6 LOONEY AVE - BUILDING INSPECTION $qz e198' 2
o
The Commonwealth of Massachusetts INS PECTIOrNAL ERIyILF
°rin Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SAL M
1114 ((;; SS eviq r 2011
Building Permit Application To Construct,Repair, Renovate Or Demo is?' ' 5 '
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
B zy )
Building Official(Print Name) Signature D to
SECTION 1:SITE INFORMATION
1.1 P5 ope Address: 1.2 Assessors Map&Parcel Numbers
L 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
l.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: PROP T OWNERSHIP'
2.1 Qwnert of Record-
N (P 'nt) City,Sui ZIP
d Street Telephone Email Address
S CTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building d I Owner-Occupied ❑ Repairs(s) ❑,1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units L Other Specify:
Brief Description of Proposed Work : 13� _ 1" tar S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standazd City/I own Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
i 6. Total Project Cost: $ ��O Check No. Check Amount: Cash Amount:
to ❑Paid in Full ❑Outstanding Balance Due:
—NUJ q--b CoIJT• sb'�Zg
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�� \J License Number Expimtton Date
Name of CSL Holder
List CSL Type(see below)
�1d Str e�t �~ Type Description
No.an -
\ r Unrestricted(Buildings u to 35,000 cu.ft.
t-' R Restricted 1&2 Family Dwelling
Ci own,State,!!,� M Masonry
RC Roofin Coverin
WS Window and Siding
GO SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 kc% �RA , r
rt t- ^ ,/� HIC Registration Number Expiration Date
HIC Cont y Name HIC Registrant Name
No.and Street I� Email address
�SaJ�!\,. W\\1 �i\%A �1�nM-,AS4A
City/Town, StaQ 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 suWeFtrr, erty,hereby authorize
to o m eZlfn Il 'attemrelative to work authorized by this tilding permit application.
ll
lPt Owner's Na e(Ele Ironic Signature) Da&, III
SECTION 7b:OWNER'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.
P t wner's or Authorized Agent's Name(Electronic Signature) Dar
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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned,provide the information below:
Total floor 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"may be substituted for"Total Project Cost"
Work Order
North Shore Community Action Programs,Inc. Job Number: 100703
- 119 Rear Foster Street,Building 13 Work Order Date:8/12/2014
Peabody,MA 01960 Ownership: Renter
Phone: 978-531-0767
Air-Tight Weatherization Auditor:Brandon Dorrington
9 Story Avenue Email: bdorrington@nscap.org
Beverly MA 01915 Cell: 781;540-8569
Email: airtigbtlle@gmail.com Phone: 978-531-0767 x121
Phone:978-998-4684
Yndira Victoria NGRID Electric $6,530.64
6 Looney Ave Total $6,530.64
_Apt:-
Salem MA 01970
978-979-8421
Contact Phone: 978-979-8421
Landlord Name:Amavris Dobre
Landlord Phone:978-902-9893
Safety Issue(s):Lead Paint Possible
Authorized' Actual -
Measure Description P Comments
^., > Qty Price -:Total ,.Qty Total
Attic Insulation - ...
R-38 unrestricted-settled cellulose 1208 $1.65 $1,993.20 1208 $1,993.20
Basement insulation
Sill two-part foam w/fiberglass batt 40 $2.46 $98.40 40 $98.40
Health&Safety
Clothes dryer vent including 1 $100.00 $100.00 1 $100.00
Exhaust Duct
Vent kit/bath fan 1 $100.00 $100.00 1 $100.00
Mise Insulation
Domestic water pipe wrap 6 $2.95 $17.70 6 $17.70
r ;Mise:Measures .
