15 GOODELL ST - BUILDING INSPECTION ' r
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
[\` J\ Massachusetts State Building Code, 780 CMR dMar
, Revised Mar 2011
r^IY Building Permit Application To Construct,Repair, Renovat r Demo
Jh 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 INFORMATION
1.1 Property Y?ress: .,?A, S; 1.2 Assessors Map&Parcel Numbers
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 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownekork cord: 504Ile-01t. ild4A
S(rint) 2C(.�eta
Name(Print) �/ City,State,zip
`s trrrtoo.G/OL/l 5 7- CC3-3a-)--y��-9
No.and Street Telephone Email Address
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.❑ 1 Number of Units Other W-1p cify: Gr/Pfi`G.pyz,`2c�r`.rr✓
Brief Description of Proposed Work : ato -t U Te4 f-,ftp
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ DOG1. 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:$
_rl� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ (� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Z43 U V
t ��0ozy License Number/ Expiration Date
Nname of CSL Hold 6r V
Y� �� �2Z� List CSL Type(see below)
No. Ty Description
!�6 U Unrestricted(Buildings up to 35,000 cu.ft.
Restricted I&2 Family Dwelling
arty own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I insulation
Telephone Email address D Demolition
5.2 jRegiiss�tee'red Home Improvement Contractor(HIC) )s y�� �Z�
J�a�I o"iy'T��� >� HIC LReggiistration Number Expiration Date
Coro y game or HIC Registrant Name
tad xZ'zg
No.and Street Email address
5
Cite,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 .......... 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�gln M,&C1A . —r
to act on my behalf,in all matters relative to worrkk�thoriized by this building permit application.
-54&,.in mgAxk ✓ I -Z4J - l 3
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 ent's Name(Electronic Signature) Da�—
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hues 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.gov/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"
CITY OF SAL.E:NI, INLAMACHUSETTS
BUUMING DEP.1,M. ;NT
' 120 WASHINGTON STREET,Yin FLOOR
'I EI- (978) 745-9595
FAX(978) 740-9846
KINIBERLFY DRMOLL
MAYOR - THOhtAS ST.PtERR13
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CO%L%aSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I n A Please /Print Leeibiv
Name t Businemorganization/Individual): �/I S Pee-�S G✓stiVGYiJ or/ � !4' 7-@ tip/
Address: 'PC) l3t p 82 z!g L
city/state/zip: i �✓ y9/1 Phone#:
Are yoam n employer?Check thLAppropriate box: Type of project(required):
1. 1 a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hired the sub contractors
2.❑ 1 am a sole proprietor or partner- listed an the attached sheet.1 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL l l.❑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' I3.�c/uur /i✓EQ/?�.CLk ,i
comp. insurance required.]
•Any applicant that darks box rl must also fill out the acetiau below dwwing their workm'compensation policy infomadon.
t 1 kxrwownm who tmbmit this aflfdavh indicating they are doing all wont and then hire outride conmKtoR most submit a new affidavit indicating such,
:Cwnntyon mat cheek this box must attached an addinonol AM showing the mama of the nth-contractors and their workers'romp,policy information.
lam an employer that is providing workers'compensation Insurance for my employees. Below/s the policy and Job site
information. -ryt !
Insurance Company Name: "/ rL-Gr�GL�P2 `J
n
Policy#or Self--ins.Lic.#: 6`L119 �Z Expiration Date: ['9 -5 - (3
Job Site Address: 15- &c9drXEff 57 City/State/Zip: 69XEv3_
Attack a copy of the workers'compeasation polity 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 SI,500.G0 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
Ida hereby certify ar d r he pains and penaltes of perjury that the information provided above Is true and correct
i>nt r • Date:
f(
Phone# Ro
OJfichd use only. Do nor write in this area,to be completed by city or town official
City or Town: _ Permit/1.1cense#
Issuing Authority(circle one): -- ---
I. Board of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
i21i9/2012 21: 20 17815955E20 AMBROSE INSURANCE PAGE 02/09
CERTIFICATE OF LIABILITY INSURANCE 12i^ 2D Zi
►RODLCER - THIS CE PICATE IS ISSUED AS A MATTER OF INFORMATION
Ambrose Insurance Agency, Inc. ONLY AN CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLOE% 'PHIS CERTIFICATE DOES NOT AMEND, EXTEND OR
