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151 NORTH ST - BUILDING INSPECTION t t The Commonwealth of Massachusetts OF Board of Building Regulations and Standards CITY M Massachusetts State Building Code, 780 CMR SALE Revised Mar 2011 / Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Two-Family Dwelling This Section For Official Use Only l Building Permit Number: I Ditg,Ap 'ed: --Building.Official(Print Name) ign e. " Date - SECTION 1: SITE I= FORMA 1.1 Property Address:�5� 1.2 Assessors Map&Parcel Numbers Nord, S� L l a 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 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: Zone: _ Outside Flood Zone? Public❑ Private El Zone: if yes❑ Municipal ❑ On site disposal system [I SECTION 2:(PROPERTY OWNERSHIPx �.;, 2.1 Ownert of Record: e�rlY Sol(eM 1 ITS Name(Print) City, State,ZIP % S ) No �1n ��i. 97p-a35-�l16a No.and Street Telephone Email Address SECTION 3: DESCRIPTION'OF'PROPOSED WORK2 (check all thatapply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) H I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Descriptio of Proposed W rkz: eM ' + d t i- 1 e 5 SECTIO14,4: ESTIMATED CONSTRUCTION`COSTS Item Estimated Costs: l Official`Use Ord yi + Labor and Materials R " 1. Building $ 1 "Building Permit Fee $' Indicate how fee is determined: ❑ Standard CifylTo'wnAgplicahon Fee 2.Electrical $ I s '. ❑TotalProjectCost (Item6)zmultiplier x" 3. Plumbing $ 2:30therFees: $ � 4.Mechanical (HVAC) $ List` 5. Mechanical (Fire , �. Suppression) $ Total All Fees Check No : Check Amount .Cash Amount. 6. Total Project Cost: $ "'j �nl] 0paid in!Full Outstand ng Balance Due:: e` SECTION 5r CONSTRUCTION SERVICES 5 - Construction Supervisor License(CSL) ,, aYnl C pe,�I—S:a 1J License Number Ex ' anon ate Name of CSL Holder - 1,�� /�^(� List CSL Type(see below) SC) V`�'�ND. �" - a No.and Street Type `Descnpnon' .'� Pq\ 1 M n lit U Unrestricted(Buildings u to 35,000 cu. ft.) b�"}1 l71 R Restricted 1&2 Family Dwelling City/Town, State,VP M Masonry RC Roofing Covering WS Window and Siding e SF Solid Fuel Burning Appliances q�-�s�— a 13� I 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ,0.7gq� (IJart-eN ''(�1�'�"`T't') HIC Registration Number _EEKppiirr/�ttii/o'n—Date HIC Company Name /-or1 HIC Registrapt Name 50 P- No. a pat eet k ` MR -0-M60 9 y,y�f �� Email address Ci own, Stat ,ZIP Telephone SECTION 6:WORKERS' COMPENSATION INSURALNCE 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'APPLIIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize L r et,/ N to act on my behalf, in all matters relative to work authorized by this building permit application. / q lk< M ArJk Print Owner's Name J (Electronic 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 understanding. Print Owner's or Authorized Agent's 1,rame(Electronic Signature) �r /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.Rov/oca Information on the Construction Supervisor License can be found at www.mass.govi'ctp 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" CITY OF SALEM, i LUSACHUSETI'S • BUILDING DEPAR-MENT N 130 WASHINGTON STREET, 3'°FLOOR TEL (978) 745-9595 F.Ax(978) 740-9846 D KINiBERI EY RISCOI I S[A ;R EY DRNYOX THOS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILE)NG COSLVISSIONER 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 111.5 Debris, and the provisions of MGL e 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: P T (name of hauler) The debris will be disposed of in : S�ipM Du�.o , (name of facility) SWuM�S(o"1'I P—Q —(ass of facility) signature of permit applicant �r date GN CITY OF SiU.E ,I, 1 XSSACHLSETTS BUILDING DEPAItTMENT 120 WASHINGTON STREET,3aa FLOOR TEL (978) 745-9595 F.tx(978) 740-9846 K)JBERI.6Y•DRISCOII MAYOR 'Ittoht.►sSr.PiFxRB DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\6INIISSIONER - Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aprilicant information ink Please Print Leeibty Namc(Busitxs&organizatiorv))lndr�ividual): / 'V vovt-,- fYr�{old Address: I So E (/V Amml, city/state/zip: �� °e�.t, M 1 (0)166 Phone#: 9-11-_LS a939' Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 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 i Z E]Remodeling ship and have no employees These subcontractors have S. ❑Demolition working for me in any capacity. workers'comp. Insurance. 9, ❑ Building addition (No workers'comp. insurance 5. We are a corporation and in officers have exercised their 10.