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30 IRVING ST - BUILDING INSPECTION The Commonwealth of Massachusetts °1 Board of Building Regulationsend Standards CITY Massachusetts State Building Code, 780CMR, 7�hedition OFSALEM Rao sed January Building Permit Application To Construct, Repair, Renovate Or Demolish a 1,2008 One-or Two-Family Dwelling Building Permit Nu This Section For Off icial Use Only DateApplied:V Signature: WWI( Build gCanmi�ona/InspectorofBuildings Date � SECTION 1: SITE INFORMATION 1.1 Property Address 12AssessorsMap& Parcel Numbers 1.1aIs this anaccepted street?yes no Ma,Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions Zoning District Proposed Use Lot Area(sgft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rea Yard Required Provided Required Provided Required Resided 1.6 Water Supply: (M.G.L a 4o,§54) 1.7 Flood Zone Information: 1.8 Swage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ Onstedisposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owne'of Record: ,ICecr MOS�CO 30 Lrv',yld S� NTIC)' (Print) Address for Service � I LMa 9 1 -�, qa.5 - oa5 b Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction Existing Building Owner-Occupied ❑ Repairs(s) Ilit 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Amory Bldg. ❑ Number of Units Other ❑ Specify: Brief Descriptionof Proposed Work2: — i SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Esti named Costs Official UseOnl Y Labor and Materials 1. Building $ 1. BuiIding Parma tFeac I ndi cate how fee i s determi ned: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Costa(Item6)x multiplier x 3. Plumbing $ 2. Other Fees $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire Suporession) $ Total All Fees $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ (R 4,49 0 Paid in Full 0 Outstandi rig Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) .�cf.W^eS Vl LioenseNumher Expiration Date Nameof CSL-Hdde List CSL Type(scetx9ow) V k o �, +� \fin n\\ ),, r\y {ddress Type Description U Unrestricted(up to35,000Cu. Ft. ure e%A R Restricted 1&2Famil Dwelling � on �b�`, M Mason ON' _1 RC Residential Roofing Covering Telephone WS Resdetid Window and Siding SF Residential SolidFuelBumi A ianceinstellation D Residential Demolition 5.2 Registered Home]mprovement Contractor (HIC) HIC CompCompanyor HIC Rel ist Nane Registration Number d1 S\rN4rSA �V� �-. +Vt,64 Address - b - \�— q 1� cyyl-� Expiration Date ature Telephone SECTION6: WORKERS COMPENSATION I NSURANCE AFFIDAVIT (M.G.L. c. 152§ 25C(6)) Workers Compensation I nsuranoe aff idavit must be completed and submitted with this application- Faluretoprovide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes..........l, No...........