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18 PINGREE ST - BUILDING INSPECTION The Commonwealth of Massachusetts ° Board of Building Regulations and Standards CITY OF 1 Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling JThis Section For Official se Only Building Permit Number: Date A plied: h ) ti- Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Ad 4S to t 1'X �-� , 1.2 Assessors Map&Parcel Numbers 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: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes[] Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner ofgecor Izsrbid ( Lr "s4 So)en, MP Name(Print) City,State,ZIP zap ' � Avg 7 y4 - S►�2 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building'0 Owner-Occupied ❑ Repairs(S)1S1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': r00 rY noJY 4- f -I M a f nPJ— /o�PdeCP t SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 6 / 5� ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) LY0 � License Number E puati Date Name of CSL Holder Xk- C� List CSL Type(see below) No.and Street JJF',� l Type Description TPGhUCy , 1 M R 11� V�� V U Unrestricted(Buildingsu to35,000 cu.8. R Restricted 1&2 Family Dwelling City/Town,State, IP M Masonry RC Roofing Covering WS Window and Siding qq l G ^ SF Solid Fuel Burning Appliances 1 "7$F-�.�3$ trF�reN1UPnrSaN C' foNt2�C)ir1't'_) 1 Insulation Telephone - Email address D Demolition 5.2 Registered HonW Improvement Contractor(HIC) War t�N fr{ XSz1`J /C0R1iS�ionNumber Ex irtationDa[e HIC Company Name or HIC R58�strant Name I..�1J ✓�/J./V�*. a• Wa^rxM9PalSen,ik wer ,A41 No.and S eet p���U Mn z>06() Erna l address Ci /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.........>0 No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ],as Owner of the subject property,hereby authorize i ,/rpe/-- to act on my behalf,in all matters relative to work authorized by this building permit application. R ,W (]Ae re,' /Q Print Owner's Name(Electronic Signature) ID. e 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. Print Owner's or Authorized Agent's Name(Electronic Signature) ate 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.gov/dps 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 halffbaths 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" CITY OF SM E:N4 2UNSSACHUSETTS • B1:ILDLNG DEPARi1L.-4T 1} 120 WASHINGTON STREET,3W FLOOR °f TEL (978)745-9595 FAX(978)740-9W [V,,%tBER7 RY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDIIVG COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Busin�ssiOrganizatioNlndividual): W617re� >J Address: I S o R- LA/Ian ht& <4.. City/State/Zip: `/© 0 Phone#: 271'ls1 "a43K Are you an employer?Cheek the appropriate box: 1.0 6 I am a employer with 4. ❑ 1 am a general contractor and 1 . []New construction pe of project(required): employees(full and/or part-time).* have hired the sub comrscmrs 2. 1 am a sole proprietor or partner- listed on the attached sheet: 7. ❑ Remodeling ship and have no employees These sub-Contractors have 8. Demolition working for me in any capacity. workers'comp.insurance. g, Building addition [No workers'comp. insurance 5.� We area corporation and its required.] off seen have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.`n Roof repairs insurance required.)t employees. [No workers' 13.❑Other comp. insurance required.] •Any applicam that clucks box®I most also fill out the section below showing their worker'compensation policy inlomtmion. t I lnmcownm who submit this affidavit indicating they arc doing all work and than hire omside contractor must submit a new affidavit indicating such :Commoton that check this box most attached an additional sheet showing the name of the sub-eotardam and their wmkm'camp,policy inlonwtim. I am an employer that is providing workers'compensation insurance for my empleyees. Below Is the policy and job site information. � I_ Insurance Company Name: ,I yeI r-s )�N$ur-apjue Policy#or Self-ins.Lic.#:_ U06 8 6�I�I6 Expiration Date: Job Site Address: 3 R? :5 l — Adi"y7 RiA�rw City/State/Zip: e Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 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 pal s and penaties of perjury that the information provided abo/ve,is true and correct. m r r )ate! 7 Phone_#: Official'use only. Do not write in this area,to be cumpleled by city or town afciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: CITY OF S'U1 &Nls N'LXSS.�CHUSETTS BURDING DEPARTMEN''T 120 WASHINGTON STREET,Yo FLOOR TFL (978)745-9595 FAX(978) 740-9846 KI,%(BERLEY DRISCOLL ;MAYOR T Hoaus ST.Pwj= DIRECTOR OF PIBLIC PROPERTY/BUILDING COMMSIONER 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 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: 12L6 T (name of hauler) The debris will be disposed of in : (name 6T facility) MQs�'Otj l —CI �41 ejo (address of facility) �tur�a�ant T/ date dehrivtrdce PEARSON BUILDERS �co�amor VVWM A.Pearson 150 R-V%nom St -Phaee4J&7�-2938 . W.H®6ady tMA 07960 fax gM415-mm QePavtment of Public Safety . Board of Building Regulations and Standards • Cartstructlon Supervisor Ucense license; CS 40996 -WARRENA PEARSON 1SOR WINONA STREET W PEABODY. MA 019W Expiration: 4/12=3 'Tr* 14M OIGeeCoammer88ba' ` . HOME IMP R t Re81stra67on: iO7999 - Type:' . s, '. ExPlrann: >z Individual A.PEAFqj� Waaen Pearson 150t Wino..n``a/Syyk 96Q t ACORO` OP ID:JD CERTIFICATE OF LIABILITY INSURANCE QATE{wmDIY'YY` THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO ER. 