10 HAZEL ST - BUILDING INSPECTION i7n®�1s
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SA EM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair novate Or Demolis a
q One-or Two-Family elling
This Section F Ofricial Use Only
Building Permit Number: 11Xate pplied:
Building Official(Print Name) re Date
SECTION 1:SITE INFO AT N
1.1 Property Address: 1.2 Asse rs Map&Parcel Numbers
�-
Lla Is this an accepted street?yes l no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
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 Owner'of Recurd• �, �� H
^
m d�4 vvl 7j N+A s �_Lt'1
Name(Print) City,—y,�te,ZIP
/& 2e 7r1-241a7-V- 1
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repans(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other [r*�pecify: A&4n 21ia% • l
Brief Description of Proposed Work': $(4glAi CLAC)IOSE—V1G 14hQ-Ae-kk-.�1.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ Q 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑Standard Ci(y/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
3 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ v0 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1p3yN ��? -Zo13
yy 0.�.�f License Number Expiration Date
Name of CSL Hol er
�n�
Lis[CSL Type(see below)
25 AmdAC`-2 Type Description
No.and Street
nn Unrestricted(Buildings u to 35,000 cu.ft.)
P d.•r t of N/ 038).1 Restricted 1&2 Family Dwelling
City/Town,State,CIP M Maxonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
73(-94q I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Wr7- �t, V yd. � 6y.s-by
apst /"Its l e HIC Registration Number Expiration Date
HIC Comp y Name or HIC Registrant Name
_76 r
N�di�eto and Street 7t��sfQ-wo Email address
cJ
Ci own,State, IP 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 Issuancegf 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
1,as Owner of the subject property,hereby authorize M Q t fdrin d'1 �5
to act on my behalf,in all matters relative to work authorized by this building permit application.
/V54"M .,, A4 or -2S�f
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 ap �` y�is true and accurate to the best of my knowledge and understanding. � �,f
Cc�tu.Y lVld /1Tf'f -��t—
Print Owner's or Autho zed Agent'N ame(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
www.mass. op v/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 S.0 E1%4 N-'LAsSACHUSETTS
BUILDING DEPARTMENT
• 120 WASHINGTON STREET,Yo FLOOR
bj T�El- (978) 745-9595
FAx(978) 740-9846
KINtgFRt FY DRISCOLL
T
MAYOR HoN As ST.Pm Alm
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSSIONER
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 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:
(name of hauler)
The debris will be disposed of in :
VV (name of facility)
(address of facility)
si a Vrfrn`Mp a [
date
dub If doe
CITY OF S.0 ELI, NLA SSACHUSETTS
BCIIDING DEPARTMENT
• + 120 WASHINGTON STREET,3aa FLOOR
dj TEL (978)745-9595
FAX(978)740-9846
[Q,,IBFAi FY IDRISCOLL
ivt,taYOR TriOMAS ST.PfERR6
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CONI.XtISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information } Please Print Legibly
NameIBusiness:OrgtnizatioNlndividual): t4n 5e46,3,V4 NzyVd0 ( JrNsCd�CL�O�✓
Address: 0 R424 k 12A
City/State/Zip:_j Ka✓1l, M4 Q190i( Phone#: 7)Xl - Ll- (T, -)6
Are you an employer?Check the appropriate box: Type of project(required):
1-0 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or pan-tine).` have hired the sub-contractors
2-El I am a-pie pmprietnr or parfner- listed on the attached sheet.I 7. ❑ Remodeling
ship mid lave out employees These sub-contractors have S. ❑ Demolition
workingfor me in aut capacity, workers'comp.insurance.
Y P tY� 9. ❑Building addition
[No workers'comp. insurance - 5. ❑ We arc a corporation and its 10.❑ Electrical repairs or additions
required.] of have exercised thew
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers camp, C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.[No workers' Q •�
COMP. insurance required-) l3. then
ur �itt�LI:TC^� sG4.