56 Central Ave. ALTER THE_COVERAGE AFFORDED B 'Y TH POLICIES BELOW.
Lynn, MA 01901 1
781-592-8200 .INSURERS A�EORDING COVERAGE NAICk
IN6uRED All Seasons Windows 6 Insulation INSURERA: 5 ottadaLq
P.O. Box 8229
Lynn, tAn 01904 sURERG: T3ava1,Ora—
INSURER 6' __T�,J
COVERAGES
.THE POLICIES OF INSURANCE USTEC BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOI FOR THE Policy PERIOD INDICATED,NOTWITHSTANDING
ANY REO(.:IR6M6NT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RIISPECT TO WHICH THIS GERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE APAORDED BY THE POLICIES DESCRIBED HEREIN IS SVBJ60TTO ALL THE TERMS, EXCL.USIONSAHO CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS$eOwH NL4!HAVE BEEN REDUCED BY PAID CLAIMS.
-��_ LI V E"° GTIVE L' YU7 MlR TION '-1
T11GfffL
E O"Nf)()EPOLICY NUMRFR , Y ;NAIOCr�Y �---- LIMITS
AIUTY : EACH OCCURRENCE tRCIALGEHER�A'^LLIASLITYIM6MACE COCCUSCPPOOSS607 3/19/12 3/19/13 PERSONAL&AOV IWILRY
GENERALAGGREGATEs 2,000 0GATE LNIT APPLIF8 PER PRODUCT COM1IP:OP AGG s__2
- _ QQL"'
LrY - {�
A CPOOIELAOIUTY('�I ,. OMBINODSINGLF GM'.T ,T 1,000, QQQ
ANYAUTU i I[a eccld.,I)
P all.ObNN60 AL'706 6OCILYINAUPY
I
I x 8CHEOULEC AUTOS r�I,^''P°'III t
g i HIREDAuros 37797400001 i S/1,5/12 'S/15/13 I EODILYINJURY a
NONOWNEOAUT09 I ry�rnP:ICeta7
PROPERTY DAMAGE S
IAatBCLI7Ml)
GARAGE-LAILITY AUTO ONLY.EAAC.CDENT E
ANYALTO GAACC $_
OTHER THAN
AUTO ONLY. AGG 6
ESSANSRELLA LIAELLRT j EACH OCCURRENCE Ay___—
OCCUR I� OLFpM6MhOE ,; 'AGOREGATE S
OEDUC7I6L.E
RETENTION f 5
WORRER000MPENSATIONAND
EMPLOYERa'.LABILITY j I
E L.$ACH ACCICENT 4 SQQ
ANY PI6WlIRON°APtNEflIE%ECL'�h F: ���WJQQQ I
DFGr.ERMEUBER Prcl:n><w $B55119-A-12 ! 8/9/12 18/9/13 6.L.DISEA9E_EA EMPLOYE S $00 ,000
n H 0!O'llCOunMN
S EOIAL ogOVi51pN5=1e.. E.L DI6E46E POLICV LIMIT S Q Q
i
DESC0.1PT;ON OF DFERATIONylIJCAnON6,VEI IICLE9'EXCLUSIONS 4UDED BY ENCORSBMENT/SPECIAL.PRGVISIONS
Carpentry/Insulation/Electrical
I
I
CERTIFICATE HOLDER -� CANCELLATION
City aL Salem SHOULD ANY OF'1TNE ABOVE DESCRIBED POLICIES eE C."CELLE0 DEFORE THE EXPIRATION
Attn. ; Building Dept.
