5 HOLLY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
t 1 Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 730 CMR, 7"edition OF tiALEM M� Revised
0,1 n•
Building Permit Applicatiun'fo Construct, Repair, Renovate Or Demolish a l. :0I/tLY
One-or Tu•o-Fur u•el ing
This Secti For Ot tcial Use Only
Building Permit Number/__________,_L,, D e Applied:
Signature: �-D"" �YiQ/
Building Commissioner/Ins •or of R Jin Date
SE T I:SITE INFORMATION
1.1 PrppertycAddfess:�T 1.2 Assessors Map& Parcel Numbers
1.la 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 11) Frontage(11)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided ReyuireJ Provided Required Provided
1.6 Water Supply:(M.G.L c.qo,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'?
Public❑ Private❑ Check if yes❑ Municipal❑ Onsite disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owners of Record: jlU`l �r•....� >
G',e/r'L S;r7eS
Name(Print) Address for Servic : „
� �� 91B-� qq - sgLjU
'Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
11 JvriA�f10
r
DO K-
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
d. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ! Q t7 ❑Paid in Full ❑Outstanding Balance Due:
0
r r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Numher Expiration Date
N:une of Csl:I lulder
Liu C'SL Type Isee below)
'I\
Description
:\dJress tl llnreslricteJ(up to 35.000 Cu.Fl.)
It I Restricted 1&2 Family Dwelling
Signature M Nlasonry Only
RC Residential Rooting Covering
I cicphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
1) Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or HIC Registrant Name Registration Number
Address
Expiration 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 BUILDINGPERMIT
I, s {4. &�/ r ,t TOwner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work author building permit application.
Sire of owner Date
SECT N 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
I, ,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. �?
Print V�Cu•�4�
Signature of hvner or Authorized Agent Date z r v f/
(Signed under the pains and penalties ofperjury)
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(IIIc)Program),will not have access to the arbitration _
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total Iloors area(Sq.Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Ilabitable 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 he substituted for"Total Project Cost"
ACTION, INC
47 Washington Street
Gloucester, MA 01930
Tax Exemni # 042-
Agency: NSCAP NGRID Application#
PROGRAM: AARAWAP 0
JOB NUMBER: 0
DOE Work Order# 0 I E.S.C.performed?
Work Order Date: 12/21./10
Primary Contractor: Mass Weatherization
Other Contractor: Manchester Electric, bs LLC #
Cost lin led
Bu
Client: Gail Strzesak nspt$125.00 Max
Street: 5 Holly Street S21- Other In Kind
Electrical Work 01970 -
City; State; Zip: Salem, Ma
Telephone: 978-744-9940 $ Amount Keyspan
$ Amount National Grid $0.00
Blower Door Test: No
$0Other utility >�.1'=
Inspect Knob &Tube: No
Date Job Completed: estimated Repair Total $ .00
I Actual Repair Total $0.00
Est Act Cost Est Cost Act Cost
Weatherization $43.00 $301.00
Door Kit 7
15.00 $90.00
DocrSwee 6
Automatic Door Swee 1 $22.00 $22.00
Air Sealin 2- art foam er hour 3 $75.00 $225.00
Attic Air Sealin 2- art foam er hour 1 $75.00 $75.00$5.00
Weatherstri Window er side $62.00
Seal Ducts-Mastic $32.00
W/S&Insul. Attic Hatch R30 FB $0.00
I $0.00
$0.00
$0.00
$0.00
$0.00
Weatherization Totals: $713.00 $0.00
Insulation Est Act I Cost Est Cost Act Cost
Attic Flat R38 o en $1.40
Attic Flat R30 o en $1.30
$1.41
Attic Flat/Slo es R30 restricted 1.35
Attic FIat/Slo es R20 restricted I $1.25
Attic Kneewal R13 FG
Attic KWall R13 Cell w/Membrane $1 41
Attic Kneewall Floor R Irest. SII $130.00
Insulate Attic Stairs&Walls $1.70
Sidewalls-Vin I R13 DP $1.81
Interior Wall R13-Plaster R13 DP $60.00
Test Drill Sidewalls-4 sides $2.95
Duct Insulation R5&Seal Seams 100 $3.25 $325.00
H dronic Pi a Insul to V R5 $5.25
Steam Pi a Insul to 1.25"R5 6 $2.50 I I $15.00
'insulate
i a Insuation RS 2 $44.00 $88.00
Door $2.00
art foam wl FG Batt R19 $42ion Totals:
Page 2 DOE 0
Gail Strzesak Pa g
Other Measures Est Act Cost Est Cost Act Cost
$76.00
Roof Vent-small $88.00
Gable Vent-Rectan ular $390.00
Vin I Re lacement Window-73 ui $400.00
Vin I Re lacement Window-83 ui $410.00
Vin I Re lacement Window-93 ui $425.00
Vin I Re lacement Window-101 ui I'1 $325.00
Vin I Re I. Bsm't Ho er Window $610.00
Steel Pre-Hun DoorwlLite $350.00
Solid Core Door w/Hardware $15.00
Faucet Aerator $25.00
Low Flow Showerhead $45.00
Blower Door Test $20.00
Window Grids- er sash 1 $100.00 $100.00
Buildin Permit Fees $100.00 $0.00
Other Totals.