'Any applicant that checks box tit most also fill out the section below showing their workers'compenwion policy infurmatim,
t I Imceownen who submit this affidavit indicating they see doing all work and then hire outside eonrmerois must submit a new affidavit indicating such.
'Contras+en that cheek this box must anxlyd an ad ditiwpl shxt showing 1M nome of the sub.rnntroctpa and their workers'camp.policy infomw000.
I am an employer that Is providing workers'cotepensaidon Insurance for my emplayeex Below Is the policy and Job she
information. t
Insurance Company Name: C(A.RGL'7-rbi
Policy#or Self-ins.Lic.#: r��7 fd Sig Expiration Date-_1-4
1 �t
Job Sire Address: !a_ me- � !i 6-r City/State/Zip: . -o+ Ma`I•
Attach a copy of file 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 S 1,500.00 and/or one-year imprisonment,as wall act civil penalties in the form 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
Investigalians Of the DIA for insurance coverage verification.
I do hereby cord y a tder the pains and penarld"of perjury that the informadon provided above Is trite and corrre&
. i rn 1 ire• Date: —Z
o
Official use only. Do not write in ibis area,to be cumpleted by city or town affair[
City or Town: Permit/License
Issuing Authority(circle one):
L Board of Ilealth 2.Building Department 3.Cilyffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Curtact Person: Phone#:
04/03/2011 22: 53 17815955820 AMSPoJSE INSURANCE PAGE 01/03
Il QERTIFICATE OF LIABILITY INSURANCE
F CA rIE(MM/DUKVYY; �
414;2011 j
! Ambrose Insurance Agency, InC. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION !
56 Central ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
AVL, WOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
' Lynn, MA 01901 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.7 8 7,_5.92,qj p��
- INSURERS AFFORDING COVERAGE LI
Lynn, MA 01904 —_P.O. Box 8229 j INyurJnHn: Scottsdale NAIcp
1 3exsons Windows A Insulation
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Carpentry/Insulation/Electrical
I
I
ART;F!CATE WOLDER
CANCELLATION
City of Sale!n ^3P CLILO ANY OF TrIF-ApcVEmtscRInFD rot ICES nF CANOrl,I FDneFOPE TII 11111'All 11
Attn.: Building Dept. ')^T'E n-!raeor. n+E Is stnNa wsbrr_R \vn.L cNnrnvnR TD L1nn,20 oar.: wRlnI;N
City Hall NO'I)CE TO THE CPR''IFIUlIT'1101I NAMr:O TO'rgC 1rP1',O!'1'Pn.LLiIRG. iU f:0:0 swd
Salem, MA 01970 'M)'OSE u0 OELICoA'AON OR LI IUTY rnNY awn uroN nIr 'e'sur:rR ;n nl rNrs n!r
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AU MOP4F -PR51NTnT —�
:ORD 25(2001108)
AC —
PJ ORO CGRPORATION 1998
R
Massachusetts- Deportment of Public Safety
Board of Buitding Regulations and Standards
,,,Gonsfrtictjorj.Supervisor License
Lfcense CS 103474" hOt
�. :
Restricted to
,JEFFREYMYO �TtE t I� it I
29 ANDREWS
EAST KINGPTOI N;'NH 03627
ly __.
Expiration: 1/23/2013
('unenissimierl ,i + Tr#: 103474
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JEFFREY MAYOTTE
JEFFREY MAYOTTE - .i - r >i*' il..
