0011 WOODLANDS, BPA-19-979, HERS, ROUTING SLIP ijq 7 a!lC-fzk,
The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
CS' Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Section For Official Use Only
0— Building Permit Number: Date Applied:
1
Z-- 5/A410_ ,(,1•02/.'uLA''Co > ..,,, — e
'�i Building Official(Prin( t Name) Signature Date
1 SECTION 1: SITE INFORMATION
q1). 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1/ WOOJ'cols 2ock.el O —0O26
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
2 1 s;A \c_ ccw.k,y 7ao3 go . lz
Zoning District Proposed�se Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
/S I 9 . I 6 /o /S, 6 30 Jl
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public�l Private 0 Zone: _ Outside Flood Zone? Municipal jY On site disposal system ❑
Check if yesj
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: L 2 /� �y
tido0c1`1�AS (lc 6-1-1— 7-cosi 2//1 '1 Mck . V / / oc
Name(Print) City,Stat ,ZIP-7‘ A �^
� OV.v I1L 5 . 7(/ .5-4/ ,.7333 t/'1-Ctigce.00mt',,ST./d
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2: • s C o O F /1 r cA..l
SiASVC— M, > GM-L_
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:
2. Electrical $ 0 Standard City/Town Application Fee
l.?I D O O 0 Total Project Cost3(Item 6)x multiplier)7s x 7
3.Plumbing $ /7, soap 2. Other Fees: $
4. Mechanical (HVAC) $ '._ 00 O List:
5. Mechanical (Fire $ a v
Suppression) /0 i 000 Total All Fees: $ J,9
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0775; d d O 0 in Full 0 Outstanding Balance Due:
91:T0 C-raL�� %,\ T-u
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) _ 0690249 ��/�� / U
40 M t R License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
I?a t3 b X 3
No.and Street Type Description
o �( 5--- U Unrestricted(Buildings up to 35,000 Cu. ft.)
AA CI'r )-(--Lk" M Q, R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
I SF Solid Fuel Burning Appliances
978 a39—y9// tr) CL I A nC oM C6�.ST. net-
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HI )
HIC Registration Numb Expiration Date
HIC Company Name or HIC Registrant Na
No.and Street Email address
City/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 Issuance of the building permit.
Signed Affidavit Attached? Yes . 0 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 a An.aS � L \ . (2 c, -L G.
to act on my behalf,in all matters relative to work authorized by this building permit application.
As/9
Print Owner's 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.
Print Owner' 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) � 3 9 a (including garage,finished basement/attics, decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces n Number of bedrooms 4
Number of bathrooms 3 Number of half/baths
Type of heating system 1A.40c.+ e t,H 2 Number of decks/porches 1
Type of cooling system 't Enclosed Open X
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
nr a,ummunweuun uJ inua3uuru3eiia
Department of Industrial Accidents
Office of Investigations
600 Washington Street
- Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): -fizz CO� A s+r1c o 7-4 e,M, e-S 2 i-C
Address: jib a o < 3 9
City/State/Zip: M 0,61.cL ea t i M& 619 61 Phone#: ��� a 3 / Y9/L/
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6.jgNew construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P h' 9. ❑ Building addition
[No workers' comp.insurance comp.insurance.$ 10. Electrical repairs or additions
required.] 5. We are a corporation and its ❑ P
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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.
I do hereby certify under the pains and penal ' of perjury that the information provided above is true nd correct.
Si nature: Date: 7 S I 7
Phone#: ! 7 j 3 7
Official 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.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
f ( (ill vc a\oi &s Ro (-of 6 0 6 - co z 6
CITY OF SALEM
ROUTING SLIP
New Construction V
Certificate of Occupancy
LOCATION DATE
ASSESSORS i i ' DATE 89-1S' y
93 Washington St. /(5f/
CITY CLERK ,`p \ P ATE r
93 Washington St.
PUBLIC SERVICES0t%_,__ DATE
120 Washington St.
WATER t 6,�1 DATE 8
120 Washington St. (``
CROSS CONNECTIOA�` � ( DATE k
5 Jefferson Ave
PLANNING Axiimiiae,DATE & 2//
7
120 Washington St.
CONSERVATION t- 4'NZ DATE C'J.)-mil r F
120 Washington St.
ELECTRICAL DATE g/_947
48 Lafayette t.
FIRE PREVENTION 044,LAJi2,2 DATE f7,21/l;
29 Fort Avenge
tI
HEALTH ., � DATE L 3
120 Washington St.
BUILDING INSPECTOR DATE
120 Washington St.
JSR AdaptiveSolutions
Energy LLC
RE : Salem Woodlands HERS ratings
To, Thomas St Pierre
Town of Salem Building Department
Cc, Nick Meninno, Tom Rice
I have been contracted by Meninno Construction to perform HERS Rater duties
for the new residences in Salem Woodlands. We have several energy models
that are all meeting the Stretch Code. However, we are currently considering
the source energy available for these home sites and hope to make a final
selection within the next few weeks. Once we have completed our value
engineering process, we will submit "Projected Ratings". If you have any
questions, please feel free to reach out to me. My contact information is listed
below.
Thank you,
John S. Rodenhizer, Rater ID # 9335873
6 Pilgrim Road S. Hamilton MA, 01982
CPHC/PHIUS Certified Builder/PHI US+Rater/CertiledPHIUS+Verifier
jsr@ jsradaptivenergy.com
Office 978-468-0297
Cell 508-734-0177