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3 GOOD CIR - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 730 CNIR Y Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section;Forbfficial Use Only. Building Permit Number.': Date App(iedr Building Official(Print�Namz) - .'Signature - Date SECTION 1: SITE INFORMATION 1.1 Property A ress: 1 L2 Assessors Map& Parcel Numbers L> - t7nn Mfl © 9 —e_353-0 1.1 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 WaJtgr Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.S Sewage isposal System: Public 60 Private ❑ Zone: _ Outside Flood Zone? Municipal;PC site disposal system ❑ Check if yes❑ SECTION 2:, PROPERTY OWNERSHIP'' 2.1 Owneri of Record: .-S 1e „ 1k2tr g t} lao.� l_LC. Re�v1 l Mfl e�tC t Name(Print) City,State,ZIP � ion (c �� Hcx - 0l5l�ioa_- q 3p �N�Iloic �taHoa r-\ No.and Street Telephone Email Address SE TION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply) New Construction Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. Cl Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': W c ,) o" SECTION 4: ESTIIvLaTED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only-,., Labor and Materials 1. Building S 1 Building Permit Fee: S Indicate how fee is deterrhined: ❑ Standard City/Town Application Fee 2. Electrical S ❑ fotalProlectCost"(Item x multi plier x 3. Plumbing S 2. Other Fees: Sr I Mechanical (IIVAC) S List: 5. Mechanical (Fire $ Su i pression Total All Fees: S Check No. Check Amount: Cash Amount: 5. 1'ntal l'rnject Cost: S �� U ❑ I''ai�l in Full ❑ Outstanding Balance Dne: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) 7b —7— — tN ao( TiroNu MSS V_ C ow _ License mbber Expiration Date Name of CSL 1-lolder R List CSL Type(sae below) G� 4— No. and Street Type Description U Unrestricted(Buildings up to J 5,000 cu. ft.) R Restricted 1&2 Family Dwellin City/Town, State, ZIP iI l-lasonry RC Roofing Covering WS Window and Siding SF Solid Fual Burning Appliances —71.0`C) _ F on Pale hone Email address D Demolition 5.2 Registered Hone Improvement Contractor(HIC) HIC Registration Number Expiration Date IIIC Company Name or HIC Registrant Name No. and Street Email address City/ own,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 ...........L 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 to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW 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'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. I42A. Other important information on the HIC Program can be found at avww.m:ass.eov%oca Information on the Construction Supervisor License can be found at CIL 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 tirrplaces_ Number of bedrooms _ — Numberofbathrootts __ Numberofhalf/baths _ l'ype of haating system _—_------ — Number oFaacks/porches _--- -- I'ype of cooling systeut _-- FnClosed --_---Open — J-- Total I'n+jact 5yuarc Irnnt;tgc" may be sub;[indal tax""fntul Pro jcct Cos"C CITY OF siu.F_m, AxsSACHUSETTS ° BUILDING DEPAR-F-M&iT 120 WASHIDIGTON STREET, 3ra FLOOR TEL (978) 745-9595 F.ge(978) 740.9846 KIJIBERLHY DRISCOLL MAYOR THo&w ST.PiFxas DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%WISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information 1, � l Please Print Leeibty ri t 1i Nac(BusiiwsyOrginizatiorvindividual): Sad Q � t).Nle- )1 grid f LLB, Address: A00 G V--u _4%(ce t City/State/Zip: Mk 01q15 Phone M:fC 7 cat) gi Ol - 25q`1 Are you an employer?Check the appropriate boat 'type of project(required): 1.❑ 1 am a employer with 4. 0 1 am a general contractor and 1 6. 0 New construction employees(full and/or part-time).• have hired the subcontractors 2.0 1 am a sole proprietor or paMcr• listed on the attached.sheet t 7. ❑Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working fur me in any capacity. workers'comp.insurance. 9, 0 Building addition (No workers'comp.insurance 5. 