GATE THEREOF.ITNG ISSUING INSURER MILL ENDEAVOR TO M/;IL20 DAYS
City 1VRRTEN
—
Hall NOTICE TO THE CII�BR'fIFICATG NOlOER NAMED i0 THE LEFT.BVT FAILURE TO DO sc SHALL
NFOBE NO OBLK.ATION OR LAIIILTY IY RIND UPON THE INSURER,ITS AGENTS Ok
Salem, MA 02970 _
REPRESSNTATWOB, A '
AUNORIyEO
4CORO25(2001108) W ACORD CORPORATION 1988
I
i CITY OF &Uy'l t, INWSACHUSETTS
BL'I[=Nr,DEPARTNiE.VT
130 W ASHINGTON STREET, 31O FLOOR
TEL (978)745-9595
PAX(978) 740-9846
(u.NtBER FY DRISCOLL
MAYOR T Homm ST.PmRRis
DIRECTOR OF FLUX PROPERTY/Bt umm.cmaass[ONER
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 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting&tim
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:
(name of hauler)
The debris will be disposed of in
C Yr, -.__044
T—(name of facility)
(address of facilit
ig permit applicant
date
JcbrisalrJuc
Massachusetts - Department of Public Safeq
Board of Building Regulations and Standards
Construction Supervisor -License
CF 10„307e
-.asmcted to: 00 -1
i
JEFFREY MAYOTTE
29 ANDREWS LN
EAST KINGSTON, NH 03827
Expiration: 1/23✓2013
('onuni.ciuner Tr#: 103474
. \ Offire� omerA airs—& ss egu ah�o
TEY
HOME IMPROVEMENT CONTRACTOR
Registration 164564 Type:
Expiration 10/21/2013 Individual
MAYOTTE
JEFFREY MAYOTTE _
29 ANDREWS LN. __ i
EAST KINGSTON, NH 03827
Uaderseeretary
is " dmowledgea ih p ha iu oompie t@d ,
�34hourl)coupatlon a e
ft
bgw. o COrltr of y „�` ,r °
w effre• . Ala
a n
i RpnY Jabour " 92/02/12
<,
gainer name printor.type) t v, �'. r' ( end Cate)�„
Ilk
WAP Work Order
North Shore Community Action Programs,Inc. Job Number: 130053
98 Main Street Work Order Date: 1/7/2013
Peabody,MA 01960 Ownership: Owner
Phone: 978-531-8810
All Seasons Windows& Insulation Auditor: Doug Cranford
P.O.Box 8229 Email: dcranford@nscap.org a`F illl
Lynn MA 01904 Cell:978-335-7154
Email: njmayotte@comcast.net Phone: 978-531-0767 x135 J I M U 8 2013
Phone: 603-642-4451
BY: ..................
Sarah Merchant NGRID Electric $8,688.9 ��
15 Goodell St Total $8,688.90
Salem MA 01970
603-387-4454 -
Safety Issue(s): Lead Paint Possible
r � tho zed q�
^ 10 1 W
CP�ID¢9CC1
Qh t � h )i
.aa p A' Pdceioalll QYt a1 F§ l I � w1 �� 1m e�nft�
e awl : `'aAi 'i t' ^ .;ti �la �Rj?gt1' �. sl.'� {I"t I�I'�.`' ,�
i ce' t irtik,v a d� »ud .. " '.-..-lit IJi 1 e.r
IIiib."tlfixa2 �9t•' �'' hqVy;i�;i� y�'.w.a;�e
�.ons -
= W 1211 WINGi
R-30 restricted-slopes/floored fill 180 $1.48 $266.40 180 $266.40
w/cellulose
R-38 unrestricted-settled cellulose 576 $1.47 $846.72 576 $846.72
R-38 unrestricted-settled cellulose 576 $1.47 $846.72 576 $846.72
1 • 1 F " .SY!' f+>+'slr 'rx�i 6r tb" iT' P M ,;n r !4a-, d �«a� "l�i !-a VAS it�r's'E 1iPhu�J4 arv� 4'>r'c.'wt'm°ts "J•
' c,Y,enhlahon ;`+; + ale, - Er, W �s PJ' 4 r'�µ 1 '
w
t
a
�'tIL< Sks' fde luw�4udl��ilel�:r�t. ��armA�tSs�"�_L���m
Rectangular gable vent 2 $92.00 $184.00 2 $184.00
Rectangular gable vent 2 $92.00 $184.00 2 $184.00'
tY-
�ase.,en In�sul`atto r yet,' a 4 s' ry��re.F w s'it•ACfic�ih�+lm"�i c"9.&. R�3�G :.
Garage ceiling cavity filled with 24 $2.10 $50.40 24 $50.40
blown cellulose
Sill two-part foam w/fiberglass batt 134 $2.20 $294.80 134 $294.80 - -
ai ?� f floxx l M9 Aii bi ngliigAt iV r t Nei.
