21 RAYMOND RD - BUILDING INSPECTION i t
IL. The Commonwealth of Massachusetts
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 O
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORNIATION )
l
1.1 Property ddress: 1.2 Assessors Map&Parcel Numbers
�f r��. ( 2e, .P
1.1 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 er'of or
7�);CA. AQ &F
Name(Print) p City,State,ZIP
%Z1 61.a .0.4 S7751���3Z
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_ I Other ❑ pecify:
Brief Description of Proposed Work :_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 14, `t7;o 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: ( G
5.Mechanical (Fire $
Suppression) Total All Fees:$
6.Total Project Cost: $ 4,47d tw
Check No. Check Amount: Cash Amount:
0 Paid in Full 13 Outstanding Balance Due:
c
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) y D / r �3
�' Oy r'fN 7)o License Number Expiration Date
Name of CSL Holder
hQ R— ( )t List CSL Type(see below)
MDNL. S') -
No.and Street Type Description
JJ(/ U Unrestricted(Buildingsu to 35,000 cu.ft.
Crty/1'o 11r,�O P �� R Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
7�7S�-ag � -,w ceNppmt�br ��M[P� SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Ho a Improvement Contractor(HIC) o�
�,�eA) �,� ! 9�19 —�1o1
I , )
CAS HIC Registration Number Expiration Date
HIC Company Name or HIC Regis t Name �}
and Street� d rONq (�IcrCr^NIP[�r5J,N
V Pe46DLI � of b _T2 7S5 --",1 T Emataddress
City/Town,Stale,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 .......... 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 I/�yl� 4w-l�
to act on my behalf,in all matters relative t k horized by this building permit application.
s�
f
.�o 4 s�;x
Print Owner's Name(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 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. og v/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
The Commonwealth of Massachusetts
Department of lndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
tiI www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Paint Ledbl
Name (Business/Oran tion/Ladividual): C Cd
Address: L '_
City/State/Zip: f� Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
I:ElI am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp. insurance comp. insurance.:
required-] 5.j'We are a corporation and its 70.❑Electrical repairs or additions 3. I am:a homeowner doing all work
officers have exercised their 11.❑ Plumbing repairs or additions
❑
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13.0 Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
iContracibrs that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �/ � _
InsuranceceCompany Name:: 4 �'"�� `��✓ �S � �
Policy#or Self-ins.Lic.#: L/ / /'/�(� Expiration Date:
Job Site Address: /G� rN r ^ /{� City/State/Zip: i .
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$1,506.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 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 ofperjury that the information provided above is true and correct.
/ ���
Signature: r�2� s Date
Phone# ��'
FE6. Other
se only. Do not write in this area, to be completed by city or town officiaL
Town: Permit/License#
Authority(circle one):
of Health 2.Building Department 3. City/Iown Clerk 4.Electrical Inspector 5.PluE
Person: Phone#:
I 04-08`11 13;43 FROM-Richards Insurance 1-978-774-1318 T-132 P0001/0001 F-198
AC URO' DATE(MNpDONYM,
ter, CERTIFICATE OF LIABILITY INSURANCE 04108)11
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 INSURER(S), AUTHORIZED
- REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANY: if the certificate holder is an ADDITIONAL INSURED,the policy(los) 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
canIficate holder In lleu of such endorsemen s.
PRODUCER 978-7744338 - co ¢Or
Phil Richard&Assoc Ins.,Inc 97B-774.1318 PHONEPA
27 Garden Street Unit 10 Ale Na
Danvers,MA 01920 E+Aa
Diane Famigliedi o°DEER
c s MERromPEARS-1
INSURE S AFFORDING COVENAOE NAKIR
INSURED- Pearson Builders Inc INSURERA:Arbella Protection
150R Winona Street INSURER a:Travelers Insurance 10647
Peabody,MA 01560 INSURER C:Ace GrOu
INSURER D:
INSURER E:
INSURER P:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCIES 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 VOTH 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 -
ADOL EVER
L TYPEOFINSURANCE POLICY NUMBER M D EFF POLIC EXP LIMITS
(MMIDOGENERAL"A""TY EACH OCCURRENCE S 1,000,00
B COMMERCIAL GENERAL LIABILITY 680565M53SS 11/28110 11/28/11 REMISES eocwtre ce S 300,00
CLAIMS-MADE.❑DCCUR MEDEXPD wOneDamon) S 5100
X SUSIneSB'QWaere PERSONAL&ACV INJURY S 1,000,00
GENERAL AGGREGATE S 2,000,00(
GENL AGGREGATE LIMIT APPLIES PEA: PRODUCTS-COMP/OP AGO 8 2,000,00
POLICY - PR • LOC S
AUTOMOBILE LIABILITY v. COMBINED SINGLE LIMIT S
(Eaadddad)
A ANY AUTO 37262400001 07j18H0 07118111 BODILY INJURY(Per pesor) S 250,DQ
SCHEDCHEOALL NEDAUTOS BODILY INJURY(PBl acaden0 S _ SOO,OO
X VLED AUTOS PROPERTY DAMAGE .
