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0162 BAYVIEW AVENUE - PBA-13-285 The Commonwealth of Massachusetts ° Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM vo Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or a olish a a One-or Two-Family Dwelling,— This Section For Official se Only Building Permit Number: Date Yplio a7 i Building Official(Print Name) Signature rDate SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers L l 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 1p, Private❑ Zone: _ Outside Flood Zone?Check if yeyes[] 7V Municipal��tr On site disposal system [3 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Rec d: A* o Lq.�6 Name(Pont) --- Pc City,State,ZIP No.and StreeT ITelephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Ot r ❑ Specify: Brief Description of Proposed Work':^ \ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ 1. Building Permit Fee: $ Indicate how,fee is determined: 2.Electrical g ❑Standard City/Town Application Fee ❑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: $ s say b ❑Paid in Full ❑Outstanding Balance Due: �� k46t h SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1� �� f}�� L ense Number Expiration Date Name of CS Holder \\ List CSL Type(see below) y No. tr Type Description and Sut \ U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State, M Masonry RC Roofing Covering WS Window and Siding (� SF I Solid Fuel Burning Appliances I Insulation Tele hone Email address D Demolition ,,ff5.2 Registered Home Improvement Contractor(HIC) t1�d'� \�0�' v_ Lr ?_ HI�stration Number Expiration D e HIC Company�Jame or HIC Registrant Name A 'A k4 k)k N .and She t vF d—� IC��-t11✓1 vC�Yt� �� „�� Email addr s 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 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,as Owner of the subject property,hereby authorize l 1'1 y -t s rl�/� 34 c AAit pry? cl to act on my behalf,in all matters relative to work authorized by this�uilding permit application. Print wl�Name(Electronic Signature) - 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. Lt a h ,�1� A�,Ot A , ( 2 Print Owner's or Authorized Agent's Name(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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eovid�s 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" WAP Work Order North Shore Community Action Programs,Inc. Job Number: 1540 98 Main Street Work Order Date:7/7/2012 Peabody,MA 01960 Ownership:Renter Phone:978-531-8810 Air-Tight Weatherization Auditor:Brandon Dorringlon 9 Story Avenue Email:bdonington@nscap.org Beverly MA 01915 Cell:781-540-8569 Email: airdghtllc@gmall.com Phone:978-531-0767 x121 Phone:978-998-4684 Madeline C Belisle NGRID Gas $3,763.23 21 Prescott St Total $3,763.23 Apt.2 Salem MA 01970 978-745-9175 Landlord Name:Gianna Delia Monica Landlord Phone:978-744-3264 Safety Issue(s): Lead Paint Possible AutlSorized Acival MOeaureDescriptton Comments -Qty_ Prlco `:Total $ ^Qty Total Basement Insulation Sill two-part foam w/fiberglass bait 170 $2.20 $374.00 .0 I'sV. _ _. Automatic Sweep 2 $23,00 $46.00 9 Fixed Sweep 3 $15.75 $47.25 oC R-5 Ductwrap or R-max on door 2 $51.00 $102.00 w/foam board I Repalr/Ref1t Door 1 $52.00 $52.00 Weatherstrip s/Q-lon or equal 5 $45.50 $227.50 Clothes dryer vent Including 1 $89.00 $89.00 Exhaust Duct Vent klt/bath fan 1 589.00 $89.00 Date:7/7/2012 Page I J r� WAP Work Order North Shore Community Action Programs,Inc. Jab Number:Ineligible 98 Main Street Work Order Date:7/7/2012 Peabody,MA 01960 Ownership:Renter Phone:978-531-8810 Air-Tight Weatherization Auditor:Brandon Dorrington 9 Story Avenue Email:bdorrington@nscap.org Beverly MA 01915 Cell:781-540.850 Email:airtightllc@gmail.com Phone:978-531-0767 x121 Phone:978-998-4684 Robin Perley NGRID Gas $1,639.23 21 Prescott St Total $1,689.23 Apt.Apt: 1/Floor Salem MA 01970 Safety Issue(s):Lead Paint Possible Authoriisd Actual Measure Description Qty Cbmmenis ' Price Total Qty Total Doors Fixed Sweep 2 $15.75 S31.50 Weatherstrip s/Q-Ion or equal 2 $45.50 $91.00 MlscIneulallon -::: .; Domestic water pipe wrap 6 $2.63 $15.78 Steampipe insulation to 1.5-21n. 185 $6.35 $1,174.75 Iron pipe R-5 Drill Bnish patch plaster(dense 198 $1.90 $376.20 pp pack) j 1 p Total $1,689.23 Contractor Instructions: Before Startin the lob; 