48 JEFFERSON AVE - BUILDING INSPECTION (3) � Y
t
ILI, The Commonwealth of Massachusetts
b Board of Building Regulations and Standards OFSALEM
CITY
Massachusetts State Building Code, 780 CMR, 7 b edition Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
L /n
Building Commissioner/Inspector of Bfiildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
4% J�FFe{LS� Ave
I.la 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 fit) Frontage(11)
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 El Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o ecord•
y8 J�FFc2so� qve
9N e(Print) Address for Service:
6 I') - 9 57 - 93141
Si Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Con truction❑ Existing Building❑ Owner-Occupied 01 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other F]13pecify:
Brief Description of Proposed Work : p0010 F B[eul-o' S�lgZyb
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 5 (x70 1. 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: yGS
5.Mechanical (Fire $
Suppression) Total All Fees: $
5 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 000 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) `O3 ' / -Z 3-z6d
FLicense Number Expiration Date
Name of CSL-Ho er List CSL Type(see below) U
2A .0" EMT k; 55=pN
Addwr s a,/f� T Description
�� Unrestricted(up to 35,000 Cu.Ft.
YVL rr��77��11 R Restricted 1&2 Family Dwelling-
Sigrylwy M Masonry Only
:W-1y�00, RC Residential Roofing Covering
Telephone INS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) // q r/ u
HIC Company or HIM R istrant Name Registration Number
1' Alt
Ad ss �0 -� � �
'���-�t,lG�-W7 Q Expiration Date
Si Telephonnee
S CTION 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 ..........0,-" No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, )U ptAl - 'N-&6 7-CA , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to K
authorized by this buildi g permit application.
SigrZnc o ier Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I,�J EfP22y M &tycli" ? ,as Owner or Authorized Agent hereby declare
that the statements and mf�on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
-3E Ttf—
PrintN e
G - Ag - A0
Signat o ?I Autho ed Agent Date
Si a un er ains and penalties of pe
NOTES:
1. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and l 10.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"maybe substituted for"Total Project Cost"
i The Commonwealth of Massachusetts
Department of IndwrtalAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Apuflcant Information Please Print LeeMy
. Name (Business/Organization/Individual): Fyt'seAf2d;ms N jN�.�J
r� i .�VATt.•✓
Address:-TO OX S2,2C,
City/State/Zip:_LYMw✓ MA- 01�0 Phone #: —791 - 8qq - ft 767
Are you an employer?Check the appropriate box: iL
f project(required):
1. am a employer with�_ 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractorsEl construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t Remodeling
ship and have no employees These sub-contractors have Demolition
working fot me in any capacity. workers'comp.insurance. Building addition
[No workers' comp. insurance 5. ❑ We.are a corporation and its
required] officers have exercised thew Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL lumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no oof re airs
insurance required.] t employees. [No workers' h/
comp. insurance required.) ther dt2S .T..►SvAny applicant that checks box NI must also fill out the section below showing(heir workers'compeneatidn ation.t Homeowners who submit this affidavit indicating they are doing all work and(hen hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the time of the sub- ontractora and(heir workers'camp.policy information.
I-am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information. JJ��
Insurance Company Name: I9 I'/- I/� 1 " t VT 0c '
Policy#or Self-ins. Lic. fe009 igzaoz2wQ Expiration Date:
Job Site Address:_ ? JEFBibQ0A) 4✓ City/State/Zip:S91 PM MCI
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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as 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
Investigations of the DIA for insurance coverage verification.
