20 LIBERTY HILL AVE - BUILDING INSPECTION 3 3-- 1 `-f CK q -7 Z�,a'
The Commonwealth of Massachusetts
} Board of Building Regulations and Standards Cl'rY OF
Ij( Massachusetts State Building Code, 730 CMR SALEiv(
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised blur ZUl!
One-or Tivo-Family Dwelling
This Section For Official UseOnl
Building Permit Number:, Oote A lie 3
Building 0 cia (Print Mime) gn Dnte
SECTION is SITEINFQfmu
1.1 Property Ad�resr. 1.1 Assessors blip&Parcel Numbers
' o L�Aco, � , <✓;jv g
/ A
I A a 1s this an acce ted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensional:
Farling District Proposed Use Lot Area(sq R) Frontage(n)
1.5 Building Setbacks(It)
Front Yard Sid*Yards Rea:yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(M.O.L c.40,§54) 1.1 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zane? Municipal Q On site disposal Check i/ esQ P p system ❑
SE�CTIONZq PROPERTV•OW(VERSHDDI
2.1 Ownertof Fcard: /
r h ! S oIJ L /�L,
"met""") i City, ae,ZIP
A
Na,and Street Tel hone Email Address
SECTION 3: DESCRIPTION OF PROPOSEDSVORKs'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied (3Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ NumberofUnits_ Other ❑ Specify:
Brief Description of Pttopased
/ S'r��v�lov curd all
SECTION a: ESTINLATED CONSTRUCTION COSTS.
Item Estimated Costs: OfRc1nl Use Only..
y' .
1. Building 3 11 0 I. Building Permit Fee:S lhditata how fee is determined:
t. Flectrical y QStandard.Citytrown.•lpplicationFeel '
CI rotsl Pioject Coat](Item 6).x multiplier x
). Plumbing i ). (3ther Faez .3
I ,\lach,(nic.11 (1IV.it:) i List:.
i. ,\I<eh.mic.tl (Pint
---rj
n — -- -_ total All 1:e::s' i _
Chac.l' No. Check,\utunnt: t',i;h ;\uwunt:I'ntal I'rnjcet ( 'mt oD I U I'.tid is I iill 0(hitst'lltding I4il:utea I!u:
SECTION 5: cavi-i-Rucrwry SEItVICE:S
5.1 Construction Supervisor License(CSL) — v'
(7 e / OVI-1
license Number Gspiruiou uro
N;tme of OL I lolder List CSL rypa(see baluw)
//I* ct e-�a/r I rYpa Description
No. and Street U Unrestricted BIt In s u to)S,OUA cu. 11.
/S C/)�r�2 a itRmtricted I Vie?F.unil Dw¢Ilin
City/town,State,L Ro
IP M uunr
RC utin Cuvcrin
WS \Vinduw and 5idin
SF Solid Fuel Burning Appliances
I Insulation
6/ 389.7f5� Email address
D Demolition
Tole hone
5.2 Registered Home Improvement Contractor(I11C)
HIC Registmtlon Number Expirodun Date
I IIC Company Noma or 110- Registrant Nmne
Email address
No. d Street n /,q o/ 7.f/-3�-7CA?
's"�� '����� — T2Ie hone
Ci ITo� State ZIP
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(dLG.L.C. 15L 1 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...........0
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 �
Q ✓ 4/S
to act o my behalf, in all matters relative to work authorized by this building permit application.
Date
grin U% ncr's Nmne(E ronie Signature)
SECTION 7h: OWNER1 OR AUTHORIZED:kGENT 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. !
/ f O/ Rule
�t wner'su:\mhurited:\gar sV,une(ElectrmticSigmitura)
NOTES:
I. higher uwn work,or an owner who hires an unregistered collimator
An Owner who obtains a building permit to do
(nut registered in the Home Improvement Contractor(HIC)Program), will M)l have access to the arbitr:aiun
program or guaranty land undcr \LO.L. c. 142A. Other important infurmatiun un the FRC Program can be found at
arwv m:u+.euv;oca htfurmation un the Construction Supervisor License can be found at a ww.ntas.<.,�W
2. Wile sab;tantial vwrk is planned,provide ilia information balu'f,1 a finished busemenduttics,decks or purch)
Petal tluor.uea(;.i. lt.) _----- _(including,. , g .
