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138 HIGHLAND AVE - BUILDING INSPECTION _ 7 I lie C'onunonss'calfh uf'NLui;lrllusclts r a Board of Building Regulations and Sl;uiJards Cl VY OF s?ti,.1r "Ltssarhusctts SIMI:Building Cudc,'790 CNIR S.\LI:\I Building I'erinit 1\11plicution TO Construct. Repair, Renovate Or Demolish a l?"I' fed I/w•:6// One•Or rilw4'rnn(r Dil'elliny Building permit Number: This Section For Official Usc Onl Date Applied: IIuJJin�Official il'nm N;une) Siynaturc Daly I. rty lid y+ / SECT�I,O�N 11:SITE INFORhIAT10N /313 tIGr!! �clhrlr/- —dr= 11 Anessurs,Hap,i Parcel Number I.la Is this an acce led street? es no Nap Nuniher I'urcel Numlicr 1.3 Zoning Information: 1.4 Property Dimensions Lnniny D— Islricl 1'mpascJ D.r�— LulAmo(syll) n'n tasei )l) I.! Bulldlns Setbacks(R) F From Yard Site Yards Fluor Yard Reyuircd Provided Required Side Rcyuind I'nsviJeJ 1.6 Water Supply.(M.CJ.I.c. A§)a) 1.7 Flood Zone Informatlonr Ltt Sewap Disposal System: Public❑ Privale❑ Zane: _ Outside Flood Zone? Check if es❑ Municipal❑ On file disposal s)stem ❑ 1.1 0 nertofRecordt SECTION31 PROPERTY OWNERSHIP' i Ind N;ms (Print) qq I .Wm,/IPf s l 970 9 phone � f moil AJdnss reln a SECTION J: DESCRIPTION OF PROPOSED WORK'(Check all that apply) New Construction❑ E.visling Building❑ Owner•Occupied ❑ Repalrsla) ❑ Aheratlan(s) ❑ Addition O Demolition ❑ Accessory Bldg.❑ Numberof nits griofDescri it fproposed Work-: Other ❑ .Specify: 7 SECTION 4: ESTI,II.ATED CONSTRUCTION COSTS licnl Estimated Costs: Labor and.Materials) OR:clal Use Only I. Building BuiWiuy pertnilIndlnte hose fee if JetennineJ: '. I:'lcelrical S ❑Standard Ciry+Tussn Application Fee s I'Iunih;ng S ❑Tulal Project Cosh(Item,6)1 multiplier 7. Other Fees: S_ j \ — 1 \Icch,uiir,d ill\ \(') S List: 9 Ve,h.wiad (Fire •---�—__.. ll//ll// SU I IN" Un) S foul \Il Fecs; S a Tufal Project Cost i ryry CC ('hecA \o. _. —< hcd .\mount: C,ieh \mw on: N 7Ua.Q(7 ❑P.tid in Full ❑Outsuwding Hal.tnce Due: sh:('l'ION3: ('t)Ntil'Rll('TIONSI•'.RN'I('ES IC SO /_QQ _ S,I C'msstruclimisupenisurl.ic(t�n/st ' IrspiraliouU;Ile Namo aj CSI, l h,l,lcr, l ul C SI. 1.pc bcc hcluel p ¢ /�i Description Na. .uIJ Slrcet tl 14vesuicteJ 1pulldill s ti t Ulltl to i cu. ll.) % atrict.J I t?I.lulil�\I \loam l it ,l a,ul, nc,LII' R Kadin 020in N'indu,s'.uld Sidin •' SF Solid Fuel Ilurning Applianccs Institution 1'cic hone I s D Dcnu,liliun Inail addru S,2 Registered llulne Improvement Contractor(HIC) IIIC'Itegisl r Ilspiralioo I)utc E Il'Contpu Nan `or I IIC'Ilegisimol Nunto ' limull uJJresa No Id treat - -ZJo2y Ct ITow , late ZIP talc huge SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 2sC( Workers Compensalion Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuan a of the building Permit- Signed A Mdavit Attached? Yes.......... No...........13 Ell SECTION 7a:OWNER AUTHORIZATION TO BE CODIPLETED WHEN OWNER'S AGENTORCONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner or the subject property,hereby authari:e ' to act on my behalf,in all matters relative to work aut orized by this building permit application. Ahy L/I S Dula Print Ugsner's Nwnt Itwctrungc a,aiun,.,-E SECTION 7D:OWNERt OR AUTHORIZED AGENT DECLARATION By entering Iny name below, I hereby attest under the pains and penalties of perjury that all of the information contained in thisapplication is true and accurate to he best or my knowledge and � understanding. y / I'nul U,,ncr'i uh\ulhonreJ Agcm s Nknw l NarEst It hires an I. Inut registered in thelsa Howe hllpruing vanm11ermit 1Clnumctur 1HIC) Program).s her o It oork, n ill raw shave access to thearbitrationtround nd at pr"g`am or guar i`t IyInfa nation on he Construction Supery sor Lie information c can be found at Prugram'c'nsball ronJ at l\hen substantial,sork is planncu, prusidt the infurmatiun below: I including garage. linished basement attics.Jerks or eurclu ralaI flour area I sy 11.1 . --- Ilabilable room count r2Gross Using area uy. d.l .--._, \umhcr of bedrooms \unlherol'lircplaas ., _ gouhcrul'hall'haths \umhcrol'halhraolni \i,mherA'Jecks parches I\pc of hcming I' s),Icln (teen ncl„'cJ h\I`l' i 1 "f,d.d Proiect 1,Illllft 1',,,n.luc Ills\ IV �Ilh,llhllpt li`r"I',dal I'mjecl Coll" CITY OF SALE,,[, l'L-kssi1cHtiSETTS BUILDING DEPAR:TMEJiT d tr < 120 WASHINGTON STREET,3-FLOOR `r TEL. (978) 745-9595 FAx(978) 740-9846 KI.%BERLEY DRISCOLL IN AYOR THomsST.PtEm DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LUISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nance(Busin//ess&OO�rganiizpatiow[npdividual): Address: ( n rl/i7iL� �wAy City/State/Zip: Phone It: �9) -,5 9d 2 0 0 'trey ygis an employer'.' heck t e appropriate box: 'type of project(required): 1.Wit a employer with 4. Q 1 am a general contractor and 1 6, New construction employees(full and/or part-time),* have hired the subcontractors 2.❑ I am a sole proprietor or partner. listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These subcontractors have R. Demolition working for me in any capacity. workers'comp, insurance. 9. ❑Duilding addition [No workers'comp.insurance 5. ❑ We are a corporntion and iu required.] officers have exercised their ME]Electrical repairs or additions J.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.j t employees. [No workers' 13.0 Other camp,insurance rcquin d.j 'My applicun dot checks box al noun a1:w fill out the sectiuo bdow showing their workers'compensation policy inibrmmion. I hxe¢uwnen who ruhmit this affidavit indicating they am doing all work and then him outside ccnlmcron most suhmit a new amdavil indicting such. :;ontmotun that check this box most attached an a klitional,host showing the name of the subaontrscton and their workers'comp.policy infommtion. lam on employer chat is provldltrg workers'c ompensatlon insurance for my employees Below Is the pollcy and Jab site innformatlom Insurance Company Name: 00. Policy 4 or Self-ins. Lie, �-)Q 3Q 13. Expiration Date: Job Site Address: /� 1d1 City/State/Zip:, 7 D Attach a copy of the workers'comp nsation policy declaration page(showing the policy number and expiration date). Failure to wcurc coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to S1,500.00 und/arone-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off ice of Investigulions;of rite DIA for insurance coverage verification. l da hereby certify under the pules rand penulN�s of perjury that the information provide) Bove is true and correct. �i ±aturr o Data: i�����y P u A• OJJiciul use only. Do not write in this area,to be completed by city or lawn gjlcial Citynr'1'uwn: __, ,_ PcrmitR.lccnseq Issuing Aulhurity(circle one): --- -^ — —_.._..._ 1. Board of Ilealth 2.Building Deportment J.Cityfrown Clerk 4. Electrical inspector 5. Plumbing Inspector 6.O deer Contact Person: _.._ ._.. Phone th [ DATE(MDD1YY) ACORE ' CERTIFICATE OF LIABILITY INSURANCE 9/5/hV013 7RODUCER THIS CERTIFICATE IS ISSU:D AS A MATTER OF INFORMATION ONLY AND CONFERS NC RIGHTS UPON THE CERTIFICATE Ambrose I nurance A(n'. , Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 56 Centre.. Ave. ALTER THE COVERAGE AI'FORDED BY THE POLICIES BELOW. Lynn, MA ".1901 INSURERS J,FFORDING COVERAGE - 781-592-c,! a,O__ -- --. — NSURED Dr 1"J:1C31s, Z f1.11.ium INSURERA: Northland AFt'.:riLcan Door, Window 6 Insula.tio INSURER B: Arhella Prol-ection Vi )'L!Liley l,v'e. INSURER C: SFi:trias, MA C'1906 INSURERD: I INSURER E: COVERAGES THE POLICIES SURANCE L STED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIC f PERIOD INDICATED.NOTWITHSTANDING ANY REQUIRE.A:'!! TERM OR XINDI ION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIG I THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,1; INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AG(F I .;NrE LIMITS E HOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. VSR u POLICY EFFECTIVE PO ICY EXPIRATION LIMITS R TYP_:I IMISURANCE _ POLICY NUMBER AT /YY) DATE MM/DDfYYI GENERAL Lli E " -- EACH OCCURRENCE $ COMMEId n.GENERAL LIRE ILI TY FIRE DAMAGE(Anyone tire) $50 ,000 JBHIRED V III;VADE � 0XUR MED EXP(my one Person) $5 ,000 _ , . _,_ WS162282 5/20/13 5/20/14 PERSONAL S AOV INJURY $1 ,000,000GENERAL AGGREGATE $2,000 ,000RII(,' E LIMIT APPLIE': PER: PRODUCTS-COMP/OP AGO $2,000 ,000Y. 1L(.C IIECT LE I1 IMUTY COMBINED SINGLE LIMITu'; (Ea accident) E1,000,000 n '..ITOS BODILY INJURY b (Per person) LL:: IUTGS A'J : ; 4'7635400001 8/17/13 8/17/14 BODILY INJURY b (Per ecc!denUV4I I �I,DTOS PROPERTY DAMAGE S (Per accident) AUTO ONLY-EA ACCIDENT S trT OTHERTHAN EA ACC $ AUTO ONLY: AGO E EXCESS Al II I 1 _ -- EACH OCCURRENCE 8 1 ,000 ,000 IJ ' ' OCCUR _I CLAIMS IAJE AGGREGATE b b b DEDUC I RETEN111 I WORKERSC i'F•ISATION AND —� TORY LIMITS ER EMPLOYERS II IIIILITY E.L.EACH ACCIDENT b C wc231S1189403013 2/11/13 2/11/14 E.L.DISEASE-EA EMPLOYEE b El.DISEASE-POLICY LIMIT E OTHER DESCRIPTION OF III I I�O.TIONSILOCAT ANSIVEHICLES/EXCLUSIONS ADOED BY EHDORSEMENTISPECIAL PROVISIONS Carpentr- !: insu].a.ti4Drl CERTIFICATE I ;I.OE�— ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCR BED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSUI!ER WILL ENEVVOR TO MAIL 1.n DAYS WRITTEN C: Iy Of Revarbs A( I'JA. : BU31d111C] Dept NOTICE TO THE CERTIFICATE HOLDIiR NAMED TO THE LEFT.BUT FAILURE TODOSOSHALL all IMPOSE NO OBLIGATION OR LI rY OF ANY KIND UPON THE INSURER,ITS AGENTS OR B �AII'IIiI$ 02.�5'l REPRESENT AUTHO V ©ACORD CORPORATION 1988 ACORD 25-8 17'I 'I ' t Massachusetts -Department of Public SafetY Board of Building Regulations and Standards License: PSSL 100524 .. W ILLIAM 3 DEL LNG 15 BAILEY STR1&ET SAUGUS MA 01406 .01 .. ExpiratiOd 05/05/20'14 Commissioner Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 111123 Type: DBA Expiration: 11/25/2014 Tr6 234005 AMERICAN DOOR WINDOW & INSULATIO WILLIAM DeLANGIS 15 BAILEY AVE — - SAUGUS, MA 01906 Update Address and return card.Mark reason for change. Address 0 Renewal ❑ Employment Lost Card SCA 1 0 20101-05111 - WAP Work Order North Shore Community Action Programs,Inc. Job Number:: 130164 119 Rear Foster Street BLDG 13 Work Order Date: 1/16/2014 Peabody,MA 01960 Ownership:Owner Phone: 978-531-8810 American Door,Window,&Insulation Auditor: Brandon Dorrington 15 Bailey Avenue Email: bdorrington@nscap.org Saugus MA 01906 Cell: 781-540-8569 Email:wdelangis@comcast.net Phone:978-5.31-0767 xl21 Phone:781-231-0244 Lambros Ladas DOE WAP 2013 .7750 138 Highland Ave NGR[D Gas $$8$87 .50 Salem 9 01970 Total $4,952.15 978-2365 -2195 DOE WAP 2013 Repair/Health&Safety $0.00 F re R-18-20 restricted-slopes/floored 1006 $1.42 $1,428.52 1006 $1,428.52 fill w/cellulose R-30 unrestricted-settled cellulose 250 $137 $342.50 250 $342.50 Tenmats 5 $30.00 $150.00 5 $150.00 Thermodome or Magnetic pull 1 $180.00 $180.00 1 $180.00 down stairway box Roof vent 865(4 sq It NFV)small 3 $80.00 $240.00 3 $240.00 Garage ceiling cavity filled with 406 $2.10 $852.60 406 $852.60 blown cellulose MEN IN Fixed Sweep 5 $15.75 $78.75 5 $78.75 Repair/Refit Door 3 $52.00 $156.00 3 $156.00 Weatherstrip s/Q-lon or equal 5 $45.50 $227.50 5 $227.50 Date: 1/16/2014 Page 1 WAP Work Order: Job Number: 130164 Clothes dryer vent including 1 W$89.00 $89.00 1 $89.00 Exhaust Duct Vent kit/bath fan 1 $89.00 $89.00 1 $89.00 zi Domestic water pipe wrap 6 $2 63 $15.78 6 $15.78 R , Attic sealing with two-part foam 3 $75.00 $225.00 3 $225.00 Basement sealing with two-part 1.5 $75.00 $112.50 1.5 $112.50 foam Blower door set-up with pre&post 1 $45.00 $45.00 1 $45.00 tests Clean gutters 2 $60.00 $120.00 2 $120.00 Pulldown Stairs 1 $500.00 $500.00 1 $500.00 MEAf_ b Y3t 4 as fpi9kx, tl .. Building Permit 1 $100.00 $100.00 1 $100.00 Total $4,952.15 $4,952.15 Contractor Instructions: Before Starting the Job: Durina the Job: 1. Please notify us 24 hours before starting or scheduling a job. 1.Incorporate lead safe practices as applicable. 2. Obtain required building permit. 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. Date: 1/16/2014 Page 2