❑ SECTION 7a: OWNER AUTHORIZATI ON TO BE COM PLETED WHEN OWNER'SAGENT OR CONTRACTOR APPLI ES FOR BUI LDI NG PERM IT I, M Y Q) as Owner of the subject property hereby authorize to act on my behalf, in all mattes relativ((etto work authori thisbuildingpemitapplication. (11 Si gnatureof Owner Date -- SECT]ON 7b: OWNER'OR AUTHOR]ZED AGENT DECLARATION I, .N v r^ 1 Q i'� V1 asOwne or Authorized Agent hereby declare that the statements and i nfomrati on on the foregoi ng application are true and accurate,to the best of my knowledge and behalf. _ —\iv,, \y-�C V) Pr Name oOwxorsAaorzed Agent Date S e r penaltiesof NOTES 1. An Owner who obta ns a building permit to do hi s/he own work,or an owner who hi res an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program),will not haieaocees to the arbitration progran or guaranty fund under M.G.L. c. 142A. Other important information on theHIC Program and Construction Supervisor Licensing(CSL)can befound in 780 CM R Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, providethe information below: Total floors area(Sq. Ft.) (i nd udi rig garage, fi ni shed tasement/atti cs,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 cool ingsystem Enclosed Open 3. "Total Project Square Footage!' may be substituted for"Total Project Cost" ACTION, INC u, f�"i '�fC fli illtjl(Ip If 111' 1 47 Washington Street Gloucester, MA01930 Il+ ICI ire ,"I '' ;��; , 1, . - I Agency , NSCAP: �I "I N6RIDIrApphcation#,! �i a': I'�' I PROE`RAM , ,aAARAWAP I�, , ; JOB,Nl7MBER 0 `, „ DOE Work Order# 0 i E'SiC Iperfprmed?I II,,�i r�ol f �� la r 11 r f i :n , , A it ';LI i Flli 11 I,_ , I I{ q : It , ' F. 02�28111 ;I',; , I ill I� III fry ✓:IIII ,� IrI�,ll l ,�I .WOrk Ofd@f Date .� : �x l : ''I ' I '' 'PmmarylCohiractor AIr:,I If tWeathenzattonr- III ContractorIt NA' F #Bulbsuhstalled :fw Cllent[Shirle 'O Iba ", nspt$1125 i y= 9 r 1 i 'ri ' ji f , nl Ih ,l ri Il,jf(_ I EI kk;Street11rvingStreet 1�tFloor I :If I I : I©therinKlnd , I. o nu `- i lllMSi{ I �r hne78' 145 007,4 P $ Amount KeySpan�� �.}S� q�l ; S a a , NO : III 1 BIOWeG OOriTest i I' fllnspectlKnobl&Tube' ,,I INo 11i +`'i,:i'i'IDate,90b Completed ' 1,= I 'I,: , ,II EstlYna�ed Repair Totahli ' i, fr$10D 00Nil !I h,;111Yrvl„i,l . 5 bctualiRep�It Tutal:,u) , ,,. i,$0 00;, flVeathetizatlon , .I; Est'`; ", ,J iAct. '! 1 Cost 11i, Door.Kd' 3 " 't '611$43100yII$129'00!,1'h D001'U.9W00�1. Ba�i ll9', ''1 U , 3 :2i ' $15AQ4,l gill�l' $4.5i!00q JI' ,..x+,": Y °4(i�i=' ...� _ fl r 1i., , , - A,�U10matlCd'D'"O�Of$WBB N ws �L i� h4,1$22:O,On>`I ,�II is ,lf,,I,IIN AlriSeahn"'2= artlfoam "erihour.t.k. 3 i•: !1iI' 75;00 G'1 r':i,$225900 'Llli'll 1, f?p' I I' ^s[sii IAttic Alr*Se81{h ,2 9ft.fd8h1, ' f hOUf j''!$75.00'I,ii ,R ,.:; ��,,'4u4.,:I,i:'.0 14„fail Weathersfhp,iWind6W iBr.slde I i'' I,f i' - ''t SHOO ,l L�II"tir' a�' I .:, ilr'y:IR? hll ll eal.Ducts:4 astic ' i ll?. 1' ,•,I 1 9 y 3 . $B2.00�i�,I,,,li,!