0005 NICHOLS STREET/COLONIAL TERRACE BPA 4
33-OIo2 -o CK l Zoo Z _ �3(oIT1
The Commonwealth of Massachusetts 0
ECEIVE cITYOF
�4 Board of Building Regulations and Standarr$��RIpHAt SERVICES
Massachusetts State Building Code, 780191�iR SALEM
�R3i6ed Mar 2011
Building Permit Application To Construct,Repair, Renovajsg0 t�r4Q�ishQ J
One-or Two-Family Dwelling l�
This Section For Official Use Only
Building Permit Number: Date Ap red:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
C cv
L l a Is this an accepted street?yes==Ij= 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 Sewag Disposal System:
Public 1® Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
'Es`\.�-�- 1A�vS�ht9
Name�Pnnt) City,State,ZIP
No.and Street Telephone �' r Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building Cl I Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Uni[s_ Other ❑ Specify:
Brief Description of Proposed Work : ih5 \T
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
_(Labor and Materials
1.Building $ % ,0 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(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: $ 5-I d QM ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�saS�� a-off License Number Expiration Datee
Name of CSL Holder
List CSL Type(see below) \1
l C] rJ: Description
No.and Str�— Type
,-� , Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 FamilyDwelling
City/Town,State P M Masonry
� RC Roofing Covering
u nv WS Window and Siding
SF I Solid Fuel Burning Appliances
90 I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
CalHIC Aegrstration Number Expiration Date
HIC Compa�ame or HIC Registrant Name
S4 ertr(�y.a
No.and Street � Email address
Ci /Town, St ,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 ..........14 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 \- t T,L' 1
to act on my behalf,in all matters re Live to work authorized by this building permit application.
Ci
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERt 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.
e—
rint wner's or A thorized Agent's Name(Electronic Signature) Dat
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.gov/dps
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"
Weatherization Work Order Facility ID:0 Work Order Date
Action Energy 47 Washington St.,Gloucester,MA 01930 Auditor&Email: Brian Beote,bbeote@actioninc.org
I Project Name Colonial Terrace Auditor Phone(s): O.978-283-2131 x240,C.978-879-9896
Address Nichols,Butler and Boston Sts.,Salem,MBA Wx Contractor -
Owner/Sponsor Salem Housing Authority Contractor Phone: #N/A
1 Primary Contact Russ Tenzer,Maint.Supervisor,978-423-1300,rtanzer@salemha.org
Other Contact Debra Tucker,Asst.exec Director,978-744-4431 #Bldgs,Apts&Area:10 Bld(s),40 Units,0 SFt.
Lead and Contact Notes: Facility Notes: Construction Type(S)'.Wocd frame-masonry cladding
0 0 Foundation Type
Slab on Grade �� V
Unit Ot. I I Ene conservin Measures
EnergyCone trin Measures De rI ptoror Location Unit Est Actual Unit Cost Est Cost Act Cost Lot
Wall Insulation
15
was Construction Typets) Section 1: Wall Type Sect 2: 1B
Wood da board/shakeslshin lesor vinyl tlense ack sq ft $1.79 17
Single nailed asbestoslas halt densepack) sq It $2.21 1e
Double nailed asbestoValuminum densePeek) Sq ft $2.31 1e
Onll on.cm Plaster Patch car finish wood Plug(dense It $1A2 - m
Vinyl over asbestos tlense ack sg ft $2.31 21
Test drill 4 sides flat rate $60.00 n
$2.50 23
`` Conrad, ditor K&T
Knob&Tube Wiring F I Finainea one location 24
Door Measures
25
Weathefsui w/O-Ion Ofa equal rronl and back hallo egress ea 30 $45,50 $1365.00 26
Fixed Sweepfrom and back hall egress ea 30 $15.76 $472.50 n
Automatic Swee as $23.00 _
e
R-5 Duchvra or t-max or a uivalenl on door ea $51.00
29
Re air/Refit Door ea $52.00 30
31
Window Measures
32
Weatherstrip Window/Schle al or equivalent per side $6.00 33
Glass Replacement to 64 ui ea $44.00
34
Top Sash Lock ea $9.50
35
Miscellaneous Insulation
3]
Distribution Type Secondan,toge -
38
Duct insulation R-5 sq ft $3.10
3B
Domestic water Pipe war, In It $2.63
40
H dronic pipe insulation to 1"copper pipe R-5 In It $3.41 41
dronic pipe insulation 1,25"-1.5"copper e R In ft $3.68 42
Steam pipe insulation to 1.5'-2"iron pipe R-5 In ft $6.35 43
Steam i e insulation 3"iron pipe R-5 In It $7.61 44
45
Water Conserving Measures
46
Handheld showemead 2.OGPM handheld as 40 $38.00 $1 520.00 m
Aerator 0.5 GPM bathroom ea $15.00 48
Aerator 2.0 GPM kxchen swivel/dual spray ea 40 $21,00 $840.00 49
so
Auditor Notes-Page 1 5
Heating Energy Service 52
National Gdd Electnc Heal
53
Colonial Terrace Wx WO x(-Up by D.Legg JorAction Energy 7MO14
UnitD Ene Conservin Measures
Energy ConeeNln Measures Descnptor or Location UnR Est Actual Unit Cost Est Cost Act Cost me
Attic Insulation
u
R-38 unrestrictetl-settled cellulose use markers ing It 10760 $1A7 $15,81T20 55
R-30 unrestricted-settled cellulose S ft