[�L � 'r to F���� � �s�i �w�'?,n
Fixed Sweep 5 $15.75 $78.75 5 $78.75
R-5 Ductwrap or R-max on door - 1 $51.00 $51.00 1 $51.00
Date: 1/7/2013 Page 1
/ WAP Work Order: Job Number: 130053
Repair/Refit Door 1 $52.00 $52.00 1 $52.00
Weatherstrip s/Q-loner equal 5 $45.50 $227.50 5 $227.50
tH¢sl[h� Safety �" .h"` ',� ,+J {'l�'"` -.; y�,"7gi�' j�T t�l" 1"' A �°iI{ Xi"kv'�j,��6k '�aa�t� w:m'�Rli q� ' `iii-41+`•w5 'v*
an 'a`tizS�iir"aNRee' .rl•�i �fA4�.'.w.'Jm.'�ll6:d.p :.Meli�k. iAI .Ii6,:ii �ne�Jl :lre��H�s. rt ,*J6N ' '�u
Vent kitfbath fan 1 $89.00 $89.00 1 $89.00
9s:t!�r. p.pt��"!(zxiit.ic,y at' xw �•-txf's+''� iva'�uIrH ' nwi.n� nmG111�8 'Iw LL � A I ronx'Ku wR
e xq
Domestic water pipe wrap 26 $2.63 $68.38 26 $68.38
Hydronic pipe insulation to I in. 20 $3.41 $68.20 20 $68.20
copper pipe R-5 -
`"9�." '3m
w
`t��i'$' I�nricplays
,eq""I.'I . IF.J-• i ,
K+as�MF3� v� rWi."�leln .v.+rrrT_.�.6- Mi-R �.: .�IF
Attic seating with two-part foam 3 $75.00 $225.00 3 $225.00
Basement sealing with two-part 4 $75.00 $300.00 4 $300.00
foam
Blower door set-up with pre&post 1 $45.00 $45.00 1 $45.00
tests
Cut/close attic-kneewall access 1 $78.75 $78.75 1 $78.75
Labor only charge 1 $60.00 $60.00 1 $60.00 Remove/Dispose Fiberglass in attic
Weatherstrip(Q-lon or equal)& 2 $33.50 $67.00 2 $67.00
R-30 attic hatch ,y s "`PCrmits r� p ""f" + Fc a, u�11
��� �-- a#'S ' eJ
.'Y �:,; ..a.� r•�ii�l ���«:TM,�,e7 �ti:xr'.� ;�Jw..,'elfin'm'..Ng,.d�`wa'x>��,"I�:tiM*a�'�tMr~,r�rriactW�ai�• ,-,fi:�±l:a.-���i.s�'r'Jwx-..Fz6 r_..9..
Building Permit 1 $100.00 $100.00 1 1 $100.00
,
Date: 1/7/2013 - Page 2
f 1 ,
WAP Work Order: Job Number: 130053
rc- r vtyw r+, $°',,it,.utaww-2riwr t _ .: H+�I �i q:p�,,.
A�" Wall TIISR18tlOn c�' v Ih A �"i vl +t II >Ht .;, r a ,(
"a' N_a ,r3e�—�r`.rF�2k:;f'.:.. '' »�'•
Double nailed asbestos/aluminum 1578 $2.31 $3,645.18 1578 $3,645.18
(dense pack) '
Wood clapboard/shakes/shings or 440 $1.79 $787.60 440 $787.60
vinyl(dense pack)
.1Yrv1" , '*,ft Ai .y., +4z• rY ]ra i
..w i 4vYF,iWmdOWS ew awc'':yl I a f•�' Ile,
;�, > ' .. ,A �'�
.,.eru a...: .,;:....�"a .,S�_+.a4.a'. - --- '''��E' u.
Glass replacement to 64 ui 1 $44.00 $44.00 1 $44.00
Top Sash Lock 3 $9.50 $28.50 3 $28.50
Total $8,688.90 $8,688.90
Contractor Instructions:
Before Starting the Job: During the Job:
1. Please notify us 24 hours before starting or scheduling ajob. 1.This residence was built before 1978.Lead safe practices are
2. Obtain required building permit. required.
2.Total for Heath&Safety and Repairs cannot exceed$2500.00.
3.Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form WH-347.
Additional Contractor Instructions:
Certificate of Insulation posted? Yes No (Circle One) Attic Inspection form attached? Yes N/A (Circle One)
Where Posted:
Contractor: Date: WAP Auditor: Date:
Energy Director: Date: Fiscal Officer: Date:
Date: 1/7/2013 Page 3