(„ . '''_ '' r Irl�'1I L,iIIP,�I i rE: J �M,S': ;Ins I1ate Attic Watchi R30 f + f It,ir a a r' �''11I111 $Ol00iil I ills, a ' ., Iftt ..r, le,l,;tl `,. ,$0?00i I'., I,`mi1ES �, :` i.L" 're n - . : [:11 ?:d,Glll¢'I. $ WeatherizatlonlTotals: ; .: it , .,.I ' i%„I i,l6l$399"001'lll I!!ulu$000' ', I'I '! I' '� Il,a, -�yr I r II .: ' rl, l , 11+1 VI :: ii til II( iti ,If ,I II'I, f wn: ll ry+ I'll h „I„!} : ,,u I,i r. aL. f il !i14 -.16,u u .ur a :-7i.1., ,Id ,a;wl J(f i ..'SIN fll=.! 1f +1 6 +.In Ihsulationr'';; s REstl.r .11Pgct' � i.�t�t'!Costlll;11'lil'L1EStftOst„" 1.1 'i,''Act'Co'st4u' Attic FlatR38,o en, l 1P1.,'r: i,e' ri"I I'i$11140!'F ,' ll`s' ;,-I.Hi< .11; AtbCIFiatR f �yliA' ' 3O o enl ..III 4 30.,i: Att1C FIAVSIo es+R30'restnctetl. I;'" +,r a 1': i IiF"a , AtticlFlat/Slo es.R2©itestndad; r,. E r,' U:35 I ,I. v i %I I' 1":i l ' !'it Attic'Kneewal R'15FO, •il i' � ,$1:2'5 1, 'I;J IAttic ttWeli-R15 Ce111wl�Membrane AttioKnee*all+FloorIR31 rest.. g.:. lhsulafelAttic'Stalrs'&aWalls ",` I,$1i30100'1 ', [i =' Si ewe =.Vn I'R15'DP_ .i ' ' 872 4$.1'4'82.4'0`',1 I'nterlorWa1HR13 'PlasterRl&DPI 312:r , ;,1' $1t.B1! u'I.$564Y7Z itli; " q; Test Dnil:Sitlewalls.v4°sl'des ,Y i 60.00li 's�' 1 1' :i mil'ii Ductllnsulation,RS&Seal Seams i 200.'` 2.95; i,a, H dfOftlClPl a Insulrf0`.1i:R51 I'' I''' ' �, ",' :IiI Steam PI e�lhsul to 1 25' R5 : :j ! "? 5.25� I I '1� 1 ' P ` IU dHW,PI e.InsuatlonRS?'�I• u 8 ' 1 `:i $2.50.i, lhsulafe'Doo'r 1 $44.00<Ii'` 5i$44'i00' 21 Sill'2- artfo'amw/FGB'attR19,'. 126 .' i , $200;:;ti "„+ ,;$252?OD „ I , ',_'r;y,.,, ',.ti-�l`l. Insbibb6hlTotals ;I?; r.� ' ! ' : >.'i„' 1.'., ^'i 11 i.'$2;948 1i2,„"„i '1 ', $0 0Ull 411 if,,:' 7' Illr , 1 , IIFs L Ii I''"" Fu'i,+ II tl, VI i' f,I `+�Ua' i , i Wi ll , !at ,uI:L'J ',> I,I I�,I I ...... t'i ti . ..pl, .�. I, 11I11I,hI.. r 0. S„hirley,Oglba I P age 2 n 1 -�+ _ n 'i ., s ESt GO&t + ' ' Ad COStI Othi er MeaSUfes t -�I r It . t I�4 1 I�ESt n(i'� i l'A& , h i4 COSU .nl I r Roofvdnt I'small , -_dj r - '11' G'ableNent,;fRectari ular L' IIIiI:$88 001 r' , $390'.00' ' ' G'< Vin',I'Re IacemeM Window 73 uu , ,Uin I R lacement Wmdo'w 83 un F s 1' ' '' $400t00 ;I I Vin I Re lacement Window 9a.w IW IIRe lacement Window 101 m '- " Ili$425I00•k I 325.00 ' 1 Vint Re 1.'rB"sm'ti Ho 'er:Wmdow - It 5 I fit' I Faucet Aerator L'ow Fiow-Sh'owerhead• Blower Door Test..,. .-: • 1 $45 00 , " IWindowGrids- ersash X $20.00 itn 4 IIII ,,l.t Other Totals. " l u 1 r 1 r r r!$0T00 $0 00 - •, .!<' ! 117 }� liar 1 q 7- IEnef ',COf1'SeNatlOn ± I'1iI 'ql, I', ', ' ''1 I irlESt(`ryOSt l 41'ACt COSt s',. l OtaIS.� MaX$10 000t00 r. i" "l t, a, "„r u I,y l li r 1 iI r •11� ,' 1$3;3N]r 12 ' f' t o$D ODI ;I', ,I'll1 -16'' I,l '1 'tAln P ,li,l r I r Re alf$I!, 1 h 1 ESt+.i'I I, ., 'ACt 1i, Inil <L I' ICLOet ,�11�1 is'I'i Eet`Cbst: t +,ittAct!CbM,,'IS � . Ike av/Refitrpoor $50 00,, Ad ust Door:Stnker•Plate 'f �.; I'$20 00!iAl N ' - - �Re I I 1 1 :•,:-, : III 20.00' I� r. lit.IPit. I $9!25:: rl I,IA I t11111 r{ Sashl Lock,.:' it GlassRe'lacement-to 64u f� ; 1 $4200,' i 11 -I 1 I' III? I11�I ill, y h F �- $01001. Bulldin Pennd Fees 1 $100 00';lii`�I 100 ODI ;+' t 1'I I I I I N/ent Cl0lhes D r er tO EXteflO(„ ` 85 00,1�� 1I �t � � ! 