Loading...
10,12 PARK ST - BUILDING INSPECTION • ��iJ C�5�3$blS The Commonwealth of Massachusetts Board of Building Regulations and Standards PEC I� grS WMassachusetts State Building Code, 780 CMR INSPECTIORAL 5�ABIENP`' Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or De P 1: 12 ltx�t One-or Two-Family Dwellings� � 2 (v 1 This Section For Official U4q Only - Building Permit Number: - Date App ed: . Building Official(Print Name) Signature V at31 e SECTION 1:SITE INFORMATION 1.1 Pro erty Add ess:pxS1 1.2 Assessors Map&Parcel Numbers 1_Q � 12 � f1 I.1 a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' r 2.1 Owner'of Record: - Fjazg , th �jvzar't ;aH / , 014�U NY a(Print) City,$tate,ZIP is gfkls�. -_ I- y�s� No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brire�f,D�es�cripytiq�nof Proposed Workk2: 44Z e5 x SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: - Item Labor and Materials F fticla)Us Only 1.Building 1. Building Permit Foe; Ia catc how fee is determined; 2.Electrical $ ❑Standard City/Town A tee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List - 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 O ❑Paid in Full ❑Outstanding Balance Due: I SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1'j 08.7[{ License Number Expiration Date Name of CSL Holder L/( List CSL Type(see below) No)artd s/�tr� Oet /A ' ls Type Description 1.,.5 17th i �F�/ ry dl U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted l&2 Family Dwelling Cityfrown,State,ZIP /y M Masonry tic,, /447 /1/%�� RC Roofing Covering_ WS Window and Siding SF Solid Fuel Burning Appliances ,Z1/-0Z2 t/4/ Insulation Telephone Email address D Demolition 55..12 Registered'�Home Imprrovement Contractor(HIC) Nt�Aatti.[_�'M /f.Fen! ^I li�,4;4ej ul HIC Registration Number Expiration Date TBC Com anm a or HIC Registrant Name /S �u_ ,/N.t Ve No and Street Email address �S4d9t/S 3/-0,2yy 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 ,I 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 to act on my behalf,in all matters relative to work authorized by this building permit application. g,2-4-4e� n2�rrlaN /oZ / /5 �t Owner's Name(Electronic S ature) Date SECTION 7b;OWNERt 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. Print Owner's or Authorized Ag is 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 »vw.mass.gov(oca Information on the Construction Supervisor License can be found at v\nvw.mass."ov/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" QTY OF SALEM, MASSACHUSETTS jK s. 1F� BUILDING DEPARTMENT ;t 120 WASHINGTON STREET,31D FLOOR TEL. (978)745-9595 F KIMBERLEY DRIS�LI. FAX(978)740.9846 MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUIMING WAMSSIONER 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 c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: 1//GP I' b t- (name of hauler) The debris will be disposed of in: Alahe o� �ti ,s Joh (name of facility) (address of facility) /Signature 'oapplicant i2 /iljg Date The Commonwealth of Massachusetts Wrkers' Compensation Department oflndustrialAecidents I Congress Street, Suite 100 Boston, ma 0govldi 017 www.mass.gov/dia Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information //�� Please Print Legibly Name (Business/Organization/Individual):� �f / _ Address: Chi .t7 saD City/State/Zip: 1q01 Phone#: ;W1-A11-(2J-q1 Are you an employer?Check t appropriate box: Type of project(required): l.�am a employer with employees(full and/or part-time).- 7. ❑New construction 2.F1 I am a sole proprietor or partnership and have no employees working forme in 8. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'camp.insurance required.]t 10 E]Building addition 4.F-1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical Iepairs or additions proprietors with no employees. 12.F-1 Plumbing repairs or additions 5.F-1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet ]3.E]Roof repaii5 These sub-contractors have employees and have workers'comp.insurance.= 6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other/0 f)IO IldW 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 11 *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ,1 Insurance Company Name: ,f,l/I) .xr1 eA Policy#or Self-ins.Lic.#:yiyl(�E Expiration Date: Job Site Address: e�`�//64 City/State/Zips40,AV Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify,under the pains and penalties ofperjury that the information provided above is true and correct. 4 mtature' i t t l Date: fol/%//,J Phone#: 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.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions'- Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Massachusetts -Department of Public Safety Board of Building Regulations and Standards C'ons"Uu ion super icor specialfc t License: CSSL-100824 WILLIAM J DEL*NG1S,.. .,. 15 BAII.EY STREET - SAUGUS MA 01406 wraticn Commissioner 05/0512016 -Office or Consumer Affairs&Business Regulation ObME IMPROVEMENT CONTRACTOR . .registration: 111123 Type. ! -Expiration: 11125/2016 DBA' AMERICAN DOOR WINDOW B.INSULATION WILLIAM DeLANGIS 15 BAILEY AVE SAUGUS, MA 01906 -- --z�-- Undersecretary 06/24/2015 22:15 7813970115 PRESCOTT AND SON PAGE 01 PRODUCER CERTIFICATE OF LIABILITY INSURANCE !25/2015 �1 r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Ambrose Insurance Agency, Inc. HOLD-F THIS CERTIFICATE DOES NOT AMEND, EXTENDIOR 5fi Central Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lynn, MA 01901 ' MAIC# 781-542-8200 INSURERS AFFORDING COVERAGE INSURED Delangis, William INSURE0.A Northland American Door, Wirgdow 6 Tnsulation INSURERS' Arbella Pre action 15 Bailey Ave. NsuRERc: ibert Mutua Saugus, MA 01906 INSURER 0 ---T---� INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NO TWIT ANY REQUIREMENT;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 CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -- POLI Y EFF ' POLI ATI N LIMITS A t POLICY NUMBSR DAT MM /YY DAT Mm M' LTn 'NSM rCCLIRR' OCCURRENCE $ 1 OD OOO GENERAL LIABILITY $ 50 000 COMMERCIAL GENERAL LIABILITY ISES Eao VOVIca ' x XP(AnyPnaP•�Faro $ 5 000 CLAIMS MADE OCCUR Binder 6/24/15 6/24/16 ONALaAnwNJuav $ 1 000 000 A j RAL AGGREGATE $ OOO GOOUCTS-COMP/OP AGO $ 000 000i CEN'L AGGREGATE LIMITAPPLIES PER, POLICY JECLOC INED SINGLE LIMIT $ 1 00'0 000AUTOMOBILELIABILITY cdanUANYAVTOLY WJURY $ALLOWNEDAUTOS arsonli X SCHEDULED AUTOS HIRED AUTOS 1020020026 14/4/15 9/4/16 oeiwt) g eCidenqNON OWNEOAUTOS PERTY DAMAGE I g Idw') AUTO ONLY,EA ACCIDENT S GARAGE LIABILITY I EAACC S OTHERTHAN !I ANYAUTO AUTOONLY: AGG S EACH OCCURRENCE $ I EXCESSIUMBRELIA LIABILITY AGGREGATE $ -`I OCCUR �I CLAIMSMAOE 1 I W S DEDUCTIBLE $ RETENTION 5 W y g U X R j WORKERSCOMPEN5ATIONANO $ SOO OOO 1 EMPLOYERS'WMAILMY El EACH ACCIDENT Nr PaoPRICTJR/I+AMTWEFIEXEG1Ir•Yf 6/20/15 6/20/16 E DISEASE-EA EMPLOYE S 500 OOO C. 06PICEaM MBER EXGLVOBPT Binder E.L.DISEASE.POLICY LIMIT $ rInD DOD uy s W IWw.eer SPECIAL PROVISIONS haloes OTHER S ADDED BY ENDORSEMENT!SPEGWI PROVISIONS GESCRIPTION OF OPERATIONS,LOCATIONS,VEHICLES I EACLVSION Carpentry 4 Insulation National Grid Corporate Services, LLC d/b/a National Grid, d/b/a Boston as o d/b/a Essex Gas CO. , and Action, Inc. are listed as additional insureds. general liability only- CANCELLATIDN CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXP RATION , ARCD DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR To MAIL_-- DAYS WRRTEN 178 Tremont S t. NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL Boston, MA 02111 IMPOSE NO OBLIGATION OR LIABILITY Of ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVE AUTHORIZED B E -w-96rIIII, v ACORD CORPORATION 1988 ACOR026(2009108) ej 0 p.2 Work Order North Shore Con.munity Action Programs,.Inc. Sub Number. 100077 119 Rear Foster h4reet,Building 13 Work Order Date: 81172015 Peabody, MA 01960 Ownership:Renter Phone:976-531.1767 American Door,%Yindow,dt Insulation Auditor:Brandon Dorrington 15 BaRey Avenue Email:hdorringtoa©nscap.org Saugm%MA OPIOt Cell:781-5404569 Email: wdelongis(aloomcast.net Phone:978-531-0767 x121 Phone:781-2314:%4 Ana Pena NGB1D Gas '&4,447.38 10 Park S1 Total $4,497.38 Apt.2 Salem MA 019''D L9711-744-7243 � aadlorddlord Namr: Elizabeth Boratjiao //1' Landlord Phone:1,78-7413046 Safety lasuc{s): Knot&Tube Wiring/Lead Paint Possible 9tI ,C 4N.i..r.r?f:+ - �`:4�r...� 'c��ri.>•;�,.:4.w. nl A g r01. i..`-. tiS R4 u r e l ' needed no access �It 9 unrestricted eel. 209( 1 $2 176.20 72D4 17620 adjust as Tle $ .8U 62, 7 ' Recta ngolarsoffit vent ' 4 $30.00 3.120.00 4 $120.0411 view notes A a DIM ftY Fixed Sweep 2 $17.64 535.26 2 53528 Weatherstrip sl"n or equal 2 651.00 6102.00 2 $702.00 " ;. ' y I' Vent kiVbath fua 1 6100.00 5100.00 1 6100.00 4 check if more on other units Attielbssemenl sealing with tw:>• 6 684.10 $504.00 6 63.14.11 4'headroom partfoem Dale. 6/!7/2015 Page 1 0 p.1 Work Order: Job Number: 100077 Cut/closeatMe-kneewallae:ess 1 388.00 $88.00 1 588.00 main flat . b'e� i....y y _ ,. �7 'R4. s� JFK,. '��.„�� 1.�:.�xxn�i�` w_.. �,. ._ wi.�i5•� `� € ��� .•y+� r . .iL�' rsdr�i.i;.. ��6�SJP�':o-"i#'°2. 'ai.{:x��rJv..�.... °+I? �.. i �•: ��1:. N'-'�'t.' Building Permit 1 5100.00 5100.00 1 5100.00 �:K$)' `�,���b 't£i:Yt�wk�.v.V_4.r�7F.Ti 3I%n•'�4j1�'"+�i'�LLu2�t 1: �. �.rS.�'e:/5i:�=,. ��A"yy ?,r�wt5.,'.i Drill finish patch plaster(del,se 230 5213 $489.90 230 5489.90 pack) Wood clapboard/shakeVsItiu;+s or 391 $2.00 $782.011 391 5982.00 vinyl(dense pack) Total 54,497.38 $0.497.38 Contractor Instructions: Uefnre 4rarting the lob: During the 1nh: I.Plcase notify im 24 hours befrre starting or scheduling a job. 1.This residence was built before 1978. Lead safe n�ractices am 2.Obtain required building ponrit. regnired. 2.Total for Beath&Salary and Repairs camtot exceed$_500.00. S. Davis Bacon briar sheets required for ARRA work on US Department of Labor Certified Payroll Report Form Wf6347. Additional Contractor lastroctions: ttic Inspection form ante R?-Yee NIA (Circe e Certscatc of Insulation posted'.' Yes No (Circle One) American Door,Window,&In::ulttion hereby certifies that this 13 was supervised and completed in compliance with all Department of Labor Standatds and Lead RRP regulations. Contractor Signature: Date: RRP License M- 1 herehy acknowlege that all wnrl has been compleUd and inspected. Customer Signature:,___ bate: 811712015 Pagc 2 0 p.4 Work Order North Shore Comaennitq Action Programs.IOc. Job Number: IOOJ76Work Order Dale!0117/2015 119 Rear poster Strep,Building 13 ownership:]tooter Peabody,MA 019611 Phone:978-531-0767 Auditor'.Brandon Dorrington American Door,Window,&Insulation Email,Ddorring[oo@nscap.org 15 Bailey Avenue Ccn:781-540-8569 Sougus NIA.01906 Phoae:978-531-0767 x121 Email:wdelangU@co+ncascnet Phout:781-231-02414 NGRID Gas44'232'56 Paacualo Morel Total '54,232.56 12 Park St Apt. 1 Salem MA 01970 978-744-5485 Contact Phone:978-230-9294 Landlord Name: Elbr.,beth Bozarjian Landlord Phone:978 741-3046 Safety lssut(s):SGnob&"Vibe Wiring/Lead Paint Possible ft� . ( ..0. r 4 tti.t°S. •. ..1 j783.80 adjust as needed no access 417783.80T91 $l, -09 unrestricted,-uttkdceIlol,�se 991 81 80 �-5 R 526.00 Automatic Sweep 1 $76.00 -526.00 1 Fixed Sweep 1 S17.64 $27.64 1 577.64 $57.00 Thermax(or equivalent)op door 1 $57.00 557.01) 1 Weatherstrip$IQ-Lon or equal 2 551-00 $102.00 2 4102.00 R a+' ,y. Nom[ C IOSLes dryer vent including 1 $100.110 5100.00 1 5100.00 - Exbaust Duct •Y Drill finish patch pinsttr(de a 324 52.13 5690.12 5690.12 pack) 00 51.456.00 728 $1,456.00 Woodelapboardlshakeslshit or 728 $2. vinyl(deme pack) Page 1 I __ 0 p.3 Work Order: Job Number: 100176 Total $4,232.Sb 54,232. 66 Contractor Instructions: Refnre Sta tins the 7oht During he lob: 1. Please notify us 24 hours before darting or scheduling a job. 1.This residtmcc was built before 1978.'e-*J a fP pfd =are 2.Obtain required building permit. required. 2.'total for Heath&Safety and Repairs cannot exceed$2500.00. 3. Davis flacon time sheets reowred for ARRA work on US Department of Labor Certified Payroll Repurr Norm WI-1-347. Additichal Coulractor Instructions: Attic Inspection form attac hed'! es N irc ne Certificate of 11130121500 posted" Yes No (Circle Onej American Door,Window,&)nsnlstiou hereby certifies that this job was supervised and completed in compliance with al I nr�.�.r��+.nr of Y ahnr Rt„n�lxrrl.an,l Lead RRP fe£L1nIl00S. Contractor Sigoatan- _ Dnte: RRP License k: I hereby acknowlege that all work:as lxen complcttd and inspected. Customer Signature: Date: Energy Direcwr.__ pan• Fiscal OtTiter: �Datc: Page 2 darn un Tnuts