79 LAWRENCE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
\ Board of Building Regulations and Standards CITY OF
1\ Massachusetts State Building Code,780 CMR SALEM
\ Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
\� One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Am)lied:oqi 4`'��///
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION ,
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
- 7-9 Z-o"ae-e e s r
I.Ia 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 R) Frontage(n)
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?Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Record,
icq
Name(Print) City,State,ZIP
-?:�7 .3 w
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) Mn
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other k-Specify: li✓Ptr`rj }r��✓
Brief Description of Proposed Work : w w
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ D 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard CitytTown Application Fee
❑Total Project Cost;(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
SQ� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
z3 -�s
� �,� ��.1/n License Number Expiration Date
Name of CSL Ho der -
List CSL Type(see below)
No.and Street —Z Type Description
W� `Y•'(A^ U, �G Unrestricted(Buildingsu to 35,000 ca.ft.
A !4 R Restricted 1&2 Family Dwelling
Ci ffown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
N e461 I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
e� l-G �1564 ri 2
��P` /kA y'- f r �p HIC Registration Number Expiration
Date
}jC Cgmpan Name Z orstmnt Name
2,4
No.and Street Email address
M
Ci ,Town,State,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 .,Ia�
to act on my behalf,in all matters relative to work authorized by this b ilding pemu application.
Wrou'L.,G 6— Y— e3
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.
b -y-i3
Print is d ge Name(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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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.U.E,%4 ANSSACHUsETTS
BUILDING DEPART.%I&NT
' 120 WASHLNGTON STREET,San FLOOR
TFL. (978)745-9595
FAX(978) 740-9846
KIitBERLEY DRISCOLL
AAYOR I Horns ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG COMIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information v
/) Please Print Leeibi
Nalric(dusitws OfganizationAmlividual):_/f&// S�La L16w�(�J_t 77tlt'f>�4T
Address: 26 944 92,257
City/State/Zip: Lyw t1 RtA Phone 9:
Are you an employer?Check the appropriate box: Type of project(required):
1.&-Fanra 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 on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its
required.] affieen have exercised their
I0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees,[No workers, 13.�therbsV- .Weo.i247-r
comp.insurance required.]
•Any applicant that ducks box dI must also fill out the stttion below,showing thou workers'compensation policy infatmatiom
't hxmowners who submit this affidavit indicating they are doing all work and than him onside contmctws must submit a new affidavit indicating such
=C..ntneton that cheek this box must attached an addttiwml sheet showing the oa n,of the sub- fflrwors and their wo kem'ramp.vat i y infomt moo.
I um an employer that is providing workers'compensation insuroirce for my employees. Below Is the pollay and Job site
information. �-/
Insurance Company Name:. t &-ottae—1 eee
Policy 4 or Self-ins.Li—c.#:_ /) 8,b✓�'�o2 Expiration Date: 3
Job Sire Ad&css: /7 / L.AW s2pr••C S 7— City/State/Zip:
Attach a copy or 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 51,500.00 and/or one-year imprisonm°nt,as well as civil penalties in the form of o STOP WORK ORDER and a fine
of up to$250,00 a day against the violator. He advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
!do hereby certify u tder the in and penalties of perjury that the information provided above is true and correct.
Si+rrtt ire• Date: 14
P cart r:
Qfrcial use 0111y. Do nor write in this area to he completed by city or town official
City or Town: Permit/License
Issuing Authority(circle one): _
1.Board of Health L Building Department 3.City/town Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other—
Contact Person: __ — Phone#:
1
ns:[Vi�nta Li: 3L HIIWKUJL INZWKMINUt Y:VVt Oi/nCl
®.CORD.. CERTIFICATE OF LIABILITY INSURANCE I
OATGIM91291
'ROouCER ITHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
nCyl Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Ambrose Insurance, A
4e HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
56 Central ATPe. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
I
Lynn, MA 01901
781-592-820 INSURERS AFFORDING COVERAGE NAICs
MauaeD All seasons Windows s Insulation l!TU_n Scottsdale
P.O. Box $229 INSUREREL Arballa Protection „I
Lynn, MA 01904 INSURER C' Tra Lars
NSURER D
I INSURER
.OVERAGES
THE POLICIES OF INSURANCE LISTED DE40W HAVE BEEN!SSUEO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTkVI T HSTANDING
ANY RECuIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRISEO HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDMIONS OF SUCH
POLICIES.ACGREGATE LIMITS SHOWN NAY HAVE SEEN REDUCED SY PAIOCLAIMS.