1 I )Yent'Bath'EzhaustFanitoEj6H,&: $8500,. ,I t Vu I+;II Re laceD.'erHose :r ±;'- rl+1IA+11, '1", I Ii it II 1 +fit Stee kb-H'un IDoorw/Llte ! ? P!!i. 1'0'0011,11u1'" '" '�I Ir' *t,�mil' " •I " iS011d'COre'©o6r4k/HardWare,"'. i'I:II $�SDIDDpl'i:,li±l l' a �` :, ,r, i II I 42e air Tot:i; Maz$25UO.00 c_ '?:a.,. �I •w l I I+(I. t,.' 11,E I I' ,rill t" Vh nvil 1 1 0 00j,.1,. � 14 �' �!, � ' '. FI ' r il� f(•! ,Ily rll ',Iu 1 III II Iti1 'l' ii l rPf`I " I , r, h i 1Ill'I I 'al,L a 'tI I'I - 'l 11 !'� � ' 31� I! ' ( ,!I f Ii 't ICI �I''�i i,i 1 , �lid I I (I I,I II 171 tl.� '1 e' Illy N(j'1( Wdrk+Order.SubTotal. '., ki>!,, c " w'6 rr r 1Y$31447121 $000 y?rii? a l i,f I .i Ili'! 1'1 .,I r ' li I i 1,I 111,E 11 I1t 1 3 1 l kl i IIII I , r1 i t Anil' r rr +r1 III,I �,11 I;' !� I1 IRI, rl I I II 'I Ilr I I ,I',I'.'la IIII IIII I['I 1 +I I � i A y I r t " 1r 6 t111{I III,t 1 t II Iq I, , I� Measmres-, r Est , ' Act" , ; 1 'J:I Othes 1,,;; Iii. $0.0D, -.--'';Other i ':i' }I'I '$DIDD .."I' Ii Head♦` S stem Re air. - r Ir y l , ACtlOnlapplOVal OOIy J [ I I ,ail It i, IN Estunated±Joti Tlotal „ -` a '$3 4'47 12 'a 1 11 1 - raRlII 1 1 ,111' III r , - Job Cannot eXeeed �7 Di000 ; ,, 1 „ p,+1 i 'il v It l 1 -I 11/11 :I i� , I I,pr i t t Job minimum $200 00 r " Job,Grand T,atal rIL , h x a I ie r4, I rl _ , r 1 R r AUDITOR. ` �Dou `CrarVford ;'. ;. u, 1, q ' , , 'd r " . 'I r _� 91 t ,l. h I. I. �'.41,1 -I ., ICJ:. .. . i` ACTION, INC 47 Washington Street '��' "`'' ��' '' _ IF Gloucester, MA 01930 I I I% 1 i �.. 'f li �I,F"Ill fit NGRID Apphcatfon'# '4 II � , IF II� en Ir I II 7 I , : "! r f 10. I'I ! ' I r ' II PROGRdM I -AAKAYM I '? F. JOB NUMBER 0 0. DOE Work Order.# I 0, E S C perfortnedy ,, Work Order Date ©212811'1, , ? 'r '„ u f. Primary Contractor' Air.Tight Weathenzatlon.! 4 , ' 'll ' " ' - I iOther'CAMraCYOr " 'I ' ',I NAe ,t t Fr IF 1 1 1 - . 4 ,, , t , ,V ! h nS tl$125 QO Ma% - $0 010 Chent Kern Mosko u P " 1, ;' ;Street 30+Irvmg+Street 2nd'Floor I,Other In Kmd r io I o 0 o ,I 01970 *" '' Electrical Wok !, "Slo ool�II ; Clty State,Jim p Salem 'MIA ; Telephone 978 1825 0256 I 51 Bmount xepspan yo ,0� I �. I ,iil , $ Amov izt,Na,tional�'Grxd 11 IiSO I�pn , 'I In I'I 'R I, �BIOWer DoortTest ' 'No i p 711" : If f I II III,, II,II IIII!OtfheLli utility v� DO li IF, 3�' Irtllnspect Knob BTllbe ! � 11 I,NO� III ' ICI 4 II hII I I - III 1 11 ih r !,III, Estimated Re air Total !I k, $109 251i Date Job Completed ul ,I I p , .11 , 1 f! II li, 111,.1 ' {p ';I ,.1 ,,,I. II, I( �;, I , " ' r I i,,,l� ti III AChlal Repa,if TOtal,n $1100 Weattlenzation , tl , ' ,� 'Est!'