HIREDAUTOS (PeiowdenU S 100,00
NON.OWNEOtAUTOS S
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE S '
EXCESS.LIAO CLAIMS-MADE AGGREGATE $ -
DEDUCTIBLE - 3
RETENTION S S
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIAEILITY
C ANYPROPMEZORIPARTNERIERECLIUVE YIN C002602555 03117111 03117/12 E-EACHACCIDENr 3 100,00
OFMCERJMEMSeR EXCLUDED? El NIA
(MaAdatery In NM1 EL DISEASE•EA EMPLOYE S 100,00
If yyec dawibB under
DESCRIPTION OF OPERATIONS below SA,DISEASE-POLICY LIMIT 3 SDO,OO
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Reau to SC&BCNIe,N MGM BOSCB G ngVlodl
Evidence of Insurance
CERTIFICATE HOLDER CANCELLATION e
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES af-CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
7-
0 1985-2009 ACORD CORPORATION. All rights reserved,
I ORQ25 2009109 The ACORD name and logo are registered marks of ACORD
Printed wit gdtFactory Pro trial version -purchase at www.pdffactory com
PEARSON BIMMIS
Warren.A Pearson
tso R.Winona St Phone&Fax 978-635-6555
W.Peabody.MA01880 Celle _ _ 878-753-293B
1" Massachusetts-Department of Puhlic Safety
BJIMoanl of Building Regulations and Standards ,
Aohstructibn Supervisor License
• 'License: CS 40996 - - -
1NARREN�4i4 EARS�OI�V� � 5
,150R V1%I �3�"
W PEA9OC !960
Expiration: 41212013
` . f'ommi59ioneY^r . ..Trig 14981 1 -
. {oln7siana�ea�l�a `� License or registration valid for individul use only
Office of ConiumerAffaas$rH mess Regulation g -
HOMEIMPROVEmENT CONTRACTOR:. beWre the expiration date. If found return to:
Registration: 07ggg Type: Office of Consumer Affairs and Business Regulation
�Expiratlon: ,012 Individual lOParkPleza-Suite 5170 -
Boston,MA 02116
Warren Pearson
150R Winona St. - - ll�Ni ' - "rr—• - .
.Peabody,MA 01966 °:Undersecretary .' - Not valid withbuf signature -
Mem er Better Business Bureau LAUGHLIN HOMES,INC. Mass. Reg. # 161925
Member Beverly Chamber of Commerce 9 Charles Street/P.O.BOX 252 Since 1978
Member Beverly Kiwanis BEVERLY,MA 01915 Warren Pearson CSL#CS40996
(978)922-5579 HIC License# 107999
Bob L.'s cell: 978-828-3979
Proposal Submitted To: Phone: Jason 617-512-7932
Jason Ford & Rosi Susi Date:
Cell:
Street: 21 Raymond Road Job Name: Roof and Windows
City, State & Zip: Salem, MA 01970 Job Location: Same
Architect: Bob L. Date of Plans: 8/2/11 Job Phone: Rosi 617-512-9967
We hereby submit specifications and estimates for:
I. Strip all roofs and redo: main front and side porches and doghouse bulkhead. Remove two
(2) layers of shingles, dispose of, clean job site, we pay all dump and permit fees Includes
-install: -- —._... --- --- --- ---- — — ---------
• Ice and water shield (3') to eaves, includes to front porch and around chimney base.
• Tarpaper base, (2) 4" stack flanges to stack pipes
• Cut and install 30+ feet Cobra ridge vent
• White 8" aluminum dripedge to all edges f c�✓���
30 Year Certainteed Landmark Woodscape architectural shingles. Ten (10) year labor
guarantee. Customer is responsible to cover/tarp attic items and clean any resulting debris
in attic.
O ,A9 Ai -2
y
Payment Schedule: Initial Payment: 1/3 at start
Payment 2: 1/3 when approx. half completion
Balance due upon completion of contract.
The Law requires that most home improvement contractors and subcontractors be registered with the Director of Home Improvement contractor
Registration. You may inquire about a contractor registration by writing to the Director at One Ashburton Place, Room 1301, Boston,MA 02108,
or by calling 617-727.3200 or 1-800-223-0933.
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 unregistered contractors the owner shall be excluded from access to the guarantee fund.
Unless otherwise noted in this document, the contract shall not imply that any lien or othe unity mtere s en places on the residence.
DO NOT SIGN THIS CONT75ignatur
ARE BL
Acceptance of Contract
The above prices,specifications and conditions are satisfactory \
and are hereby accepted. You are authoriz to do the work
as specified. Payment will be rn de as out'ted/above.
Date of Acceptance � /
You may cancel this Agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main office or a branch
thereof,provided you notify seller in writing at his main office or branch by ordinary mail posted,by telegram sent,or by delivery,not later than midnight of the 1
third business day following the signing of this agreement. See attached Notice of Cancellation form for an explanation of this right.