!do hereby ceHi under the pains and penafties of perjury that the Information provided above is true and correct
Si nature: Date: "10
Phone#:
Official use only. Do not write in this area, to be completed by city or town ofjlclal
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
05/20i2010 01: 21 17815955320 AMBROSE INSURANCE PAGE 02/05
OATF(MMIDUNYVY)
ACS2 - CERTIFICATE OF LIABILITY INSURANCE 10
IODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
76mbr08e Insuranc® Agency, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Inc. HOLDER. THIS CERTIFICATE pOES NOT AMEND, EXTEND OR
56 Central Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Lynn, MA 01901 NAIC#
781-592- 2�� 00 INSURERS AFFORDING COVERAGE
iSURE' Delangis , 'Thomas C. INBURER A: PrOVidOnC@ t 1
All Seasons windows & Insulation wsuRERB: Arbella Protectio
P.O. Sox 8229 INSURER c; A_SM Mutual
INSURER O:
Lynn, MA 01904
INSI aPR E
I
:OVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDR HIS tON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T CERTIFICATE MAY BE ISSUED OR
MAY RT NCe AFFORDED
HAVE DESCRIBED 14EREIN
DCLAIMS. 4SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICi AGGREGAT6 UM
4Rv POUOY NUMBER OA EC I PO PIpA LIMITS
'NARR P'
I�O'6�NIERAL LIABILITY ' EACH OCCURRENCE A 1 O 0D
](I COMMERCIAL GENBRIA-I..11ABILITY PKFMISES��A 5C .ODQ
��CLAIMSMADE L I OCCUR I I MEC EXP(Myene Pe".0 E 5,000
Ai - — CPPDO58607 I3/19/10 3/19/11 PERSONAL&AOVINJUKY _ A 1,0001000
I GENERAL AGGREGATE $ 2 00 QQ�
GENT,AGGREGATE LIMIT
APPLIES PER: PRODUCTS-COMP/OP AGO 8 2 00 D ,ODD
POLICY j I j�C`I -OC
---i,-_ AUTOMO8fi-EI-IASVTV I IGOMB`NED SINGLE LViR g 1,ODO t�pC
F7 ANYAUTO i
—I
A 90DILV INJURY
LL4WNED AUTOS
11 (Par PnteM; I
�X I� SCHEDDLEDAUTOS
HIRED AUTOS 377974D0001 5/15/10 5/13/11 BQOILnwueY a
NON-OWNEDAUTCS IPnratCiOenq
I( i PROPERTY PAMAGE .
—, I I (PereccMenO I
I GARAGE UA3ILITY AUTOONLY-EA ACCIDENT 3
i� ANYAUTO OTHFRTHAN EAADC A
AUTOONLY. AGO SS
EXCESSIUMORELLA LIABILITY 1 EACH OCCURRENCE R
OCCUR C'�CLAIMSNWDE AGGREGATE E
i
r DEDUCTIBLE
_I RETENTION S A
V(ORNERSCOMeE,'JSATi4NAN0 TOTYLIMI�
'. 8.VPLOYERS'UAB!L!TY EJ_,EACPIACCIDENT A 500 000
PNV PeOCPRTURIPnR*NER!EXECUTIVE
C UFlGE9rmtnRrK 9/17/10 E.LGI$EA$E•9AEMVLOVE A 500 ,000
Irc OLUOEV vwcGC09502012008 9/17/09e+.aeEPrbaurlCP• E.L DISEASE.POOCYLtMIT A 500 000
SDECIAL Pft ISION$tlntm�
C-HER
I I I
O F.Sf.RIPT!CN OF OPERATIONS!40CATIONS!'✓EHICLEEf EXCWSIGNS MOEO BV ENOORSEN9ENT!SPECIAL PROVISIONS
Carpontry & Insulation
CERTIFICATE HOLD R CANCEL TION
SHOULDANYOFTHE ABOVEOESCRIBED POLI:IES»E CANCELLED BEFCRETHF EXPIRATION I
City Of Salem DATE THEREOF,THE ISSU'NC INSURER WILL ENOEAVDP. TO MAID_ DAYS WRITTEN !
Atta, : SuS.ld ing Dept. NOTICE TO THE CERTIFICATE HOLDER N WED TO THE LEFT,BUT FAILURE TO DO SO$HALL
City Hall IMPOSP NO OBLIGATION OR LIABILITY OF ANY KING UPON THE INSURER. ITS AGENTS OR
Salem, MA 01970 REPRESENTATWF,S,
AUTHORIZED RP3RESENTATIV�
ACORD25(2001106) LIU CR ACORD CORPORATION 199U
eW.Al A sowwo+6101216
I �
Office of Consumer Affair,&Bnsinese Reselatlon License or registration valid for individui use only�.
HOME IMPROVEMENT CONTRACTOR Refire the expiration date. If found return to;
Registration: 16458d Office or Consumer Affairs and Busiaoss RegulaW;n
Expiration: 10121/2011 TO 289821 30 Park Plaza-Suffe 517019 !
