5 MARCH ST - BUILDING INSPECTION The Commonwealth of Massachusetts
' Board of Building Regulations and Standards CITY OF
S EM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
1 Building Permit Application To Construct,Repair,Renovate Or Demolish a
T One-or Two-Family Dwelling
This'Seetion For Official Use Only
Building Permit Number: 1,6ate Applied:
i
I� 9 r
Budding Oflicial`(Prmt Name) Signaturc ate r-
1 SECTION 1:SITE INFORMATION a
1.1 Pr e ddressq• n �f 1.2 Assessors Map&Parcel Numbers
I.Ia Is this an accepted street?yes no Map Number Parcel Number m
1.3 Zoning Information: 1.4 Property Dimensions:
N n
m
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 Pmvided
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 Owne t.of Record:
4�&1-911ne, MC.n " MP 0/171)
Name(Print) City,State,ZIP
3 979-71s -- ',qS
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Prop ed rk'
SECTION 4;ESTIMATED CONSTRUCTION COSTS,
Estimated Costs:
Item Official Use Only
(Labor and Materials
1.Building $ SgrJ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard"City/Town"Applicatioa Fee
'
2.Electrical $ {a,'jt7r 0
❑Total Prnjed Costa(item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
a Check No.- Cheek Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full O Outstanding Balance Due:
0)0111 l_AI�:70 al l
C�2e �/fin err /nsfdl/ /�Qn .i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City,fFown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 egistered Home Improvement Contractor(HIC)
dk m A ey L 2gi4j S HIC Registration Number E pira on Date
HIC Com�paqy Name CHIC Registfapt Name / y
�r 4//rLll.GQ 4ir ��dldt�l V� Y,</ Lri tie Gc7 ais - 00"h Ca6'Ss VP
�5d 3iQ//e./ �le -1S)63 V, 76 R� mad address
City/Town, State,ZIP Telephone
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
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:OWNEW 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.
�Zt�lra.>7 d2 �nh4/S 9/��
Print Owner's or Authorized Ag nt's Name(Electronic Signature) Date
NOTES:
I. 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
w�vw.mass.uov'oca Information on the Construction Supervisor License can be found at www.nrass.eov/das
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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
l
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ��Aq -- Please Print Legibly
Name (Business/Organization/Individual): //.l�rLQ/1(,�y/1 .!l-ctA7 'd
r
Address: A946l -
City/State/Zip: Oagk&gd / Phone#: 7el-5ff"7- 74j&t
Are you an employer?Check tiVappropriate box:
Type of project(required):
1. I am a employer with J employees(full and/or part-time).- 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for mein g. ❑Remodeling
any capacity.[No workers'bomp.insurance required.]
3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
❑
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition.
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I an,a general contractor and I have hired the sub-contactors listed on the attached sheet.
These subcontractors have employees and have workers'comp.insure nce.1 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _-/,,- '
Policy#or Self-ins.Lic.#:---0 � � Expiration Date:��//// j/ l
Job Site Address: City/State/Zip:�Yd'O,lr �(7
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 ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby�.ceeerti'(/y eu/ndde��r��th��the pains and penalties ofperjury that the information provided above is true and correct.
Sumature'/L�.J,t.`iXrt��rz 6d Date JQI✓Vkr
Phone#: 7 g/"'3$g- 76S'� .
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: 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 of 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,§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 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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC 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 appropriate 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/licrose number which will be used as a reference number. In addition,an applicant
that must submit multiple pemvt/license 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 marked 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
1 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
Office of Consumer Affairs and Business Regulation
uV 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration' 411123
Type: DBA
Expiration: 11/25/2016 Trlt 260215
PN&PltAN DOOR WINDOW & INSULATIC3 --
ILLIAM DaLANGIS
M - - -
�I'6 gAiL1=Y AVE -- - -- -
SAUOUS, MA 01906 - - - -
Update Address and return card.Mark reason for change.