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. �n / nq q �- ,^ 3.Davis Bacon time sheets required for ARRA work on US �/ h r o�(, Department of Labor Certified Payroll Report Form WH-347. Date:7/7/2012 Page 1 WAP Work Order: Job Number: 1540 Nit Insuladon - Domestic water pipe wrap 6 $2.63 $15.78 Sleamplpe Insulation to 1.5-2 in. 250 56.35 $1,587.50 Iron pipe R•5 Mfse Measures77.77777777 . Attic sealing with two-part foam 4 $75.00 $300.00 Basement sealing with two-part 3 $75.00 $225.00 foam Slide bolt 2 $22.00 $44.00 Building Permit 1 $100.00 $100.00 1Vall.insulatlon Drill finish patch plaster(dense 198 $1.90 $376.20 pack) I Windows ::. Glass replacement to 64 of 2 $44.00 $88.00 Total 1 $3,763.23 Contractor Instructions: Before Starting the Job: During the Job: I.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 or Labor Certified Payroll Report Form WH-347. Date:7/7/2012 Page 2 (l�c.% ClC fGCu� • _ �12� VG'��iZ7Y�j �� 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 Trk 222331 AIR - TIGHT LLC. WEATHERAZATION JAMES FORTIN — --•- - 10 PINE KNOLL DR. BEVERLY, MA 01915 — - Update Address and return card.Mark reason for change. Address Renewal Employment i—i Lost Card J^•CA'. is SC�7-810»•GI❑1's ;f Consumer Affairs •` ` ss iegu License or registration valid for individul use only W office of Consumer Affair&Business Regalatloo before the expiration date. If found return to: _r_ HOME IMPROVEMENT CONTRACTOR = a Registration: 165640 Type: Office of Consumer Affairs and Business Regulation Expiration: 3/15/2014 LLC 10 Park Plaza-Suite 5170 Boston,MA 02116 AIR-TIGHT LLC.WEATHERAZATION JAMES FORTIN 10 PINE KNOLL DR. Q =� �,�,�•�_� __ _ BEVERLY, MA 01915 Undersecretary Not valtd without signature eta. �1,t..dchu.ct[• - 11r p.u';mrpt •,t Public 'Act 9 K,,.[rJ „t Kuildiu_ Kr ol.t[i„n•-[nJ �t.utd.[nl UCanse 52576 JAMES E FORTIN 10 PINEKNOLL DR BEVERLY, MA 01916 =,p,raoon 10/3/2013 6700 The Comnwnwealth ofMassachusetis Departxtent of lndtesi;W Accidents office of Investigations 600 Washington Street Boston,AM 02111 W1 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician&?Im abers Ani licant Information P lease Print Leeibly Name(Business/Orgenizadon/Individuai); G \ r — Address: \ U City./State/Zip: v e r-\ Phone#: Are you an employer?Check the appr4riate box: Type of project(required): 1.Eq I am a employer with t a 4, ❑ I am a general contractor and I employees(full and/or par me * have hired the subcontractors 6. New construction 2.❑ I am a sole proprietor or partner• listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition woddng for me in any capacity. workers'comp,insurance. [No worl�s'comp.insurance S. ❑ We are a corporation and its 9• ❑Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I E1 Plumbing repairs or additions myself.[No workers'comp, c. 152,§1(41 and we have no 12,❑Roof repairs insurance required.]t employees.[No workers' � comp.Insurance roqulredj 13.®Other iv><,tl\t.1r L04 Any apociat that ehada box gl must also all out the ssedna below showbil their workers'compuuatioa policy Intimation. t Homeowners who submit this dMa it indicating they am doing all wod:and dam hire outride contractors most submit h. a new eflidavit indicating oat tCeetrutora that check this box must attached an additional them slowing the name of the subconaaotott and their workers'comp.policy dtttonmsuc I am an employer that Is providing workers'compensation husamicefor my employem Below is thepolky mad job site !al/ormatlon. Insurance Company Name: _i� ('CT •,c* \ y C..< 1y\ Policy#or Self ins.Lic.#: Y^ Expiration Lev�P �' - \ 5 - a'ol3 Job Site Addrags: City/StaW2ip: 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 oferiminal penalties of fine up to b1,S00.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ER and of up to$250.00 a day ageing the violator. Be advised that a copy of this statement may be forwarded totl ofce of a fine Investigations of the DIA for insurance coverage verification. I do hereby cV*ander thepahas and penowas 00CRIary that the iaformadon provided above is true and toned. Signsture. - Date OfcW use only. Do nor write in this area;to be completed by city or town oJj3eld City Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 1.Building Department a.City/rown Clerk 4.Electrical Inspector 5. Plumbing Impactor 6.Other Contact Person: Phone#: