20 LATHROP ST - BUILDING INSPECTION (2) -
9 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
SALEN[
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 Vse Only
Building Permit Number: Date �pl/iied'' '
Building Official(Print Name) Srgna[ure - '` ..
SECTION 1: SITE INFORMATION
l,�per Address: D ST 1.2 Assessors M & P cel Numbers
1,l a Is this an accepted street? yes_ no Map Number/ Parcel Number
1.3 Zoning Information: 1.4 Prop rty D' ensions:
Zoning District Proposed Use Lot Area( t) 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:; PROPERTYOWNERSHIPr
2.i�Owner ofR vrd:
DI)IM ItI Sri t�wl, W D157 0
Name(Print) City, State,ZIP
No—and Tlelephone Email Address
SECTION 3: DESCRIPTION OF, PROPOSED WORK=(chec that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repahs(s) Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg, ❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Wor Z: R/
r V
/ St I..I.S
SII t0
SECTION 4: ESTIMATED eONSTRUCTIO&CO TS (# 13A54eKSI
[[em Estimated Costs: Official Use Onl
Labor and Materials y�-
1. Building Building Permit.Fee: S Indicate how fee is determined:
Cl:Standard City%T%own Application Fee
2. Electrical S ❑Total ProI Cost',(Item 6)xmultiplier x
3. Plumbing S 2 Other Fees: $
1. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
-suppression) Total All Fees: $
`,
r Check No. Check Amount: Cash Amount:
'Total Project Cost S .
�DtJ ❑ Paul in Full ❑ Outstanding Bal:ytco Dno:
1�Ci�`I 7e� �otitrs� v
SECTION 5: CONSTRUc rION SERVICES
5.1 Construction Supervisor License (CSL) 7i1 S _ let )
q-I.tAr..) License Number Gs iratiot Date
VCI,_Name ofCSL I folder List CSL Type(see below)
-Type Description
No and Street
R Unrestricted 2 FlJin s u Dweto lling
00 cu. ft.)
R Restricted 1.4c2 P:miil Dwellin
City(rown, State,ZIP M blasonr
Roofing Covering
1V Window and Siding
SF Solid Fuel Burning Appliances
M361+oq I I Insulation
Telephone Email add?vs D Demolition
5AIIE�SotayName
2 Registered
Home Improvement Contr tor(HIC) 1Z
FIIC O�an�pNumb rrLatito n DILate
CR:egis
Name
I. a eet f ' Em 'I address
et
Ci /Town,State, Zl Tele hone
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 ofthe,.Isleue of the building permit.
Signed Affdavit Attached? Yes .. .. No...........
SECTION 7a: OWNER KUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize t
to act on my behalf, i all matters relative to work authorized by this building permit application.
It 1�o ( Z
Print Owner's Name(Electronic Si nature) ate
SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest tinder 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 AutlmritNd:\gent's N:unN(Electronic Signature) Due
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. Id?A. Other important information on the HIC Program can be found at
www.m:us. ovoea Information on the Construction Supervisor License can be found at www.ntass.gmvddL
2. When substantial work is planned, provide the information below:
Total door area(sq. ft.) _(including garage, tinished basement/attics, decks or porch)
Gross living area (sq. ft.) _ Habitable room count
Number of fireplaces _ Number of bedrooms --
N111116Nr of bathrooms _ Number of halfibaths _
I ype of heating system _-_-_----_ Number of decks/ porches _ _-_ _—
fvpe of cooling system -- _ Enclosed _
3. "fotalPlkvctSquareFoontgc" way besub;titutedfiu'`I'WAIPrujectCo>["
CITY OF S-U.F-M, AxSSACHUSETTS
Bt.ILD4\G DEPART\LONT
3 N• 130 WASHNGTON STREET, 3" FLOOR
T EL (978) 745-9595
FA.K(978) 740-9846
KIJiBERI.EY DRISCOLL
'AAYOR Tmwis ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/SLUXI \'G CO\61ISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
Tn 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
Gem-��,►.t � s fVC
(name of facility)
(address of facility)
)signature
of permit applicant
date
dcbn»it:Jx
tea° SETTS
CITY OF S:1I.E`rt ANSS:ICHL
BUILDING DEPIRT\IE. iT
120 WASHLINGTON STREET, 3'a FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIMBERL.EY DI ISCOLL
THo
MAYOR ntAs ST.FIEeRl3
DIRECTOR OF PUBLIC PROPERTY/SUBD17NG CO%LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r ilicant Information I
[ Please Print Legibly
Name(Busiiv.s,&Orypniraftiatvfndivid�uaal) T
` o
Address: �StWSTf'8,�[A/ gz
City/State/Zip: k* 1G(LL PhoneN: 5:76- &(-4P0R '
Ar y)u an employer?Check t�e appropriate boxt
i. 1 am a empiq�oyith 4. Q I am a general contractor and 1 Type°f Now
cons(required):
d):
employees( I door part-time).• have hired the subcontractors 6. ❑New construction
2.❑ I am a sole proprietor or partner-
listed on the attached sheet 1 7• ❑Remodeling
ship and have do employees These subcontractors have a. [] Demolition
working for me in any capacity. workers'comp.Insurance. 9, El Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their f0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I EI 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'
camp.insurancercquired.) 13. er )0`5 y
;Any applic:un drat 0mitt box sl must also fill uui thv scoloo balow thawing thaw wurken'comptnudun puflcy into a tea
't r.w uwn,ne who submit this aflldovit indicating they ur datng all work and then hiro uutsida camraetar most submit a new,affidavit indicating such.
Cumneton that chwk this box most attaahad an addidumtl sheet thawing the name afthe subcdnt actors and their worker'comp.policy informanon.
l um an employer that Is provldl ig workers'compensation lnsurance for my employees: Below G the pollry and Jab sloe
la/ormarion.
n2D st NG Insurance Company?lame: ' nn 'i
Policy 4 ur Scif-ins. Lic. dn: '4JJ— 0Ub�_Wq-b, -0 �7/ Expiration Date -Y
Job Site Address: t'7V l�Tl tt(CU{� S� City/State/Zip: &t Dell O
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate).
Failure to sucunt coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imp onment,as well as civil penalties in this form of a STOP WORK ORDER and a line
of up to$130.00 a day agair la r De advised that a copy of this atatcmenl may be furwardcd to the Office of
Invesligutiul 'd r u rm e c scrag°verification.
"a
do hereb retwo p 1 u d penuldes of pef/ury 1/ref 1/t0lnfuratatlan pro vid ied a uvr true cord c orreca
Dar ,
1"hone,3
OJJJc iul use only. Du reef write in Mir urrut to be completed by city or town a/Jlcl=5. Plumblnglaspector
Citynr'Ibwn: P¢rmitR.IcemeXIssuing Authority(circle one):
L hoardofhealth Z. 1uildingDepurtmcol 3.Cilylfown Clerk 4. Electrical 6.Other
Contact Person: Phon¢/t:
I
WAP Work Order
� V
North Shore Community Action Programs,Inc. Sob Number: 110310
98 Main Street. Work Order Date: 11/2/2012
Peabody,MA 01960 Ownership: Owner
Phone: 978-531-8810
Heat Quest Insulation Auditor:Doug Cranford
5 Shawsheen Road Email: dranford@nscap.org -
Lawrence MA 01843 Cell:978-335-7154
Email: heatquest@aol.com Phone: 978-531-0767 x135
Phone:978-691-1166
Donna Cauley NGRID Gas $5,654.18
20 Lathrop St Total $5,654.18
Salem MA 01970
Safety Issue(s):Lead Paint Possible
sa. frn X $.� ? ti<f7x� '-'ftv xc+j* ? i -. <rA^o-
AOthonzed'w av" :n s +?x n 1 n�, d r . >
3 'kb ACtuBI 4�-��' ,i +.a.r5. `�k L,{, {Rh a ' c,
j1 Y v hT :1`fl
x ¢ k"�'
- MeasureDesc tion ` ^ F C icrp i „ ans + omments
' `'^i��''�� su�s 4'Q'
xy n''` ls�^.�.i.,�?A� .rt�9.x✓+`n�'cr.�tzr,r'.z � ." x. a w�`d�.d� �4� s:3 7 *d �Y y '�� >4 a��+'�.'��-.,im�."��::a. �z ``r wy °`"AthC IllSnlah011' S i'., a `°% b
�fr,4„K: n��
' `
gi� y+ Ai y�
R-30 restricted-slopes/floored fill 224 $1.48 $33152 224 $331.52
w/cellulose
R-38 unrestricted-settled cellulose 224 $1.47 $329.28 224 $329.28
"+`E�'
'a.�' ... -m w.. n .v. ,,.s? 9 ,. �.� +. � vry$., :. > ..#:�r 4?�xi J.hx"r .,,. �...-.. `i� r a- .r A4.a1`S .,•
Sill two-part foam w/fiberglass Batt 150 $2.20 $330.00 150 $330.00
, oe" -
s^ Doors .a. 1�F„cq.pcmt+r�xA xra ace r5k+'vx+,iyy *xe:a 5„Smu *' .,y. r abs
