4 LINCOLN RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards OF SAY
Massachusetts State Building Code,780 CMR, 7 edition
LEM
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 N brier:_ Date Applied: /e
"t Signature: ""°mil �n v 7
Building Commissi er/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
4 � !col. 14�
Lla Is this an accepted street?yes1z no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: _
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Zone: Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Regd:
R"gf!er ISr�TI S l-q 2oP
Name nnt) �/^J ) Address for Service:
10V/ ' Ili i ✓ J�/ 4)78- 7Ns'- / ?67 .
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building V1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other gl.epecify:
Brief Description of Pro posed Work 2: &JJmC&V6 `
W'w u
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ /0 •OOd 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 (t4VAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
6.Total Project Cost: $ r U d0 Check No. Check Amount: Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
go7u
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ID3 9>q /-23 `tat
WiLed M.o�/art License Number Expiration Date
Name of CSL-Hplder r v
(/ Aa t✓S L y &T �t:'N(5ny fW List CSL Type(see below)
Ad ess �� T Description
Unrestricted(up to 35,000 Cu.Ft.
Si a R Restricted 1&2 FamilyDwelling
St-g -ro It M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Nome Improvement Contractor(HIC) !6 y C�_,
-IEFJC2f y M VaT4@ 710"1
! . _�7 '" ' Registration Number
HIC Company N e or HIC Reg�s[rant Name gi
Address
aZ.S & itew5 I � FA5T-L'2w 5 ram/ Nr
?81 _ 8yy-gp)0 Expiration Date
si�goao r VTelephone
SEC ION 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, R D 6'e2-r EuTrd4s as Owner of the subject property hereby
authorize I FfF2L'V M 44�l01N t! to act on my behalf,in all matters
relative to
work authorizedby�g permit application.
Signature of Owner Date
r SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I, .,�Ftr E&.2,I M.A y O(1`� ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
rwr A
Print N
y-e3 - tQ
Sign r or Autho zed Agent Date
Si a �mder a gas and penalties of
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 110.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 .
e' Department of Indisirtal Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
ww%mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Appitcant Information / Please Print Let=ibly
_ Name (Business/Orgahization/individual): J N/ &/
Address:- 'p0 Qo Y
City/State/Zip: LIVwey !VJ4 0650`f Phone #: 781 - 81S1- 8070
Are yotl an employer?Check the appropriate box:
I.(2 I1aam a employer with 4. Type of protect(required):
❑ I a e a general contractor and I 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El I am a sole proprietoror partner- listed on the attached sheet.t ?• ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for mein any capacity. workers'comp.insurance.
[No workers' comp.insurance S. 0 We.are a corporation and its 9. 0 Building addition
required.] officers have exercised their 10.0 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.❑Roof repairs
insurance required.) t employees. [No workers'
comp. insurance required.) 13.0 Other
'Any applicant that checks box#1 must also fill out the section below showing Iheu worken'wmpensalidn policy information.
i Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such.
lConnactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
Jam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /
Insurance Company Name: `_' AIM M yrya t
Policy#or Self-ins. Lic. #: Y Wi6Qe3 ,C rQ /�ne Expiration Date: l l7 tQ
Job Site Address: Q i v�/ (1 I +c.a City/State/Zip: 59 Iton- &7#4 06 *7
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 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.
f do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#: $t{y
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
I. Board of Health 2, Building Department 3. City/Town Clerk 4. Electrical Inspector 5• Plumbing Inspector
6. Other
Contact Person: Phone#:
0c/69/2616 22: 59 17815955920 AMBROSE INSURANCE PAGE 01/02
� DATE(MMIDD/YWYI
A, �ry CERTIFICATE OF LIABILITY INSURANCE 10 20 0
'ROOUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Ambrose Insurance Agency, NLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Inc.. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
56 Central Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. I
Lynn, MA 01901
781-592-8200 !INSURERS AFFORDING COVERAGE NAIC#
SJaFD Delangis , Thomas C. INSURER Providence Mutual
All Seasons Windows & Insulation INSURER B. Abella Protection J
P.O. Box 8229 INSURER0: AIM Mutual
Lynn, MA 01904 INSURER 0'
INSURER E:
'OVERAGES
T1;'c POLICIES OF INSJRANCE LISTED BELOW NAVE BEEN ISSUED TO THE INSURED NAMEC ABOVE FOR TH_POLICY PERIOD INDICATED,NOTIJIThSTANOING
ANY REOIJ'REMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO'WHICH THIS CERTIFICATE MAY BE ISSUED OR
"IT Y PERTAIN.THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
GIVE P01 YEXPIRATON
.rn 6,anu __ POUCV NUMBER L e M p LIMITS
GENERAL LIAB%tTY EACH OCCURRS14% :3 1 ,000,000
X: COMMERCIAL GENERAL LIABILITY --
: PREMISES;fS.ecnrcmv+ 3 501.000
CLAIMS'AADE D O6CUR MEDEXPWYe Pvl") D 5 1 P00
A'I CPFOOS8607 3/19/10 3/19/11 (PERSONAL&ADVIwJJRY 00 000 ;
I
_ (GENERAL AGGREGATE q 2 000 OOO
GETL AGGREGATE LIMIT APPLIES PER.: (PRODUCTS-CAMPIORAGG S 2 000 QOQ_
+_I POLCY r JE O- F7
UTOMORILE UASIL"Y
COMBINED SINGLE IWBT !4� 1 000 OOO nwvAUTO '' I IEe eulasnp � , ,
ALLCWNF.DAIJTOS BODILY INJURY I.