❑ Electrical repairs or additions required.) of 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑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 applicant that Omits box al must also fill uul the scuioe plow showing their workers'compensation puticy infurtnation. t IGowuwners who suhnia this atNdavit indicating they am doing all work and then him outside contractors must submit a tow affidavit indicating such. :Cummetors that chtak this box main attached an additiutud sheet showing tho none of the subatintractors and Chair workers'comp.pulicy infomution. I am on employer that Is providing workers'compensadon lttsarance for my employees: Below Is the polley and Jab site information. Insurance Company Narne,._TM v�ref> —"�"�N1�A✓1/t'�. Policy 4 or Sc)f--ins.Lie. 4: (413 d Its 6 _c_ )) 3 I ii Expiration Date: 2� /3 Job Site Address: t<) Alm-y 11 5� City/State/Zip: •s i° Attach a copy of the workers'compensation policy declarallen page(showing the policy number and expiration date). fuiluro to secure coverage as required under Section VA ot'MGL c. 152 can lead to the imposition of criminal penalties of a tine up to SI.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.Q0 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby t errrrljyyuunder fire puns and penoldes ajperJury dial are fnjurritmloa provideCd/above is true and correct Dates Phone -7-7 OJjfria!use auly. Do not write in/h/j areas to be completed by city us-town oJJlelad City oe Town: ____ PermltR.lcense# __ Issuing Aulhorily(circle one): 1. Board of Ilculth 2.Building Department 3.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing inspector 6.Other.-- Contact Person: Phone M: !"1 OP ID:JD A411 06/25 CERTIFICATE OF LIABILITY INSURANCE DATE D/YYYY) 06/25/12 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 endorsements . PRODUCER CONTACT 978-774d338 Phil Richard Insurance,Inc NAME: 978-774-1318 PHONE FAX 27 Garden Street Unit 1B ac No E><t: INC,No: Danvers,MA 01923 E-MAIL _ Diane Famiglietti PRODUCER CUSTOMER ID p:PEARS-1 INSURERS AFFORDING COVERAGE NAIC# INSURED Pearson Builders, Inc. INSURER A;Arbella Protection 41360 Warren Pearson, President INSURER B:Travelers Insurance 10647 150R Winona Street Peabody, MA 01960 INSURER C: INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 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. INSR rypE OF INSURANCE ADO B POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 B X COMMERCIAL GENERAL LIABILITY 680565M5386 11128111 11/28/12 MA E (PREMISE ERENT PR occurrence) 8 300,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,00 X Business Owners PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,006 X POLICY PRO LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ A ANY AUTO 37262400001 07/18/11 07118/12 (Ea accident) BODILY INJURY(Per person) $ 250,00 ALL OWNED AUTOS BODILY INJURY(Per accident) $ 500,00 X SCHEDULED AUTOS PROPERTY DAMAGE $ 100,00 X HIRED AUTOS (Per accident) X NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY T RV LIMIT E B ANY EMSER/EXCLUDR/EXECUTIVE YIN UB613621316 03/26112 03/26/13 E.L.EACH ACCIDENT $ 100,00 (Mandatory in ER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,00 If under describe OF O DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 f.. DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Evidence of Ins., ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE v ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD I { ;I THIS CHECK IS IN PAYMENT OF THE FOLLOWING PEA BUILDERS INC.150R . r0 1 3462 /07 150R WINONA STREET W.PEABOD(978)55-6555 TTS 01960 (978)535�6555 I 53 17&11s PAY DOLLARS CHECK DATE TO THE ORDER OF CI-E DESCRIPTION ( pi G T AMOUNT ' zy� $ - i ®EastemBank R�.NRY} 0 � INYGSlERH i 11T 1100 1 3 4 6 2V 11:10i1301, 79131: ,00 001335900 i 3 vda i 1 { H3080 A3NOA IVNOSI=13d r, 3H101 'ualolS io pelelllnw'Isol el tI li IwaAa awl ul pepunlw io peoeldw ep - Illm Apego,;l41.g�Nag peilnbei ew lllm pdng.h ual uSllo:aJiSw=d ayj Y S.`3.^r I - -:7...'�ni L"V 1;' ??•M`i 13�i;d t;I�,��aP[,�)Ei -Yny�A:.E Avd _ 83WO1Sno O13OLLON `n'T cz 4 1'1_i I b'-no IYY,'I 31VG Ol LZO F/A 'NOlS08 9 E g L V T S .DN Ii uug uja4sp3 eu sc%es-es PEARSON BUILDERS General Contractor Warren A. Pearson - - _ - wartenpearsonOmmrat.net 150 R Winona St Phone 978-758-2938 W.Peabody,MA 01960 Faa 978-535-6555 a.� Massachusetts- Department of Public Sitter Board of Buildind Regulations and Standards F Construction Supervisor License - - License: CS 40996 WARREN,A PEARSON 150R WINONA STREET W PEABODY, MA 01960 Expiration: 4/1212013 ('ommissinm•r -Trq: 14981 n&RM \ . Office of Coasome�Affairs&B araexs Regtlla6oa f _ HOMEIMPROVEMtNT CONTRACTOR - �? I Registration �107999 T3* Expiration 8�19f2012 Individual - W EN A PEARSON Warren Pearson (- - ISM Winona St. Peabody.MA 01960 -� Undersecretary`, i I f I i I i GJS�OM BUitt) TANZELLA Vito U Vito Tanzella F�q :C 0 N"f R PLC Bachelder Road Foreman : Tom Anthony , Raymond, NH 03077 Proposal 603-895-1316 63 Fully Insured MA Lic.# 059428 [Job roposal Submitted to: kckv Phone Date 131 , treet �� e L ��Y City, State, Zip Name Job Location « Job Phone � A/d r� � 4Tl We are pleased to quote to you the following price for the work as specified below. i V i We hereby propose to furnish material and labor for the total sum of: DOLLARS( ) AMOUNT Payments to be made as follows, 113 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: %�� Signature: