2A SUNSET RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR RECEI ED SALEM
INSPECTION 16JUIM2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling UA-Y _
This Section For Official Use OnLy,
Building Permit Number: Date Applied:/'
Building Official(Print Name) Signature Date
l� SECTION 1:SITE INFORMATION
(J , 1.1 Property 1.2 Assessors Map& Parcel Numbers
J} SUNSf� � d
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
S A n\
Zoning District Proposed se 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recoi�l:
nlh.f Jaworsit ` JpM MJ't
Name(Print) City,State,ZIP
2 p StnN5ei 9 . 97�t 7ST-V3$1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 19 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : j ekA rr— m r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ oc) 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 $
S ssion) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �� ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /J�q/ L
1A1,,r-T-e.0.0 VnrSoN License Number Exppif/attio�n✓�D��.atTe
Name of CSL Holder
List CSL Type(see below) U
Nop.Jant.Jd SMtreet ,,,,I� /l Type Description
I,� o I� o - R Restricted 1&2 Familyted l(Buildi up to ngs cu.ft.
City/Town,SAte,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Hoy�,e Improvement Contractor(HIC)
Iarrnmi 1'r� Sor) 107s44 �S�)11�
HIC Registration Number Exp rati n Date
HIC Company Name or HIC Registrant Name
�r- W I "1WNA ��'
N d S et Email address
1 0 -` sl-zy� �,. 9?Sf 35�
Ci /Town,8tate,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.......... q 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 //va r rW �rn1�o JJ
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nfye(Electronic Signature) Date
e
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 applicatio s 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"
— — The Commonwealth of Massachusetts
Department of Industrial Accidents
>f — Office of Investigations
_ 600 Washington Street,7th Floor
s f Boston,Mass. 02111
Workers' Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors
f Applicant information Please PRINT legibly
name: (/ J1%rTVJ PO 01d
address: �50 1F— Wih�lsfu. ��• h �}
city �,n AJ� ^-� /� state::? A Mzip: (L9 �� phone# gn-,7Sb'Zg3b
work site location(full address):/, 't'I SNNS0 e- Sa Im I ' f�
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
1❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition
I am an employer providing yw�orkers'compensation for my employees working on this job.
comoanymtme: I
bbI�eJ3Jw1 IJOIIcrs �J c
addressQ�
city: g.4 �u phone#: 51$'Z 9 C
insurance co. uh,? ffr--5 policy# ALL �O`l ��,bd 01
i 1
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
company name:
address:
city: phone#: -
insurance co. policy At
company name:
address:
city phone#:
insurance co. policy#
fAttach additional sheet if necessary -
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Sue of$100.00 a day against me. I understand that a
copy of this statement may he forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby cerl))ify//un''der the pains ad penalties of perjury that the information provided above is true and correct.
Signature 47k.+�^1 / qy� Date
Print name V,k eJ�1 oCO OA) Phone# 31
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
(revised&,L 2")
PEARSON BUILDERS
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Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Conitracdc'n Snperisor "
License:CS WOM
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PEABODY MA
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Commissioner 00212017
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MEMBER BETTER BUSINESS BUREAU LAU IN HOMES INC. MA REG. # It
MEMBER CHAMBER OF COMMERCE 9 'a Strat/PO.Box 252 FED it) #41-20!
MEMBER BEVERLY KIWANIS ttt
WARREN PEARSCN C5L$C.�..e
4
978)828-3979 cell HIC LIC. # 1(
,SINCE 1979
DATE
SPECIFICATIONS SUBMITT D TO, I-Irl PHONE:
zi
STREET: � �!L !' JOB N
CITY, STATE, ZIP: 1PY9,t22 J LOCA 1 '
ARCHITECT: _Z l DATE OF PLANS: JOB PHONE:
Installation of a complete Certalnteed L Shin IS roof to the entire house.
Color Ic
I. Includes strip all old shingles,we haul all debris,clean jobsite thoroughly and pay all dump and permit fees
Includes install:
-ice and water membrane to maul house eaves, around chimney and in valleys
-tarpaper bat and flanges to stacks
-Sa aluminum ddpedge to all edges. Color. -
-Starter shingles to all rakes and fascias
-cobra ridge vent to all heated ridge areas
-repair.reinforce as necessary and neatly seal chimney flashings, any step and apron fleshings.
2So /7 _Z:7 eArcr's o �
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Colors
C�i s �crt t r j U4...e le
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Customer responsible to coverftarp attic items and clean any resulting debris in attic.
Ten Year workmanship guarantee
We Propose hereby to famish material and labor-complete in accordance with above specifications for the of.
_ dollars($
Payment to be made as follows! `-Yd Lc fGG GQ�7 zw;i; «- Gc,6�1 ' -a if U y-
1/3 start, l balance upon Completion.Thank you. 44-LI- CX e C
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Acceptance of Contract
n
The above prices,specifications and conditions are setisfacoory
and are hereby accepted.You are authorized to do the work
as specified.Paymeat w' be fa do as utlinad a
Daze ofAccepmn7 a signs= '__�4�
You may cancel this Agreement if it has not been eonsmamted by aparly thereto at a place other than an add ew of the Saller,afiid may be his main offic
or a branch tbereot provided you notify Seller m writing at his main office or branch by ordinary mall posted,by telegrem awt,or by delivery,tmt later that
midnight of the third business day following the signing of this Rgreement,