Typo, Individual Boston,MA 02116
JEFFREY MAYOTTE
JEFFREY MAYOTTE
29 ANDREWS LN.
EAST KINGSTON,NH 03827 Undersecretary --*at aid witAo igoature�y�—
( .Massachusetts - Department of Public SaI'ch
Bo:u'd of Building Rt•Culalinns and Standards
Construction Supervisor License
License: CS 103474
Restricted to: 00
JEFFREY MAYOTTE ; ti3
29 ANDREWS LN
EAST KINGSTON, NH 03827
Expiration: 1/23r2013
(lnunisvi..ner Trg: 103474
' ACTION, INC
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
Work Order Date: 06/24/10
Primary Contractor: All Season Windows & Insulation
Other Contractor: NA #Bulbs installed $0.00
Cost of Bulbs $0.00
Client. Juan Peralta nspt$125.00 Max $0.00
Street: 48 Jefferson Ave Other In Kind $0.00
City; State; Zip: Salem, MA 01970 Electrical Work $0.00
Telephone: 617-957-2349 $ Amount xeyspan $0.00
$ Amount National Grid $0.00
Blower Door Test: Yes other utility $o.00
Inspect Knob &Tube: No
Date Job Completed: 01100l00 Estimated Repair Total $0.00
Actual Repair Total $0.00
Weatherization Est Act Cost Est Cost Act Cost
Door Kit $43.00
Door Sweep $15.00
Automatic Door Sweeo $22.00
Air Sealing(Der hour $75.00
Attic Air Sealin 2- art foam(per hour $75.00
Weatherstrip Window(per side $5.00
Seal Ducts-Mastic $62.00
W/S&Insul Attic Hatch $30.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Weatherization Totals: I I 1
$0.00 $0.00
Insulation Est Act Cost Est Cost Act Cost
Attic Flat R38 open $1.40
Attic Flat R30 open $1.30
Attic Flat/Slopes R30 restricted $1.41
Attic Flat/Slopes R20 restricted $1.35
Attic Kneewal R13 FG $1.25
Attic KWall R13 Cell w/Membrane 100 $1.65 $165.00
Replace Missing FG Kneewall 75 $1.40 $105.00
Sill Boxes 2 pt Foam&R19 140 $2.00 $280.00
Sidewalls-Asbestos DP $2.20
Interior Wall R13-Plaster RI DP $1.81
Test Drill Sidewalls-4 sides 1 $60.00
Duct Insulation R5&Seal Seams $2.95
H dronic Pie Insul to 1"R5 20 ; c $3.25 $65.00
Steam Pipe Insul to 1.25"R5 Y tt + V1. $5.25
DHW Pipe Insuation R5 6 $2.50 $15.00
Insulate Door 1 $44.00 $44.00
$0.00
Insulation Totals: $674.00 $0.00
Juan Peralta Page 2 DOE 0
Oth6f Measures Est Act Cost Est Cost Act Cost
Tyveq over existing FG 283 $0.50 $141.50
Cut&Finish Attic Kneewll Hatch 4 $100.00 $400.00
Vinyl Replacement Window-73 ui $390.00
Vinyl Replacement Window-83 ui $400.00
Vinyl Replacement Window-93 ui $410.00
Vinyl Replacement Window-101 ui $425.00
Vinyl Re I. Bsm't Hopper Window $325.00
Steel Pre-Hun Doorw/Lite $490.00
Solid Core Door w/Hardware $330.00
Faucet Aerator - $15.00
Low Flow Showerhead $25.00
Blower Door Test $45.00
Window Grids-per sash $20.00
BtF- Perm it Fees 1 $0.00
Other Totals: $541.50 $0.00
Energy Conservation Est Cost Act Cost
Totals: Max$10,000.00 $1,215.50 $0.00
Repairs Est Act Cost Est Cost Act Cost
Repair/Refit Door $50.00
Adjust Door Striker Plate $20.00
Door Threshold $40.00
Repair Door Hine $25.00
Slide Bolt $20.00
Sash Lock $9.25
