5 GOOD CIR - BUILDING INSPECTION 1 1
+a The Commonwealth of Massachusetts CITY OF
\!vl Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CNIR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section for.Official Use Only
Building Permit Number:` Date Applied>;.
Building Official(Print Name) Signature Date. -
SECTION 1: SITE INFORNIATION
1.1 roperty Address: 1.2 Assessors Map& Parcel Numbers
`i , 00iC.CcLX SdAe� InF\ 09--o33Y -0
L l 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 Water St1pply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
_/ Zone: _ Outside Flood Zone? Municipal urD On site disposal system
❑
Public tsr Private❑ Check if yes[] p p y
SECTION2:, PROPERTY OWNERSHIP.'
f
2.1 Ownert of Record:
SO& I�oM. Q�;Ir�?rb�silG, 4�s 3c�%� I. Ma olRt�
Name(Print) / City,State,ZIP
/00 'i78 90 Z ' ZS f �FF � '�oll�mn fo»tlp4 ks . �o^t
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Lyi Existing Build ng ❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': n/fe r fwn:.
SECTION 4: ESTIbIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only-
Labor and Nfaterials
1. Building $ 1 Building Permit.Fee $ Indicate how fee is determined:
❑ Standard City/Town Application Fee �� `� 76
2. Electrical S ❑Total Project Cost'L(Item,6)x multiplier x
3. Plumbing S v, Other Fees: t� .--
4. Mechanical (HVAC) 3 List
5. Mechanical (Fire S
Su i ression) Total All Fees: :S
Check No. Check Amount: Cash Amount-.
6- Total Project Cost: S Lt�� o 0 0 0 Paid in Full 0 Outstanding Balance Due: —
1 r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSC,) --t jo—)4 b ��13
=V�1,0 K.rnS �� License Number Espi anon Date
Name of CSL 1[older
C � List CSL Type(see below)
"� So�-w. Type. , Description :
No. and Street _
d�` S U Unrestricted Buildings u to 35,000 cu. ti
��FO r� r M N R Restricted 1&2 Family DNvellin
Cityrrown, State,Z[P M Masonry
RC Roofin Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
rcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I11C Company Name or HIC Registrant Name
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 mast 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 ..........V 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. 142A. Other important information on the HIC Program can be found at
toww.mass.eovr'oca Information on the Construction Supervisor License can be found at ww•w.ntass.uo��rdit_;
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _ _(including garage, finished basementlattics,decks or porch)
Gross living area(sq. ft.) _ Habitable room count
Number of fireplaces_ Number ofbcdrooms
Number of bathrooms Number of hall:Amths _
1'vpe of heating system -_ Numberof decks/porches_ _ _
Type of cooling sysiout_ Enclosed ---Open
3 ['0ta1I101xtlqu1re1`00M"e finnybosub.titu0.d for`Total IrojectCost"
i
i CITY OF S:1LE.NLt, NL1SSACHLSETTS
BUILDING DEPAXIN ENT
j ' +_- r• 120 WASHINIGTON STREET, 3"n FLOOR
TEL. (978)745-9595
EA.e(978) 740.9846
(UAigFRt FY DRISCOLL
MAYORTHoi`tAs Sr.FtlaRRf3
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG CO\C�IISSIONER -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name(Busiiwss Orginizaliatvindividual): SCJ ( M wort tz. !iSo I ARI a r Lt— C.
Address: 100 Cc
City/State/Zip: I�cc/ _ MS Phone#: �Q 1!6) C1 0a,- a!5-q N
Are you an employer?Check the appropriate boxi 'rype of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6• 0 New construction
employees(full and/or part-time).* have hired the sub-uantractorz
2.❑ I am a sote proprietor or partner• listed on the attached sheot I 7• ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working fur me in any capacity. workers'comp.Insurance. 9• 0 Building addition
(No workers'comp,insurance 5. ❑ We are a corporation and is
required.) officers have exercised their
10.0 Electrical repairs or additions
3.❑ i am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.¢1(4);and we have no 12.❑ Roof repairs
insurance required)t employees.(No workers'
cump.insurance requin:d.J 1
13.Q Other,
;Any appikam that d1wks box it mutt alto ell saw the"mian blow showing their worker•compensation policy inifa mutloo
I hweuwnen who submit this amdavil indicating they am doing all work and than hire aettide coaaaatnn must tuhrrll a new amdavil indicating Such
:Omlmtors that chuck this box most aenchad an additional sheet showing the name of the mbsamnctors and thalf workers,comp.policy infomslion.