iros; living:uc.t(;rl. It.l fl.tbimbleroomcount ,—
`hnnbcroflircpl,rce;. _--
Numberufbcdrnomt; .---.---
`lunrber of hathnnnus _ Numl�cr of h.tlE'b.0 is -- . --___---
---
fucla;cd
u'•: I�„ ,Lr,a. --
WAP Work Order
I'iorth Shoi a Community Action Programs,Inc. Job Number:267:�7
fill Main SI reet Work Order Date: 10/13/2013
Peabody, 1111,01960 - Ownership:Rentz r
Phone:97f M-11830
kinerican )oor,Window,&Insulation Auditor: Brandor Dorrington
15 Bailey r.venue Email: bdorringtr n@nscap.org
!iaugus M,.01906 Cell:781-540-856 1
I3mail:wd 4:mgis(q!comeast.net Phone: 978-531-0''67 x121
Phone:78. 31-0244
Nicole Bisl on NGRID Electric $3,124.16
20 Liberty 8 ill Avc Total $3,124.16
Salem MA 019711
9"74-.;P 0-6:3 L
Landlord Vame 1 Bill Reddy'
:Landlord ?hone:
Pi cstricted-s lopes/ticored Y,9'7 $1.30 $386A0 297 $386.10
Hll W/•': lose
R-10 ! . mrestricted-settled 297 $1.21 $359.37 297 $359.37
celluh _
7-38 r r:atricted-s:64ed cellulose 88 $1.47 $129.36 88 $129.36
11MAg :
Roof v 1 86,5(A sq it iNFV)small 1 $80.00 $80.00 1 $80.00 front access for blow get OK from L.L.
�'I16re 111 !N 'I!i N�N,I�i! !��+11!!'i+�!�Pl"''!qi lJltl'u�N'Ndtiti'u♦1N�1I1��NI�I!Ja N1 �N1N,
b u �i�1N1% NNNN N N
Sill r v )airt foam v/fiberglass ball 59 $2.20 $129.80 59 $129.80
; .',Iy !'I ' IdINU�Ni'I! INIIIII!�� N ill 1;lJ(I!INtlI!NN!IN'll�llN%,!NI'I! NNN!I!!iNNNIVi! !!!NINN�! N!N!!iIN' NiNN! Ilr{6'N IIiINNNIIN� N !NiCNi
Fixed veep 1 $15.75 $15.75 1 $15.75
- —� _ 3 $52.00 $156.06 3 $1§6.00
Repw ' befit l)oor
Weat n,trip s/Q-1, or oqual 1 $45.50 $45.50 1 $45.50
Page 1
Dat, I 1,1312013
WAF Work Order: Job Number: 2673 7
I; :�1` I
AlIM f MINI
Clothes er vent inc ludinl; 1 $89.00 $89.00 1 $89.00
Exhaust'I wt
Vent kit whfan 1 $89.00 $89.00 1 $89.00
Domes,l. o� I I��f�4i fll I! I ��f !I� �� �! .!!! !! ` _ . !,�� I ' '!I !�I! ) . . s. . , I1..Ik�',I�lll I I?�.
rater pipe i+rap 6 $2.63 $15.78 6 $15.78 -
�s�'� �I' '��I'�l ilk�l!II�IN!I il!lil!IINIGI I!'I�Illfl� ' h' ,�N l���i�!!I�.�,li!II'�!pIIIJI(
Attica n g with twc-;,art foam 2 $75.00 $150A0 2 $150.00
Basem a dealing wit:11 wo-part 2� $75.00 $150.00 2 $150.00
foam 1
Blowe ur set-up a it11 pre dK post 1� $45.00 $45.00 1 $45.00
tests
Clean k ers 1.5 560.00 $90.00 1.5 890.00
Remo r I dpe insulati w 1.5 $60.00 $90.00 1.5 $90:00
Weal urip(Q-Ion nr eq tat)attic 1� $31.50 $3llS0 1 $31.50
hatch ' I �pp�i I '' I� I 'I I�III
l' f �I. ''�I { j I� fI u��I�vI�II!il II!�� !y`II�I@� 71rlll!Illfl,�l�lil�! 11� i9 l I li�.i Ik Iflff!I� ilfi7lim �l l�l!'QW0.1 &p _
�' ���!I 1 Ililllf� ffl�l dull �� l!6��64,��1,6..11�u1 �� HI�a.
Buildu Permit 1 $100.00 $100.00 1 $100.00
� ; r�'i711! li!!�!!fl!I�! l!il!i.11!"I;III!I!i�!I18 �;, I!i!!f ��llll�l8!II �6hi�!lid!dIJ!G' '��I ���; � Glr , i , l ..�p� ' Gfl ;����:d�l ,;i,u
�sl����i ;.:� I� ao,-.nllli ar, x�fl !Ia !,
Dout I Bled ashes o daluminum 400 $2.31 $924.00 400 $924.00 Fill Voids dense pack as needed
(den!e : l l;k)
Page 2.