$1.37 �
RA8-20 unrestricted-settled cellulose s it $1 28 57
R-18-20 unrestricted-settled Cellulose S ft $129 se
R-10-12 unrestrictetl-settled cellulose s ft
$1.21 ss
R-30 restricted-slo es/Floored rill w/cellulose S ft $1.48 60
R-18-20 restricted-slopes/floored fill w/cellulose s ft $1 42 61
R-10-12 restricted-slo esl loored fill%/cellulose S ft $1.30 62
Thermodome or Magnetic pull down stairway box Be $18"0
Attic/Kneewall Floor Transition Dense Pack w/cell Drill a castle bloww 63
th feed bag In ft $2.52 6
65
Attic Ventilation
as
Rectangular gable vent 3 per bldg site space ea 33 $92.00 $3,036.00 67
Roof vent 135 1 sq ItNF large as $95.00 fie
Rectangular soffit vent ea $27.00 6e
Pro pa vent 16 in.O.C.Roger on as fi65 $4.00 $2 650.00 no
n
Miscellaneous Measures
>z
Weatherstrip 0-Ion orequal)8 R-30 attic hatch Be 11 $33.50 $36&50 73
Blower door set-up with pre&post tests Be $45.00 74
Attic/basement sealing with two-pan foam all enotrarons man/hr 100 $75.00 $7 500.00 75
AttiUbasemenl sealing with two-part foam man/hr
$75.00 76
Seal ducts with mastic or but I backed toe hr $65.00
Cut/finish attic-kneewell access as
$105.00 r6
Vent kitNath fan as
$89.00 r9
Clothes dryer vent including Exhaust Duct as $89.00 so
Labor only cha a man/hr $60.00 61
az
Basement Insulation 83
Garage ceiling cavity filled sq ft $2 10 64
Sill two- n foam w/unfaced fiberglass bait In ft $2.20 65
Perimeter Wrap R-5 reinforced foil or vinyl faced it sq ft $1.91 e6
Perimeter 2"T-max orequivalent foam board sq it $2 50 67
6 ml poly on unoural sclit $0.75 as
Air Sealing Descri 'ons 69
Hours ao
Bulk heed door vestments
91
Other door or window repair Block and insulate window at 92
Other Prog ram Repair
93
Perand.uOes Penetandon cases tErearlcallPlumbotd;CV=chimneyNenl deal EP=Elecrncal penetrallons,PP=Plumbing penetrations,WP=wall Hours 94
0esc Locafixx,1dpron: plates,RL=Recessed fghts,EB=Elect ducts —
dcal boxes,F or D= Fans or
95
By Pass or Perimeter ay-Pass Codes:FKT=under kneewall,CAN=cailin,Mell xbdsecgon,Sim=saint mtetoh onto=cantilever ovemang.BSL=Bsmt sill. Hours 97
Locariants)Descdptisa
as
s9
Auditor Notes-Page 2 Air Sealing Costs Estimated $9,706.00 Acwai $
Facility Notes:
0
Completion Date: $33,579.20 <Estifnated Total Costs $0.00 jAct Total
Colonial Dace W%WO XL-UP o.tegg)oraction Cnergy 7=14
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston,MA 0211 4-2 01 7
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses
Applicant Information Please PrintLegibly
Business/Organization Name: k \ `- tg_,•L
Address: _ U��iVC't'lt LS
City/State/Zip: 'Cv� 1� �W Phone#: CC� C�( ut(ocLf
Are you an employer? Check the appropriate box: Business Type(required):
1.,R I am a employer with employees(full and/ 5. ❑ Retail
or part-time)." 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We arc a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, $1(4),and we have ME] 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.] 12.❑Other
'Any applicant that checks box#1 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
organirmion should check box#I.
I am an employer that is providing workers'comp{nsation insurance for my employees. Below is the policy information.
Insurance Company Name: I j fv��U�? LU
Insurer's Address: f \ tS k C t`
City/State/Zip: C p
Policy#or Self-ins. Lic. # `,—);C1X Soy (-LSD Expiration Date: I ZCy l�
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 S1,500.00 and/or one-year imprisonment, as well as civil penalties in the fort 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 D1A for insurance coverage verification.
I do hereby certify,under the painsand penalties ofperjury that the information provided above is true and correct
Si nature' Date•
Phone#: / CVqtc LrCeK-LI-
Of icial 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.Cilyfrown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone M
wunm.mass.gov/dia
r
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Go ltractor Registration
Registration: 165640
Type: LLC
1 1 A N I Expiration: 3/15/2016 Tr# 248557
AIR - TIGHT LLC. WEATHERAZAtI ,'
JAMES FORTIN tF f
10 PINE KNOLL DR.
BEVERLY, MA 01915
Update Address and return card.Mark reason for change.
scA1 is 2CM-05/11 Address D Renewal Employment Lost Card
- --- - Clfee ipiinvvroo7unea�L�z o��-o4aocFucaeCGi --- - -
U'Expiration
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OMEIMPROVEMENT CONTRACTOR before the expiration date. If found return to:
e9istration 165640 Type: Office of Consumer Affairs and Business Regulation
3/15/2016� LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
AIR-TIGHT LLC.WEATHFFERA-bN
JAMES FORTIN -
10 PINE KNOLL DRY
BEVERLY,MA 01915 Undersecretary Not va id without signature
t Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Consllucih,❑ Supcnt.or n ,.
License: CS-052576 t*`
JAMES EFORTH)=` '
10 PINEKNOLL DR
'.� Beverly MA 01913
10/03
' ConuYu551pnP,r
10/037201015