Basementloutside door-w/jambs 1 $435.75 $435.75 1 $435.75
Door Pull 1 $15.00 $15.00 1 $15.00
Fixed.Sweep 3 $15.75 $47.25 3 $47.25
R-5 Duchvrap or R-max on door 1 $51.00 $51.00 1 $51.00 -
Slide Bolt 2 $22.00 $44.00 2 $44.00
If
Weatherstrip s/Q-Ion or equal 3 $4550 $136.50 3 $136.50
1
Date: 11/2/2012 Page 1
WAP Work Order: Job Number: 110310
Domestic water pipe wrap 6 $2.63 $15.78 6 $15.78
Hydronic pipe insulation to Iin. 270 $3.41 $920.70 270 $920.70 _
copper pipe R-5
�C. lYm Measures .r` h"v , a'a a 6:{33 �x k z,�n %7 Sr. 2
Attic sealing with two-part foam 2 $75.00 $150.00 2 $150.00
Basement sealing with two-part 4 $75.00 $300.00 4 $300.00
foam
Blower door set-up with pre&post 1 $45.00 S45.00 1 $45.00
tests
icr , "' r 1+ .�k°„ " x, ,ti-a s r ' t s 'a s #'a Paz Ys.-ia<iss
s,ti j nJ Pel'rDlt at s`4 s, "�,, �* v ,a i arF -y .i fR wFq , y ^'
Msue_ s._.M^ .. .a..,,u.„,r'.!c.w .d, x� z.6 tk""4 sc.,6 `7 ,.t"t �u +a Maw
Building Permit 1 S100.00 $100.00 1 $100.00
Wa11 Insulation .�
firs k,t h*Yt",x'h•t. Rn e{1s1'd .,L.
Double nailed asbestoslaluminum 1040 $2.31 $2,402A0 1040 $2,402A0
(dense pack)
Total $5,654.18 $5,654.18
Contractor Instructions:
Before Starting the Job: Durine the Job:
1.Please notify us 24 hours before starting or scheduling a job. 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:
Date: 11/2/2012 Page 2
S=NSCAP'Home EnerQv Report
J Job# Date Bwldine D�aenostu Spec7ahst /t Contractor p Telecphone
Doug Cranford,., X%" �
335 z7154 Cell
_ _
chant
Budding Type: Ke, 4 PeW h f q(7 Siding Type: , V y -add'
�
Attic inspections es o CertrFcate p�.Insulationi. Ye No - Blower Door Test: Yes;No Notes: V -
Install Bath Fan:Yes No iring Required:Yes( Include Light:Yes No Existing Fan: Yes N Existing light Fixtur Ye No Wall Mount:Ye No
Location/Notes: `� (r vu, "A (si ri o:� _ pJr„�yS qbC.r Date Sent:
-knob&Tube Inspectloni: Needed:�Yes N Completed: Yes No Where `Date Sent
Door/Location Notes
LI V L�.Qrr i�o C- _._ . -7- T1I- 1 __1 I - -- __�r� dQ i_7`r4M
(CA-_
i
iv
---- - - --- _cam, to C f��
- jj
Notes:
<1 C -
MOA
t,30k r 2 Y6 ard -
Clean Gutters: Yes No
(�\ Office of Consumer Affairs&B sin Regulation
HOME.IMPROVEMENT CONTRACTOR ,
Registration .s-153660 Type: .
Expiration 12121/2012 DBA'-
H A QUEST INS,LATION CO LLGG
gr• AL LAN VEILLEUX JRH
5SHAWSHE {
J�—
LAWRENCE,MA 01843 Undersecretary,
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialty _
License: CSSL-099215
ALLAN M VEILLAUX d
5 SHAWSHEEN RoAII
LAWRENCE MS:01843, r
s a
�1..� ��*� o 10 Expiration
Commissioner 08/19/2014