Glass Replacement-to 64 ui $42.00
$0.00
$0.00
$0.00
Health & Safety
Vent Clothes Dryer to Exterior $85.00
Vent Bath Exhaust Fan to Exterior $85.00
Replace Dryer Hose $38.00
$0.00
$0.00
$0.00
Repair Tot: Max $2500.00 $0.00 $0.00
Work Order Sub Total: $1,215.50
Measures I I Est Act I I Cost Est Cost I Act cost
Other
Other
**Heating System Repair I I 1 $0.00
••Action approval only
Estimated Job Total: $1,215.50
Job cannot exceed $10,000.00
Job minimum= $200.00 Job Grand Total: $0.00
AUDITOR: Woody Swan
r.,
NSCAP
98 Main Street
Peabody,MA 01960
Tax Exempt#:042-385-280
Agency: NSCAP
PROGRAM: National Grid/2010
JOB NUMBER: 0 NGRID Application#; 0
Work Order# 0
Work Order Date: 06/24/10 Job Limit:
Primary Contractor: All Season Windows&Insul Per Unit $4500.00
Other Contractor: NA
Client: Juan Peralta K+T Yes=1 No=
Street: 48 Jefferson Ave K&T: 0
City;State;Zip: Salem,MA 01970
Telephone: 617-957-2349 Stand Alone: No
Fee Code: 0
Blower Door Test: Yes Stand Alone Yes=1 No=0
Inspect Knob&Tube: No Flee.Contractor:
Attic Insulation Est Act Cost Est Cost Act Cost
Attic Flat R49 open $1.53
Attic Flat R38 open $1.40
Attic Flat R30 open $1.30
Attic Flat R20 open 432 $1.23 $531.36
Attic Flat R10 open $1.15
Attic Flat/Slope R30 restricted $1.41
Attic Flat/Slop a R20 restricted 366 $1.35 $494.10
Attic Flat/Slo a R10 restricted 356 $1.24 $441.44
Attic/KW Floor Transition DP-In.R. 72 $2.40 $172.80
Attic Kneewall R13 $1.25
Attic Kneewall Floor R30 rest. $1.41
Finished Attic Access $100.00
Temporary Attic Access $75.00
C.1 Space w/Poly Vapor Bartle' $2.53
Garage Ceiling/Floor R30(with ap 'oval) 110 $2.00 $220.00
VentDryer/Bath Fan $85.00
Thermadome $175.00
Roof Vent small $76.00
Turbine Vent $160.00
12"Stack Vent $145.00
Pro pa Vent $3.75
Gable Vent(all sizes) $88.00
Soffit Vent $26.00
Attic Air Sealing 2-part foam(2 hrs mar) 2 $75.00 $150.00
L
Juan Peralta Page 2 National Grid2010
Est Act Cost Est Cost Act Cost
Wall Insulation
Single Nailed Asbestos/Asphalt DP $2.10
Double Nailed Asbestos/Aluminum DP $2.20
Brick/Stucco DP $2.75
Interior Wall Blow_
Plaster DP $1.81
Clapboard/Wood Shingle/Vin 1 DP $1.70
Test Drill 4 sides 1 $60.00 $60.00
Air Sealin Limit:
Single Family w/Blower Door=5400
All Others=5200
Door Kit 2 $43.00 $86.00
Door Sweep 2 $15.00 $30.00
Automatic Door Sweep $22.00
Air Sealing(3 hours max). 3 $75.00 $225.00
Sash Lock $9.25
Glass Replacement $42.00
Blower Door Setup 1 $45.00 $45.00
Total Air Sealing Cost:
.Heatin2 System Measures
Duct Insulation&Seal Seams(sq ft) $2.95
H dronic Pipe Insulation to 1"R5 $3.25
H dronic Pipe Insulation 1.25"+R5 150 } $3.50 $525.00
Steam Pipe Insulation to 1.25"R5 $5.25
Steam Pipe Insulation 1.5"-2"R5 $6.05
Boiler/Furnace R lacement $0.00
-*Program Re air $0.00
**Action approval needed:Max 5500.00
••••Actual Total does not include$125.00 K&T chg. $2,980.70 Est Total
$0.00 1 lAct Total
AUDITOR: Woody Swan