29 ANOREWS LN.- ' -
EAST KINGSTON,NH 03827Act
AUR i 14 tho ipwwie�=
ACTION, INC J n
47 Washington Street
Gloucester, MA 01930
Agency: NSCAP- - , NGRID Application#:
_ PROGRAM: AARAWAP 0'
JOB NUMBER: 0
- DOE Work Order# - 0 E.S.C.performed? No
# c Work Order Date: 08/03/11
Primary- Contractor: All Season Windows&Insulation
s "Other Contractor: NA - #Bulbs installed $0:00
Cost of Bulbs $0.00
Client: Miriam Thomas • - Inspt$175.00 Max, $0.00
Street: 10 Hazel Steel Apt: 3/Floor 3 - Other In Kind -$0.00
City; State;Zip: Salem,Ma 01970 Electrical Work. $0.00
Telephone: 781-248-8761 - _ $Amount KeySpan $0.00 -
- $Amount National Grid $0.00
Blower Door Test: No Other Utility - $0.00
Inspect Knob&Tube: No -_
Date Job Completed: Estimated Repair Total $1,568.50
Actual Repair Total - $0.00
Weatherization Est Act : Cost 'Est Cost. Act Cost
Door Kit - 3 $43.00 $129.00 '
Regular Door Sweep 3 $15.00- $45.00
Automatic Door Sweep $22.00 `
Air Sealing 2-part Foam(per hour) 2 '.$75.00 $150.00
Attic Air Sealing 2-part Foam(per hour) 3 -$75.00 $225.00
Weatherstrip Window(per side) $5.00
Seal Ducts-Mastic $62.00-
W/S&Insulate Attic Hatch R30 1 $30.00 $30.00
$0.00
$0.00
$0.00
- $0.00
$0.00
$0.00
Weatherization Totals: _ $579.00 $0.00
Insulation Est Act -Cost- Est Cost Act Cost
Memb.Rafter Slope Blow R30 178 $1.95. .7$347.1.0 '
Attic Flat R30 open - - $1.30: ."• -
AtticSlo esR30restricted 395 $1.41- . $556.95
Attic Flat/Slopes R20 restricted $1.35
Attic Kneewal R13 FG $1.25
Attic Kneewall R15 Cell w/Membrane $1.65 -
Attic Kneewall Floor R30 restricted $1.41. K: A: -
InsulateAtticStairs&Walls 1 $130.00 - $130.00
Swalls-Vin loverAsbestosRI5 685 $2.20 $1,507.00
Interior Wall-Plaster R15 DP 110 $1.81. - $199.10 -
V Rigid Foam Board- $1.85 - .il;r .. -. . ,
Duct Insulation R5&Seal Seams- - $2.95;
H-dronic Pipe Insul to 1"R5 120 a$3.25 - $390.00
Steam Pipe Insul to 1.25"R5 $5.25. !t -
DHW Pipe Insuation R5 L 6 $2.50 ' $15.00
Insulate Door w/FB(1"min) i'$44.00 -
Si112-part Foam w/FG Batt R19 $2.00
Insulation Totals: ` $3,145.15 $0.00
° - Miriam Thomas Page 2 DOE 0
Other.Measures Est Act Cost Est Cost Act Cost
Roof'lent-small $76.00
Gable.Dent-rectan lm $88.00
Recessed Can Cover $30.00
Cut/Finish Attic/Kneewall Access $100.00
Test Drill Sidewalls-4 sides $60.00
Blower Door Test $45.00 _
Vinyl Replacement Wiindow- 10lui $350.00
Faucet Aerator $15.00
Low Flow Showerhead $25.00
$0.00
$0.00
$100.00
Other Totals: $0.00 $0.00
Energy Conservation Est Cost Act Cost
Totals:(Max$10,000.00) $3,724.15 $0.00
Repairs Est Act Cost Est Cost Act Cost
Door Entry Lockset 1 $70.00 n$350.00
Clean Gutters( r hr) 2 $60.00
Strapping for Memb.(@ Rafter SI. 178 $0.75
Steel PH Door w/Lite $610.00
Solid Core Door w/Hardware 1 $350.00
Sash Lock $9.25
Glass Replacement-to 64 ui $42.00
Site-built lot Bulkhead Doorw/lambs $415,00
Building Permit Fee 1 $100.00 1 $100.00
Knob and Tube Inspection 1 $175.00 $175.00
Health & Safety
Vent Clothes Dryer to Exterior 1 $85.00 $85.00 .