Est Cost Act Cost
Ener Conservation $1,241.00 $0.00
Totals: Max$10,000.00
Re airs Est Act I Cost Est Cost Act Cost
Plane/Refit Door 1 1 $50.00 $50.00
Ad'ust Door 2 1 $20.00 $40.00
Door Threshold $40.00
$25.00
Re air Door Hin a $20.00
Slide Bolt $9 25
Sash Lock $42.00
Glass Re lacement-to 64 ui $0.00
$0.00
$0.00
Health &Safe $85.00
Vent Clothes D er to Exterior $85.00
Vent Bath Exhaust Fan to Exterior $38.00
Re lace D er Hose
$0.00
$0.00
$0.00
Re air Tot. Max$2500.00 $90.00 $0.00
Work Order Sub Total: $1,331.00 $0.00
Measures Est Act Cost Est Cost Act Cost
Other $D'00
Other $D.ND
-Heating System Re air !
$0.00
Action approval only
Estimated Job Total: $1,331.00
Job cannot exceed$10,000.00
Job minimum=$200.00 Job Granit Total: $0.00
AUDITOR: Brandon Dorrington
r
10/19/2010 13 :09 FAX bU9 3811 bll8 DA&ICMN lila NUMIMDUnUUD
yot'C& O-pLr
DATE(MWDONYYY)
AC"R& CERTIFICATE OF LIABILITY INSURANCE 1Q 18 2Q1Q
vRooucER phone: 508-651-T7DG Fax: 6o8-ssl-eGB9 THIS CERTIFICATE 19 ISSUED ASA 'NATTER OF INFORMATION
);astern Insurance Group LLC - Main ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER- THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
233 West Central Street ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW.
Natick NIA 01760
INSURERS AFFORDING COVERAGE NAIC 0
INSURED INSURER&We St PT-T: World InBurar CO .-
Mass Weatherization Inc INSURER e: ,F.ter-Oaks..Ei re ----
3 Ocean Avenue INB_VRER c:CHARTIS
Salem MA 01970iNsuRERaS -o .tdalgYns. Co.
NSURERE
COVERAGES
'L'IfE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TLIE INSURED NAMES] ABOVE FOR T, EOIICY PERIOD INDICATED.
NOTWTTHS'L'ANDING ANY REQUIREMENT, TERM OR CONDITION ON ANY CONTRACT OR OTHER DOCUMENT WITH AEEF ECA' 1'0 WHICH THIS
HEF
CERTIFICATE ISSURD OR MAY PE
ONS OFRSVCH POLICIF•Sv GGAEGATERANCE RLIMJ:ED PS SHOWN MAY tIAVEY THE POLICIES EBEENeNFOUCF❑ BY Elm I PAID CLAIMS.