X SCtEUULE❑AUTO° (P° Oegpn) I'
g WIRED ALTOS j 37797400001 5/15/09 5/25/10 BDDILYINJURY
I_I 4ON-DIVNEGAJT06 (Pmoc-JdnNj
--�1-- PROPERTY DAMAGE
E PROPERTY
rGA 4017,I,IA°ILITY AUTO ONLY-EAACCICENT I E
--' ANYAUTO EAAGC 3
OTHER THAN
AVTOONLY'' AGO
EXCESS 19REL-A LL413I1-I:Y EACH OCCURRENCE 4
OCCUR CI DLAIMBMADE ACGR66ATE 3 __
if
' I OEDUC7131E � I° I
I
R9TENTION f S
WORKER$COMPENSATION AND 8 'H
CMP C'YCRT LIABILITY
',11''+noPR:c+ca+iarxER2¢wrne
E.L.EACH ACCIDENT E 500 0 0
C VWC6009502012008 9/17/09 9/17/10 E.L.DISEASE-EA EMPLOYEI s 500,000
�S ac;AL TROVISIONStCao E,L DISEASE,POLICY LRAIT 3 500 ,000
C-H=r.
I I
i
ESCAM710H OF DPERATIONG I LOCATION$?VEHICLES i EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Carpentry & Insulation
:ERTIMCATE HOLDER CANCELLATION
City of Salem SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE TI+E EXPIRATION
Attn, Building Dept. NOTICE
THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL.IO DAYS WRITTEN
wOTICE TC THE CERTIFICATE HOLDER NAMED TO THE LEFT,SLIT FAILURE TO DO 90 S'NALL
City Hall IMPOSE NO OBLIGATION OR LABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR
Salem, MA 01901
REPRESENTATIVES.
AUTHORIZED REP S I�
iCOR025(R001108) MACORD CORPORATION 1988
+ecA1 A 50M-0,0N0101216
O16es Of COusaw,Af i,&Basineae Rexaladon Llewue or registration valid for individul use only�.
HOME IMPROVEMENT CONTRACTOR - before the expiration date. If found return to
Registradow.. 1846gq 0MC4 of Consumer Affairs and Business Regolatidn
10 Park PUxa-mite 5170
Euslratlore t0l21/20t 1 TrR 289821 Boston,MA 02116
TYFQ; IndrMoal
JEFFREY MAYOTTE j
JEFFREY MAYOTTE
29 ANOREWB LN.
s ..
FAST KtNGSTON,NH 03827 Uodenaxr'etary ignsture
Vo i .—.__—., - ..
