30 RAYMOND RD - BUILDING INSPECTION The Commonwealth of Ma55aC'lILISCUS
Board of Building Regulations and Standards Cl IN OF
Massachusetts State Building Code. 780 C NIR SARevivedllar
2011
Building Permit Application TO Construct. Repair. Renovate Or Den
One-ur Tn u-Fmnllr Dlrellhnq
This Section For Official Use On1
Building Permit Number: Date Applied:
I"�ia�uans.0 _ zYKsc��� � ZZ
Budding 0111cial(Print Name) Signature Dale
SECTION I:SITE INFOR IATIO
1.1 Properly ABdress' l p 1.2 Assessors Ala Parcel Numbers
� 4MoNa 1�c!
I.la Is this an accepted scree . yes no Asap Number Parcel Nunlher
1.3 Zoning Information: 1.4 Property Dimenslans:
Zoning District Proposed U c Lot Arco(sq It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards
Near Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40.§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if ,—M Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Rec�o{{d. 1
Viro l lurie A PJfb bw�, Eot1lrw, MA
Mane(Print) City.State.ZIP
ZO 0. 745-210'7
Nu.and Street rclephune &nail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Othtr ❑ .Specify:
Brief Description of Proposed Work-: ,e— e
SECTION a: ESTIMATED CONSTRUCTION COSTS
Ilene Estimated Costs:
(Labor and.Materials) Official Use Only
I. Building S 3 5c) 1. Building Permit Fee: S indicate how fee is determined:
'. Electrical S ❑Standard City?own Application Fee
❑Total Project Cosh(Item 6).x multiplier
7. Plunlhiny S 1. -----
_. Other Fees: S
a. %fechanical ill\ \0 S List:
S. Mechanical (Fire --- ---- --. . ...
Su,+ression) S Toad ,\11 Fees:
$ — '-- - --
L,, Check No- __('heck amount: _ l',uh \motmt:
n, Total Project Cult S 7 3 SO ❑paid in Full ❑Outstanding Balance Duc:
SECTION 5: CONSTRUcrION SERVICES
5.1' /(bnstructims Supervisor License(CSL) 14 14fL
I.icoisc Nul/nhar Pcpir don Dane
' N;unc of l'SI. folder
f I isl('St. I)Pe Isce helmll.__.U-.----
Sd (C W i n�l�
----------- -�--- --- ---------- T)pe Description
No and Strcct
��1 6 J R I in lrilt d 1 I2 Family
li lu 1$,UIIO eu. IL)
b l �1 ` v l R Rextricwd IR? Pumil Dttcllin
Cilsi roll n,State,LlP bl Alusun
RC Rtloliiig Cmerin
...—._ N'S Window amd Siding
SF .Solid I'ucl Ilurning Appliances
4 x,--75fs'�h3g WpCSt'?r,+PZGS,�-N @lc�nCaS{'•nnrl' 1 Insulationlcic hone If mail ad dress D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1O-7 yqq
I,) zn,r-" IIIC Registration Nunll+cr ENptrouon Date
IIIC'C'ontpunnny Nat Ie ur IIIC'Registr//ant Name /� ,,i
No. and
Ie— 1n�IlAroAl�� \'r - (/c1ZS1'rN et$S°/`) E:CEMt'e'j1.N<l
No.and StrLet
a o p4A �,19 d q A75�-� r L tall addre y
City/Town. tate,ZIP fde hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 I5C(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...........Cl
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 Wex Mw PAT-50N
to act on my behalf, in all matters relative to work authorized by this building permit application.
Y.rt.rie CCp�c..rn.h /-'�1-12
Print Owner's Name(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.
��✓/ 1-� 3-lam
Print l)��+r:\u�ed Agent's Name Ili wclrunic Signature) Date
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 Hume Improvement Contractor IHIC) Program).will mr have access to the arbitration
program or guaranty fund under".G.L. c. IJ?A.Other important information on the HIC Program can be found at
s %,% m•I., ; c,,.,I Information on the Construction Supervisor License can be found at+++++1 m.7,+ > � -111,
2. When substantial work is planned,pro%ide the information below•.
Total floor area(sq. ft.I . (including garage. finished basement attics,decks or porch)
Cross lining area I sy. 11,1 _ Habitable room count
\umber of fireplaces _ Number of bedrooms
Number of hadlroonu - . _ _ _ -_ Number
I)Ilk:m heating 5)item Number of decks, parches -
I I\lie of C+N11117g i1>tClll Mlle)+lied - _ ._(ll,ell
1. "l ot.0 Project Squaw footage-ma) be suhstimlcd I'or I'ml Project Cost-
The Commonwealth of Massachusetts
Department oflndustrld Accidents
Office of-Investigations
600 Washington Street
Boston,MA 02I11
UIP www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information , Please Print Le lb
Name(Business/Organization/Individual): P£OfSpr•' J?y,JtLPS
Address: ISa p- Wi 8N6 51.