0 We are a corporation and its roytdreJ.) officers have exercised their 10.0 Electrical repairs or additions 3.0 lain a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No worker comp. c. 152, $1(4),and we have no 12.0 Roof repairs insurance required.)t employees.(No workers' comp.insurance rcquimd.l IJ.❑Other, •Any applicant that ehaW box rl most Aw nil out the snfios below showing their warkus'mmpanurion polity intormatlon. r I hvnauwm"who suhmir this aeidavit indicating they am doing all work and then him"aide'contract=mtat submit a new atlldavit indicating such. :Contmnon that check this box must attached an additional shms shuwi its the time of the rulactintndor and their worker'mmp.put icy infomuaoo. l urn an employer that Is providing ivorkers'canpensadan Laurance for my employeex Below&ille polley and fob site infarmufiom p� 1 T �y Insurance Company dame: VO !�'14 T, i"\c Cc./ v 1_n ail/r. n(JL q IBC y Policy it or Sdr•ins. Lic11. 0: W C. 10 a Qnn 1 hQ�1�, Expiretion Data• 11 I UCH+,�_ Job Site Address: UyY a.31 (_)(;,no c /C (A' City/State/Zip:.S�le rat. t MR Ui c17 8 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 23A ot•MGL c. 152 can lead to the imposition of criminal penalties of s tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a Jay against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations of ilia D1A fur insurancd coverage verification. 1 da hereby certify under the pubts mad penuUleesslof prrJury drat the h1fun ialloe provided above is true and correct. q 1?i p m ,1 0 OJJic•ial use only. Do nor write in thlr array to be completed by city at lawn nJJicluf i I%sul ng,kui horily(circle one): 1. Buard of health 2. Building Department .1.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: -... . _ ._._. Phone d• �--� ,aco�zo - CERTIFICATE OF LIABILITY INSURANCE DATE ozrov,MLVDD2o,3 �i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: (978)744E433 Fax: (978)744-3575 CONTACT Deb Tournas AME:—_ __—___ —_ __—.—___—_SEES—_ GERALD T MCCARTHY INSURANCE AGENCY,INC PHONE (978)744 6433 rrF"'( (978)744-3575 92 NORTH ST .wc_No_E_,u:_ -------------I`ac.Na._ —_ 4-3575 __ EMgIL debbiet@gtmccarthy.com P O BOX A 0 9DDREsZR__ _---- --------- -----------.._----- SALEM MA 01970 PRooucER 537 INSURER(S) AFFORDING COVERAGE NAIC#___ INSURED -HOLLORAN DEVELOPMENT LLC INSURER Acadia Insurance Company C/O JEFFREY HOLLORAN INSURERS 41 FAIRMOUNT STREET INSURERC SALEM MA 01970 INSURER D: INSURER E INSURER COVERAGES CERTIFICATE NUMBER: 22728 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE, FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CLUSIONS AND CONDITIONS OF SUCH POLICIES L EN REDUCED 13Y PAIQ rl AIMS INSR ADD'L SUBR POLICYEFF FOUCYEXP TYPE OF INSURANCE POLICY NUMBER LIMITS _-- ._.._IMMlDDiYYYYL IMMIDDLYYY]fL GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ ---'-- PBEMISESJEIaocasRnseL_ CLAIMS-MADE OCCUR MED.EXP(Any one person) $ PERSONAL a ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIESI PER. PRODUCTS-COMP/OP AGG $ POLICY LIERCL_01O�_._ ._.- .._. � _ _— AUTOMOBILE LIABILITY CO ,__—_ _—_______ ------- POLICY SINGLE LIMIT $ ANY AUTO Ea accident _ BODILY INJURY(Per person) $ ALL OWNED AUTOS — BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA UAB OCCUR E HCA OCCURRENCE $ EXtEas LU1a CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION It A WORKERS COMPENSATION WC2020001688 11106/12 11/06/13 OTM $ WCSTATI}—I--I OTH — --" AND EMPLOYERS' LABILITY YIN _IJOBYLNllIS_LJ_.ER_I ANY PROPRIETORIPARTNEWEXEOUTNE O E.L.EACHACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED] NIA — (MandatorylnNH) EL DISEASE-EA EMPLOYEE $ 100,000 Ir yes.eeacnBe uMer "-- — DESCRIPTION OF OPERATIONS 1xi. _ E.L.DISEASE-POLICY LIMIT $ 500,000 __— DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION CITY OF SALEM i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 93 WASHINGTON STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SALEM,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. —___.._._.__ __SENT__.__._ _ _---._— ____ AUTHORtZEO REPRESENTgTIVE Attention: y/ rights reserved. The ACORD name and logo are registered marks of ACORD T h e d' To Salem Building Inspectors: Holloran Company has secured me as their HERS rater for building on Nurse Way and suroundings as of 1/1/2013. I am currently processing the Projected HERS scores for these homes. Thank you, ]an Rex i Dominic Pezzulo Fwd:Holloran Companies January 31,2013, 11:47 AM - Jeff Holloran Sent from myiPhone Begin forwarded message: 3 I Ian Rex Energy Efficiency Analyst & HERS Rater 978-578-1782 11 Broadway, # 3, Beverly, MA 01915 i The_- HO.Und , i ._ ,d ciltu ..., � � t-�';(l I_9 <- LiiN .'� �;9(� c, aq G; � ..-Y :'I_' N ._S.•. { l'z,LPu - � .. „ :d;C! �78y (}tl� CE!�i (J." !t' f '.,j `�l ai .:IiT't a _'.1'�: f '_ { 1a,�, i9i di J �.`F"PiC r� '•:f�!(, r :do's , , i V% ti 211 t..11 1 l., is 1 s I `1 I',U q�li'' Il y I 4' ;:._ �t jn .`!W r'7"i . :.:. iv a 9r.V ., A. ? tail , - r; �.f. - •f 311b �l:i hi,:'",,. ItemlCost Name permits $,,_.W.._ --1,135.00 pull permits based on 145k=$1595. $11 per$1000+$5=1600 city water and sewer hook up fee $ 250.00 architechtect $ 100000 engineering $ 2,000.00 windows $ 4,368.00 utility water and sewer final grade rough loam perimiter and basement stone excavation,backfin,rough grade excavate for foundation tree clearing and stump removal foundation $ 8,500.00 foundation coating $ 40000 concreate floor $ 2,50000 framing labor $ 9,000.00 8k usher framing lumber $ 16,000.00 decks $ 1,500.00 trash removal $ 1.000.00 hvac $ 8,675.00 plumbing $ 9,175.00 i PUMP sewer $ 3,500.00 bath vanitys and tops $ 1,000.00 water heater $ 650.00 fire place $ 1.400.00 fire place mantel $ 500.00 electrical $ 10.370.00 insulation $ 4,000.00 sheetrock $ 9,149.00 kitchen cabinets $ 2,500.00 finish floors $ 6,400.00 hard wood carpet vinyl light fixtures $ 500.00 trim and stock $ 3,000.00 doors trim stair parts finish carpentry $ 3.000.00 install all doors,trim,kitchen and bath cabinets and vantys and microwaves stairs painting S 2,400.00 appliances $ 2,500.00 cleaning $ _ 400.00 ley John $ 200.00 mailboxs $ 10000 siding labor $ 3,500.00 siding $ 3,200.00 3200 labor tucci roof $ 3,700.00 18.5 square garage doors $ 2 000 00 countertop $ 2,300.00 landscape $ 3.000.00 drive way $ 2,500.00 misc labor $ 3.000.00 contingencies 8 4,728.00 $ 145.000.00 Subtotal Subtotal Real Estate Taxes Light/Electric insurance Total 2 - d � fV CP E E 21 O pGol iT?d xTy.+ g - Construction Supervisor License f ' license: CS 76746 �Aci. n a A THOMAS J BRYAN= , 84 SOUTH£ST FLOOR #1 ° k rt, " ,.x, r ,4 MEpFORD;;MA,02155 h .. Expiratio 5li9/2013 n •F F R 7�' ' 14491 C u pinisa�nt�T O - - - jram')) G -c ti � M E N ) f Yf r < CITY OF S'U.E�I, 1.I.�SS��CHUSETTS E3uu-oINGDEPARTMENT �, �iut-0yf 130 WASHNGTON STREET, 3 °FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI\t[3F_RLEY DItISCOLL ,+LWOR Tt-lou us ST.PtERRa DIRECTOR OF PUBLIC PROPERTY/BCILDL iG CON W ISSION ER Construction Debris Disposal Affldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: Y J R \ �0.JI1 f pp (name at hauler) The debris will be disposed of in -- (name of facility) —'-- (address of facility— )--- tti l signature oCpermit ap scant a�4 � t3 date da,r; ri d.w G.10f z3 N,,�� fci, ��1 s�b�t✓eta., CITY OF SALEM ROUTING SLIP New Construction t/ Certificate of Occupancy LOCATION T DATE ASSESSORS DATE 93 Washington CITY CLERK DATE 93 Washington St. PUBLIC SERVICES 4 / DATE I� 120 Washington St. I WATER DATE 6 o 120 Washington St. CROSS CONNECTION `d DATE V4�I(e N 5 Jefferson WSt. PLANNING DATE L /j 120 Washing CONSERVATION 120 Washington St. ELECTRICAL DATE 48 Lafayette St. FIRE PREVENTION DATE 29 Fort Avenue HEALTH DATE 120 Washington SI BUILDING INSPECTOR DATE 120 Washington St.