4 S PINE ST - BUILDING INSPECTION 1V The Commonwealth of Massachusi CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMRpp� visedyar 2011
Building Permit Application To Construct,Repair,Renovate CT Il o ish aj'
�— One-or Two-Family Dwelling
This Simon"For Otllcial•Use Only
r Bnikling Psamt Ntuaber: Date Appliedk
I
Building Offl ti0(Prot Name) sign ahare -. v. .. Date
SECTION I.SITE INPORI►7ATIOIV
i 1.1 Property Addr � 1.2 Assessors Map&Parcel Numbers
SGCef
l.la 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, 9,'§54) 1.7.Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ •Zone: _ Outiide Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[
SECTION2: PROPERTYOWNERSIW .
2.1 err of Recor i O f!11 s
Name(Print) I fa'2, U city,State,ZIN i Lj oytq S�o 2Y d dal- �;ry,'f r ael'r�
y es 77p•752--ISO' a} CPA. esf�: n�f
No.and Street Telepbone Email Mdress
SECTION 3:DESCRIPTION;OF PROPOSED WORK(check all that apply)
New Construction❑ Existing BuildingA Owner-Occupied ❑ Repairs(s). All I Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Des 'ption of Proposed World: ' C a•o a + rr S t
Qwr3 n� Yeaw1IX
�d01w
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 6 g oo o.eo I. Bailmug Permit Pca:$ indicate how fee is determined;
❑Standard Cityfrown Application Fee
2.Electrical $ °o. ❑Total Project Cost'(Item 6)x multiplier x. .
3.Plumbing $;, oao, ad 2: Other Fees: $
4.Mechanical (HVAC) $}, ndXA� List:
5.Mechanical (Fine '$ Total All Fees:$ ,".r
Su ression
o.� Check No. Cheek Amount:_ <i Cash Amount:
6.Total Project Cost: $ �Q �'p ❑Paid in Pull ❑Outstanding Balance Due:
ot s
SECTION 5. CONSTRUCTION SERVICES
5.1 Construction SupervtsoNL"icense(CSL)
_ ��
hG/yt Q S r✓ License Number Expiration Date
Name of CSL Holdex'I
�S Lis[CSL Type(see below)
Min'-w aV4M V'l..
No.and Street - TYPC - 'Desar3Ption. -
Q/lY Ci Ol il8 unreatridea Family
u 35 000 cu.ft.
Restricted 1&2 Famil Dwelling
City'rrown,Sta4p,ZIP Masonry
RC Roofing Covering
WS Window and Siding
per7F, r� 7 owes .KAf- ee+^ ✓ae SF Solid Fuel Burning Appliances
7 -95,L-Wet CZI C-."OLcaff • 1nLf I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ..- - - -
-Z7.4[ HIC Registration Number Expiration Dale
HIC Company Name or HIC Registrant N e
15
S�2t`'./r R µt"
N .and Street Emai]address
15ol'eela kyl,-fS ct41S Q &SZ 3So1
Ci /rown State ZIP Tel hone
SECTION 6.WORI{ERS°'COMPENSATIQN INSURANCE AFFHIAVIT OLG.I;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? ...❑ No \c�:2....❑ a)ocd 2,Ot
SECTION 7a OWNER AUTHOR17A , TO RE C011IPI.ETED WHEN
OWNER'S AGENT R CO CT R FQA PURMING PERMIT
I,as Owner of the subject piopesty,hereby authorize_ Lf��t�
to act'on my behalfiri all mat1ters relative to work authorized by this building permit application. "
Print Owner's Name(Electronic Signature) I 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.trrllre.and accurgtie to the best of my knowledge and understanding.
wl�s , 'B✓Jh.� 7641 jG14 2016
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 infomtation on•the HIC Program can be found at
mmjjj ss.wv/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) P6o d (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) 'doe Habitable room count• :6
Number of fireplaces O Number of bedrooms
Number of bathrooms 'U Number of half/baths G
Type of heating system Car I Number of decks/porches
Type of cooling system A o abt„ Enclosed 1 Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
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Construction Debris DisposaiA�`fidOW
(required for all demolition and.renovation work)
In accordance with the sbA edition of the State Building Code, 780 CMR, Seddon 111.5 Debris,
and the provisions of MGL coo,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 deposit facility as defined by MGL c 111,S 15d A
The debris will be transported by.
/7 )/ /L L15pDSR/
(name of hau er)
The debris will be disposed of in:
(name of bdlhy)
sz Ir ul Ed
(address of facility)
Signature of applicant
16
Date
v The Commonwealth ofMassachwseAts
Department oflndustrWAccidents
I Congress Street,Swrte 100
Boston,MA 02114-2017
WWW mosagov/dia
WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
AaoBcant Information WITH TO BE FH,ED THE PERMITTING AUTHOTY RI .
