0004 PYBURN AVENUE BPA 811-12t
I'he Cumnwnt cuhh of blassarhu,clls
V a Board of Iuilding Regulations and Standards CI 11. OF
Massachusetts Slate Building Cude. 780 CAIR SALE%I
Building Permit ,Application To Construct. Repair, Renovate Or Demolish a
Orle-or Avo-Fortin p Alin,
This Section Fur Ilicial Use Onl
Building Permit N nber: Dale Applied;
Budding 0111chilillrint Mane) Signature Dala
I,WTION I: SITE INFORAIATION
1.1 Property Address: 1.I Assessors Hap& Parcel Number
I.la Is this an accepted street('yes no Map Numher Parcel Numlxr
1.3 Zoning Information: 1.4 Property Dlmenslons:
lolling District Imposed thw Lot Area(sq 11) Fnwlaga(11)
1.5 Building Setbacks(R)
Fruit Yard Side Yards Rear Yard
7
Required Provided Required Provided Required 1'roviJed
1.6\Vat/Rr Supply:(M.G.1.c. 40.154) 1.7 Flood Zone Information: 1.3 SewageDispossl System:
Rrblle Q Private ClZone: _ Outside Flooddyune2
Municipal 6/on silo disposal s)stem Check il' es
SECTION I: PROPERTY OWNERSHIP'
7.1 Owner'of Reeord:
i sQ 07 P feu,. 01-ss'.
Mena(Print) city.slate.ZIP
NV.§®
u umi soP sz-r 7S,f
et relephune E(nuii Address 1
SECTION]: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction E.rist(ng Building Owner-Occupied Repairs(s) Alterotion(s).) Addition
Demolition 1 Accessory Bldg. Number of Units_ Other .Speciry:
Brief Descriptionf4of Proposed
r))WN orGkt': Fr w.11 r
t -& 1144
wst.
er / I/GVd 4
a sv +ni li
l .
SECTION J: ESTIMATED CONSTRUCTION COSTS
Mein
Estimated Costs:
Oft NI Use OnlyILaburandMaterials)
1, Building S 7600 , co I. Building Permit Fee: S Indicate how fee is determined:
lileorieal S Standard CityiTuwn Application Fee
Tunsl Project Cost'l Item 6)s multiplier
1, I'lumbing S q0o ,C , Other Fees: S_ ss - -- .-
J. \lah,mie,d (II\ \l'1 S r' a /l co• e, LisC._ --_--X ... .
S Vechanie.tl (Fire
VVV..- .
u.ve>siunl
S / l°U+ °+rota ,\11 Fees:i
he" No. heck :\mount: C.uh \mount:
I, I'mil Project Cuvl: 1 P,dd in Full Oulsta(Jing llul.mcc Due:
I
SEC PION 3: CONS 1-RUCTION St.R%'I('ES
5.1 ('onetructimtSupenisurl.iceuse((Sl')
o_ Y
17 `- 1 icellse Nunther - I',1 veto i Dale
Vnun>cul'l'S Le.IhJJct lull'SLI)pelseehelmvl.__.._._—..._
1_.JLfl.=!1 1 --. ''_ I')pe Dcicripliun
No. .md.street
l I (hlrc,triaeJ I IhIilJin s ti to )S,IAIt cu. ILI
Ci /`
P-19_J VS R Re'striocd IS] P.mlil - Dwellin
n /IP 1 Mason
NC Rmlin Onerin
W'indow,md Sidio
SF Solid Fuel 1111ming Appliances
I Insulation
felc bona Finail addre,s D Demolition
5.2 Registered Ilome Improvement Contr"Ctar(111C)
Nuntt+er vp Minn Pile
I Ilc('ontpan) Nen+e nSS I IIC'l(cgi,trunt ne
Tl• u t dl wt i
No. Id Sine Vmui JJress
City/Town.State ZIP Tale 3hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 152. 1 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..........17 No...........
SECTION 7a: OWNER AuTHORJZATION TO BE C011IPLETED 1VHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Nmne(Elcetrunic Signature)
Date
SECTION 7b:OWNERn 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.
Ci
k
f Zo I LO
I'riN Uwner'i ur:\ulhorircd Agenl'i N:une IF.leetmniv..\ign;nurul jaw
NO fES:
7henn
er who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
istered in the Hume hmprovcntent Cuntmclur(HICI Program).will no have access to the arbitration
Program or guaranty lund under M.G.L. c. W.A. Other important information on the HIC Program can be 1lcund at
n, „ i Information un the Construction Supervisor License can be found at ,,,1 t111,; '+
IDbstantialIwrkisplanned,provide the infurnumiun below:
rea I;y. 111 1 including garage. lmishcd basement attics,decks or purcht
tea 1 sy. It ._---. Ilobilable count count
unlheral lireplacei .. ._ ._ umbero(hedrooms
umherofhothrounls . . umber ofh:lfhalhi
I\lie of he,Uing i);tent tunhcr al'Jccks, porehas
l\pe,1 Qo„hllg it;lelll I'ndu,cJ pen
1. "Im.11l'rojv%Iti,lllareFoota5e nice\ he ;uh,wutudl'or-local 'rojeetCoil"
CITY OF SAL&ti(, AkSS.,CHL'SETTS
OLILOLVG oev.,antE`r
1 '0 W-UNNGTON STIM, 1"FLOOR
I1t. 978) 14 959!