�Nlassachusetts - Department of Public Safeh
} Board of BuiitlinL Rc�-ul:u iuns :Ind ShuuLu Its
Construction Supervisor License
License: CS 103474
Restricted to: 00
JEFFREY MAYOTTE -jl'-+
29 ANDREWS LN
EAST KINGSTON, NH 03827
�L_ s
Expiration: 1/23t2013
t'numissi.np... Tr#: 103474
NSCAP
98 Nlain Street
' * i..:Peabod�,Nl, 01960
{
i
' - . Tax Exempt 4:.042-385-280 .. ..�;. ' ... .�.,% „ Wa
Agency NSCAP. `
PROGRAM:National Grid/20I0 , "•��. _. `.;
` . JOB NUMBER: 0 NGRID Application#: 0
I Work Order# 0
F,,Work Order.Date 01/25/10 Job Limit-
Primary Contractor. Al]Season Windows&Insul Per Unit $4500.00
+z 5�
's Other Contractor Manchester Electric,LLC
Client Robert Butters - K+T Yes=t No=O
_`' Street: 4 Lincoln Road _ K&T:
Ct State;Zt Saletn -_ + �` A
T U ry _ p Mal 0197I , - t
;Go,' Telephone 978 745-1767 Stand Alone ;No' -I. �',, .'.a .Z
;Fee Code 0
Blower Door Test Yes - Stand Alone Yes=] No 0
Inspect Knob&Tube: - No Elec.Contractor: ;:-: .•
Attic Insulation Est "`Act _ Cost - Est Cost Act Cost"
Attic Flat R49 open iin: $1 25
Attic Fla[R38 open s .„ ac:' 6. 676 -$1.12 $757 12
Attic Flat R30 open ^
Attic Flat R20 open =$0.99 -
Attic Flat RlOopen ,. '' $0.91 v"-"-t"-'o- "
Attic Flat/Slope R30 restricted F rS; $1.14 . ,t •`�' «,,,>$Pw,
Attic Flat/Slope R20 restricted ¢•$L08 i _, . , ru r `emu ;, xis '^�•w
Attic FlaUSlope R 10.restricted $0.99
Attic/KW,Floor Transition DP '
Attic Kneetball.Rl 3, * ,,,is. <r;_._. :_$0.91 ._, .r.,
Attic Kneewall Floor R30 rest.
Finished Attic Access'" I $84.00 ..: $84.00 xz ri r g
Temporary Attic Access - .u, .;; -_,$62.00
Crawl Space w/Poly Vapor Barrier
Garage Ceiling/Floor R30(with approval) '- „ $1.21 i
rRoof
ryer'/Bath Fanr, ',. I U"-'- $70,00 �:$70.00
adome $152,00
en[small '_ $66.00e Vent."7°^.'r - $138.00 -
12"Stack Vent & - i_$126.00 S° si2".m
Propa Vent $3.25 <--
Gable Vent(all sizes)5. r. .;,yr -" - " $76.00
Soffit Vent 10 . "i$23,00 ".$23000,� 'a-
. .,, .:,.
Attic Air Sealing 2 part foam(2 firs max)'" :2 #" -, $60.00 i','$720 00
-"Robert Butters 4Page 2 ' National i3 112010 -- ss .. . ;x • ,
-Est . ..Act Cost w Est Cost Act Cost
SVall Insulation
Single Nailed Asbestos/Asp haltDP
Double Nailed Asbestos/Aluminum DP - $I52 . ' 9 .--" -
Brick/Stucco DP ^`a
Interior Wall Blow-Plaster DP $1.40
Clapboard/Wood Shingle LVmyl DP °' 1678 n. $139 -- $2 332.42'"' _
Test Drill 4 sides - - $53.00 - .^:x•+ a_ ,
Air Sealine Limit.
-
SingleFamilyw/Blower Door=$400 =
.All Others=$200
Door Kit 2 $37.00 $74 00 ...,,N .-
DoorSwee 2 - _ $12.25 -; $24.50-
Automatic Door Swee ','.119.25 i "+ • t,:.a r.,,, <:
Air Sealing.(3 hours max):.. M. +3 $165.00
Sash Lock $7.75
Glass Replacement
Blower Door Setup I $45.00 $45.00-- - -
Total Air Sealing Cost: .-- •"+g n_ -
Heatin System Measures ... .. - . ,.
Duct Insulation&Seal Seams(s ft) $2.22
Hydronic Pipe Insulation to l"-R5 60 - -412.89 3+ .„, $17340 c rP-a t2?_ : _
Hydronic Pipe Insulation 1.25"+R5 -` - $3.33
Steam Pipe Insulation 1.5"to 2.5"R5. " s $4.68 •' ''" -• . r 'r',.
Steam Pi eInsulation 2.5"+R5 Boiler/FurnaceRe lacement,
$I.00
a,+Program Repair <"�"' :, r
" Action approval needed:Max$500.00
y�m Actual Total does.i.�nggot include$125 00 K 8 T chgS4,075.44 i Est Total
o^
r s c
SO.00 Act Tota
l I
- Z AUDITOR`Br'andon Dorrington
K
rw j
ACTION, INC
47 Washington Street
Gloucester, MA 01930 +
-139
t ry A
h
E "
"
'Agency NSCAP NGRID Application#
PROGRAM-
JOB p "
JOB NUMBER. 0 ;x
DOE Work Order# " ,,0 E.S.C.performed? No ,.•
..Work Order Date: 01/25/10
Primary Contractor: All Season Windows and Insulation
Other Contractor Manchester Electric, LLC w r #Bulbs installed ,. o 00 _
- CostofBulbs DSO cic, li
',Client: Robert Butters
nspt$125.00 Max $0.00
Street, 4 Lincoln Road Other In Kind oo.