-" Address Renewal Employment ❑ Lost Card
scA i ri 2auosrii - -
tauolsspuwop '
MV901so
uol;ejtdxgf 49,
9 10 VH SnNnVS
yffaars ATE"si
jgr raa r W VIT�iM
vzaoo��sso :88i,001�
.QlntiadS msi:uadng"'PrMsu"
gpiepue;s.pue suol;eln6e2l 6u!pl!n6 do pryeoe ANN
Il;a;eg oggnd;o;uawNedap-suasnt;aesseW �` i
06/24/2015 22:15 7813970115 PRESCOTT AND SON PAGE el
DATE(MM@D/Y'YYY)
SL2 . CERTIFICATE OF LIABILITY INSURANC IS E rssurD As A MATTER of wFORMAnoN
TC
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFD OR
Ambrose Insurance Agency, Inc- THIS CERTIFICATE 00
ALLTER THE COVERAGE AFFORDED BFS Y THEPOLICI S BELOW.
56 Central Ave,
Lynn, MA 01901 j INSURERS AFFORDING COVERAGE ' NAIC#
781-592-8200 imuRERA Northland
INSURED Delangis, William INSURER B� Arbella Pro ct'on
AWeriOan Door, W'ndow 6 Insulation. )
INSURER C: L• ert Mutus
15 Bailey Ave. NSURER D.
Saugus, MA 01906 INSURERS:
NG
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED--TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.MAY
BE ISSUED
DI
THE REQUIREMENT;TERM DR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THiS CERTIFICATE MAY BE ISSUED 4R
POLIC ERTAD,THE INS RANGE AFFORDED
HAVE BEEN REDUCED DESCRIED BY PB DGHdRUIN IAIMS. IS SUBJECT TO ALL THE TERMS,EXCLUSIONS ANp CONDITIONS OF SUCHMAY
OL EFF DOALI M M, LIMITS
A POLICY NUMBER D T OD Finn
LTR , R IEACH OCCURRENCE S 1 S
_GENERAL LIABILITY PREMISES BdCCWen $ s0 000
1 X COMMERCIAL GENERAL LIABILITY MEDEXP(A.Y.-P°,son) S 5 OOO
CLAIMSMADE �X OCCUR - 6/24/15 6/.24/16
A PERSONALBADVINJURY S Dpp 00O
Binder 1 GENERAL AGGREGATE S OOO OOO
PRODUCTS-COMP/OPAGO S 000 000
I CENL AGGREGATE LIMIT APPLIES PER:
POLICY jE C I LOC 3 ].,00'0,000
COMBINED SINGLE LIMIT
AUTOMOBR.ELIABII.ITY (Ea Zdant)
ANYalRO i BOOILYm b
I (Pw Person)n)
ALLOWNEDAUT05
I x, SCHEOULED AUTOS 4/4/15 4/4/16 BOOILYINJUKY S
B i HIRED AUTOS 1020020026 (PereeoldenC
NON-OWNEDAUTOS PROPERTY DAMAGE S
(perecTJdent) _
ALITOONLV.EAACCIDFM S
EAACC 'S
I GARAGE LWBILITY OTHERTHAN
AUTOONLY: AGO
ANYAUTO S
EACH OCCURRENCE
AGGREGATE If
EACESSIUMBRELLA LIABILITY S
'�OCCU0. L_I CLAIMSMAOE 1
i I 3
S
DEDUCTIBLE A U-
e X R
RETENTION S I
WORKERSCOMPENSATIONAND ' GA-EACHACC_ a 500 000
EMPLOYERS LIABILITY - g/20/15 1 6/20/16 E,L DISEASE-EA EMPLOYE S 500 000
C I,wY v OPRIEtORIVARTNSRIFXEPIRIVE E.L.DISEABE-POLICY LIMIT $ ��
oFAKeRe eNseA E%cLUDdW Binder
II E IAJp OMSIr
S�ECIAI PROVISIONS Balaw
OTHER
CIAI PROVISIONS
DESCRIPTION OF OFERATIONSILOCATIONS,VEHICLE51 EXCLUSIONS ADDED BY ENDORSEMENT lSPE ~
Carpentry 6 Insulation d b a Boston Gas Co
National Grid Corporate Services, LLC d/b/a National Grid, / /
Natio assex Gas Co. , and Action, Inc. are listed as additional inaureda-
general liability Only.
