50 TEDESCO POND PL - BUILDING INSPECTION The Cummonwcalth of Massachuscils Town of
s. Board of Building Regulations and Standards �W
%Ijssachuselis State Building Code. 780 CMR. 7's edition Building Dept
` Building Permit Application To Construct. Repair. Renovate Or Demolish a
One.or rt6u-Furrti/1-Dsveffrng
This Section For Official Use Only
Building Permit Num Date Applied: r
Signature:
sue g Commtsstone/ of Btnldmgs Dats
SECTION I: SITE INFORMATION
1.1 ?report Address: 1.2 Assessors Map& Pared Numbers
I.la Is this an acce tealMap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Um
Area(sq n) Frontage 1 R)
13 Building Setbacks 00
Front Yard Side Yards Rear Yard
Required Provided Required I Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek if vesO
SECTION 2: PROPERTY OWNER3HIP-
2.t 0 otr-of R rd: ; `9
Name(Print) Address for Service:
Signature - Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek a that apply)
New Construction D Existing Building O Owner-Occupied O Repairs(s), Alteration(s) Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllctal Use Only
Item Labor and Materials
I. Budding � I. Building Permit fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)a multiplier x
Plumbing S 00 2. Other Fees: S
0. Mechanical (HVAC) S List:
s Mechanical (Fire S Total All Fees. f
Su ress,on
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost S k4 AW 13 Pad ,n Full 0 Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL) "143 �a
Y1<A41A6 !J TXJ p.i6� L,ceme Number E.pu/,n, n Da
L
NOW tit(' - Ilplder /= ,j Lt.t('SL Typcfxrchcluw) (ft.
A v ! 6 iT T)Par Description
U I Unrestricted(up to 15.000 Cu. Ft
R J Restricted 1&2 Family Dwell,n
�,t/M/1Yre p r�r `t I NlasonrV Only
Rf Residential Roo(n Coverm
Telephone w'S Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D 1 Residential Demolition
5.2 R er Ho Ins emeot Contractor(HIC) 7r� Y
('.�` ,6 I row"1
HIC Company Name othf IC Repstnnt N Registration N mber
AdFSECTION
l
1�CIO il,]9 apiran Data
i Telephone
ECTION 6:W RS'CO PENSATION INSURANCE AFFIDAVIT(M.G.I_e. IS2.§ 25C(6))
Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
affidavit will result in the denial of the issuance of the building permit.
R)tlavit Attached? Yes.......... O No........... O
N 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
to act on my behalf,in all matters
work authorized by this building permit application.
SignammorOwncir Data
//JJ �� � //SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, F--�v Ynv'�t -Tyalr , as Owner or Authorized Agent hereby declare
that the statements and4nformation on t e foregoing application are true and accurate, to the best of my knowledge and
behalf CC�
rJ PY D
Print N
-2e/D
Signature of Owner or Authoriz Agent Date
Si tied under the ins and ties of r ,
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 M have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 1 10.R3, respectively.
2. When substantial work is planned,provide the information below-
Total floors area(Sq. Ff.) (including garage, finished basemenbapics,decks or porch)
Gross Irving area ISq. Ft.) Habitable room count
,N'
umber offireplaces 3 Number of bedrooms
`umber of bathrooms Number of halfbaths
Type ofheating system Number ofdeckv porches
Ts pe of cooling system Enclowd Open
'Total Protect Square Footage"may he.uh,muted for-'Total Protect Cost"
CITY OF S.UX.,NI, ,L%SS.ICHL;SEM
BUILDLNG DEP.1MMNT
Ir 120
W.\SHGNGTON STREET. Yo FLOOR
f TEL (978) 745-9595
FAX(978) 740-98 4
K1%(9Ei t EY DRISCOLL
MAYORTHOItw ST.JymxAi
DIRECTOR Or PLBLIC PROPERTY/gl•RDLNG CO%L%OSSIO.%ER
Workers' Compensation Insurance ARldavit: Ouilden/Contractors/ElectrlcianslPlumbers
Antslleant information �yQ/'• II Please Print Le iblr
Nainr lawincarorgantaarion Irwbvtduall: /��Wa�3Q.[��.n avYt ¢ 1
Address. VUe-a S-1-
City/Statrizip: Paj'Id, Ma 6 Phone 0:
Are you an empley all'Cheek the appropriate box:
Type of project(required):
I.C] 1 am a employer with 4. 01 am a general contractor and 1
era ycaa(full and/or pan-time).• have hired the adf corttraccons 6. ❑New construction
2. am a sale proprietor su pttrtner- listed at the anached sliest
7. Q-lt-cmodeling
ship and have no employcen Thee sub-contractors have V. 0 Demolition
working rot me in any capacity. workers'comp.insurance, 9. Building addition
INo workers'comp. insurance S. 0 We area corporation and in
required.) ori<Icas have exercised their I0.0 Electrical repairs or additions
).0 1 am a homeowner doing all work right of exemption per IWOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 112.41(4).and we have no 12.0 Roof repairs
insurance requited.)r emplayeaa.LNo workers' 1),0 Other
comp. insurance required.)
-Any apyicam the checks boa Of mum also fill um the action below,.' attitude -mks 'canpwmmlkw policy inuwmsrloa.
't homecoming,who submit this aaldva indicating they am Joins an work and than him outside contractors mtw mtmhs a two alltdsvil indicating ruck
T.mrtswumit that carat this has mum aoach.a as 3"Iiad dirt showing do neon d roe wA.e.rrmsam pod their onohm care.policy iarnrmetom
/soar an employer that 6 providing workers'compearadsa lNwaaea jot try aatp/oyaas, er/ow/x IIM pNfey cad fab sim
Insurance Company Name:
Policy N or SelPins. Lie. p: Expiration Date'
)ub Site Address: City/StatNZip:
Attach a copy of the workers'compdusatloa policy dociesstlsn pap(showing the policy number and explrades date)6
Failure to secure coverer as required under Section 25A of MGL c. 152 can lead to the imposition of criminal panaltiee of a
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fSna
Of up to S250.00 a day ipinsl the violator. lie advinxl that a copy ur this statement maybe rurwarded to the Oalice of
Invcattgaiium ter ilia DIA for insurance coverage vetiticatioa.
/de hereby er 1 under a pains and pen do o/per/try that rM informarloa provided above is true and correct
Phnnc 1: (p�7 _
O/fiadel use an/y, Do nor write in rhis arse, te be curwp/Ned by airy a sown n/�h•iaL
City or rutrn: Ycrmit/I.Icenrt M
Asuing.\urhurily (circle une):
I. Ituard u(Ilralih 2. Huddlnil Department ). Cilyffown Clerk 4. Electrical Impector S. Plumbing Impeetor
6. Other
lunlacl Prnan: __ _. Phone x'
CITY OF SALEM
_s.
� I PUBLIC PROPRERTY
1 ,, / DEPARTMENT
1 ie Vr.\il IIN(.I i INS rN EL'T .S.\I I'\I, fit.\iiAl I II
J.AX:979-740-984e
Construction Debris Disposal Affidavit
(required 11or all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p _ - - is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:/
(name of I uler)
The debris will be disposed of in
--_(nrmeul aci it__y)
(address of lal'Ilily)
V
,ignature of per It applicant
date
Ichin�ll du.
ELDON CONSTRUCTION CONTRACT
259 West St
Randolph, Ma. 02368 DATE: 12/16/09
617.908.7956
To:
Ken &Amy Maas
14 Tedesco Pond Place
Marblehead, Ma. 01945
781.913.8553
DESCRIPTION AMOUNT
Kitchen
$19,950.00
Plumbing $14,000
Electrical $6,500
Tile (2) bathrooms $10,325
Hardwoods refinished $1,700
Materials $6,875
Dumpster $650
TOTAL $60,000
Homeowner:
Contractor:
THANK YOU FOR YOUR BUSINESSI
Massachusetts- Department of Public Safets-
Board of Building, Regulations and Standards
�! Construction Supervisor License
License: CS 88183
Restricted to:. 00.
KIMBERLY J TOOMEY
259 WEST ST
RANDOLPH, MA 02368
Expiration: 2112/2010
('onm�issl..nrr Tr#: 161
O/T7
✓/Ee SJomLM4'iel(�eaUI4 ✓�ra�i'
Board of Building Regulatlons and Standards
HOME IMPROVEMENT CONTRACTOR
Registratibnc. 158728
Expirations. 2%28I2010 Tr# 264583
qyp Individual
KIMBERLY TOOMEY
KIMBERLY TOOMEY- ".
259 WEST ST -
RANDOLPH,MA 02368 Administrator
s