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 INSURER(S), AUTHORMED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be emlorsed, ff SUBROGATION IS WANED,subject to the terms and conditions lieu o of the policy,certain polices may require an endorsement A statement on this ceRificafe does not confer rights to the certificate holder in lieu of such endorsem s. PRODUCER s76-n4.4.{,�6 CONTACT Phil Richard Insurance,Inc NAME 27 Garden Street Unit iB 978-774-1318 PHONE F Danvers,MA 01923 R.mAa Ho Diane Famiglietil ADDRESS: PRODUCER® PF-AHS.1 INSURED Pearson Builders,Inc. S ATFOROING COVERAGE NAICp Warren Pearson,President INSURERA:Arbella Protection 41360 15OR Winona Street INSURERS-Travel erslnsurance 10647 Peabody,MA 01960 INSURERC: INSURER D- INSURER E: COVERAGES CERTIFICATE NUMBER: INSURERF: 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. NOTWUHSTANDING 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. TR TYPEOFINSURANCE D GENERAL UABIOTY POLICY NUMBER PO EFF POLICY UNITS 3 X COMUEROALGENERALwewn 68056SM5386 11/28/11 11/28l12 EACH OCCURRENCE S 1,000,00 CLAIMS-MADE ❑X OCCUR I PREM$ES S 300,00 X Business Owners MEDELP(Anyonepmmn) S 5,00 PERSONAL aADV INJURY $ 1.000,0a GENERALAGGREGATE IS 2,000,00 GENL AGGREGATE LIMB APPLIES PER: X POLICYPRO- LOC PRODUCTS-COMPIOPAGG S 2,000,00 Jim AUTOMOBILE LIABILITY S COMBINED SINGLE OMIT A ANYAUro 37262400001 07118111 07118112 (Ea awkmn) S ALLOWNEDAUTOS BODILY INJURY(PBIpmm,) S 250,00 X SCHEDULED AUTOS - BODILY INJURY(Per emdmtl) S - 500,60 X HIRED AUTOS `PHeU�N)DAMAGE $ 100.00 - X NON-OWNEDAUTOS- UMBRELLA LUM OCCUR S EXCESS tIAB EACH OCCURRENCE S CLAI SMAUE DEDUCTIBLE AGGREGATE S S RETENTION S - ' WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY WC STA"^U- OTH- j ANYCENUMEEIORIPARTNDED?ECLmVE YIN UBBB621316 03rM12 03/26113. EL EACH ACCIDENT s 100,00 OFFlCERAIE! NH)EOU].UDEDT ❑ N!A (MmIdiLWY61 NLO '. DIq EL DISEASE-EAE P S 100.00CEvfigOPERATIONS N EL DISEASE-POLICY LIMIT S 600,00 j SCRIPTION OF OPERATIONS/LOCATIONS/VERICLES (42ftaII idenae of Insurance ACORD 101,Additional Remarks 3f',IIPJIWe,ImpRamm yplBQUTARI) :RTIFICATE 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. AUTNDR®REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ORD 25(2009109) The ACORD name and logo are registered marks of ACORD ;- t t yn� EMBER BETTER BUSINESS BUREAU LAUGHLIN HOMES INC. ' --C r�� D I REG. # 154365 G-S il/Lt-�� FED ID # 41-2054365 EMBER CHAMBER OF COMMERCE 9 Charles Street/P.O. Box 252 'EMBER BEVERLY KIWANIS Beverly MasS3C WARREN PEARSON CSL # C540996 ucE 1978 /✓n/G� (978)922-5579 (978) 828-3979 cell HIC LIc. # 107999 PHONE.J DATE 7 _/ ij;P ATIONS SUBMITTED TO: . , /� 2 JOB NAME��JJ 7 T�EET l �Z3 �i✓ Irm �'7�-e c;� /� H'//z -L 7l'i/r'1� ZITY,STATE&ZIP�CZ OB LOCATION ^ A L ARCHITECT DATE OF NS JOBPHONE re hereby submit specifications and estimates . ........... ter..,,.................... %.... : . .��.............. . ... .. . ....ter'//�_ il!tL�.d...... c�..�.. . .. .. ...../.� .y? tfd .. ..�`z!•r .._. .ILSrL.f1... .f � .. ._.C... : _f )ate work will begin: ate work scheduled to be substantially completed: 'avment Schedule: Initial Payment: TAr..PiliHoiv due upon signing of contract Payment 2: 3 �� due upon completion of Payment 3: due upon completion of contract The law requires that all home improvement contractors and subcontractors shall be registered by the Director of Rome Improvement Contractor Registration,and that am-inquiries about a contractor or subcontractor relating to a registration should be directed to:Once of Consumer Affairs and Business Regulations,10 Park Plaza, Room 5170,Boston,MA 02116(617)973-8700. It is the contractor's obligation to obtain any and all necessary construction-related permits,should the owner secure their own construction-related permits or deal with nnre 'stored contractors the owner shall be excluded from access to the guarantee fond. Unless otherwise noted in this document,the contract shall not imply that any lien or other security interest has been placed on the residence. DO NOT SIGN TBIS CONTRACT IF TBERE ARE BLANK SPACES Acceptance of Contract `�. The abol*e prices,specifications and conditions are satisfactory Signature and are hereby accepted You re authorized to do the work ar specified.Payment will be a as oGutltline/�abov Date of Acceptance % / ���\ signanuE/k` i' may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,whrch may be his main office or branch thereof,pruv,A cm I mt notify the contractor in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business d; rnrinu4ng the signing of this agreement. See attached Notice of Cancellation form for an explanation of this right