50 CFM bath fan(replace existing) 1 1 $575.00 $575.00 1 $575.00 80 cfm standard
Date: 8/12/2014 Page I
Work Order: Job Number: 100703
Attic scaling with two-part foam 3 $84.00 $252.00 3 $252.00
Basement scaling with two-part 1.5 $84.00 $126.00 1.5 $126.00
foam
Block/Dam/Baffle soffit areas DO 2 $67.00 $134.00 2 $134.00
NOT BLOCK ALL
Blower door set-up with pre&post 1 $45.00 $45.00 / $45.00
tests
Build and finish hatch 1 $60.00 $60.00 1 $60.00
Downspout 10 $4.84 $48.40 10 $48.40
Recessed Light Enclosure 6 $33.00 $198.00 6 $198.00
Seal ducts with mastic or butyl 2 $73.00 $146.00 2 $146.00
backed tape
Weatherstrip(Q-Ion or equal)attic 1 $35.00 $35.00 1 $35.00
hatch
Permit
Building Permit 1 $100.00 $100.00 1 1 $100.00
Wall Insulation ,
Double nailed asbestos/aluminum 966 $2.59 $2,501.94 966 $2,501.94
(dense pack)
Total $6,530.64 $6,530.64
Contractor Instructions:
Before Starting the Job: Duringthe e Job:
1.Please notify us 24 hours before starting or scheduling ajob. 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 12111,11,
3.Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form WH-347.
Date: 8/12/2014 Page 2
Work Order: Job Number: 100703
Additional Contractor Instructions:
Attic Inspection form attached? Yes N/A (Circle One)
Certificate of Insulation posted? Yes No (Circle One)
Air-Tight Weatherization hereby certifies that this job was supervised and completed in compliance with all Department of
Labor Standards and Lead RRP regulations.
Contractor Signature: Date: RRP License#:
I hereby acknowlege that all work has been completed and inspected.
Customer Signature: Date:
Energy Director: Date: Fiscal Officer: Date:
FOR AGENCY USE ONLY
Pre Post Language Other than English needed? Yes No (Circle One)
Dryer CO 0.000 - If Yes,indicate language:
Stove CO 0.000 Occupany change in last 18 months? Yes No (Circle One)
H2O Tank CO 0.000 Comments:
Heating System CO 1.000 Number of windows
Ambient CO 0.000 Number of rooms
Blower Door 0.00
Date: 8/12/2014 Page 3
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office oflnvestigations
I Congress Street, Suite 100
Boston,MA 02114-2017
Ulf www mass.gov/dia
Workers'Compensation Insurance Affidavit: General Businesses
Applicant Information \ Please Print Legibly
Business/Organization Name: t \,� Vk C,;,VA— '��
Address:
City/State/Zip: �,\� ` ��\ Phone#:
Are you an employer? Check the appropriate box: Business Type(required):
'I.8( I am a employer with� employees (full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl,real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] S. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑Health Care4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 12.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organisation should check box#1.
I am an employer that is providing workers'camp nsation insurance far my employees. Below is the policy information.
Insurance Company Name: � t y 1 �n� L0
Insurer's Address:
City/State/Zip: � S
Policy#or Self-ins.Lie.# 0TU- 5-7(a LLSD Expiration Date:
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.
I do hereby certify, under thee pains and penalties of perjury that the information provided above is true and correct.
Signature: �1� 3 r�rDate:
Phone#' �3Q ��(C L�Co�:-4
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): 1 ,
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
eaNt
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165640
Type: LLC
1- Expiration: 3/15/2016 Tr# 248557
AIR - TIGHT LLC. WEATHERAZATION
JAMES FORTIN
10 PINE KNOLL DR.
BEVERLY, MA 01915
Update Address and return card.Mark reason for change.
sCAn 4� 20M.05n1 ❑ Address ❑ Renewal ❑ Employment ❑ Lost Card
Off,ce ofconsumer Affairs&Business Regulation License or registration valid for individul use only
q,�IOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
ogistration 165640 Type: Office of Consumer Affairs and Business Regulation
Expiration 3115/2016' LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
AIR-TIGHT LLC.WEATHERAZATION
10 PINE KNOLL DR
BEVERLY, MA 01915 Undersecretary Not va id without signature
1 Ntassacbu ett-. - Deportnaent or PubJc Snfety
M- Board of Building Regulotions nf o st +ndar0
iu
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(nntu uClion StrlR IN I%IPI 4 y fi=
Lice nFi : Cs-052576 ��
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JAMk:S E FORT IN-
it)PINLKNOLL DR -.
Beverly MA 01915
10/0312o15
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