s SUBJECT TO ALL THE
—_
'TEAMS, EFFEETIVE VolCV EXPIRATION UMrtb
IN6R OD' POLICY NUMBER
A GENERAL UARII,TrY pp11675172 5/29/2010 5/29/2011 EACHOCDUN4ENCC
PRE M$ESIE: S.100, 000
COMMERCIAL GENERAL UI AEIU1Y
CLAIMS MADE I OCCUR ME EXP(L& are INjy5) 5_,5000
PERSONALa IDVIWU0.v
GENERAL AG•iREGATE S 2._Q O.Q.,..QQO
-..—_._ PROOUCfS-•COMP/OP AGO 02,_000
DEVIL AGGREGATE LIMIT APPLIES PER ---
POLICY FrT F71
PRO. AC
B10/4/201.0 10/4/2011 COMBINED 61 401-6 LIMIT —
AUTOMOBILE LIABIUTv
A464H7036 (Ea awleam) 51,000,000
ANY ALTO P
SCIDL
ALL OWNED AUTOS (Perve Im) q
IPef Pdf80n) _
SCHEDULED AUTOS
HIRED AUTOS _ BODILY INJUI V S
NON-OWNED AUTOS
PROPERTY o-MMAGE g
AUTOONLY-1ACCIDF,NT S _-
GARAGE LIABILITY EAACC S
OTHER THAN
ANY AUTO AUTO ONLY. AGG S
:LO/18/2010 5/28/2011 EACH OCCUF RENCE S1 000 000
D EXCESS fUMBRELLALIABIITY TSA AGGREGATE 51 000,0.00
I( OCCUR F-1CLAIMSMADE S
DEDUCTIBLE S
K6YLNT10N S WC STP rU- OTH-
WORKERS COMPENSATION WC9442071 9/3/2010 9/3/2011 R TORY UI - •-
C AND EMPLOYERS'LIAB UYV YIN C.L.EACH AC NOENT $ 0
ANY PROPRIETOWPARTNEWEXECUTIVE O
OFFICERAIEMSHi EXCLUDED? E.L.DISEASE•EA EMPLOYE S 00-,000 _
(Maedalory in NH) E.L.DISEAIF--POLICY LIMIT S
If yyaS deSIXICS U11dw
5p EI AI.PROVISIONSbelow
OTHER
DESCRIPTION050PERATION51LOCATION61v HICLEE 1EXCLUSIONS ADDEO BY ENDORSEMENT I SPECIAL PROVISIONS
vinr Gas is named as Additional Insured With TCgard Lo General Liability Where required by v: iccen Cont,=L.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY DY TILE ABOVE DESCRIBED POLTCTF.6 BE CANCELLED
BEFORE THE EXPIKA110H DATE THEREOF, TTIE YSSUTNO TNSURER
WTT,L ENDEAVOR TO MAIL 20 UAY9 WRICTEN NOTICE TO THE
EFT NStar CERTIFICATE HOLDER NAMED Tu THE L:F'e, BUT FAILURE, TO OO 50
&HALT. TMPOSE NO OBLIGATION OH L1AdIWITY OF ANY KIND UPON
P 40 Washington St THE IN6URFR, ITS AGENTS OR HE PRES 0TAT 1V bS.
Westborough MA 01587.
AUTHORIZED REPRESENTATIVEf.}.7/ /,YJ
®19662009&CORD CORPORATION. All rl9hts reserved.
ACORD 25(20091D1)
The&CORD name and logo are registered marks of&CORD
Office of Consumer Affairs and usiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contraetor Registration
Registration: 111617
Type: Private Corporation
Expiration: 1/12/2013 Tr# 207574
MASS WEATHERIZATION, INC
RICHARD LAMBY =
3 OCEAN AVE , " ---
SALEM, MA 01970
Update Address and return card.Mark reason for change.
--�- ❑ Address ❑ Renewal ❑ Employment ❑ Lost Card
JPS-CAI 0 5OM-04/04-GIO1216
+- Massachusetts- Department of Public Sarety
Board of Building Regulations and StandaMs
Construction Supervisor Specialty License
e License: CS SL 102293 -
Restricted to: ICS
RICHARD LAMBY
3 OCEAN AVENUE
SALEM, MA 01970
Expiration: 5/312012
('nnuui>.ioner Tr#: 102293