8 POPE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition 10001111111110
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Fumily Dwelling 4�1.
This Section For Official Use Only
�\ Building Permit Nu er: _ Date Applied: 1
Signature: a 4� /OZ�(
i Building C mmissionerYlnspector of Buildings Date `
�\O SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.l a Is this an accepted stritoolkyes 4 no Map Number Parcel Number
1.3 Zonin$Information: 1.4 Property Dimensions:
2'�
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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'of Record:
Llevys Dwil•. 5S tg 1 44w k S+ Shkr. r+tA a% q '14
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building IF Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
••:.st. h^ee....rA v: U yY•k\..r• ..�
s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
I. Building S (eoo. 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ f ou v ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2 Iry v 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Protect Cost: $ frSov.6r ❑ Paid in Full ❑Outstanding Balance Due:
G � ��
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) .rj-.e� fi it _ 2c t e,
'•-, ( tD - tic) q,q lv License Number Expiration Date
NSmc of CSL- Helder List CSL Type(sec below)
tw_yw...w,� P��,w..c r.-- T Description
Address U Unrestricted(up to 35.000 Cu. Ft.)
(S o t "x"�� S~ A{/�Ar wx R Restricted 1&2 Family Dwelling
Signature M Masonry Only
q'1C^7 S4- a q s 11 RC Residential Roofing Covering
Telephone
�s /� WS Residential Window and Sidin
SF Residential Solid Fuel Burning A22hance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) I O '1 4 CL 9
M",, ��`"s — Registration Number
HIC Company Name or HIC Registrant Name
I GryO0- WJrs'-'h S! PG^A• ' `I g7-1
Address e26Z 'a 5r)Q .-Isca- 2cocb Expiration Date
Signatur ~ Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, Lt_ A Po 1.%(rrt �, S�ce6,v/t L. ,te 6 as Owner of the subject property hereby
authorize rclk -5(,� to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
M L_G v%` 4L51 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
S'1eaP�.w P 1,o�e l� g s y
Print Name 1 2— 2 ,. La o &
Signature of Ownhil orzgent Date
-(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned, provide the information below:
Total Floors 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
ACOR TM CERTIFICATE OF LIABILITY INSURANCE °"'�`it 33 OMM° /0
B
PRODUCER THIS CERTIFICATE IS ISSUE)AS A MATTER OF INFORMATION
Phil Richard & Associates CNLY AND CONFEM NO RIGHTS UPON THE OEffnFICA'TE
491 Maple Street ALTER THE COV�GICp BY THE�tyEXTEND O
Suite 102
Danvers, MA 01923 INSURERS AFFORDING COVERAGE NAIC9
INSURED INSURERA SCOTTSDALE INSURANCE COMPANY
Pearson Builders, Inc. INSURERS:aranite State ins Co
15OR Winona Street INSURER C:Ar el a Protection
Peabody, MR 01960 INSURER D:
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSIR wol TYPFOEINSMAMOR POLICY NUMBER OU EFPRITIIV@ FIOUCY RATION LIMITS
BUREN&LAXwTY FAC"OOCURRRENCE S 1 0 0
A CoMMEGENERALLI49m a CLS1445653 11/28/07 11/28/08 OANARET RENTED
RCWL 6 100,000
CLAMS MADE QOCCUR M®EXP(A ae9 ) s 5,000
PERSONALSADVNJORY E 1,000,000
GENPRALAGGRETNGE s 2,000,000
GEMLAGCREGATE LMITAPPLIES PER PRCOUCTS-COMPAPAGa i 24000,000
POLICY PR LOG
MOBILE UJIBILITY CLIMBNEDSNCLEUMR
E
C ANY AUTO 37262900001 7/18/08 7/16/09 (ee00bo'T)
ALL OWNED AUTOS SOa LY N JURY
SCHmuLECAUTOS (RWOWSOD i 250,000
HIREOAUTOS EppLV N AIRY 500,000
NONOWNEOAUTOS
( .man) i
PRWERTYMMAGE i 100,000
(Rr.Ada )
RNIRKiEL NILLIL Y AUTOONLY-EAACCDBNT 6
ANYAVTO - OTERTNAN PAACC s
JUTOOKY: AGO 6
O(CESSNMIRELLA LIABILITY EACH DOC UR RENCE s �.
OCCUR GLANS MADE AULREOA 6
S
DEDUCTIBLE i
RETENTION S S.