TR tuto
POLICY NUMBER PlYRIPT&WAIVEN LIATTS
GENERAL LIABIIf•Y EACH OCCURRENCE 1 1 4�. QO.OOO�
�[ COMMERCIAL GENERAL LIAS0.ITY 1 MIMI ES fenc rcnw 1 50.0001
CLAIMSMAOE E&7I OCCUR i MECEXP(kyOm. Pmw) S
A CPSiH57066 3/19/13 1 3/19/14 MWNPLSAOVINJURY s l OF �0�0
GENERAL AGGREGATE S 2, )00, 000
IGEN'LAGGREOATE LIMIT APPLIES PER, PRODUCiS•CONWlCIp AGG 1 Q00.000 .
POLICY i0G
I�AUTOMOBILE LIABILITY CDM&WED81MOLE LENT S 1,000,400 !
1 _ ANYAUTO
ALLOVJNEOAUTW SOOILYINNRY 1
SOH69VLWAUTOS (PmPasen)
g, HIKOAVTOG 37797400001 5/15/12 d/15/13 `ePoca�Y nRY s
NON•OWNSOAUTOS
fPMxecRIV OWAGE
9
GARAGE JASILITY AUTOONLY-EAAC0ID2NT S
ANYAUTO OTHER THAN EAACC 4 i
AUTOONLY.. AGG S
'EItCESS'UMBREL'A IIABILTYY FAOH OCCURRENCE S
OCCUR C AIMSMADE I AOORE�TE S
i S
DEDUCTIBLE I
RETENTION S I 1
WORKERS COMPENSATIONAND 115KM67CER
EMPLOYERS'LIAELTTY I ELEACHACCIDENT S 1 000 004
Binder 3126/13 I 3fa6/14
,
ptl( A CNI BER A G EL DISEASE-E0.EMPLOYE 1 1 0 0 Op
C,
°M`tl°itS1b01�Bf E-L DISEASE•POLICY UWT 1 11000,000
SPECIK PROVISIONS Plelew
OTHER
i I
I _
OEaCRIPnON OFOPERATIONS!LOCATIONS I VEHICLES,EXCLUSMOWAODEO SY ENDORSEME.'IT/SPECI.4LPROVISIONS
Carpentry/Insulation/Electrical
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE E1�IRATION
City of Salem DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MA!424 DAYS WRITRN
Attn. : Build-ing Dept. µOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 008O SMALL
City Hall IMPOSE NO OSUGA1104 OR NA OF ANY MND UPON THE INSURCHt ITS AGENTS OR
Salem, bM 01970 REPRESSNTA'MVES.
AUTHORP.019W%SVrIVE
ACORD 25(2DD110S) OACORD CORPORATION 1988
VITA' OF S.UEN4 NL-kss.A c usET a J
BuimmG DEPART%MNT
N• 120 WASHNGTON STREET, r FLOOR
TEL (978)745-9595
FA (978) 740.9M
KINfBERLEY DRISCOLL
MAYOR THo%w ST.Pw2AE
DIRECTOR OF PUBLIC PROP£RTY/BUILDLNG CONMSSIONER
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:
1AIA 5.'Yc2s C
(name of hauler)
The debris will be disposed of in
__f�5�� �IDS?•cr2
(name of i'acil ty)
rJC V.rj
(ad ess of facility)
gna r o p rmit applica
date
dcbrivlr.dcx
rNt Massachusetts Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor '
License: CS-103474
JEFFREYLMAYOT-IE
29ANDREWS1IY 9
East Kingston NIf 0382�7 f'
Expiration
Commissioner 0112 3/2 01 5
� 1
do^^'r.R++..++,�wn-'_rxa•'..'-/✓R7 eyf jp, -... ��/.J.