a City State; Zip: Salem, Ma ;;w 01971 Electrical Work
r
+,,Telephone: 978-745-1767 Amount KeySpan 't`o0 b0
Amount National Grid $0.00`
..Blower Door Test Yes other utility co +u
Inspect Knob'&Tube. Yes r 8
Date Job Completed. 01/00/00^ Estimated Repair Total $0.00
.Actual Repair Total $0.00
Weatherization" Est �>Act - Cost Est Cost Act Cost
D00 t - $37.00� s lr, sdx;
Door Swee
$12 25 c
AutomaticDoorSwee __ - $19.25
Air Sealin er hour 2 = $55.00 $110.00 a
Attic Air Sealin 2- art foam(per hour 2 $60.00 $120.00 aW? e
Weatherstri Window er side 6 $4.25
Seal Ducts:"Mastic N ss $54.00
zt
$0.00 "0
.. _ $0.00
$0.00
$0.00 s€ L' ,
$0.00 vie':: w "
7-
$0.00 z €
$0.00
Weatherization Totals: $230.00,x $0 00
Insulation. Est ' Act " Cost Est Cost =Act Cost
Attic Flat R38 open _ $1.12 ta.
Attic Flat R30 open n' $1.05 = F, '
Attic Flat/Slo'esR30 restricted- $1.14 Y'
Attic Flat/Slo es R20 restricted $1.08
Attic Kneewal R13 FG<i T' " $1.05 c-JM'f to dr rr
Attic KWaII:R13 Cell w/Membrane $1.3359
i s,. p atzk
Attic Kneewall Floor R30 rest.
$1.14
Kneewall Floor R30 $1.14
Sidewalls'-Vin I R13 DP $1.39
Interior Wall R13-'Plaster R13 DP $1.40
Test Drill Sidewalls 14 sides $53.00
Duct Insulation R5 R Seal Seams :°. $2.22 t
H dronic Pie Insul to P'.R5 $2.89
Stearn PipeInsul to 1.25"R5 $4.68
DHW Pipe Insuation R5 '. 6 $2.05 $12.30
Insulate Door 1 $36.50 _*$36.50
Insulation Totals. $48.80 r $0 00 '"
- j Robert 6utters Page 2 DOE. " _; 0
Other Measures Est '^ €Act •.r: Cost Est Cost Act Cost
Roof Vent-small $66 00 =
Gable Vent $76.00 = -
Vinyl Replacement Window-73 ui 1 $312.00 $312.00 =
Vinyl Re lacement Window--83.ui 2 $327.00 $654.00
Vinyl Re lacement Window-93 ui 18 $338.00 : $6,084.00
Vinyl Replacement Window-101 ui $353.00
Vinyl Re I. Bsm't Hopper Window $200.00 S
Steel Pre-Hun Door $490.00 -
Solid Core Door w/Hardware $330.00
Faucet Aerator $15.00
Low Flow Showerhead $25.00 f..
Blower Door Test $45.00
$0.00
$0.00
Other Totals' -L $7,050.00°' $0 00
Energy Conservation- s s. : ; Est Cost Act Cost
Totals
:-(Max$10,000.00) x $7,328.80
i0qr
Repairs Est Act Cost Est Cost - Act Cost
Repair/Refit Door $37.75
Adjust Door Striker Plate '$20.00
Door Threshold-_ - $33.00 ,+
Repair Door Hine $25.00
Slide Bolt $20.00
Sash Lock
Glass Replacement to 64 ui - - $36 50ss5
$0.00
$0.00 €
rHealthE&Safet . s x .. ;
VentClothes Drver to Exterior = "' $70 00 w Vent Bath Exhaust Fan to Exterior; $70.00
Replace Dry
er Hose $32.00_.
$0.00
$0.00
$0.00
Repair Tot: Max$2500 00 »
z
411
Work Order Sub Total $7,328 80 $0 00 =.
{
Measures "- =., = Est , Act I Cost I I Est Cost I I Act cost
Other $0.00
-
Other $0.00
- **Heatidg System Repair $0.00 t ( $0.00
Action approval only I",`` <„2` - -
fi _ z'
Estimated Job Total: $7 328 80
Job cannot exceed$10,000.00
'Job minimum = $200.00 - Job Grand Total: $0.00
i _ AUDITOR, Brandon Dorrington