Vent Bath Exhaust Fan to Exterior 1 $85.00 $85.00
Replace Dryer Hose $38.00
Bathroom Exhaust Fan 1 $450.00 $450.00
$0,00
Repair Tot: (Max$2500.00) $1,568.50 $0.00
Work Order Sub Total: $5,292.65
Measures Est Act Cost Est Cost Act Cost
Other $0.00
Other $0.00
"Heating System Repair $0.00 $0.00
Action approval only
Estimated Job Total: $5,292.65
Job cannot exceed $10,000.00
Job minimum=$500.00 Job Grand Total: $0.00
AUDITOR: Doug Cranford
NSCAP
98 Main Street
Peabody, MA 01960
Agency: NSCAP Client Application #:
PROGRAM: Keyspan/2011 1.10370
JOB NUMBER: 0
Work Order#=i8n
Work Order Date: Job Limit:
Primary Contractor: Insulation Per Unit $4500.00
Other Contractor:
Client: Miriam Thomas K+T Yes=1 No=O
Street: 10 Hazel Steer Apt:3/Floor 3 K&T: 0
City; State; Zip: Salem,Ma 01970
Telephone: 781-248-8761 Stand Alone: No
- Fee Code:. 2
Blower Door Test: No - Yes=1,No=2
Inspect Knob & Tube: No Elec. Contractor: -
Attic Insulation Est Act Cost Est Cost Act Cost
Attic Flat R38 open $1.40
Attic Flat R30 open $1.30
Attic Flat R20 open 584 $1.23 $718.32
Attic Flat R10 open $1.15
Attic Flat/Slope R30 restricted $1.41
Attic Flat/Slope R20 restricted $1.35
Attic Flat/Slope R10 restricted - $1.24
Attic Kneewall R13 $1.25
Kneewall Floor R30 restricted $1.41
Finished Attic Access $100.00
Temporary Attic Access 4 $75.00 $300.00
Crawl Space R19 w/Poly Vapor Barrier $2.53
Garage Ceiling/Floor R30(with approval) - $2.00 -
Thermadome $175.00
Roof Vent large $95.00
Roof Vent small 1 $76.00 $76.00
Turbine Vent $160.00
12" Stack Vent $145.00
Props Vent $3.75
Gable Vent(all sizes) $88.00
Soffit Vent $26.00
Ridge Vent(per In. ft.) $22.00
Attic Air Sealing 2-part Foam(2 hours max) 175.00
Vent Dryer/Bath Exhaust Fan $85.00
. r
Knob&Tube Wiring Inspection $175.00
Page 2
Miriam Thomas
Est Act Cost Est Cost Act Cost
Wall Insulation
Single Nailed Asbestos/Asphalt R15 DP $2.10
Double Nailed Asbestos/Aluminum RI5 DP $2.20
Brick/Stucco R15 DP $2.75
Interior Wall Blow-Plaster R15 DP $1.81
Clapboard/Wood Shingle/Vinyl R15 DP $1.70
Test Drill 4 sides $60.00
Air Sealing Limit:
Single Family w/Blower Door=$400
All Others=$200
Door Kit $43.00
Regular Door Sweep $15.00
Automatic Door Sweep $22.00
Air Sealing 2-part Foam(3 hours max.) $75.00
Sash Lock $9.25
Glass Replacement $42.00
Blower Door Setup $45.00
Total Air Sealing Cost:
Heating System Measures
Duct Insulation& Seal Seams(sq. ft.) $2.95
Hydronic Pipe Insulation to V R5 $3.25
Hydronic Pipe Insulation 1.25"+R5 $3.50
Steam Pipe Insulation to 1.25" RS $5.25
Steam Pie Insulation 1.5"-2" R5 $6.05
Boiler/Furnace Replacement $0.00
Program Repair**** $0.00
""**Action approval needed: Max$500
Actual Total does not include$175.00 K& T chg. 1 $1,094.32 1 JEst Total
$0.00 1 lAct Total