Office 0l C e5ea1[ra a��1I' QSIOG Op r
- HOME IMPROVEMENT CONTRACTOR ¢
5` Registration 164564 Type:
PFEAtY
Expiration 10/21/2013 Individual
a _ MAYOTTE - -
k I
JEFFREY MAYOTTE
t 29ANDREWSLN
EAST KINGSTON NH 03827 .
3 - Undersecretary
S
x
s
av rn
J.I I(']L ww.m xwim
t This card acknowledges that the recipient has successtulty completed a
30-hour Occupational Safety and Health Training Course in
Construction Safety and Health
Jeffrey Mayotte
Rory Jabour 02/02/12
(TMleer name—print or type)
(Conrse dantlte
WAP Work Order
North Shore Community Action Programs,Inc. Job Number: 110805
98 Main Street Work Order Date: 519/2013
Peabody,MA 01960 Ownership:Owner
Phone: 978-531-8810
All Seasons Windows&Insulation Auditor:Doug Cranford _
P.O.Box 8229 Email:dcranford@nscap.org
Lynn MA 01904 Cell:978-335-7154
Email: njmayotte@comcast.net Phone:978-531-0767 x135
Phone:603-642-4451
Patricia O'Connor NGRID Electric - $6,46131
79 Lawrence St - Total $6,46131
Salem MA 01970
978-744-3745 -
Safety Issue(s):Knob&Tube Wiring/Lead Paint Possible.
Authonzed t r g Actual
Comments
MeasureDescnphon _Qty Price ,�!1Tota1— _Qty , Total
-Attic Insulation �- •r _ - ""' "�trs
R-30 restricted-slopes/floored till 432 $1.48 $63936 432 $63936 Attic Floor
w/cellulose
R-30 restricted-slopes/floored fill 208 $1.48 $307.84 208 $307.84 Attic Slopes
w/cellulose
R-38 unrestricted-settled cellulose 140 $1.47 $205.80 140 $205.80
Site Built pull down stair insulation 1 $180.00 $180.00 1 $180.00
2 in foam box
�,�Attic V_entilahon ( '. ,. .��� `�'' h _ ' ��_I
Rectangular gable vent 3 4$92.00 $276.00 Y3 $276.00
Roof vent 865(A sq ft NFV)small 3 $80.00 $240.00 3 $240.00
-'Bssementlnsulahon Y • w, a Tr=,
Sill two-part foam w/fiberglass battH96i$2.20 $211.20 96 $211.20 -
y. nUO[$ ,m, � ' +.+ z Fixed Sweep 5 $63.00 4 $63.R-5 Ductwrap or R-max on door 0 $51.00 1 $51.00 -
Date: 5/9/2013- - Page 1
WAP Work Order: Job Number: 110805
Repair/RefitDoor 1 $52.00 $52.00 1 $52.00
Weatherstrip s/Q-Ion or equal 6 $45.50 $273.00 6 $273.00 Inclludes 2 kits for pull down stairs
Clothes dryer vent including 1 $89.00 $89.00 1 $89.00 -
Exhaust Duct -
;3;Mtsc Insulation
Domestic water pipe wrap 6 $2.63 $15.78 6 $15.78
Hydronic pipe insulation to Iin. 205 $3.41 $699.05 205 $699.05
copper pipe R-5
-77
iVTiscMeasures '� +' 'S ` '
Attic sealing with two-part foam 3 $75.00 R$225.0013
$225.00
Basement sealing with two-part 3 $75.00 Blower door set-up with pre&post 1 $45.00 $45.00
tests
Permit t - _ + - ` - a- .� ,.
Building Permit 1 $100.00 $100.00 1 $100.00
Wa11.Insulahon _ -x. 7- - zr
- ;
Wood clapboard/shakes/shings or 1432 $1.79 $2,563.28 1432 $2,563.28
vinyl(dense pack) - --
Total $6,461.31 $6,46131
Contractor Instructions:
Before Starting the Job: Dunne the Job: -
1.Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978.Lead safe uractices 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.
Page 2
Date:5/9/2013