8 LYME ST - BUILDING INSPECTION The Commonwealth of Massachusetts
: i ;Lti
Board of Building Regulations and Standards $ALEM
WMassachusetts State Building Code,780 CMR U L rVf 0.�3 6
Building Permit Application To Construct,Repair,Renovate Or DemAh a�
One-or T1vo-Family Dwelling
This Seet3on For 01 17se .Onlyj
Building Permit Number Pate Applied:
�9 ew
'"n1' ��cTloly 1:sITE ioRi►�rlort
1.),Prpperty Address: / /'p 1.2Assessors Map&Parcel Numbers
SI ! n, I
I.1 a Is 's an accepted street?yes ✓ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
_iX 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: P20ETYOW K
2.1 ntK rd� eaiec : ac /r , �RCS HI�0t 19 7 a
_
N-- ern O f S �
City,State,ZIP
8 L✓ices Ue- nz- 019
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(eheck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ jAddition ❑
Demolition ❑ Accessory Bldg.❑ N ber of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTI0IV 4:ESTl747ATED COPtSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Buil ng Permit Fes:$ - indicate how fee is determined;
❑Standard City/Town Application Fee
2.Electrical $ p Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fens: $ /�1
4.Mechanical (HVAC) $ List-, (/
5.Mechanical (File $ Total All Fees:$
suppression)
Check No. Cheek Amount: Cask Amour;;
6.Total Project Cost: $ �J71 0Cj ❑Paid in Full ❑Outstanding Balance Dne:
SECTION 5: COItfiTlt-IIG1TfIlN S>BRYILS a
5.1 Construcifim Supervisor License(CSL) C.s�L-/
.-I. I't �`� IIA'�IMN O 1
m Li-cease Number Expiration Date
ae of CSL Holder' (
y�/ /2 List CSL Type(see below)
/ �
No.and Street
U Ihvestricted(Buildim(Build' up to 35,000 on.ft.
l)Q C9U S� /a I R I Restricted l&2 FamilyDwelling
6ty/roveg
state,
/ZIP M Masonry
RC Roofing Covering
WS Wind and Siding
ow d
SF Solid Fuel Burning Appliances
I I Insulation
Tel hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) / / J I G
J I - L /f HIC Registration Number Expiration Date
HIC Com any N e or HIC RegL t Name
i At�� inP /Ieaen I)�ra�„�1e rJ,JP1,Z#4g ns�
N and treet '!:mail address
City/Town, State ZIP Tel bane
SECTION 6:WOR�'COA4I?TNSATION PMRANCE.AFFMAVIT(ALG:L c.152.i ?5C(4))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the IssuapeC of the building permit.
Signed Affidavit Attached? Yes ..........46 No...........❑
SIBCITON is.OWNER ALM96RUATION TO BE COA4PLETEA�'�1V
OWiR^S AGENT R 9R F R INfa kER1111f
I,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:OWNFW 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 understanding.
/JJI 10,VA rl e Lang it � , /G
Print Owner's or Authorized Agent's Name(Electronic Signore) - hate
Nt)_ S:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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
w�vw.mass.sov(oca Information on the Construction Supervisor License can be found at wwtiv.nmss.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.R.) (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 haWbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth ofMassachuseft
Department oflndustrialAccidents
I Congress Street,Suite]00
Boston,AM 02114-2017
www mass.gov/dia
VJWorkers'Compensation Insurance Affidavit:Builders/Contractors/ElecWcians&iumbers.
TO BE FH.ED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Paint L blv
Name(Busmess/Orga�tion/lndividuao: l c 1 /I l ion C.L g h
Address.- a ,601 �ry ve
City/State/Zip: 'c8 u US � Phone#: 7 2 t2�11-OJ�y
Are you as employer?Check the appropriate bor:
1.01 am a employer with E
f project(required):
emrpkyers(ruts endrmpart-time).• ew construction
2.01 am a sole proprietor or paftaship end have no employees woddng forme in
enY capacity(No wodrea`comp,+aa,•�•... tequoed) emodeling
3.01 not a hormeowna doing all work mysetr IN.workers' W.imumnce requoed.J 1 emolition
4.0 I am a homeownc and win be hiring contractors to co doct all work on my pmparty. I wig uilding addition
ensure that all contractors affiahaw workers'compensation insurance or are sole Electrical repairs or additions
proprietors with no employees.
5.01 am a umbing repairs or additions
geaerel connector and t haw:hoed the subcomracrore listed on the attached sbeet.
These sub-contracors have employees and have wodras'comp,insnsaotx.+ oofrepays
6.0 We are a coryoration and in offices have exercised t6eirright of exemption paMGL c hCI�,/s//15Z§1(41 and we have no employees.[No workers'eomp.:..�.. one requood,J
fAny a�liram cleat checlo boxNI oatlsoffllomtheseaonbelowworkers' on on,
Honseo—who subndt this affidavit odicatmg they are doing an work and than rare omrside cooneeors must submit a raw afidavit mdiciong such tConhacmrs that check this box must aseched an additional sheet showing the sense ofthe sub-coffiectors and state whether a not those entities have
CmPloyees. lfthe sub- ftac tors have employees,they must provide lh.. work.,comp.pohey nmmber.
lam an employer that is providing workers'compensation wsurancejor my employees Below is ikepolicy andjob site
bnjormatlom
Insurance Company Name: . e
Polity#or Self-ins.nLic.#: q Expiration Date:
lob Site Address:2i z r210 X 1J" City/Statcaip_�a_le-W, 14'?