.; .I`';..'ACt-1 I llpi COStl1�'I Estf 6St 11FJ ;i rAdfGi t� i DoorKIt d f .'�f I If 2 I li'� ,$g3b06 llf I 11'$85i!OD ,I11 ,ai ' a boocSwe .ii " I 2 I ,11600 : 11 iP,t$30100 ,i�li ;��s'I ' !I ' +^�hh AUtomkC D'COr$Wee , 1 i, , 11 �.I III 22`0011 V II I,PS �'�fi'( I ' rl,l;'I'. 0 11 Alr Sealln 2 art foamy' er,houo; 2 r I!.$7,5'00 I'I'.`19fi1$tl btll'00a1'�+ (t d 51 W' 'n ! a AtIIcAlrSealih2- e'rCfoeml ' er,hour` 3 �:rl - ,'- t'f�$715,OOIrf!I,'f 11,$ 0 !`,f Weatherstri Window(?''erside)1; I,SeaIIDUets`-',MBStIC },: 1, Im. i(i Ji; i II�i $BtDOI !,I lll'IiII,II I 'b'NJIGk 62 00, r, W/S&=Insulate Atticl'H'atch R30 :�,I $32.00:`l A+nr LL�I, '1,$D.DDia'�i �.li'4AI, INa 1 l li OFUIII If, 1 Bari .i I. ,w; $0.00.,:l,4:I I , ..(;!WI,II IL . . ,.!%I I : ,Iv4 11,r ,_fine I ,e O.00fI �Il!!, f^I I, Iu 1La . , • n I , I f IJb '$0.00d l+I 'FFI iI ' lailtilI ;^ 6L � �l .:$O.DI"i ,� Eli"I P 1 6 tl:; ;.V, I,f. .1 I.1, rwl �,. 1 _ ,• Weatheriiatton Tiotals;l 1.. Il.a1 dit ,;;,,�� ',! la Sul I,I „t,rll'I";',,I ' ' 'rl,ui 6�If1»�'$65S DO,.,._,. 6{lu. $0!OO,r'V!�' :I u+ .�V,l I 'c', III IfV,.i.""'b}' I'll it l,l:J ;I1v,iio��,�bi'li".Au' �x, �,`L�'i�l.l.,fni'v itlSUlatlOn li - I t 'i,ESt-I , '. , ', 31ACt i "' 'li,'"gICOSt,.!M;I 1J.,E!k!C05tl i ki mCN2ost4ii!fi AtticFlat.R38o en. ! .! II . f' 4,1 Ih.x it :,,I II - p,;ip r , ,I, b AtticFlat,R30o en >::I If. .�,. 950 i' "I $11.3011; !^ 1,248.001,11t1i3ii ?�' 'Attic!Flat/Slo es R30`�restnctedl "'�I' II'' 11.41ai Fi g IF 1 ,1��, ` ' A tticFlat/Slo esR20irestncted' *' $1`t35rj,x,,,l I'N,fIF l ,I'I „ AHIC Kneewall R15 FG. i I$1.2'S I k ! Ir Ila "` "' 9ttIcKWa11fB15 Celltw/Membrane:' Attic Kneetiall Floor,'R3'01 rest' Site-buihTllennodorne''ocAtt�c,Tienl 1, .L , $176;,00!i ! .' 1i75.00 ' +I, I 'I, ' Sldewalis-:Vm I R15'DP 872 i' i I f .I '$1`482.401'' 1 ^, f 'I iInter;drWall!R13':PlasIter'R15DR',' " 312 I1;: ,�fl $56�R7,2 ' I'`'': r iTestDriII:ISidewalls 4�Sides ""''. I�r:u $SQOOIiiI„', �, I,I. iV, ! Ia' Ductlnsulation•R5;&'$eal`Seams ' 200 i,, 2.95 6'' "$599.00.. IF %Steam Pi e:InsW�t0,1c251 R5 .I' ,'` r - " 5.25^ I,Ii' '! ' '.', ' ': it $250I $1bDHW Pi a lisuatlor;RS 5i r,l i.4 Insulate Doorif 44,00 Sill 2 artfoam w/FG Batt IB19 I" -1,11„ 1$4075.12. , t 1i Si IPIII:I , i3 .,..�:.. , n „ tl .. u u 1.1'.I. „l10 dI II , , , ,,..I Fei, . Kem MOskO ,Page 2 DOE s� " Other NYeasures " Est , - Act Cost 'IEstnGost!',I �'( � !Act,Cost 1 .. I•± ' ± 11, ±,I': I Roof Vent.small '� �' '' I " Gable Vent-Rectan ular $390 00 r" '" Vin fike lacement Wlnd'ow'-73•ui r r;. Vin the lam menUWmdow.,63 ui $4Q0 00 �Vln I'Re IacementWmdow-=93 ui ., ,,, , , , _ � • 42500 .. -. ' e Iacement,Nhndow-%10t �Vin. .R L I •r• �- , �ih I Re P Bs_:� GHo er�ndow �' m , �i pe it Faucet Aerator Overhead ,r r , ILowFlowSho � •�i. '� `� fill 45.00 (Blower,Door TFit est Niindow Grds- ersash $20.00 r Other Ti6tals Sher •COr15BN,atIOn r,j; " �77It ,f.IEst.COst .";IACt i; W62$ $0100, 1 •) Re aIB, ESL ACt f ' I' 'i „,c 'i ., t''i ESt'COSt'tl! , ACt COSY Re alr/RefitlDoor ! $50 00 I, ,; i�.''r $2Q QQI " I I ili Pill Ad ust Door$tnker Plate. . ,I . ,i•t,lll 4Q QQI'.