9 1-2 MEADOW ST - BUILDING INSPECTION The Comth'onweRth of Massachusetts CITY
fll Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code,780 CMR,7 h edition Revised January
L�J Building Permit Application To Construct,Repair,Renovate Or Demolish a I,2008
_ One-or Two-Family Dwelling
This Section For Official Use:Only
Building Permit N her, - - PP
DateA lied:
Signature:
-Building. mmissioned Inspector of Buildings -Date
SECTION 1:SITE INFORMATION
1.1 1.2 Assessors Map&Parcel Numbers
`�•� J"s J
1.1a 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
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2:.PROPERTY OWNERSHIP'
2.1 wne lofRe� \`\O
VOM�� v`
Name(Print Address for Service:
-r 7 i Telephone
l - SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repaits(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number ofUnitS I Other ❑ Specify:
Brief Description of Proposed Work :
����"`���
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials - - - -
1.Building 1. Building Permit Fee $ Indicate how fee is determined:
.❑Standard Cityaown Application Fee - - -
2.Electrical $ _❑Total Project Costa(Item 6)-x multiplier
3.Plumbing $ 2. Other Fees:. $ '
4.Mechanical (HVAC) S List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. .,Check Amount Cash Amount:
6.Total Project Cost: $ �'t ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(C'SL) VDk%I lzlly
License Number Expiration Date
Name of CSL-Holder V C
\� \� Jc�.�iS List CSL Type(see below)
ch\ ti Q�
� � � Type - Description
Address U Unrestricted(up to 35,000 Co.Ft.
R Restricted 1&2 Family Dwelling
Siqu._.
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Telephone
SECTION 6:WORKERS'C MPENSATION 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 ..........Elm No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN -OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, \._ \�G��\ 1°ViJV �� , as Owner of the subject property hereby
authorize \N�\ s �7L�ch, to act on my behalf, in all matters
relative to work authorized by this building permit applica on.
_ D
'Si of Owner I I Date f
SECTION 7b::OWNER'OR AUTHORIZED-AGENT DECLARATION
�\j ,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.
Print Name
i �atuie Owner or Authorized Agent . Date
S, e under the sins and nalties of
NOTES: 10,
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 I IO.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"may be substituted for"Total Project Cost"
_F The Commonwealth of Massachusetts
j� =_ ' Department of Industrial Accidents
office effnyesdoo mans
_ 600 Washington Street, 7` Floor
Boston,Mass. 02111
Workers Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant information• \ Please PRINT leeibly - _ -
name'
address'
city :tz� U PS state' \ ��t� zip'%N \, nhone#
work site location(full address)' '
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
[91 am an employer providing workers'compensation for my employees working on this job.
company name, �QY�Y\Q..:C' et,�`CN�`�
address' �% "�'\\�"`�
city phone#:
insuraneeco e '����V a��rSyr �1�s'i�� policv#
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
com an name:
address:
city nhone 9-
insurance co policv#
company name-
address:
city phone#• -
insurance co Policy# _
Attach additional sheet if necessary - - -
Failure to secure coverage as required under Section 25A of 111GL 152 can lead to the imposition of criminal penalties of fine op to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form or a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DtA for coverage verification.
I do hereby certify ulftr the pains and penalties ofperjury that rite information provided above is owe and correct
°e 6, Dal
Si atu
Print name �5����\��� \��-`�'� , \C Phone It
official use only do not write in this area to be completed by city or town official _
city or town- permidlicense# ❑Building Department
❑Licensing Board
check if response is required
❑Selectmen's Office
[]Health
❑
I
He P
al[h Department
contact person: phone#; ❑Other
(revised Sep,2M.3)
1
.�anuleglu�uu,) -
rzsoo l :hU>•
ZIOZ/S/S :uollPndx3 ��i�
906LO VW 'SnE)nvS
- 1332i1S A3IIV8 SL
SIONVI34 WVIIIIA&
SM'd21 :01 Paloulsaa
tz11001 IS SD :asuawl -
asuac)Ml R11emadg 1osSniadng uoll0niisuo0 p
sparpmq$ Pur. suwlt In as =Iuippng .{o Pacug 7�
�1a.11'$ �lland.l°.ltntul.trdid -�Ilxny�rssr.11
g,it.is ant? fan at `License or registration valid for iniliJidul use only
_ HOME IMPROVEMENT CONTRACTOR - - before the expiration date. If found returaro:
t' Registration. Standards .
Expirano n. II Board of Building Regulations and Standd -
NN - ar .
- .,1j/25/2010 Tr# 276810- t> One Ashburton Place Rm 1301
1/25/2 t
TYPe:. DBA
Boston, Ma.02108
- - -
AMERICAN DOOR WINDOW& INSULATION
. WILLIAM DeLANGIS- _ f tt —JC/{ .