/ Please Print L blv
Name(Business/ogamzationRndividual): i r
Address: /S 5-*l-,)a7t4 a1c
City/State/Zip: Ue'J(V/ oSS 191f)5 phone#: 3Sof
Are you ao empbyerr Check the appropriate bor:
1.0 p am a employer win —7 Type of project(required):
—L�PtoY (fWl eoNorpart-time).• 7. New construction
2.0 Ines a sole proprietor or partnership and have on employees",long forme tn
any capacity.(No w,kas'comp.insurance regtmed] S. O Remodeling
3.0 I am a homeowner doing all work myself NO worimn'comp.iusurs cce required.]1 9. ❑Demolition
4.❑1 am a homeowner and will be hiring c,rtrap,s to conduct an work on my property. I will 10❑Building addition
em—that an contragma eitherhave workers'ceurpemetionjmmece,are sole
proprieto 11.0 Electrical repairs 07 additions
m with no employees.
5. 1 eon a 12.0 Plumbing repairs or additions
❑7hese paCtUs hawandIhovehiredthesub-cones,co p,inmfted the attached sheet. 13.0 Roofrepam
employees and have writers,comp.insuraaeea
6.0 We sm a cerporation and its olnems haw esercaed&,bright of exemption W MGL a 14.Q Other
15Z§1(4),and we have no employees fNo werlms'comp.iosmance regtmed.]
*Any applicant that checlte box al must also fill o,the section bebw showing their workers'coravmaeliom policy tnformation.
Homeowma who submit this affidavit indicating they are doing an work and rhea him cathode ceatraetms must submit a Msr affidavit indicating suck
tCma'acton that check this box must insulted an additional shed showing ale home of the aubm-cbactors end state whetba or cot those entities have
rmployees. lflbe nub<ontramors have employees,they must provide their ",hers'comp.policy number.
lam an employer that rs providLag workers'compensation uuurouce for my employees. Below is the policy andjob site
informadon. L p,
Insuuance Company Name: &ate/(,4 & 1C 1!M 1ZW J7;t5 U VC.C.C_ 1 t S— SZ -315'0 f
Policy#or Self-ins.Lic.#: Expiration Date.
Job Site Address: City/State/Zip.
Attach a copy of the workers'compensation policy declaration page(showing the poilcy number and expiration date).
Failure to secure coverage as required under MOL c. 152,§25A is a criminal violation punishable by a fine up to S 1,500.00
and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification.
I do hereby eerafy under thepams and petraEaes ofpepury that the mformakon provided above Ls true and correcL
Signature, :: , p Dare 0 ( u 6 th Lot d
Phone#: ! /�'� !i SZ— 3 O(
F
only. Do not write in this area,to be eomplaed by city or town ojfrcutl
n: Permit/Lieense#
ority(circle one):
ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
on: Phone#
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee 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 an 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 on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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 commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL 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 number(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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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 lime.
City or Town Officials
Please be sue that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one 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 or town may be provided to the
applicant as proof that a valid affidavit is on file for fugue permits or licenses. A new affidavit must be filled out eaeh
year.Where a home owner or titian is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or pewit to bun leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02 1 14-20 1 7
Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
FULLY LICENSED AND INSURED
T_ BERUBE, INC.
Massachusetts -DepartrB�$;dafandlk4Itm,%4WMontractors
Board of Building Regulations and Standards
Construction Nuperrnor 1 & 2 I-ariil) _
License: CSFA4048M
F I 1
.. THOMAS WMBERUBE..
15 STEWART AVE
BEVERLY MA 01915 _
Commissioner
Office of Consumer Affairs and ' usmess Regulation
E 10 Park Plaza- Suite 5170
_ Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration_ 123223
Type: Private Corporation
Expiration: 1772017 Tri 262068
THOMAS W.M. BERUBE CONTRACTINGg,j, ;
THOMAS BERUBE .
15 STEWART AVE
BEVERLY, MA 01915
_-'-Update Address and return card.Mark reason for change.
❑ Address ❑ Renewal ❑ Employment n Lost Card
DPS-CAl A 50M-04ffl RG1012/6 ,
✓/ {onnvrne� ai��oR i u' t License or t ..
office of�oasamer krs ar ego abo registration valid for indivfdul use only
,HOME IdIPROVEMENi CONTRACTOR - before the expiration date If found return to:
Reg-station 123223 Type: "Office of Consumer Affairs and Business Regulation
— Expiration 1172017 Private Corporation / 10 Park Plana-Suite 5170 _ -
'� y Bostoo,MA 02116
THt�iMAS W.M.BERUBE CONTRACTING,INC '
THOMAS BERUBE
15 STEWART Al
BEVERLY,MA 01915 Undersec-t ry Not valid wnhouf Ingnatuure
67R Wallis Street,Beverly,MA 01915 * Phone: (978)927-2099 * Fax: 978-968.3463 * Email: info@tberubecontracting.com