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL C. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDBR and a fine of up to$250.00 a
coverage verification.
day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance
do herebyJcertrjyu7nder the pains anndpenahim ojperjuiy that the mjomm�ahon provided Is tree and eoneeL
Sisnature• d//1Y�/ M 14 44� Date:
Phone#
r
F
only. Do not write in this area to be completed by coy or town officlal
n Permft/Lfcense#
ority(circle one):
ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
on: Phone#-
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,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 a joint 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 then three apartments and who resides therein,or the occupant of fire
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,§25C(6)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,MGL chapter 152,§25C(7)states"Neither the commonweakh 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 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLQ or Limited liability Partnerships(LL.P)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. if an I.LC or LLP does have
employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their
self-insurance license number on the ate line.
City or Town Officials
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. In addition,an applicant
that must submit multiple perrmittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or narked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
u5-14- 1b ii :oi tKUM- T-261 P0012/0014 F-629
Work Order
North Shore Community Action Programs,Inc. Job Number:22366
119 Rear Foster Street,Building 13 Work Order Date:5/17/2016
Peabody,MA 01960 Ownership:Renter
Phone: 978-531-0767
American Door,Window,&Insulation Auditor:Brandon Dorrington
15 Bailey Avenue Email:bdorrington@nseap.org
Saugus MA 01906 Cell:781-540-8569
Email:wdelangis@comeast.net Phone: 978-531-0767 xl21
Phone;781-231-0244
'\�ex4
Helen Jaworski NGRID Electric $7,474.33
8 Lyme St Total $7,474.33
�7 Salem Ma 01970-4918
`16 _ 4� a t� Safety Issue(s):Lead Paint Possible
:r
k
r r.
d'af TEN r,
R-18-20 restricted-slopesifloored 442 $1.63 $720.46 442 $720.46
fill w/cellulose
R-49 unrestricted-settled cellulose 440 $1.99 $931.60 440 $931.60
Owns M _ " .n.,. n-. :-ac%s .1. 3 o t' :iv
Rectangular gable vent 2 $108.15 $216.30 2 $216.30
Roof vent 865(A sq It NFL small 1 $94.50 $94,50 1 $94.50
Sill/mudsill seal&insulate to R-19 126 $7.58 $325.08 126 $325.08
rat ' I MEN ME
1"TIIERMAX or equivalent on 1 $60.00 $60.00 1 $60.00
door
Automatic Sweep single flange 1 $27.30 $27.30 1 $27.30
Fixed Sweep triple flange 3 $18.52 $55.56 3 $55.56
05-19-'16 11 :52 FROM- 1-261 NOO13/00"14 r-132y
Work Order: rob Number: 22366
Weatherstrip s/Q4on or equal 4 $53.55 $214.20 4 $214.20
i
'.,,or
s
Attie/basement blower door guided 3.5 $89.20 $308.70 3.5 $309.70 1.5 hr basement/2 attic
sealing with two-part foam
Blower door set-up with pre&post 1 $45.00 $45,00 1 $45.00
tests
Clothes dryer vent including 1 $105.00 $105.00 1 $105.00
Exhaust Duct
Seal ducts with mastic or butyl 3.5 $76.65 $268.28 3.5 $268.28
backed tape
Weatherstrip(Q-Ion or equal)& 1 $70.35 $70.35 1 $70.35
R=code,attic hatch
SKiw ,� w ,/. .�' ,, Xr pkr ..,s ,,a P .
:s 'r, 3, - sR�. ` . 'r. ,Az ,Ti'T, '.�' "e.�.ti 4,S, w, ;;, .«ru�� ,3?:.
Remove Duct insulation for access 1.5 $70.00 3105.00 1.5 $105.00
seal seams
�� Q. �, .b_ .� .. r t 1 '1,r. sq,- w
pp��
tt ^ �. `«.�., .2. ' q„,'Fy7x. s .:Ac>`: tytiit° F ?.
Building Permit 1 $100.00 $100.00 1 $100.00
y,� r
;�, ;an ( a
Wood clapboard/shakes/shings or 1870 $2.10 $3,927.00 1810 $3,927.00
vinyl(dense pack)
Total $7,474#33 $7,474.35
Contractor Instructions:
Before Starting the lob: During_the.Job:
1.Please notify us 24 hours before starting or scheduling a job. 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.
llm..• cH0/oO/L Panes 7
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 1.11123
Type: DBA
Expiration: 11/25/2016 Tr# 260215
AMERICAN DOOR WINDOW & INSULATIO
WILLIAM DeLANGIS
15 MLEY AVE
SAUGUS, MA 01906
Update Address and return card.Mark reason for change.
Address I__ Renewal Employment Lost Card
SCA 1 u 20M-05/11
- Mass j
achusetts Department of Public Safety
Board of Building Regulations and Standards
License: CSSL-100824
. super visor aoeciaity
r uI
WILLIAM J DELANGIS
15 BAILEY STREET
SAUGUS MA 01906
Expiration:
Commissioner 08/0 512 018
`Pid