety and Repairs cannot exceed$2500.00.
3.Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form WH-347.
Additional Contractor Instructions:
Certificate of Insulation posted? Yes No (Circle One) Attic Inspection form attached? Yes N/A (Circle One)
Where Posted:
Contractor: Date: WAP Auditor: Date:
Energy Director: Date: Fiscal Officer: Date:
Sign
Here
Date: 7/3/2013 Page 2
l
WAP Work Order: Job Number: 26468-I
FOR AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
Dryer CO If Yes,indicate language:
Stove CO Occupany change in last 18 months? Yes No (Circle One)
H2O Tank CO Comments:
Heating System CO Number of windows
Ambient CO Number of rooms
Blower Door
Date:7/3/2013 - page 3
i
r '
WAP Work Order
North Shore Community Action Programs,Inc. Job Number: 26468
98 Main Street Work Order Date: 7/3/2013
Peabody,MA 01960 Ownership: Renter
Phone: 978-531-8810
Air-Tight Weatherization Auditor:Doug Cranford
9 Story Avenue Email: dcranford@nscap.org
Beverly MA 01915 Cell: 978-335-7154
Email: airtightllc@gmail.com Phone: 978-531-0767 x135
Phone: 978-998-4684
Marlene Gonzalez NGRID Electric $4,799.03
8 Woodside St Total $4,799.03
Apt. 1
Salem MA 01970
978-429-6815
Landlord Name:Dulce Sepulveda
Landlord Phone: 978-744-1041
Safety Issue(s): Lead Paint Possible
+ aN,.,j .+ r x�
uthorizey�,r„r jito ipSar
""T 7 'i Sr.
', r rMeasure.Der�s clphon - , L,pI h ,i;Pncei -TotaY j` �Qt'y '(+i' To'tal'>~f }"f at 1" ` sa Coymmenls ig,
' '` 1. '� k-a'�S, +' "w« a. z�."`' ''"+,. �-cµ*' ,;
� "�'�_:r her ,+,;�,. .�&i%'..x.&�..t +W, !
la t•J j�a+aha}P"4 'ka t N 'ti T 1
asement Insulation r ,, a' 1-,'gyp., 1 ;aa
`Y4 'ri.1 z^U=e't' ..Yyfi'�+�a s:tllk �#'ig5.n"rk`'F-v qY.i!.; t.J x i Ns'i6+ � '.ri± psi '� 'hr s.�p�'wk aS�``a 1+,�.: �. ;L d:�✓1`�'+trt;+'.s rv'sH9�.,i1��'�.4,'+F +,�l,:e �
Sill two-part foam w/fiberglass batt 151 $2.20 $332.20 151 $332.20
,3-r.,r r >arc" T 1,mWPAR'.',
d r '.a G!v7 Y,��`r:!F�M�'a ' r
'v5 c .KR*�k rir_g'rfYc"� ats ,Nr
Fixed Sweep 6 $15.75 $94.50 6 $94.50
R-5 Ductwrap or R-max on door 2 $51.00 $102.00 2 $102.00
Slide Bolts 2 $22.00 $44.00 2 $44.00
Weatherstrip s/Q-Ion or equal 6 $45.50 $273.00 6 $273.00
4;a " jl Ilealth 8C Safe h „ J"'-'� Ae a..x4 +s hk:;' rrz ir,r Fj"�' ("
3 �."w . 5'-u' �..vrrs �'e�'�a;sr--w.i rt:
Clothes dryer vent including 1 $89.00 $89.00 1 $89.00
Exhaust Duct
� 3S �i'aY MISC ILLSLLlatiOn �b ✓ s't, } Y't�+"' 4 .5' a a s:'E':i"r"^J"3.,a. 'yr'la+ f (rFr ,M o. F 7gy ,sz3'E
= '�`.. ;x=:t'i4. ,:ar+3F` v?uu`.5 { w. ic�-a' - .a ', xd'"�.?t` ..� ,n;,%in;�w3. '`• ;; ..F uR-'.u: ;~ Trr,'�w.¢=
Domestic water pipe wrap 6 $2.63 $15.78 6 $15.78
Duct insulation R-5 280 $3.10 $868.00 280 $868.00
Date:7/3/2013 Page 1
i
J
WAP Work Order: Job Number: 26468
?;ir 1< 1VltsciVLet"su�esr .�-
s 7ni1? .? 6: .u!r M. MOM
Basement sealing with two-part 3 $75.00 $225.00 3 $225.00
foam
Clean Gutters 2 $60.00 $120.00 2 $120.00
Seal ducts with mastic or butyl 2 $65.00 $130.00 2 $130.00
backed tape �^t t
}sat Rg* `� Pe7t'i1t11`ikl ]! -'Vo
z� n'>y v(7 s f .3S S r<ir i• s� o- T4a1 + 3r�" l,sr,,. ;Fx' t .ts h t• "'c 3- }Y:
M!R ATI�L�e1 .;u,.f"SW q�',a. 4i
Building Permit 1 $100.00 $100.00 1 $100.00
ff'si^
r-',"•pplallLnsulatian�� .>ieFxa�R ru t,w'r� 'n, �, .$ r ,s, f ' 'R' ,`v7'f`, - m
r '�"1:^Fr-�.,,.w.. .:S7, x xii, _Slki•'ma'ss r.�s.e4 � .."�w153'k"ScsA. ' pf!:e-�wa.. sca... ..,c 7{...t aas. ..w .k._�v&i?° _a_s,.'
Drill finish patch plaster(dense 123 $1.90 $233.70 123 $233.70 -
pack)
Wood clapboard/shakes/shings or 1115 $1.79 $1,995.85 1115 $1,995.85
vinyl(dense pack)
N'"_'3
W1ndOWS
:fis.`.4 .Y ��.an: !,r-, ..v ri'.F.SIiuL•'4 .'RL.!1L"IiT �t 3r".SsS''. "t' i�, 7�i.5sM`. SFu' �Is..L�s +r'i T_�i.: r.ta"i'�j'
Glass replacement to 64 ui 4 $44.00 $176.00 4 $176.00
Total $4,799.03 $4,799.03
Contractor Instructions:
Before Starting the Job: During the Job:
1.Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978.Lead safe practices are
2.Obtain required building permit. required.
2.Total for Heath&Safety and Repairs cannot exceed$2500.00.
3.Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form W11-347.
Sign
Here
Date: 7/3/2013 Page 2
/
WAP Work Order: Job Number: 26468
Additional Contractor Instructions:
Certificate of Insulation posted? Yes No (Circle Otte) Attic Inspection form attached? Yes N/A (Circle One)
Where Posted:
Contractor: Date: WAP Auditor: Date:
Energy Director: Date: Fiscal Officer: Date:
FOR AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
Dryer CO If Yes,indicate language:
Stove CO Occupany change in last 18 months? Yes No (Circle One)
H2O Tank CO Comments:
Heating System CO Number of windows
Ambient CO Number of rooms
Blower Door
Date: 7/3/2013 Page 3