54 LAWRENCE ST - BUILDING INSPECTION (3) K `13 tf5 132a a
RECEIVED
r.
The Commonwealth of Massac usetts
Department Public Safety
NlassachusettsShiteBuiWingode 780 CI FEB 18 A 4u
�O Building Permit Application for any Building other than a One-or Two-Family Dwelling
.(This Section For Official Use Only)
NBuilding Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block if and Lot q for locations for which a street address is not available)
Lawv� ne e s f Sa tN, 6P/9) 0
f1 No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
�y 1 Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part-of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering eer Review requ'md? Yes ❑ No ❑
Br' f D�1�e u�i�('!� of Pr osed W rk• zWa
��F.E�r....�✓—� - .GO .EW�22o-Q .../nc0-dP.14IZ0004� '
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R-4❑
S: Storage S-1❑. S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ HA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site❑
Public❑ Check it Outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: hazards to Air Navigation: \1\11kt a nnu -- ....-
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ i Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: _
Does 11te building contain an Sprinkler System?: _ Special Stipulations:
zl2.4( 15
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner �I
Name(Print) No.and Street City/Town Zip
r
Property Owner Contact Informatio_ri:
Title Telephone No.fbV§ SI s F Telephone No. (cell) e-mail address
If applicable,the roperty owner hereby authorizes
W, 04, �e�q,� f�iS v/qC/`
Name Street Address City/Town State Zip
to act on the property owner's behalf,mail matters relative to work authorized by this budding permit application,
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered `Professional Responsible for Construction Control d
W'1114A �, LAng/s 7F/ J31 . 0.1 evdelatn70,'s®Boma, /vr,fay
Name��,�ttu7gi [rant) T dephone No. a-mail ac dress Registration Number
/� (SA,�ry /Ive .S av� yS hf 9 Q/go f, 9-1-1- /A
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
,0,& . ", 4- w
Company Name
W t //fa:r, A la rig �s /00 3� 1 1'4' e2Gadax.
Name of Person Responsibl fur Construction License No. an�Type if Applicable
45Aar/e,r /I1/4- Al 19/906
Street Address City/Town State Zip
54---"- ca y ZL t,sa wd e 1 aL n p/r (9? crn zg� r fV
Telephone No. business Telephone No. cell e--mail address
SECTION 11:bVORKERS'C0NIP6NSAIION INSURANCE AFFIUAVIP M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industriid Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the Is ce of the building permit.
Is a signed Affidavit submitted with this application? - Yes 1' No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) "Total Construction Cost(from Item 6)_$ ��I 06U
1. Building $ Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=S
3. Plumbing $ ��
d. Mechanical (FIVAC) $ Note: Minimum fee=$ (conttaQact n nic,pa tty)
:i. Mechanical Other $ 1 Enclose chock y payable to /.G�i � .GLO«•r/
6.Total Cost $ / •o (contact numicipality)and write chrCIZ number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 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.
W l 1 h d N1 �2 �Q h A I S g, day,aN d r,/>7 e r L-n?3 L_- 9,2 1-/•/
Please print and sign name lf- Title Telephone No. Date
Street Address Cit /Town ,1 State Zip
`Municipal Inspector to fill out this section upon application approval: //6�
Name Date
QTY OF SALEM, MASSACHUSE M
BLULDING DEPARTMENT
120 WASIENGTONSTREET,3ADFLOOR
TI L(978)745-9595
KRaERLEYDRISOOLL FAX(978)740-9846
MAYOR THomm ST.FIERRE
DIRECTOR OF PUBLICFROFERTY/BUILDING OCAMSSIOMR
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:
(name of hauler)
�Tnhhe debris will be disposed of in:
(name of facility)
4(a=dre—ss of facility)
A �
Signature of applicant
�2 1/81 i,s
Date
CITY OF SM E.Nf, NWSACHUSETTS
BL•Rnmr,DEPART &NT
3 •t - 120 11 ASHNGTON STREET, 31D FLOOR
TEL (978) 745-9595
R x(978) 7.10.9846
KI\IBEBL.EY DRISCOLL
INAAYOR THwAs ST.PtFm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONER
Mirkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information P►ea a Print Legibly
Name InusilxssUrganirmiun,•InJividual): /.�C�brl �iiV•p') �(,/,llyry -
Address: 424,4
City/State/Zip: ""'mac '"`'' /tea O/%b G Phone If:_7J01-J.31 O)_Y-!
,%re you an employer?Check the appropriate box: 'type of project(required):
I.YJ t am a employer with/_ 4• 0 1 am a general contractor and 1 6. Q New construction
employees(full and/or Part-time)." have hind the svbwontnclots
2.❑ I am a sole proprietor or partner- listed on the auochad ahect = 7• ❑Remodeling
chip and have no employees These sub-contractors have B. C]Demolition
working for me in any capacity. workers'camp.insurance. 9. 0 Building addition
(No workers comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'camp. c. 152,91(41,and we have no 12.E]Roorr pairs
insurance required.) t employees.(No workers' 13,Q Other
comp.imumnce required.)
-Any applir u l Ilwl ckwhs bus r t mwl also rill out the U%Iim below sbawing Their w•orkm'cempensadw palisy inrumtmlus.
'1 hums twnvr who whmil this srndnvit indicating They am doing all work and than biro oulSida colnmemrs mlrat submit a new aaldavil indicating such,
cwnr%tun that ahak Ibis box WWI anachd an aLkhdo al ahral showing the name of the subwrontnetoro and their woken'cmnp.pulley Infomution.
/am air eurp/oyer that is pruviding workerx'compenrodon hirurancer for my emp/ayeea Below/s the pulley and jab sl/e
infunnulinn.
Insuhnce(:nmpany Vame: y_ /
Policy 0 or Sclf--its. Lie.g: 60 e- !S'3d 03 0/,5' Expiration Dole:
lob Site Address:S 14a W PA d C_L H City/State/Zip:
A Itacb a copy of the nrorkers'compensation pulley dectarallaa page($hawing the policy number and expiration date).
Failure to secure coverage as required under Section 23A orMGL e. 152 can lead to the imposition of criminal penalties of a
tine up to SI.500.00 and/or one-year imprisnnrncnr.as well as civil penalties in Ilia form of o STOP WORK ORDER and a tine
ar up In S230.00 a day against the violator. Be advised that a copy of this statement may Iv:furwarded to the Orrice or
Inrestigatiuns ul'dre DIA for insurance coverage verification. -
/elu%rreby t/,eerrlfy�//�ttdder Nie''polio/x uu penuldex of perjury that the informal/on provided ubuve iv true and curreeL
S"gym ture:ll(l/.I:wYN17 1r i Oalw
Phone d:
f7%/iriu!use an/y. Du not tvrire in this area,to be completed by city ur town n/J7riut
CitynrTown: - -- -- Permidl:lcenseq__..___. ..__-- __ 1
Issuing Autlmrily(circle une): I
1. Iloard of Ilealth t.Buildlnt;Dcparturenl i.Cilyffuen Clerk J. F.leetriotl luapedur 5. Plnntbing hupeetor
6. Other
CunIaU Pernoo: . ._---_,-- phone"I: I
Massachusetts -Department of Public Safety..
Board of Building'Regulations and Standards'
Construchon'Supervisor Specialty
License. CSSL f00024 �
wILL1AM J DFI-0
15 BAILEY STREET
SAUGUS,MA 01% > '
bi?` Expiration
i
Commissioner 05/05/2016
4-
d1l �
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 021.16
01
Home Improvement Contractor Registration
. "� Registration: 111123
Type: DBA
Expiration: 11/25/2016 Tr# 260215
AMERICAN DOOR WINDOW & INSULA-T 0 1 `
WILLIAM DeLANGIS
15 BAILEY AVE
SAUGUS, MA 01906
date Address and return card.Mark reason for change. -
SCA 1 0 20M-05i11 - — Address Renewal Employment Lost Card .
Work Order
North Shore Community Action Programs,Inc. Job Number:Moreno(1)
119 Rear Foster Street,Building 13 Work Order Date: 2/17/2015
Phone: 978-531-0767
Peabody,MA Ownership:Renter
-076
American Door,Window,&Insulation
15 Bailey Avenue Auditor: Brandon Dorrington
Saugus MA 01906 Email: bdorrington@nscap.org
Email:wdelangis@comcast.net Cell: 781-540-8569
Phone: 781-231-0244 Phone: 978-531-0767 xl21
Christopher Moreno NGRID Gas 54 Lawrence St $3,744.61
Salem MA 01970 Total $3,744.61
Safety Issue(s):Asbestos Siding/Mold Present/Lead Paint Possible
a
Sill two-part foam berglass halt 130 $2.46 $319.80 130 5319.80'
Automatic Sweep 1 $26.00 $26.00 1 $26.00
R-5 Ductwrap or R-max on door 1 $57.00 $57.00 1 $57.00
Repair/Refit Door 2 $58.00 $116.00 2
$116.00
Weatherstrip s/Q-Ion or equal 3 $51.00 $153.00 3
$153.00
Clothes dryer vent including I $100.00 $100.00 1
Exhaust Duct $100.00
Domestic water pipe wrap 6 $2.95 $17.70 6-
$17.70
Date:2/17/2015
Page I
Work Order: Job Number: Moreno(I)
Basement sealing MIN I'M
with two-part 1 $84.00 $84.00 1
foam 584.00
Double nailed asbestos/aluminum 59
(dense pack) 986 $2. $2,553.74 986 $2,553.74
Drill finish patch plaster(dense 149 $2.13 $317.37 149 pack) $317.37
Total
$3,744.61 $3,744.61
Contractor Instructions;
Befor�f the Job:
Durin the-Lob:
1.Please notify us 24 hours before starting or scheduling a job. I This residence was built before 1978.Lead safe aractices are
2. Obtain required building permit.
required.
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.
Additional Contractor Instructions:
Certificate of Insulation posted? Yes No (Circle One) Attic Inspection form attached? Yes N/A (Circ e One
American Door,Window,&Insulation hereby certifies that thisjob 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:
Date:2/17/2015
Page 2
Work Order
North Shore Community Action Programs,Inc. Job Number: Bretzke
119 Rear Foster Street,Building 13 Work Order Date: 2/17/2015
Phone: 978-531-0767
Peabody,MA Ownership: Renter
-076
American Door,Window,&Insulation
15 Bailey Avenue Auditor:Brandon Dorrington
Saugus MA 01906 Email: bdorrington@nscap.org
Email:wdelangis@comcast.net Cell: 781-540-8569
Phone: 781-231-0244 Phone: 978-531-0767 xl21
Jean Bretzke
54 Lawrence St NGRID Gas $3,057.45
Salem MA 01970 Total $3,057.45
Safety Issue(s):Asbestos Siding/Lead Paint Possible
Fixed Sweep 1
$17.64 $17.64 1 $17.64
Weatherstrip s/Q-lon or equal 1 $51.00 $51.00 1 $51.00
Clothes dryer vent including 1 $100.00 $100.00 1 $100.00
Exhaust Duct
Domestic water � e wraPP -
P 6 $2.95 $17.70 6 $17.70 ONE
Double nailed asbestos/aluminum 986 $2.59 $2,553.74 986 $2,553.74
(dense pack)
Drill finish patch plaster(dense 149 $2.13 $317.37 149 $317.37
pack)
Total $3,057.45 $3,057.45
Date:2/17/2015'
Page 1
Work Order
North Shore Community Action Programs,Inc. Job Number:Jackson
119 Rear Foster Street,Building 13 Work Order Date: 2/17/2015
Peabody,MA 01960 Ownership:Renter
Phone: 978-531-0767
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: 978-531-0767 xl21
Phone:781-231-0244
Stacey Jackson MAJOR REPAIR FUND $575.00
54 Lawrence St NGR1D Gas $5,218.85
Salem MA 01970 Total $5,793.85
Contact Phone:978-740-9773
Safety Issue(s):Asbestos Siding/Mold Present/Lead Paint Possible
A
s
R-38 unrestricted-settled cellulose 1036 $1.65 $1,709.40 1036 $1,709.40
Fixed Sweep 1 $17.64 $17.64 ] $17.64
Weatherstrip 0-lon or equal 1 $51.00 $51.00 1 $51.00
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
Domestic water pipe wrap 6 $2.95 $17.70 6 $17.70
50 CFM brfan "existing) 5.00 $575.00 7 $575.00
Date:2/17/2015 Page 1
Work Order: Job Number: Jackson
• Attic sealing with two-part foam 3 $84.00 $252.00 3 $252.00
Building Permit 1 $100.00 $100.00 1 w $100.00
Double nailed asbestoslaluminum 986 $2.59 $2,553.74 986 $2,553.74
(dense pack) -
Drill finish patch plaster(dense 149 $2.13 $317.37 149 $317.37
pack)
Total $5,793.85 $5,793.85
Contractor Instructions:
Before Starting-the Job: Duringthe a 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$2500.00.
3. Davis Bacon time sheets required for ARRA work on US
Department of Labor Certified Payroll Report Form WH-347.
Additional Contractor Instructions:
Attic Inspection form attached? Yes N/A Circe One)
Certificate of Insulation posted? Yes No (Circle One)
American Door,Window,&Insulation 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:
Date: 2/17/2015 Page 2