City/State/Zip: fat MA b) b 0 Phone.#: 4W-7 54s-�g
Fyou an employer?Check the appropriate box: Type of project(required):
I am a employer with 4. ❑ I am a general contractor and I
e�tloyees(full and/or part-time)-* have hired the sub-contractors 6. El New construction2. 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.acitY• employees and have workers'[No workers'comp.insurance Comp.insnranrr t 9. El Building addition
required.] 5. a We are a-corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work offices have exercised their 1I.Q Plumbing repairs a additions
myself o workers'co right of exemption per MGL
ys [N mP• 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no f
employees.[No workers' 13.E Other �p-.(o d
comp.insurance required] 11
•Any apptcant Post checks box#1 twist also Sa out The section below showing they workers'compauatim policy infarmatim.
t Homeowngs who subrnit this affidavit indicating they are doing all wmk and aim hire outside contractors must subtrdt a new affidavit indicaft such.
tConhactors that check this box must attached an additional sheet showing the name of the sub-coaaacion and state whether a not these mtitieshave
employers. Fibe sub-conbscPors have employees,they must provide their workers'comp.policynumber.
lam an employer that isproviding workers'compensation insurance for my employees. Below is the policy and Job site.
informadom
Insurance Company Name: A Ct'_ Crt ao
Policy#or Self-ins:Lic.#: W L W a S D I S 5 1Expiration Date: - - -
Job Site Address: 30 kTo V e/J Xd• City/Stawzip: Sod pm , MA
Attach a copy of the workers'compensation policy aeciaration page(showing e po cy number and expiration
Failure_to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of tip 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 ceert_ify/under t,hl a pains and penalties of perjury that the information provided above is true and correct
Signature: W�i 11 �. yy Date:
Phone#: -7?--7 5-T q >�
Official use only. Do not write in this area,tb be completed by city or town offrclal
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
CITY OE S.1.lZNfo AUSACHUSETTS
BLLLDLNG OEP.1R71tLNr
1_'01 kS)ILNGTON STjz.ST, JAG FLOOR
rRL (973) 743.9599
KIMSERLAY DUXOLL FAX(978) 740-994
MAYOR TMosw Sir.pmxrts
011ECT0I OP Pl BLIC PROPEATY/pCMDLYC COJpltSSIONEIt
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 78 )CM R section I I I.3
Debris, and the provisions of MOL a 40, S 34;
Building Permit p is issued with the condition that the debris resulting from
this work shay) be disposed—of in a proper
111, S I SOA. ly licensed waste disposal facility as defined by NIGL c
The debris will be transported by:
Pad
(n;una ut'heuler)
The debris will be disposed of in
—_ .Sa1tM AMP
(name o�Uly)
(,ddreflorf�at iY)
uynamra ofpermit rpphunt
lire --�_
V`l—VO— 11 {JL'dJ C!)Vl l—I111,I141 UJ 111JUI QING 1 ✓(U 117 101V l AUG ' VVVA/YOVl l 1✓U
11 , VC 1Y.1Vge
CERTIFICATE OF LIABILITY INSURANCE oAT04108111YM
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.
IMPORTANT: If the Oer"CBto holder is an ADDITIONAL INSURED,the policy(iss)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 righteto the
Certificate holder In Ileu of such endorsemen s.
PRODUCER 973-7744338 - CONTACT
Phil Richard&Assoc Ins.,Inc 978-774-t3t8 plME, a t No
27 Garden Street Unit 1B
Danvers,MA 01923 `'`'1A1L
Diane Famiglietti ADDRESS:,_ - PRODUCER pEARS•1
E MER10t
INSURERS AFFOROINO COVERAOE NAIC S
INSURED Pearson Builders Inc INOVRERA:Arbella Protection
I SOR Winona Street INSURER e:Travelers insurance 10647
Peabody,MA 01960 1 INsuRERc:Ace Group
INSURER D:
INSURER E
INSURE 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 RAVE BEEN REDUCED BY PAID CLAIMS.
p TYPE OF INSURANCE POLICY NUMEER MMIOO� MMmO LICY EAP LIMITS
OENERALLIAMUTY EACH OCCURRENCE S 1,000,00
B COMMERCIAL GENERAL LIABILITY 68056511115386 11128110 1128111 PREMISES soowmonxa E 300,00
cWMS-MADE ❑OCCUR - MED EXP(Any o person) S 5,00
)( BUS(ne5 owners PERSONAL&AGVINJURY S 1,00000
GENERAL AGGREGATE S 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PEP- PRODUCTS-COMPJOP AGG S 2,000,00
POLICY - PRO- LOC E
AVTOMOBILEUAINUTY COMBINED SINGLE LIMIT i
(Eaeodden0
A ANY AUTO 37262400001 07/18I10 07118H1 BODILY INJURY IPerporson) E 250,00
ALL 61066 AUTOS BODILY INJURY(PereCdidat) 3 500,00
X SCHEDULEDAUTOS PROPERTY DAMAGE
HRREDAUTOS (Per owoono t S 100,00
NON.OWNEOAUTOS. 3
E
USIBRELLA Lma OCCUR EACH OCCURRENCE E
EXCESS.LIAO CLAIMS-MADE 11 AGGREGATE E
DEDUCTIBLE E
RETENTION S S
WORKERS COMPENSATION WC 6TATU- OTH-
AND EMPLOYER$LIABILITY
C ANY PROPRIETORIPARTNERIF.`fECU E YIN
NIA C002502655 03/17111 03/17/12 E..FACHACCIDENT 3 100,00
(Mandatory
N141 EXClUDE01 E.L.DISEASE.EA EMPLOYE $ 7 00,00
I( es,dw ibo under
DIISCRIPTION OF OPEPATIONSbel. E.L.DISEASE-POLICY LIMIT S 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atbch ACORD 1/1,Addilipnil R1mMRa Sehodul%It more epau to nquimo)
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
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTAnW
-
01930-2009 ACORD CORPORATION. All rights reserved.
'C%RD_2512009ro9 The ACORD name and logo are registered marks of ACORD
Printed With ("dPactory Pro trial version - purchase at www.pdffactory:oom
PEARSON BU L.DERS
General Cotnreotnr
Warren A.Pearson
ISO R.Winona SL Phone&Fax 978-535-6555 - -W.Peabody.MA OZA6o Cell 978-768-2938
11' iylassachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
rLicense: cs -40996 , .. ,. . .
WARREN A PEARSON
150R ViiiNOIVA
W PEA60DY MAD1960'
�y ffc Expiration: 411212DI3 -
Fommissiuner'' - Trtk: 14961.
- ✓/so•0 nwza��ea�C ays• m¢r�u�de� License or registration valid for individul use only
Office of Consumer Affaus&BQ mess Regvledoa -
HOME IMPROVEMENT CONTRACTOR before the expiration date.-If found return to: ,
Registration 07999 Type: Office of Consumer Affairs-and Business Regulation
_012 Individual iQPark Plaza 4Suite 5170
Expiration:. Boston,MA 02116.
EN A.PEA -
Warren Pearson(_ -
15ORWinona
Peabody,MA 01l360 ��� ' Undersecretary .• Notvalid withontsignature
7 /�:.i/.:�, 1, r /'rr !:-..- l!rJ�:'YIJL.. U/../l�1 CX/✓ tw� u/u.�.� uc,/T �� i r i v u
;Ll 4 f Lt/6 (6 Uri C C ?f 5,�f�i� '
7T�T J
MEMBER BETTER BUSINESS BUREAU LAUGHUHOMEiS INC MA REG. # 16192`
MEMBER. CHAMBER, OF COMMERCE 9 Charles StreeUP.O. BOX ZSZ FED ID # 41-205436`-
MEMBEP. BEVERLY KIWANIS
Beverly Massa WARREN PEARSON CSL # CS4099f
SINCE 1978 (978)922-5579 (978) 828-3979 cell , - HIC LIC. # 10799E
SPE�IFICATIONSSUBMITTEDTO: _ PHONE DATE
STREET JOB NAME
G' laLZI02z7
CITY,STATE&/4P JOB LOCATION
liter i/VAI
ARCHI CT
_ j DAT OF PLA PHONE _.... -
P �y � rj
We hereby submit specifications and estimates for:
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.C��'J ..C�L.z....✓.V`��..'.✓..7.:.
, '1� .........TOT AC.CQNTI2ACT PRICE;
........ ..
Date work will begin: Date work scheduled to be substantially completed:
Payment Schedule: Initial Payment. a.� '_ : sa i-? ' e upon signing of contract
Payment 2: due upon completion of
Payment 3: f v due upon completion of contract
The law requires that all home improvement contractors and subcontractors shall be registered by the Director of Home Improvement Contractor Registration,and the
any inquiries about a contractor or subcontractor relating to a registration should be directed to:Office of Consumer Affairs and Business Regulations,10 Park Plaz:
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 wit
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 other security interest has been placed on the residence.
Acceptance of Contract DO NOT SIGN THIS CONTRACT IF THERE ARE BLANK SPACES
1r/� .._._..
The above prices,specifications and conditions are satisfactory Signatnl@ L i' , i !°
and are hereby accepted.You are authorized to do the work ec
as specified.Payment will be mad utli d above. X
Date of Acceptance
[fudi,mag'the
on my 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 branch thereof,provid
nof 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 e
signing of this agreement See attached Notice of Cancellation form for an explanation of this right.