15 BAILEY AVE _i ,,� ,,,yyo•„-`- �1. - 44ot% 'v TSAUGUS MA 01906 ,ldminictrafor_ valid.withmrt signature '-
iiasachusetG - Dcparinwilt of Public 1�:dctc
�. Board of Buildin_ Rc_ulatiuns 1In11 Standard.
Construction Supervisor Specialty Lescense
License: CS SL 100824
Restricted to: RF.WS
WILLIAM DELANGIS
15 BAILEY STREET
SAUGUS, MA 01906 Ogg
Expiration: 5152012
( nnmi..i.nar Tr=: 100824
Bt ri�ol-tiui�rfin rf r�rilsiio antl�ian ill S
- n HOME IMPROVEMENT CONTRACTOR
iz i RI
Registration: 111123
�?��✓ Expiration: 11,25/2010 Trk 276810
Type: DBA
AMERICAN DOOR WINDOW&INSULATION
WILLIAM DeLANGIS
15 BAILEY AVE ,a.,<�-�..--`
SAUGUS.KA%01906 Administrator
l 07/26/2010 03:08 17815955820 AMBROSE INSURANCE PAGE 01/08
+' DATE(MMIDDNYYY)
,F, CERTIFICATE OF LIABILITY INSURANCE IS IssuEO AS A MATTER OF INFORMATION
INIS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
RDDDDE
Ambrose Insurance Agency, xnc. HOLDER.FIEICOVERAGE AFFORDED BY DOES TTHE POLICIES BELOW,
56 Central Ave.
Lynn, MA 01901 INSURERS AFFORDING COVERAGE NAIL#
781-592-8200 msuReRn Providence Mutual
NSURED Delangis, William
American Door, Window & Insulation INSURERS: be la rotectFir
INSURERC: National Union Fire
15 Bailey Ave.
INSURER 0:
Saugus, MA 01906 Hartford Insurance
INSURER E:
COVERAGES
THE ANY EQUIIES OF INSURANCE
E LISTED
TECONDIBEL OF ANY CONTRACT OR OT14ER SDOCUMEENNTT WITH RESPECT TO WHICH THIS CERTIFICATE MAY DAS E FOR THE POLICY prMOO INDICATED-NOTWITHSTANDING
EISSUEDDOR
MAY PERTAIN.THE INTERMSURANCE 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.POu EFFECT F EXPIRATION LIMITS
ILTR 8RP pOLICY NVMBER D EACH OCCURRENCES 1 000,00-0
GENERAL LIABILITYI
P EMISES'Stu- MA $ 50 000
g COMMERCIALGENERAL LIABILITY MEDEXP(AMy W6P"-) $ 5 000
_ CWMSMAOE FR OCCUR _
A cPP0055334 5/28/10 5/28/11 E"s Acc EGATE $ 2 0 0 000
PRODUCTS-COMPloPA00 S 2_,000 OOO
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY1:1 P LOC
AUTOMOBILELNBILITV COMBME081NGLELIMIT S 11000,000
ANYAUTO
ALLOWNEDAUTOS SODILYINJURY g
(PUPer�on)
SCHEOULEDAUTOS
B HIRED AUTOS 47635400001 8/17/09 8/17/10 B0D14YINJURY $
(Pernddwt)
NON-OWNEDAUTOS
(P DclwA) g DAMAGE
AUTO ONLY-EA ACCIDENT $
GARAGELIABILm EAACC S
ANYAUTO OTHERTHAN
AlPI00NLr: AGO $
EACH OCCURRENCE S 1 0OO 00O
EXCESSIUMBRELLA LIABILITY
R OCCUR CLAIMSMADE AGGREGATE $ 1 000 O00
EauO16859770 6115110 5/28/11 $$
C DEDUCTIBLE
RETENTION $ WRY An TH-
WORRERSCOMPENSAnONANO R
EA-
EMPLOYERS'LMSIL17Y E.L EACH ACCIOENT -S-5 0�0 O00
ANY PRDPRIeraR?MDN�NE
D DFFIGEIVM6N ""LUDEDr 4144P72 2/11/10 2/11/11 E.L.DISEASE-FJIEMPLovE a 500 00
Ifyea,deAalhoeMer E.L.DISEASE-POLICY LIMIT 9 5 0 000
SPECIAL PROVISION8 hA
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS NEHICLES/EXCLUSION6 ADDED 9Y ENDORSEMENT I SPECIAL PROVISIONS
carpentry &Insulation
National Grid Corporate Services, LLC d/b/a National Grid, d/b/a Boston Gas Co
d/b/a Essex Gas Co. , and Action, Inc. as additional insureds general liability
only
CERTIFICATE MOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF SALEM DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL, DAYS wRfTfEN
SALEM MA NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILVRE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR ILRY OF ANY MIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTA
ACORD25(2001108) ®ACORD CORPORATION 1988