19 PLEASANT ST - BUILDING INSPECTION 3g� 1 _;67 °=
The Commonwealth of Massachusetts
I " Board of Building Regulations and Standards CITY OF
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
This Section For Official Use Only
Building Permit Number: Date Applied:
�2 2Z J
Building Official(Print Name) Signature Dat
_ SECTION 1:SITE INFORMATION
1.1 Pcroperty Address: 1.2 Assessors Map&ParcelNumbers
Oe_� 13 5 ../i Sz
n� -7
v' ` L la Is t is an accepted street?yes_ no Map Number Parcel Number
I 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(fl)
1.5 Building Setbacks(R)
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 Owner'of Record:
/,&1,7.- r-"�)tJ.u// <!/cJc�s hA,1- 3'
Name(Print) City,State,ZLP
;?U CGSS/
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief DeslIcripti/onofProposedWork2: e�^o a
S fee
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ _S Q O 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 (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
T
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Aby3
// License Number Expir Lion ate
Name dl C-SL Holder _
A I List CSL Type(see below)
AL
No.and 9trect Type Description
e/I / U Unrestricted-(Buildings u to 35,000 cu.ft.)
(a R Restricted 1&2 Family Dwelling
Gown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Tele hone Email address D I Demolition
5.2 R stet H me Im rovem nt Contractor HIC
� I pSJ�. � ( ) /5'93�r7 a /�
� HTC Registration Number xpira ion Date
I Company Name o HIC R�1egi !mt Name /
r�l
No.dad!V r4/ /4 1, S s E ail address
city/Tdwn, State,ZIPf•� 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 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorizeGA.
to act on my behalf, in all matters relative to work authorized by this building permit application.
ra ,<? r /6 e
m 'Print Owner's Na (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.
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 bites 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dys
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"
i CITY OF SU1 El , NL1SSACHUSETYS
BUILDING DEPARTn[ENT
i 120 WASHINGTON STREET,3w FLOOR
TEL (978)745-9595
FAX(979) 740-9846
KISBERLEY DRISCOLL
MAYOR T HOMAS ST.PIEM
DIRECTOR OFPCBLICPROPERTY/BUI DINGCONIMISSIO.iER
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectricians/Plumbers
Applicant Information Please Print Le ibl
V8It1C(BusimstiOrganizatioNlmlividual):
Address: R,
City/State/Zip: P"eJr- U �V Phone #: �9/7 922 9 9
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ lam 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 t ?• ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9, 0 Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 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 12.0 Roof repairs
insurance required.]t employees. [No workers' I3.❑Other
COMP.insurance required.]
'Any applicant that check,box SI must also rill out the section below showing their wwkas'compenudm polity infotmation.
I Inmeownen who submit this affidavit indicating they ae doing all work and then hue outside contractors most submit a new affidavit indicating such.
=Contraaots that cheek this box must attached an additional shoct showing the name of the subs ntreston aW their wotkas'comp.policy inle,,nim.
I am an employer that!s providing workers'eotopensadon Insurance for my employees. Below Is the polley and job site
information. /
Insurance Company Name: —ZvS'
Policy#or Self-ins.Lie.#: 7hJ,t R,`q G6 ;?d q i— Expiration Date; C, S�
Job Site Address: 15 /Y,,x, .✓ S/ City/State/Zip: =24�1
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to=ore 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 that its and penalties of perjury that the informatioa provided above is true and correct
Sis¢attae• r iv Date /�/6 z
Phone#:
Dfftcial use only. Do not write In this area,to be completed by city or town of wiai.
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person _____ Phone#•
;nassacruseuo -a,�N�l.= :=. •� . __.._ ___.,
\ '
Hoard of. Building Regulaticns and Standards i
Construction Supcnisor '?
/ License: CS404381 tc �^
f •nmv�TD T/, �T9}
ARTH RR CARI)ONE /• _
3 PYNEWOOD ROAD i
PEABODY MA 01960 `j
Expiration
Commissionerr a1211112015
." _ . . - - JI ztOe o.L�Pltr11!(t�li?rua5
:mcr Af&ij S ulitien
OtSce of Coasumcr Affairs 8.Basi¢ess Reg
ME tMPROVEMENf COtdTRAO'fOR Type: >
lislratiom 1593V
DBA
ACTION 5 DEING
ARTHUR CARBONE - rt'a
3 PINEWOOD RD.
PEABODY,MA 01960. - Undersecretar9 r
Action Siding & Remolding INVOICE
3 Pinewood Rd.
Peabody MA. 01960 Number: 1033
617-939-7639
Date: December 15, 2014
Bill To: Ship To:
19 PLEASANT ST
SALEM,MA
Description Amount
REMODELING
REMODEL ALL KITCHENS(3) 32,500.00
SAND&REFINISH WOOD FLOORS
BOARD&PAINT WALLS&CEILINGS
REMODELING BATHOOM
REPLACE ROOF
Total $32,500.00