Dat: 1 1 13/2013
WAII, Work Order: Job Number: 26737
Weath i rip Windov/Schlegal or 8 $6.00 $48.00 8 $48.00
equiva.(:
Total ,$3,124.16 $3,124.16
Contra; Instructlm is::
Before_= , I.irtgtheJob During the Job:
1.Plea::; i r:ify us 24 h mrs b;fore starting or scheduling a job. 1.Incorporate lead safe practice as applicable.
2.Plea ( : :inn•ed buih.ir g p(�mtit. 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 Certifie I Payroll Report Form WH-347.
Additiiii i Contracto Instructions:
;.of Insulat oar posted? Yes No (Circle One) - Attic Inspection form atta ched? Yes N/A (Circle One)
Cerhl
Contra Kira__ Dste; WAPAuditor:_— Date:
_. __ .__. - -
Eneri} :-hector:__,__ _. Daite:_
Fiscal Ofticer: Date:
FOR AGENCY USE ONLY
Language Other than English need(d? Yes No (Circle One)
I'm Post
-Dry,, 0.000 - If Yes,indicate language:
Stogy a 0.000 Occupany change in last 18 month;? Yes No (Circle One)
. H20 ' i ilk CO 0.000 Comments: .
Hea:i I iystem CC (.000 Number of windows_
Am : CO 0.000 Number of rooms_
Bloa.i I)oor 0.00
Page 3
Dan,, : ,,11.3/2013
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supcn-isor Specialty
License: CSSL-100824
WILLIAMJDEL*NG
15 BAT LEY STREET r `
SAUCUs MA 01406 —
a
Expiratiori;
• Commissioner 05/05/2014
_ Office of Consumer Affairs&Busi6ess Regulation elt
kJOME IMPROVEMENT CONTRACTOR
_egistration 111123
xpiration DBA
11/25/2014, Type:
AMER CAN DOOR WINDOW g INSULATION
WILLIAM DeLANGIS,v
15 BAILEY AVE
SAUGUS,MA 01906
Undersecretary
LI
to 'IviralInf _
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialty
License: CSSL-100824
WELLIAMJDEL iGI!S =
15 BAILEY STREET th
SAUGUS MA 01406
�•, i
Expiration,
Commissioner 05/05/2014
Office o % iaa /uoeAjmerAffairs ess t
Regulation
_ OME IMPROVEMENT CONTRACTOR
egistration: 111123
_ xpiration. 11/252 DBA
014. Type:
AMER CAN DOOR WINDOW 8 INSULATION
WILLIAM DeLANGIS-
15 BAILEY AVE
SAUGUS,MA 01906 g
' Undersecretary
r
• :9 9 i
CITY OF S�U.E. I, TNL�SSACHUSETTS
BUILDING DEPARTM&NT
3 N 130 WASHNGTON STREET, 3° FLOOR
`�•, TFL. (978) 745-9595
F.{x(978) 7.10-9846
KIJtBERL.EY DRISCOLL
11VLAYOR T -� osw ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/B(;IMING 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 1 l 1.5
Debris, and the provisions of tMGL 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:
(name of'hauler)
The debris will be disposed of in
�c,dher live �n
(name of facility)
Linn wet�rrL��
(address of facility)
f r 7 f
signetureofpermit pplicant
date
debri>oICJ.x
The Commonwealth % assachusetts
Depa/tment oflndustrialAceidents
i office of/nuesdgatiens
600 Washington Street, 7ta Floor
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant information: .Please PRINT legibly
name:
address: 041T
city u4 , stated zip Olgab phone#
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ElBuilding Addition
,�,
❑ I_=an�nemployer providing workers' compensation for my employges orking on this job.
comgsmv.name:
( .. ..
. .address:
city: phone#.
insurance co. policy# .a
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
.company name:-
„ r
address: .
4
[eity' ' r
)insurance co. ' -Policy# t
�Somusmvpname•• - -- -
iaddress: y 17
w
r ,
mtr3° phone#.. �r
tinsurance co. :._ _ "- - ". .policy# - -.- •• - .FL•r. _-
�Attack'adAifional -
Failure m secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature Date
Print name Phone#
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
(revised Sept.2003)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law",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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street,7/6 Floor
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406