�I�ti!', :Door,Threshold �.� i•, i Re alrpoor`Hm a47 I I.., ; Sashl LOCk Jr2 $9 51, " 9 25 Glass Re lkdrnent-to 64 ul ,` $42 00; I: ` ± $Q 001,III' ' ' II lil i,.l " it Buildln 'Permit Fees 1 i $100 00 it , _„ 11Qd:00�a! `i.h, t' Healthl&Safe M„ f I f , „ ' ' ll 1,�i 1, li'1 ±iI "ii'� Vent Clothes D er t0 FXterlor "'I II'i '!li 2a I1. $85100 I . I ''d Uent,BathdFihaustifit'h Exterlor.l Il:ilI, Sb001„.,.I ( ,!, k 1 I!, OWN U I fi lI,P'`p'li i ., ��, )II!) III l d Re lace D:",er Hose :I , : .' I, i,1(, I,lil $ Q.��Q•9�1 II ' l:I ±�rli± �'I hYI+I+I SteelPre'-Hun =Doarui/Cite 61 Solid Core Door w/Hardware $360.00 !5T5111gglipjhjh lit +',I Nl,'I±'i 1 sI '' " ± i y,.. ' ,'er , I i, i 1:3., t,, I � , li ,=:1, ,.r..c Re alr..T,ot..i Max.$2500.00 9 l r� l hill' '( $1109251„,� + Ila, $Oi00+;!I:...:, Illy.i'I I 1 II I : r 1 Ir F y I I I II I fi il,' tt!I (� T' , r'I III n I "1,.I•; k 'h 1 i, ih`(•s F I LIA+¢ I± , 1 .� ,III � 1,7 .,{s 113hI, rAL YII rillI if it o +(,Work Order Sub Total I 37 737 „! + .0 $ OO±;'I , I jIll it llri il, Ili ,±II it l�iIl'I' l jlit rt�lllli r 4 ±�. III I111 n I i,i''iI1�III Illy,Ill±r�{ii 'i ` I,lL d;+ i , .1 1.1r ai'p I. ilt , lil Il + hffil Ilalll, rl, II , ' P '111Vt , 4 I, ,t + Ii,. I' r ,,! ir, Nl II 'i '11 ' , � I ' , I'I±Ili , f11'if,Ili�l rl,l ,h p i III; I ' -_t t , 5 t i, 4 , , r1 !j- l l , r ±, y I I f i'a li 'i , i" ''6u', Measures Act I Cost ±•tct costlif l Other $QIQQ �bOther "HeatinCirS ste+nift air :.Actionapproval�only , ly r e'I 'lil Ihi, 'IIi II 1 11 „ £ :r i! It'll " �l ,Estimated Job Tol ta' 1•' r A ,I + M ,, 114 r, d, 'Job I ±i I, �,i it'ri „I, r:cannox exceed.$10,000 00"� ( ! ra o ' ` I 'Job•�GndrTtal ' ' I� `11 r �' $0'00 ,', .I 'i�� ,t, Job minimum $200 00 ,I 'i I „j I, it ill rpr• -i�l ,, ',• ,r,`h i ), II I ;rE ,,_I. , , AUDITOR ,,,Dou Cranford CX�Uw ✓� eommomveaa Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 165640 Type: LLC Expiration: 3/15/2012 Tr# 294587 AIR - TIGHT LLC. WEATHERAZATIOJ>f JAMES FORTIN 10 PINE KNOLL DR. =� BEVERLY MA 01915 J Update date Address and return card.Mark reason for change. -ram Address Renewal Employment Lost Card DPS-GAi a 50M4W04G161216 CT -Piomnw9wreallle o�./�aaeaa/uteelld (� Office of Consumer Affairs&Business Regulation License or registration valid for individul use only - before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration,,-.165640 10 Park Plaza-Suite 5170 Expiration 3/t512012 Tr# 294587 Boston,MA 02116 Type: �' 1-. AIR-TIGHT LLCti1NEATHERAZ¢TION JAMES FORTIN'';.o..�.—' 10 PINE KNOLL v ,.__.:.