6 CROMWELL ST - BUILDING PERMIT APP t
a The Commonwealth of Massachusetts
Board of Building Regulations and Standards € CITY
J �� �•!� Massachusetts State Building Code, 780 C MR, 7'"edition OF SALEM
�I 'w RevisedJunuun•
Building Permit Application To Construct, Repair, Renovate:Ur,Demolish a
(Jne-or Two-family Dwelling .
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Commissioned Inspect Buildings 1,021c Ar
SECTION 1:SITE 1 ORM
1.1 Property d��0�,�! I I s I. Asae n p& Parcel Number
1.la Is this an accepted street?yes no p Num Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Fromtnge(11)
1.5 Building Setbacks(R)
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 es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2J �3,wnert of Recgr�. . 1
,? /71 :y // C Ke e C ro Elul e l l S�
Rome(Print) Address for Service:
gv 4 '09a-'e -1 97 ^ 720 - L4a5—
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED'WORK!(co-a all,.tbst'apply)
New Construction O- Existing Building❑ Owner-Occupied ❑, Repairs(s) ❑ Alterations) ❑ -Addition ❑
Demolition` ❑, Accessory Bldg.❑ Number of Units 'Other O Specify:
Brief Description of Proposed Work': _1 OVA 7 t'o _ .e_._ tjw I i S _I —
1
r;ti i
SECTION 0: ESTIMATED CONSTRUCTIO COST N S
Estimated Costs:
Item OIIIcin't Use Only
Labor.and'Matenals
w ' determined:. B i it+ee:S.. ... - Indicate how lee is determ
I. Building S I mldtng Perm ., i
❑Standard City/Pown Application Fee
2. Electrical S Cl Total Project Cost'(Item 6):x=multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (tiVAC) S List: �/CJ
S. Mechanical (Fire S
Su pp . Total All Fees: E
Check'i?o. Check Amount: Cash Amount:
6. Total Project Cost 5 3 )06 ,6 10 Paid in Full ❑Outstanding Balance Due:
�I
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration[Yale
i
NameofCSl.• IIuIJer - �81� List C'5L'fype lsee below)
1•('� -
ri•3��-s�;�t1LU'��s�s�s8� T Description
Address Sate t AA 0970 U I l Ines ricted(up to 35.000 Cu.Ft.
_ R Restricted IR2 Family Dwelling
Signature - M Masonry Only
RC Residential RoutingCovering
felephsme WS Residential Window and Sidin -
q SF Residential Solid Fuel Bumin A liancc Installation
'- D Residential Demolition
S.2 Registered Home ImD7 ,npal Contra�ctocr(+ 7a ` ;t=O F9
ttll I FF f� 1
111C Cum any Name or 111C Re tstranl Name Registration Number_
Addre J,l
Expiration- Date
7
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152. S 2SC(6))
Worker Compensation Insurance affidavit must becompleted 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...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,__,-n � /7/e yee h w l as Owner of the subject property hereby
authorize (( ^ r- 6-\ to act on my behalf,in all matters
relative to work authorized by this building permit application.
ram:
Siarwurc oroomer _ - Dale
SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the,statements and information on the foregoing application are true and accuratei,to the best of my knowledge and
behalf.
Print Name .: 2(p /-r_
Signature of Owner or AuthorizedAgent " Date
(Signed under the ainsand,"nalties of u
NOTES:
1. A7Owner btains a building permit to do his/her ownwork,or an owner who hires an unregistered contractor
( the Home Improvement Contractor(HIC)Program),willW have access to the arbitration
pnty fund under M.G:L.c. IJ2A.Other important information on the HIC Program and
Cervisor Licensing(CSL)can be found in 780 CMR Regulations I l0.R6 and 110.RS.respectively.
? When substantial work is planned,provide the information below:
Total.floorsarea(Sq. FL) (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 healing.systcm Number of decks/porches
Type of cooling system . Enclosed Open
7. '"Total Project Square-Footage"may be substituted for"Total Project Cost"
CONTRACT
Printed: 2120/2012
Work Order Id: $26964P29928C299
Contractor nfontlation Custoniet/Site:Detaiis
Atlantic Weatherization Amy Mckeehan Phone(Eve): 978-740 1825
61R Jefferson Ave 6 Cromwell St Phone(Day): 978-239-7059
Salem, MA 01970 Salem, MA 01970-4153 Site ID: S00002026964
,. ' � .,'Totalfnstalled:Measures " '
Location Description Quantity Unit$ Total$
Blower Door Test Only 1 $60.00 $60.00 -
Living Space Insulate Wood Sided Wall With 4"Dense Pack 1;895 $1.92 $3,638.40
"* Installed Measures Total $3,693.40
. .t::: ::. .d>: ,1NorkOider.Notesjj
pwnwA O�u� �✓1 c KQJL l
' w
. rPayments
Incentive Payments
W2atherization Incentive $2,000.00
Total Incentive Payments $2,000.00
Customer Share
Total Customer Share $1,698.40
Less Deposit Of $0.00
Customer Share Balance(Due Contractor) $1,698.40
L
Conservation Services Group-50 Washington Steel Suite 3000-Westborough,MA 01581 -(508)836-9500