CANCE TOM
BE CANCELLED BEFORE THE EXPIRATION
CERTIFICATE HOLDER SHOULD ANY OF TNEASOVE DESCRIBED POLICIES
AEiriD DATE THEREOF,YRE ISSUING INSURER WILL 6NOEAVOR TO MAILTHEEFT. ^„- DAYS WRITTEN I,
176 Tremont St- NOTICE TO THE CERTIFICATE HOLDER NAMED TO BUT FAILURE TO DO SO SHALL
O IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIN
D UPON THE INSURER,ITS AGENTS OR
Boston, MA REpRESENTATME
AUTHORIZED R E E
O ACORD CORPORATION 189E
ACORD29(2001108)
F
s
Work Order_
North Shore Community Action Programs, Inc. Job Number: 120021
119 Rear Foster Street, Building 13 Work Order Date: 8/5/2015
Peabody,MA 01960 Ownership: Owner
Phone: 978-531-0767 -",4 -�
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
�n
Christine Mcniff MAJOR REPAIR FUND- $750.00
5 March St ELECTRIC $7,398.66
Salem MA 01970 NGRID Electric $8,148.66
978-745-5033 Total
/ k o f .Y B00 Safety Issue(s): Lead Paint Possible
Authorized Actual
Measure Description Qty Comments
price Total Qty Total- ,
Attic Insulation
Attic stairs-fill with cellulose 1 $151.00 $151.00 I $151.00 FB walls and 2part seams
R-30 restricted-slopes/floored fill 230 $1.59 $365.70 230 $365.70 Floored flat...(adjust insul. amounts once
w/cellulose opened as needed b/c of diff. ceiling heights)
R-30 unrestricted-settled cellulose 382 $1.53 $584.46 382 $584.46 rear sloped flat
R-38 restricted-slopes/floored fill 230 $1.64 $377.20 230 $377.20 Floored flat
w/cellulose
Attic Ventilation
Rectangular gable vent 2 $103.00 $206.00 2 $206.00 install next to windows on cheeks(owner
oked)
Roof vent 865(A sq ft NFV) small 3 $90.00 $270.00 3 $270.00 middle(do not install to low b/c of insul.
height)
Doors
Fixed Sweep 5 $17.64 $88.20 5 $88.20
Repair/Refit Door 1 $58.00 $58.00 1 $58.00 attic
Site Built Basement Door 1 $489.00 $489.00 1 $489.00
Slide bolt 3 $24.00 $72.00 3 $72.00 attic
Thermax (or equivalent)on door 2 $57.00 $114.00 2 $114.00
Date: 8/5/2015 Page I
t t
Work Order: Job Number: 120021
Weatherstrip s/Q-Ion or equal 5 $51.00 $255.00 5 $255.00
Health&Safety
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
Misc Insulation
Domestic water pipe wrap 6 $2.95 $17.70 6 $17.70
Hydronic pipe insulation to 1 in. 20 $3.82 $76.40 20 $76.40 dryer room water pipes
copper pipe R-5
Misc Measures
50 CFM bath fan(new with switch) 1 $750.00 $750.00 1 $750.00 2nd floor bath in slope/attic above
Attic/basement sealing with two- 4 $84.00 $336.00 4 $336.00 EXTENSIVE...attic....once opened adjust as
part foam needed
Attic/basement sealing with two- 1.5 $84.00 $126.00 1.5 $126.00 2PART @ sills
part foam
Blower door set-up with pre & post 1 $45.00 $45.00 1 $45.00
tests
Recessed Light Enclosure 5 $33.00 5165.00 5 $165.00
Permit
Building Permit 1 $100.00 $100.00 1 $100.00
Wall Insulation
Wood clapboard/shakes/shings or 1651 $2.00 $3,302.00 1651 $3,302.00
vinyl (dense pack)
Date: 8/5/2015 Page 2
r _
Work Order: Job Number: 120021
Total $8,148.66 $8,148.66'
Contractor Instructions:
Before Starting the Job: During the 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 (Circle 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:
Energy Director: Date: Fiscal Officer: Date:
Date: 8/5/2015 Page 3