30 MEMORIAL DR - BPA-13-1048 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
(`1 Massachusetts State Building Code, 780 CMR SALEM
/I O Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print N ) Si atur D R
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
73go 1s4,F(,A6r- 1 0r,
Lla Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed U e Lot Area(sq ft) Frontage(ft)
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 Owne 'ofRecor : f
0 (J " III �(dvm rVAA
Name(Print) ` City,State,ZIP
36 (JIerlaf fAl a1 976-57�-4`6l
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) IF l I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed World: �Y rn d
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ '0� D p 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Five Su ssion $ Total All Fees:$
re
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ kt-7� ❑Paid in Full ❑Outstanding Balance Due:
k-�Aaa vU �Gt-i o GNU(/(lli
SECTION 5: CONSTRUCTION SERVICES
5,1 Construction Supervisor License(CSL)
I O.tYt tj �-rr otS License Number Expi�ation ate
Name of CSL Holder
List CSL Type(see below) U
1 t Type Description
No.and [reef
(��1_ ^ � / U Unrestricted(Buildings u to 35,000 cu.ft.
r Y) U {-1 "l�l l 0 R Restricted 1&2 Family Dwelling
City/Town,Stlne,ZIP M Mason
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
L,/GrreN�e1-�oN I Insulation
Tele hone Email address D Demolition
5.2 Registered Ho/me Improvement Contractor(HIC) )O�qq
Lt I w^t'e-N 12'',1 53 tJ HIC/Registration Number Ex [ration Date
HICK cC..ompany Name or HIC Registrant Name
J�. W i tf�.NA•—��. (.PgReN Pe�aN uF t4w d,�, '.kw—t
No.and Street, Email address
Y✓A�aa�Lu rAIN D�gla 97''6'`ZS`G-a4��
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 ..........09 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 �a R eJJ �rg rJ")
to act on my behalf,in all matters relative to work authorized by this building permit application.
pores a r;N01 ffl 6 /5 I )--
Print Owner's Nam ignature) I I Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of petjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
/A In� r-t-<.N P"i-S.t G
50
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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. og v/oca Information on the Construction Supervisor License can be found at www mass.eov/dos
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"maybe substituted for"Total Project Cost"
11!651 T�
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- Massachusetts -Department of Public safety- - - .
Board of Building Regulations a -
Cnnsrrurtion and Standards -
Supen isor _ --
License: Cg-oam
WARM A PB Ajyq;p
150R WINONASTBg '
W PEABpDyBfA 014 3
�.L 11/��, ,1 m ExpiraYior, .
Commissioner - `
7.
Ofliee of t:oasomer Aff°'rs&Baseness Hcg°tatioo License or repstration valid for iadividal use only
ME IMPROVEMENT CONTRACTOR - ? before the exPirattou date. If found return to:
"Oft: 107M - -Type: Office of Consumer Affairs and Business RegalBtion
- va0on- -.OHf2014:-. Individual 10 Park Plaza-suite 5170 _ -
WAP.REN A PEARSON` _ Boston,MA 02116
W2:ren Pearson
Peabody,MA 01�0 Underseere
�'9 Not valid without signature
't
�. CITY OF S.UXIN41'L-kSSACHUSETTS
• BUILDING DEPARTMENT
a 120 WASHINGTON STREET, P FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIN
tBERI.EY DRISCOLL
(MAYOR THOMAS ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUll.DiNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business.'Organizatiorvlmlividual):
Address: 150 W l\go
City/State/Zip: MA -014 C Phone #: q7 SC-7 51-o, q -Sq
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.2 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑Building addition
[No workers'comp. insurance 5. We are a corporation and its 10.❑ Electrical us or additions
required_] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12,❑ Roof repairs
insurance required.)t employees. [No workers' 13 ®Other
COMP.insurance required.]
•Any applicam that checks box A I most also fill out the section below showing thew workers'compensation policy information.
*I Inmecamas who submit this affidavit indicating they ate doing all work and then hire outside comraOors must submit a new affidavit indicating such.
:Conuacton that check this box most attached an additional sheet showing the name of the sub.wnttazlon and their worker'comp.policy inf xinatim.
