54 LAWRENCE ST - BUILDING INSPECTION (4) GK 7 3G -1
t The Commonwealth of Massachusetts
Board of Building Regulations and Standards
WMassachusetts State Building Code,780 CMR QE� 1� � EM
DNS Revised Mar 2�
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling ti5
1 (� Thus Section For Official Use Only
U 1 Building Permit Number: Date Applied:
1 Building Official(Print Name) Signature Date
LD SECTION 1:SITE INFORMATION
�t
1.1 Pr p Address: 1.2 Assessors Map&Parcel Numbers
— S by al/en CS' S . SG !m
Ll 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 it) Frontage(11)
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 OWNERSHIP'
2.1 Owner'of Record.
- nq)l 9re42 L9 �Sa��ity,State,� ' ka_ 01970
Name u5�/ Si
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify
Brief Description of Pro osed Work : :
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 00 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costs(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: $ 0S 00 ❑paid in Full ❑Outstanding Balance Due:
rn�lt_ �o cc J;
SECTION 5: CONSTRUCTION SERVICES
I
rNo.mdStreet
ion Supervisor License(CSL)
N1 C7 C !/J I1 q/S G7/ r E' x"p rauon"Da--
kolder �/ List CSL Type(see below)
)�-A✓e` '' •q Type Description
S'Qcm as /la. 0//D6 U Unrestricted Buildin s u to 35 000 cu.ft.)
C�ty/I�o ,State,ZIP
R Restricted 1&2 FamilyDwellin
M Maso
RC Roofin Coverin
WS Window and Sidin
�+ q SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Dem_olitiony„
5.2 Registered Home Improvement Contractor(HIC) y
1 C Itegs�_+�`Number Expiration Date
HI,CrComp y N e or C R e rstran�ame
3U JA 0. r13
No and Street
..7 94� s "M V
u .t/a. 0/90& Email address
_gi_tX/To%W,State,ZIP Tele hone
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
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 Lc// ��M Je Q h S
to act on my behalf,in all matters relative to work authorized by this building permit ap cation.
3/94i —
Ent Owner's � Signature) Date
SECTION 7b:OWNER'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 understandin .
Train Owner's or Authorize Age Name(Electronic Signature) / Dale
NOTES:
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 can be found at
www.mass.eovloca Information on the Construction Supervisor License can be found at www.mass.gov/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 ofcoolink;system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
l
i Y )r 13UUMNG DE13AaT1LENT
..,` 120 W UHLYGTON STREET V FLOOR
TEL (973) 745-9595
KINMERI EY DaISCOLL F-',X(978) 7-W-9844S
i�L4YO1L THOSLM3 ST.PIMUM
DIRECTOR OF PUBLIC PROPERTY,/8CMDLNG COJLAOSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CiAR section l l 1.5
Debris, mid the provisions of tbIGL c 40, S 54;
Building Permit N 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 L'VIGL c
l 11, S 150A.
The debris will be transported by:
1
. y
(name ut'hauler)
The debris will be disposed of in
✓rner roc
(narneoffacility) —
���� l inn
Od ress of taci ity)
signature ut permif, p(icant —
data ---
02/19/2015 21:13 17815955820 AMBROSE INSURANCE PAGE 01/01
CERTIFICATE OF LIABILITY INSURANCE 2/20/2015
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,Certain policies may require an endorsement. A statement On this Certificate does not confer rights to the
Certificate holder In lieu Of such endorsement 9.
PRODUCER CONTACT Q Demala
BAM MaryAmbrose Insurance Agency, Inc. noNe PA%
70 Munroe Street, Suite D E'Mr'IL _mdemala@prescottandean.00m
INSURE S AFFORDING COVERAGE NATO
Lynn MA 01901 INSURER AIT:TOrthland
INSURED INSURER B ilibErty Mutual Ins 2r21M - See
William Delangis, DBA: American Door, Window 8 INSURER C:
15 Bailey Ave 1
INSURER O:
INsuRER E:
Saugus MA 01906 1 INSURER P:
COVERAGES CERTIFICATE NUMBER:CL1522020311 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING 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 DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
TYPE OF INSURANCE A POLIO NUMBER DDLSURR POLICI'EFF POLICY MP LIMITS
CENERALLV101LITY EACX OCCURRENCC 4 1,000,000
x COMMERCIAL GENERAL LIABILITY S 50 000
A CLAIMS-MADE 1 OCCUR 212917 /20/201d /20/2015 MED E%P An one rnon S 5,000
PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG P 2,000,000
a POLICY F71 YPRt 71 LOC t
AUTOMOBILELIABWTY COMBINED SINGLE LIMIT
ANYAUTO BODILY INJURY(Par Penan) P
ALL OWNED F7,JrHEDUUED BODILY INJURY(Per ewld") $
AUTOS AUTOS
HIRED AUTOS AU OSED PROPE JPIx �RTYIDAMAG' 6
E
UMBRELLA LIAR OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS-MADE AGGREGATE S
F
B WORKERS COMPENSATION WC STATU. OTH,
AND EMPLOYERS'LIABILITY
II
AW P E ROPRIETOR �UCEDT ECUTIVE N/A EL,EACH ACCIDENT - S
OFF(Mandmom In NH) rC23183B9d03015 /11/15 /11/I6 E.L.DISEASE-EA EMPLOYEE S
Srye daea" uMx
OE4AP ION OP OPERATIONS Below E.L.DISEASE•POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Aeneh ACORD 101,Addlaennl RaMOAA Sehadule,R men epete H nqulnd)
Workers compensation to be mailed directly from the company
CERTIFICATE HOLDER CANCELLATION
(7 B 1)558-5692 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City Of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, M
AUTHORIZED REPRESENTATIVE
,T 8 Scholnick/SPRITE
ACORD 25(2010/05) ®190S-2010 ACORD CORPORATION. All rights reserved.
INSO26(2oi%S),o1 The ACORD name and logo are registered marks of ACORD
9LOZ/80/90 Jauoissiuiwop�
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Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 111123
Type: DBA
Expiration: 1112512016 Tr# 260215
AMERICAN DOOR WINDOW & INSULATIO
WILLIAM DeLANGIS
15 BAILEY AVE
SAUGUS, MA 01906
_ Update Address and return card.Mark reason for change.
Address F Renewal iJ Employment ❑ Lost Card
Work Order
North Shore Community Action Programs,Inc, Job Number:Bretzke
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
Email: delangis@comcast.net
Me 01906 Cell: 781-540-8569
wlangis@comcast.net Phone: 978-531-0767 xl21
Phone: 781-231-0244
Jean Bretzke NGRID Gas
54 Lawrence St Total $3,057.45
a
Salem MA 01970 $3,057.45
Safety Issue(s): Asbestos Siding/Lead Paint Possible
Fixed Sweep 1 n $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 Y g $]00.00 $]00.00 1 $100.00
Exhaust Duct
—MM in
Domestic water pipe7(dense
6 $2.95 $17.70 6 $17.70
Double nailed asbest986 $2.59 $2,553.74 986 $2,553.74
(dense pack)
Drill finish patch pla149 $2.13 $317.37 149 $317.37
pack)
Total
$3,057.45 $3,057.45
Date:2/17/2015
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