I am an employer that Is providing workers'compensadan Insurance for my employees Below is therpolAy and Job site
injonnnUon. (�
Insurance Company Name: l7C is^I �� 1-\r l.�y IASI)e' Mf1 LIZ Nq At
t—
Policy 4 or Scif-ins.Lic. H:_ ('),'I000 16 t 2 Expiration Date: 11 0. 13
Job Site Address: Co" C s C CL..4. City/State/zip:��p 11A� 01c17 C7
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Pailuro to secure coverage as required under Suction 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a find
of up to$230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invesligmiu s of the MA for insurance covcraga vcrilicaliur
I do hereby certify under the pulps and penalties of perdu that the hefurmatlon provided above is true and cdrrec6
�i n Pule: ZA /djor, Datd: a`y, 1
r n In-)(6) aoa-�S%4
IOJJicial use aJy. Do mar write in this arrtq to be completed by city ar town aJJlcluL
City car Town: Permit/7.1ceose _--_---
Nsuing Authority(circle one).-
1. hoard of health 2. Building Department 3.Cilyffmvn Clerk 4. Ctectrfcal Inspector 5. Plumbing Inspector
6.Other
Contact Person: _._ _ phone q•
r
F:
17
�Ij VY
CITY OF SU1 EM2 ILSSACHUSETTS
BL ILD4IIG DEPART 61MNT
130 W.1,5HI3NGT04N STRE "
' F ooR
TEL (978) 745--9595
KINMERLBY DRISCOLL Fnr(978) 740-9846
1A.%yOR T HONUs ST-PIERRs
DIRECTOR OF PUBLIC PROPERTY/BUM.DD;G COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of tNIGL 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 e
111, S 150A.
The debris will be transported by:
.IRV\
(nan ul'hauler)
The debris will be disposed of in
— (name of facility)
(address of t'acihty)
4ni
signatureof erit applicant
a t-1 15
date
dcbn9alld•k
a
CITY OF SALEM
ROUTING SLIP
Ne" Construction
Certificate of Occupancy �,,�°�"�
LOCATION J-.DT 2230 kur5e'13ATL
ASSESSOR DATE
93 Washingto
I
CITY CLERK DATE Z .
93 Washington St.
PUBLIC SERVICES�lJ� � ' ` —DATE
120 Washington St. II
WATER G DATE L (�
120 Washington St.
CROSS CONNECTIONDATE
5 Jefferson Ave , ZJ
PLANNING DATE H113
120 Washingto St. //
CONSERVATION ATE L�
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH - DATE 12 q I iz-
120 Washington St
BUILDING INSPECTOR DATE
120 Washington St.
♦qC 1• DATE (MMIDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 02/01/2013
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 endomement(s).
PRODUCER Phone: (978)7446 33 Fax. (978)744-3575 CONTACT Deb Tournas
.NAME,
GERALD T MCCARTHY INSURANCE AGENCY, INC PHONE 92 NORTH ST wC.No-Est): (g78.__)744 6433-_ _ _433 ---------_---cuc_Nm:__(978)744.3675
E-MAIL debbiet@gtmccarthy.com
--
P O BOX 839 noDaEss:____.._—___
SALEM MA 01970 PRODUCER 637
_ - INSURER(s) AFFORDING COVERAGE____ NAIC_p_
INSURED HOLLORAN DEVELOPMENT LLC INSURER Acadia Insurance Company
C/O JEFFREY HOLLORAN INSURER B
41 FAIRMOUNT STREET INSURERC
SALEM MA 01970
INSURER 0:
INSURERS '.