-tip :Si' - BEVERLY, MA 01915"°:_ = Undersecretary Not valid without signature 8 A1;ts:a 11,+:.etts-iDelta t. .r . ''Pt:hl': f< ' Bo:.rd of B ulding Repulatior.s and Standard.s Construc—ic.i 5 tpjtvisor L c:-r;e License: CS 52576 Restricted to: 00 JAMES E FORTIN 10 PINEKNOLL OR , BEVERLY, MA 01915 Ei:lirati ,,i: 10/3/2011 ('unnnissinncr Tr#: 200 • The Commonwealth of Massachusetts Department of Industrial Acce office of investigations 600 Washington Street Boston,MA 02111 www,massgov/dia Workers' Compensation Insurance Affidavit: Builders/ContraMora/E1 Pl ase pri t Legl licant Info awn G Name(Business/Organization/individual); -' Address: \�Zi ) n e. \ Phone#: �1C1 to City/State/Zip: \ —v a ( aired): tiara box: Type of pro' (required): Are you an employer?Cheek the Opp 4. ❑ I am a general contractor and I 6, r]New construction 1.PI am a employer with � — . * have b'ned the sub-contractors employees(full and/or peltrtime). 7. ❑Remodeling listed on the attached shcet.t 8. ❑pernolitioa 2.❑ I am a sole proprietor or partner. ne9e sub-contractors have ship and have no employees workers' comp.insurance- g, []Building addition working for me in any caPO • 5. ❑ we are a corporation and its 10.]Electrical repairs or additions [No workers'comp.insurance officers have exercised their required.] thou per MOL 11.[]Plumbing repairs or additions all work right of exemption , 3.[� T am a homeowner doing c. 152 §1(4),and we have no 12.[]Roof repairs myself.[No workers'comp. employees•(No workers, l g_�Other�— insurance required.]t comp.insurance required.] •Awry eppncent tbn checks box YI muet elm all out the section below showing t5dr worhera'compema8on policy iof°tmadon, Oecb t Homeowners who submit box his atadum indteatingthey um doing all work and then Mile ontsW oontrecmra Pug whe"it"it a nowuaidavk indicatingoation. iConaecton flat check this box mustaaadad an additional sheet nin'Oft the acme of the sub-conoeatms end their w0ft"'cmmp•Policy I am an employer that is p roviding workers'eompensaton tnsarmtee for my empboyees. Bekw it the policy and job site lnformatlon. � � C.�\� Insurance Company Name: D C Policy#or Self-ins.Lic.#: �,� & \ to — Exp ration Fvnn 2 n s �� S� City/Stste/Zip: S c)A c w.—.---- tob Site Address: gh the policy number and ezpirstioa date). Attach a copy of the workers'compensation policy declaratlou page( penalties of a re Failu to secure of a STOP WORK ORDER and coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal p . fine u to secure.00 and/or One-year imprisonment,as well as civil penalties in the form a fine of up to$250.00 a day agaimst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. do hereby cff*under the pains and penaldw ofperjory that the information provldet above it drag and correct FOther nly. Do nor wrtle in ihts area,to be completed by city or town ojjtetal n: PermittLicense# hordty(circle one): Beakh 2.Bmitding Mienrimem 3.City/Town Clerk 4.Electrical inspector 5.Plumbing:1sopector rson' Phone#: