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203 JEFFERSON AVE - BUILDING INSPECTION (2) 2-O. � - l � $ Lfb°: W (09 b(0 The Commonwealth of Massachusetts j� Board of Building Regulations and Standards CITY OF Alt Massachusetts State Building Code, 730 C(vIR RevisedSALEIA 011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling This Sect*onFor`Official Use Only Building Permit Number: DateAp hed., Buil ing Official fPrint Name) $ignatuce Date - SECTION 1:SITE INFORINIATION Ll Pro ert A ld a s: 1.2 Assessors Map& Parcel Numbers I J? zltor:�eon Ave 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 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? Municipal❑ On site disposal system ❑ Check if yes[] SECTION 2:;'PROPERTY'OWNERSHIPt' 2.1 Ownert of"] Record: n n / ar -. t�Qs�UarP 1 /a r`lf.Pt-('Dv� 01970 Name(Prin City,State,ZIP n No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF.PROPOSED WORK''(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': .�11a1Gilg�t r SECTION 4: ESTIMATED CONSTRUCTION COSTS - Estimated Costs: Item Official Use Only Labor and Materials I. Building g 1 Building Permit Fee: S Indicate how fee is determined: FI«trical i 7 1 ❑ Standard.City/`town Application Fee 2. ❑Total Project Cost (Item.6)x rrtultipiier x 3. Plumbing S 2. Other Fees: S 1. M-chanical (HVAQ 3 List: 5. Mechanical (Fire $ Sn� ression) Total All Fees: S_ Check No. Check Amount: Cash Amount: /. Total Project Cult 3 7 0D ) 7 ❑ Paid in Full ❑ Outstanding 13Aince 17na: SECTION 5: CONs'rauCT[ON SERVICES 5.1 Construction Supervisor License(CSL) jSL-- I_tsa License Number Expiration Dute Name ut CSL I[older List CSL Type(see below) Type - Description No. andNo. and t�� . ^ok� � Q q U Unrestricted DuilJin s u to 35,000 cu. tt. i R Restricted 1&2 FamilyDwelling Citylruwn tare,ZIP iv( iVlasonr RC Boutin Coverin WS Window and Siding SF Solid Fuel Burning Appliances ]�' 1 -389 7L8� I Insulation ('�.le hone Email address D Demolition 5.2 Registered Hone Improvement Contractor(IIIC) Lam,1 I r e ti. o LA NtA%S HIC Registration Number Expiration Date f lIC Company Names or I[IC egistrant Name Q Qkra- not-4- ilJjilJou No. and Street 5-PJ60 Email address a') a o '78l-,389 - 76W /Town, Late, EP rele hone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25C(6)) Workers Compensation Insurance affidavit mast 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 1, 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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER' OR AUTI[ORIZED 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. I riot Owi 's ur Autlwrizal:\;sorb Name(Electronic Signature) Rite NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 1 12A. Other important information on the HIC Program can be found at ww.m;us. uv%oca Information on the Construction Supervisor License can be found at tawo-.m;us.,nytv_'dIN 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 mca(sq. tl.) _ Habitable room count Number of tiraplaccs._.-- Number of bedrooms Nuniberorbathnwnts _---- —_--- Number nrhalt,'baths Fvpe of heating syslein ---_--- I)pe of eooling sy;lem_-- Enclosed_-- Open _-- 1. `rot,il Plolj ct5qunre FootiLle" may be iub;titutcd Cot I oi&t(bsr, o CITY OF S.0 ENI, 2%,WSACHUSETTS r BUILDING DEPARTMENT 120 \WASHINGTON STREET, 3 FLOOR of$ T EL (978) 745-9595 Fax(978) 740-9846 Kl.'%fBERLF-Y DRISCOLL MAYOR T HomAs ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BCILDING CONNISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Alitilicant Information Please Print Legibly Name(Businessorpnlzatiowindividual): - oLot-. Address: City/State/Zip: Phone Jf: '7�1_6 - $,z 0 U Arc y u an employer'Cheek the appropriate box: Type of project(required): I. I am a employer with 4. ❑ 1 am a general contractor and 1 employees(full and/or part-time).' have hired the sub-contractors 6' ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have N. ❑Demolition working for me in any capacity. workers'comp. insurance. 9, ❑building addition [No workers'comp. insurance 5. El We are a corporation and its required.) officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right ofexensplion per MGL 1 I.❑ Plumbing repairs or additions myself. [No workers'cutup, C. 152, ¢1(4),and we have no 12.❑ Roof repairs insurance required.)t employees.LNIo workers' 13.0 Other comp.insurance required.] �nny applic:mt uW clucks betel moat nlyu till uw the uctioo below showing the&workers'compenution policy inl'urmation. I hvneownera who submit this affidavit indicating they am doing all work and then hire outride canrmctars moat submit a new afndavil indicating such. =Cuntracwm that chwk Ibis box must anach d an uldiiiurwl shoei showing the nwne of the rubeonuators and their workers'comp.policy inter iition. I um an employer that is providbtg workers'campensatlare insurance jot my employees, Below Is the po/4 and Job sits ixforenalfan. Insurance Company Name: Policy N or Self-ins,Lie.N:_ [a /C'`31 R q — Expiration Date,• < Job Site Address: City/State/zip: "_© Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine Of up to S'_50.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of ' Invesligalions of the DIA for insurance coverage verification. I do hereby certify under the pains and penoldes 4perfury that the inlorrnmlan provided above istrue and c'arrect. 70thcr y. Do nor wrile its this area,to be conspleled by city or sawn official Permit/1.Icense ity(circle one): alth 2.Building Department 3.Cityiruwo Clerk 4. Electrical Inspector 5. Plumbing Inspector.0thcr Contact 1'crson: .... Phone N: I CITY OF S.XIL EM, �,L-1SSACHUSETTS l3U amLN,G DEPAR'ntHNT 3 N 120%VASHLNGTON STREET, 3" FLOOR TEL (978) 745-9595 Fla(978) 740-9846 KimBERLEY DRISCOLL VLAYOR THo.%As ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BCILDNG CommissIONER 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 I t 1.5 Debris, and the provisions of MGL c 40, 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 disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: �o(name of hauler) The debris will be disposed of in : (name of facilit r _ (ad cS' t"tacility) signature of permit applicant date _ Icbrismf:,lw s Massachusetts -Department of Public Safety Board of Building Regulations and Standards, Consrruc[ion S-11"iarr Special[} License: CSSL-100824 W ILLIAM J DELANGIS' 15 BAILEY STREET SAUGUS MA 01506 „{ ' ' 05 0512014 - 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 Tr# 234005 AMERICAN DOOR WINDOW& INSULATIO WILLIAM DeLANGIS 15 BAILEY AVE SAUGUS, MA 01906 Update Address and return card.Mark reason for change. SCA1 0 2OM-05/11 - Address Renewal Employment Lost Card ACO CE R T'IFICATE OF LIABILITY INSURANCE 9151M/01DATE -4 IRODUCER -'-'---"—"`— — THIS CERTIFICATE IS IS 3U ED AS A MATTER OF INFORMATION Ambroels. I ,.,Iuranc a :U Inic. ONLY AND CONFERS NC RIGHTS UPON THE CERTIFICATE r HOLDER. THIS CERTIFH:A"E DOES NOT AMEND, EXTEND OR 56 dent Ave. ALTER THE COVERAGE AI°FORDED BY THE POLICIES BELOW. Lynn, DI J ]1901 - - INSURER 3),FFORDING COVERAGE NSURED )� ;)gis, 3rill lam INSURERA: NoVthland JL ::'1Can Docir, 'Window IG InsUla.tio INSURERS: Z•eot:on Ins . .. I.Ililey 1A'e. INSURERC: :I i11EI, !fit C1906 INSURER D: I INSURER E: COVERAGES.. _ THE POLICIE., • SURANCE 1.3"EU BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE Pot IC(PERIOD INDICATED.NOTWITHSTANDING ANY REDUIR:` I TERM OI: XINI)mON OF ANY CONTRACT Oft OTHER DOCUMENT WITH RESPECT TO WH Cl I THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAII 1, INSURANC= WFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERN S EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AC C. I OTE LIMITS E IOW N MAY HAVE BEEN I REDUCED BV PAID CLAIMS. TY IPISURANCE _ P_OUtV NUMBER PO EFFEC O PIRATIO'T LIMITS GEN=L V "' -- EACH OCCURRENCE 3 COMMI.I 3ENERAL U,IIJTY FIRE DAMAGE(Any one fire) $ Cl) /AL'IE 13CUR MED EXP(Any ane mraon) $ ' WS162252 5/20/13 5/20/14 PERSONAL It ADV INJURY $ GENERAL AGGREGATE $ i v1.11AIT APPLII'� >ER: PRODUCTS-COMPIOP AGG $ _fOT LtJC _ - IJTY COMBINED SINGLE LIMIT AU (Ea accldenD $1,000,000 . . .ITO6 BODILY INJURY (Per person) $ I 4)T17S _ , 4'7635400001 8/17/13 8/17/14 BODILY INJURY D I 60'TDS (Per eccldeN) $ PROPERTY DAMAGE $ — '— (Per accident) GARAGEUII,1 _ AUTO ONLY-EA ACCIDENT $ ANV All' ; OTHER THAN EA ACC S AUTO ONLY: AGO $ EXCESS UIE I J EACH OCCURRENCE $1 ,000 ,000 OCCUR J CLAIMS IA.IE AGGREGATE 41 ,000 ,000 5 DEDUC' $ RETENIi $ _ $ WORKERSC FA170N AND TORYLIMdS ER EMPLOYERS 'I III E.L.EACH ACCIDENT $ C WC231S389403013 2/11/13 2/11/14 1.—DISEASE-EA EMPLOYEE $ . ....__ _- .._._.. E.L.DISEASE•POLICY LIMIT OTHER . $ IESCRIPTION OF t d I3IN8ILOCA7IIIIiIVEHICLE6IEXCLUSIONS41DDED BY EPIIIORBEMENT/SPECWL PROVISIONS Carpentl Inaul I.$iau :ERTIFICATE I ,'�,IIER= :,L014uDNAL INSURED;1141WRER LETTER: CANCELLATION �, -' SHOULD ANY OF THE ABOVE DESCR 1 ED POLICIES BE CANCELLED BEFORE THE EXPIRATION of Rev aro DATE THEREOF,THE ISSUING INSUI A R WILL ENpVVOR TO MAIL ID__DAYS WRITTEN At I ; Bul l dillo Dept. NOTICE TO THE CERTIFICATE HOLDI II NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL C: I Hall IMPOSE NO OBLIGATION OR f'OF ANY KIND UPON THE INSURER,ITS AGENTS OR b�• 021`Ii REPRESE y AUTHO `'L�r(�,�.� I__ - -- -•-•- - ®ACORD CORPORATION 1888 ,CORD 2"17 I I ' WAP Work Order North Shore Community Action Programs,Inc. Job Number: 110289 98 Main Street Work Order Date: 9/28/2013 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 O1906 Cell: 781-540-8569 Email: wdelangis@comeast.net Phone: 978-531-0767 xl21 Phone: 781-231-0244 Margaret Pasquarello NGRID Gas $5,011.97 203 Jefferson Ave Total $S,OI t.97 Salem MA 01970 978-744-5628 Safety Issue(s):Asbestos on Pipes - 'AnthonZCd,� .::xt AChIaI w. q Xx a x, t +xn:�``Measure Descrtphon �` a r � , � ,� y .z � Qty _-`PCtce ;Total v Qty �`To[aF.+p+ t+' ;"ax ✓ k,x �^" sa , n '�- ,�,��� f +'.k �n.s w .Far . rc.r. ,�" q „.�. ✓,� .}f .t+hY�`...Vl.k'A.� .,fw..} >.�Z.%"3"F!.: �s� .'A.z,'t$`'j1 thcl nsulatlon`< > 9 �' b Y.`f'rh `Ny'7 ±o rs '°aw "'"�' e"'aY'T't-t a -`"i# e3- "' OF �rY 4fi' N: MA'. � > R-30 restricted*slopes/floored fill 280 $1.48 $414.40 280 $414.40 slopes w/cellulose R-30 unrestricted-settled cellulose 20 $1.37 $27.40 20 $27.40 sub-attic R-30 unrestricted-settled cellulose 170 $1.37 $232.90 170 $232.90 Y_ i'` h dy � r A Kt a' < M{ T� Athc Yenhl'ah xon �z„ a. v ea+�,r� 's "' �+ ,a Roof vent 865(A sq ft NFV)small 3 $80.00 $240.00 3 $240.00 Basementhfsulahon itf ` Sill two-part foam w/fiberglass bast 100 $2.20 $220.00 100 $220.00 rill— Automatic Sweep 1 $23.00 $23.00 1 $23.00 Fixed Sweep 1 $15.75 $15.75 1 $15.75 Repair/Refit Door 3 $52.00 $156.00 3 $156.00 Weatherstrip s/Q-Ion or equal 2 $45.50 $91.00 2 $91.00 Date: 9/28/2013 Page I 1 WAP Work Order: Job Number: 110289 a se Insulation :Al {,w,6+ Domestic water pipe wrap 6 $2.63 $15.78 6 $15.78 , e �-r �. X -^n 'x- °'8 '� a I�yy^:.x••y-e. �.+.�.w-.s r�� �Y s_�tyYK 1^ �'w, ? '+ � 'niVltsc Nleasu�es 'a.«+ .,,� -� • u+y � x�' L <_<..s #'w#s.. b`�'.„�; a_�' >5'i'f �'£"e.)'�,.v,a3��. n -.'4 ,.+�4"'r�<.:ery n a '� i �£'s;:�.;£:u x « 'F.x �� V'',r,•�.;.1' Attic sealing with two-part foam 2 $75.00 $150.00 2 $150.00 Basement sealing with two-part 3 $75.00 $225.00 3 $225.00 foam Cut/finish attic-kneewall access 1 $105.00 $105.00 1 $105.00 Weatherstrip(Q-Ion or equal)attic 1 $31.50 $31.50 1 $31.50 hatch r Permlt q ,sr S'�. a.:"-i, . .r i• H .,x>rau gaff 9 ,:t-,x.r.M' 5r. z"4as:�� -.,rf.:s;:Y-i,..r..r .Ma-z.�,l!:a Building Permit 1 $100.00 $100.00 1 $100.00 [nsulahoa �' f f. pq 4 'r ^tjN,: >+t�' �.ia e�w,a Y '". e c '�sv y4 ""'`''' `- Y. �y„ e , - Wood claliboard/shakes/shings or 1656 $1.79 - $2,964.24 1656 $2,964.24 vinyl(dense pack) Total $5,011.97 $5,011.97 Contractor Instructions: - Before Starting the Job: Dunne the Job: L Please notify us 24 hours before starting or scheduling ajob. I.Incorporate lead safe practices as applicable. 2.Obtain required building permit. 2.Total for Heath&Safety and Repairs cannot exceed$2500.00. j 3.Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH-347. Date: 9/28/2013 Page 2