INSDRER F :
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,
EXCLUSIONS AN12 CONDITIONS OF SUCH PO .. MITS SHOWN MAY]j&E3EEU2J.D1MFQ BY PAID-CIAIMS
INSR ADD1 SUBR POLICY EFF POLICY EXP
TYPE OF INSURANCE ma POLICY NUMBER LIMITS
GENERAL LMBILITY ---_ IMMIDDD:Y.YYL (MMIDDIYM
EACH OCCURRENCE_ $
COMMERCIAL GENERAL LIABILITY DAMAGE To RENTED $ _--
.M1SES_fEaascamnaeL_
CLAIMS-MADE OCCUR ME D.EXP(My one person) $
PERSONAL S ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES'PER: PRODUCTS-COMP/OP AGG
RO
POLICY L�PECI_-CaLOC -_-_-
AUTOMOBILE LIABILITY --_--- - --- -_- ------ ---------
COMBINED SINGLE LIMIT �$
ANV AUTO (Ea accident) --
BODILY INJURY(Per person) $
ALL OWNED AUTOS -.-
BODILYINJURY(PeracaidenU $
SCHEDULED AUTOS
PROPERTVDAMAGE
HIREDAUTOS (Per accident) $
NON-OWNED AUTOS $
11
uMeRELLa Like _ OCCUR EACH OCCURRENCE _ $
EXCESS Like CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION WC20200016BB 11I06/12 11106/13 WC sTATa T r OTH
AND EMPLOYERS' LIABILITY YIN _1_TORYUMI _ER_ $ ---
ANY PROPRIETORIPARTNERIECECUTNE E.L.EACH ACCIDENT $ 100,000
OFFK:ERIMEMBER EXCLUDED? NIA - -
wandaton,InNH) — E.L.DISEASE-EA EMPLOYEE $ 100,D00
It I..dewlbe uMN -- -
DESCRIPTIONOFOPERATIONSEei. E.L.DISEASE-POLICY LIMIT $ 600,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if mare space Is required)
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM 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.
I
AUTHORIZED REPRESENTATIVE
Attention: ��P' Ah
The ACORD name and logo are registered marks of ACORD
ng s rreserve
The
Ho '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.
1 am currently processing the Projected HERS scores for these homes.
Thank you,
Ian Rex
. i
Dominic Pezzulo
Fwd:Holloran Companies
' January 31,2013, 11:47 AM
Jeff Holloran
Sent from my Phone
Begin forwarded message:
s
Ian Rex
Energy Efficiency Analyst & HERS Rater
978-578-1782
11 Broadway, # 3, Beverly, MA 01915
Th,
- --
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."J11T,10 t 7..i�� n V I, li>d ..(.tY ''1P :;(;71 k1_ i'.i,�il " ' , "11,;$01i k 1-J afi. U' 11P.1
t ,.
err-, P4 I °Yf3l nl„{ .c Il tn- s
ii.' (Nk �.fi ar]ii d!11
Item/Cost Name
permits $°' 1,135.00 pull permits based on 145k=$1595. $11per$1000+$5=1600
city water and sewer hook up fee $ 250.00
architechtect $ _ 1.000.00
engineering $ 2,000.00
windows $ 4,368.00 .
utility water and sewer -
final grade rough loam -
perimiter and basement stone
excavation,backfill,rough grade
excavate for foundation
tree Gearing and stump removal
foundation $ 8,500.00
foundation coating $ 400.00
concreate floor $ 2,500.00
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 S 9,175.00
pump sewer $ 3,500.00
bath vanitys and tops $ 1,000,00
water heater $ 650.00
fire place S 1,400.00
fire place mantel $ 50000
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 $ 50000
trim and stock $ 3,000.00 doors him stair parts
finish carpentry $ 3.000.00 install all doors,tdm,kitchen and bath cabinets and vanitys and microwaves stairs
painting $ 2,400.00
appliances $ 2 500 00
cleaning $ 400.00
jiffy john $ 20000
mailboxs $ 100.00
siding labor $ 3,500.0o
siding $ 3,200.00 3200 labor tucci
roof $ 3,700.00 18.5 square
garage doors $ p 000 W
counter top $ 2,300.00
landscape $ 3,000.0o
drive way $ 2.500.00
misc labor $ 3 000 00
contingencies $ 4,728.00
$ 145,000.00
Subtotal Subtotal
Real Estate Taxes
Light/Electric
insurance
Total
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MEDFORD` .MA 0215p5 T'
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