I am an employer that Is providing workers'compensation insurance jar my employees. Below Is the policy and fob site
information. -
Insurance Company Name: ` //L��1—G1PP 1Krs ``�/JStAr t4et
Policy#or Self-ins.Lic.q: U f> L 2 �16 Expiration Date:. I)�
,J T
Job Sire Address: V l n M-eMo r'fb,) 0 j', City/State/Zip: S,,6r,� M
Attach a copy of the workers'compensation policy declaration page(showing the policy number and aspiradon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a flue
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: .1�7 id /z /�i Date, 6/ l J
Phone 9, q�7 TT
e6`�7 J 19
Ofrcial use only. Do not write in this urea,to be completed by city or town officiaL
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
I. Board of llealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
�0410=013
,d►o h CERTIFICATE OF LIABILITY INSURANCE _
OF tNFORMA'IION ONLY AND CONS TER THE COVERAGE AFFORDED BY THE POLICIES
TE
THIS CERTIFICATE IS ISSUE AS A MA7'TEOR NEGATIVELY AMEND. EXTEND THE ISSUING INSURERISb AUTHORIZED
CERTIFICATE DOES NOT AFFlRMATNEI. -
BELOW. THIS CERTIFICATE OF INSURANCE GOES NOT CONSTI'I11TE A CONTRACT.BETWEEN
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER mraI be endorsed. N SUBROGATION IS WAIVED.subjeNx to
If tire bolder an ADDTIIONAL INSURED, n M A sfatmnent on this Nrer66cate�s not confer rights to flee
athe te terms aannA di> POW.�Sporm es nW require
cerfHlcate holder in Rau Of such endorse Paste Joyce M ICeRer -
rnoDuces PHONE - Ne
Phil Garden
Insursrhce,Inc- L �oyce�Ph9richandilsaranee'cmn
27 Garden Street NAhc s
Unit1B AFFORpgNNCOVERAGE _ 19046
Danvers.NIA 019Z3 Travelers Cas Ins CO of Amer
NNMIgEtA: - 41360 -
INSURERS: Arbella Pmtecilon 26M
INSURED Pearson—..derS,--Inc. wmausiec: Travelers Ind CO of CT
1
16OR Wirwns Street eNsuREaD:
_ Peabody.MA01960 resDaseE:
IF REVISION NUMBER* _
COVERAGES CERTIFICATE NUMBER:
OO
pNDING ANY REONR.EMENT.TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
THIS IS TO CER'DFY THAT THE POLICIES OF INSURAPICE'L1STID EELO�OR��N E POLICIES DESCRIBED HERB"IS SUBJECT TO ALL THE TERMS.
INDICATED- NOTVIa'IHST
CERTIFICATE MAY BE ISSUED OR NIAY PERfgIN,THE INSURANC Era tnars
IXGLUSIONS AND CONDITIONS OF SUCH ppLICiES LIMITS SHOPO�N��BEEN REDUCED BY PAID CLAIMS. 1,0D0,000
TYPEOFRshn+aNCE gg0565M5386 11282012 11126/2013 EAralaccuRRENCE s 300.000
s
A GteNFRAI-LIAe1LhrY mS S 5,000
COMMERCIAL GENERAL LIABILITY NEDENP PE 1,0001000
OCCUR Rs 0 N AL a ADV 1 11lURY S
CNAarS4VDE <.- GENERAL nr RrsATE s 2.000.6w
PRODUMS_CONPIOPAGG $ 2,ODO,000
S
GErLAGGREGA7E UMRAPPUESP U
POLICY PRO- LOC 1020004331 07/18/2012 07/162013
250.1XX1
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� aceILY IURYW80 ^AI S �--
AUTDNOStl.E -
eoonslNIMURYOPaa�9 s 500,000
AWAUTO
ALL OWNED
SCHEOlLED - - OABAGE S
AUTOS a oNNED S
HREDAums AUTOS EAUNoccuRRExE $
UMSS LLALIAa OCCUR AME $
8=0 UAD aaees-ew°E S
RErEem°RS UB68M1316 QT26f2013 03f262014 VICSTATLL -
oEn _ -
C AM UAeartY YIN _ _ ELFACIrAC $ 100,00I
-EA o 100,001
�CERI NIA FBI..DISEASE_POUCY LearS 500,E
p1I"ra'aIu_wym NII)
pE5(,1RPnON OF OPEi7N1ON5b
ONGFOPERATDNBILOCA7WM8/VBaCLEa(aacG ACORD@r. h
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CERTIFICATE HOLDER
. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
PEARSON BUILDERS THE IXPIRATWM DATE THEREOF, No= WILL BE DELIVERED IN
150R WDhona Sheet ACCORDANCE WITH THE POLICY PROVISIONS .
Peabody.MA 0196O �—
pGmGRUSDROI>£sENam/E
®1988-2010 ACORD CORPORATION.?�All rights reserver
ACORD 25(2010/05)
The ACORD name and logo era registered marls of ACORD
GJS10M BUILD
Vit
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*L TANZELLA
fie' -.d 7C,
A o C O N
Vito Tanzella 63 Bachelder Road
Proposal Raymond, 03077
603-895-1316 Fully insured
MA Lic.# 059428
Proposal Submitted to: I
Phone Date
of ti
Street Q"'I�'P� City, State, Zip
e- S
Job Name Job Location J P o
�7�'s�78- i6�Z
We are pleased to quote to you the following price for the work as specified below.
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(F�c`Cy.�n� P1t7CDsy .4-
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Pa/�- � 2- 'L
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We hereby propose to furnish material and labor for he total surr�"1 of: OLLARS (�7�=)
AMOUNT G WSJ 7'��rs4� 9-r'ae? �G�
Payments to be made as follows, V3 down, 113 start, balance at completion.
All materials guaranteed as specified, all work to be performed in a workmanlike manner.
This price is guaranteed for days.
Acceptance of the proposal, the above prices, specifications, and conditions are satisfactory.
You are hereby authorized to do the work, payment will be made as specified above.
Date of acceptance: � Ira Signature: � � G e-r-)r-A