WORKERS COMPENSATION AND X A
B EMPLOYElRS'UABIUTY WC8266872 3/17/09 3/17/09 ELWCNAca NT s 100,000
ANY PROPRIETOIUPAR'ME IEXECUTME
O�WFFFTCERA�ER EXCLUDED! ELDIE-2. AEhPLCI` E S 100,000
SPECWL�PR mw$ EL p�Ag-fH)LI CY LIMIT E SO DD
OTHER
OWX=PIIONOF OPERATIONSRLOCIMONS/VENI=R OCCLUSIONS ADDED 8Y9IOORSEMENTJSPECMLPROV0ONE
EVIDENCE OF INSURANCE
CERfISCATE HOLDER .CANCELLATION
I SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
TOWN OF DANVERS DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MM 15 DAYS WRITTEN
BUILDING INSPECTOR NOTICE Tp.7ME cBRTmcATE ROLDER'NA�C I�1T'RTYRE'R�RQ9tli'ML °SHALL
DANVER9, MA 01923 IMPOSE NO OBUGATON TV OF ANY KIND UPON Tf F.INSURE_.NS'j8.WM OR
REPRESENTA �� _� ��
' AUTHORIZED REP. ATIVE
ACORD 28(2001108), __.. @A&0Lf?CORPORATION 1988
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CITY OF SALEM
7 PUBLIC PROPRERTY
`.� r DEPARTMENT
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I:1 vin:'R!.P]'JB ISC,II I
\l.,n,n UK WaiHlNt310NST1AEeT • SALBt,M.,SSACIn:il%I iS01rM7
Ti,i.:978-743-9595 is R: X.978-74C-9846
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers
imnlicant Information Please Print Leeiblv
�IlMe (13usincss/0r8ani7ation/Indivldual): oCftol&# . a r Uo'!
Address: NOS 116
CitylStaleilip: PGw, O" Phone //: 01It 258
Are you an employer'Check the appropriate box: "Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 g. ❑ New construction
employees(full and/or part-time).• have hired the sub-contractors
_.❑ 1 ;un 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. 9, ❑ Building addition
INo workers' comp. insurance 5. 9 We are a corporation and its 10.❑ Electrical repairs or additions
required.) officers have exercised their
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, j 1(4),and we have no 12.❑ Roofrepairs
insurance required.) r employees. LNo workers' 13.❑ Other
comp. insurance required.)
-Any applicant thut checks box#1 noul also till out the scaian hcluw showing(heir wurkctr compcnsWiun policy information.
'l lumcuwnen who ssdrmit this affidavit indic:uing Ihcy are doing all work and then him uulside contractors must suhmit arm aff-idavit indicting such.
�Corinctun that check this box must atlachdd on additional sheet showing the name of the sub-contraclors and their workers'comp.policy information,
l a«r an employer that is providing workers'compensation inrurance jar any eniplayees. Below is the policy and job site
inforerfutiom
Insurance Company Name: 5C•'KS0'4k Tv4w-44
Pulicv k or Self-ins. Lic. *: .. .... ...... .__ p
r,.d G 4 24 by � �' Expiration Date: -O 4
4 S w lie .
Job Site :\fldress: Ia'rt' S�"'4t � S+tc%wr CiryiStatc/`Lip:
Attach it 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
time 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. lie advised that a copy of this statement may be furwarded to the Office of
Investigations ul the DIA for insurance covcra.-e verification.
l do hereby certify«ud• 'pai an en jperjury that the information provided above is true and correct.
Siena lore: �j_�.-7—/J / p _ Dater (2-11101
Ph 1 - / /6 7 �6 Yf-
Official use only. Do not write in this area, to be completed by city or town official.
Citv or l'own: ---. _ Permit/License#.-----
Issuing Aulhurily (circle one):
I. Board of health 2. 13»ilding Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _.- _- ---_ Phoned:
Information and Instructions
;Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplgyee 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 a n individual,partnership,association or 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 out the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.%IGL 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 commonwe$lih'fdr' any
applicant who has'not produced,acceptable'evidence of compliance with the insurance coverage required."
.additionally, bIGL 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 nu nber(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 continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retooled 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till not in the event the Office of Investigations has to contaet-you-regarding the applicant.
Please be sure to-till-in the permit/license number which will be used :is a reference number. in addition,an applicant
that must submit multiple pennitAicerise applications in any given year,need only submit`orie 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 d town inay be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled 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. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
the Olticc of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number: _ -
K
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Ro%iscd 5-26-05 -
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
TMENT DEPAR
12" %X oNS IY1.1 T # SA I I M, %fAll't
I 1 1 978-74�-9;95 4 1 %N; 9,78 74.- 984t,
Construction Debi-is Disposal Affidavit
(lC(lLLilCd fior all demolition and renovation work)
In accordance with the sixth edition of the state Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit It_' — is issued with the condition that the debris resulting from
di this work shall be disposed of a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
C^^twgt SOO.—
(nanic of hauler)
I he debris will be disposed of in
Vj Oft%%,V.CO- C A,%I.-
(riame of facility)
(address ofA lacilav)
ignalule of permit applicant
/2--2- 9 9'
date
Building
atta��«� i
Board of Building Regulations and Standards ,
HOME IMPROVEMENT CONTRACTOR
Registry one 107999 ;
i9 ExPuation jll/2010 Tr# 272451
lug dividual
v _
u WARREN A.PEARSON - 1i
Warren Pearson .�
�E 150R Winona St.
Peabody,MA 01960 Administrator
711. -Pianva:avrwea o�./C7oeaac/uraelta
Board of Building Regulations and Standards
Construction Supervisor License 4 -
License CS 40996
Birthdate 4/12/1957
gExplration 4/12/2009 Tr# 12294 i
.. ((Restriction
0I3
00� {} I
WARREN A RSON'
i
150R WINONA STREET,,r�
W PEABODY,MA 01960 - Commissioner i