K)Jopxf fiY ORLSCOLL Fr.kx(973) 710.984
NCAYOA mcmu Sr.PMXXA
OfucraRo sEICpROplRTy/8t:mDLNGCO.%O1,331ONex
Construction Debris Disposal At'tldavit
required for all demolition and renovation work)
In accordance with the sixth edition orthe State Building Code, 190 CMR section I 11.1Debris, and the provisions of MCL o 400 S 34;
Building permit a
is issued with the condition that the debris resulting fromhisworkshellbedisposedofinaproperlylicemedwastedisposalracilityasdefinedby,bICL c11I, 3 1 JOA.
The debris will be transported by;
Go Oulu)
The debris will be disposed of in :
Marne of faci)ity)
joarns or'rZ1,1y)
A:
u ln mra ufp rmit ipp6cnr
ua
C C['['Y UN S:\LEml NWSACHUsE'ITS
BUILDING DEP.+Rra(E.T
110 WASHLNGTON STREET, 3w FLOOR
TEL 978 M-9595
Rvc(973) 710.9844
CI\IBE,UEY DRISCOLL
THosLksST.P1FEytxa
NLAY01 DIRECTOR OF PUBLIC PROPERTY/8t:MMC'COWNIISSIONER
Workers' Cumpensation Insurance AMdavit: Builders/Contructorv/Electrlcians/Plumbers
koolicant Information Please Print Legibly
VIIInC(nusitw,.r.UrWtmratiun,Individual): T Pti hL lt I/u [v-/ __ J/Jc,
Address:
CityiStatc/Zip: e e Phone H:r'i M 11SZ •35'cl
ire you an employer!Check the appropriate bolt Type of project(required):
1. 1 am a employer with 4.-® 1 am a general contractor and 1 6. New construction
dmployces(Rill and/or part-time).* have hired the subcontractors
2. I am a sole proprietor or partner• listed on the astachad sheet.% Remodeling
hip and have no employees These subcontractors have i). Demolition
working lilt me in any capacity. workers'camp. insurance. y, Building addition
No workers:corny.insurance 5.Z we are a corporation and its
required.) officers have dxerciacd their
O. Electrical repairs or additions
3. I atn a homeowner doing all work right of exemption per MOL I t CI Plumbing repairs or udditions
myself.(Na workers'sump. c. 152,§1(4),and we have no 12. Roof repairs
insurance required.) I employees.(No workers' 13.0 Othereump. insurance squired.)
coy applku drat chucks but It mail also nil our tits aectiuo hcidw showing Iheir wakes'compenmtun poncy inMrmotloa
I I,. vmcnare who whmir this a rldavil indicating they are doing ill work and then hire outside conlncwe total ruhnh a new allldavil indtalina,tick
tl,mmctvn Ihsi chak this hex mma anwhud+n addtdunul.hst.hawing the name al the rubwunimtore and thaie waken•comp.policy infamatiae.
l urn an employer that Is provfdLrx workers'comperradan hrruranee for my employers. Below lz the pollcy and fob site
infurrnurinn.
In.,urmce Company Name:
Policy 4 or Self-its. Lic. 4: Expiration Date:
Job Site Address: Cityislate/2ip:
Anacb a copy of the workers' compensation policy declaration page(showing the policy number and expiration dato).
Failure to wcuru cuvdrage as required under.Section 23A of WL c. 152 can lead to the imposition of criminal penaltids of a
rinc op In S 1,500.00 andlur one-year imprisonment,as well is civil penalties in the farm of a STOP WORK ORDER and a line
Of up to 52ACO s day sgainst the violator. Ile advised that a copy of this.tamnent may bat furwirded to the Office of
Lter,rigatiuns of the DIA Ilan indunnce coverage verilieatiun.
Ida hereby cerrify under ilia paint and penaldes of perjury/but the fnfunrrudat provided above is cue and eorrers
j Dar :2011-
L
i.qlf- RS-L- 35et•,;e,r 1
Official rue only. Da nor write in stir area, fa be curapleted by city ue town ,ffl,iait
Pcrmitil.lcc¢re
k, tiioa ,\ulhurily (circle one):
I. I;oard of Ilcallh S. ILrildln.- Dvparimeol I. Cilyi fawn Clerk J. h.Icctric,il lit,pcchtr i, I'hunhinr; Intpectur
5. Other
l'u nt.Kl i'crnn: ___ Phone J:__ _
Office of Consumer Affairs and Efusiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement qnj actor Registration
Registration: 123223
Type: Private Corporation
Expiration: 1/7/2013 Tr# 213320
THOMAS W.M. BERUBE CONTRACTING;A_ t
THOMAS BERUBE I,r
t 1
15 STEWART AVE
BEVERLY, MA 01915
r --.,{,+ —y 1,f
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
DPS-CAI 0 50M-04/04-G101216
Offke foeumeAKPLBdsi'a s YFe"g`ula`u ona License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 123223 Type: Office of Consumer Affairs and Business Regulation
Expiration 1/7/2013 Private Corporation 10 Park Plaza-Suite 5170
1 Boston,MA 021161465-As W.M.BERUBE CONTRACTING, INC
THOMAS BERUBE
15 STEWART AVE
BEVERLY,MA 01915,;; Undersecretary Not valid without signature
t'
j Massachusetts - Department of Public Safety
a
Board of Building Regulations and Standards
Construction Supenisor I * 2 Famil,
License: CSFA-048884
THOMAS W At ERUB$
15 STEWARgAVE
t<
BEVERLY lyfA 01,913
x
Commissioner Expiration
11/22/2013