7-7 1/2 HERSEY STREET - BPA-15-1333 The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR SALEM
RECEIVED RevrsedMar20//
(n Building Permit Application To Construct,Repair, RenovaM9, rElpy;Il��J"{5'�S tV?CES
^n One-or Two-Family Dwelling
1` This Section For Official Use Only 7gjS pEC _ : 4
CO Building Permit Number: Dateplied:
IIS
U J Building Official(Print Name) - Signature Date
1 SECTION 1:SITE INFORMATION
n 1.1 Property Address: '' II 1.2 Assessors Map&Parcel Numbers
7 - ri
1.1 a 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 RequGed Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public 13 Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwner,ofRecgrd: 1 /
/G.ez, �1�d r�Aa l� _5
Name(Print) City,State,ZIP
a6S G- sx Sr. y7�r-335-s�a�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) IM I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': — NfiPr-t'
SECTION 4:ESTIMATED CONSTRUCTION COSTS .
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 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 $
Su ression Total All Fees: $
9 Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ � ❑Paid in Full ❑Outstanding Balance Due:
LA
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) / 096 0q6
'�/JQ.rr{hl tion, fi License Number Expirat" ion/Date
Name of CSL Holder
150 R '.1 I\tv�.' 9{ List CSL Type(see below)
No.and Street UV Ulwti Type Description
D t Unrestricted(Buildings up to 35,000 cu.ft.
l b 4 t 11Mp,, "�b R Restricted 1&2 Family Dwelling
City/Town,SAte,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�7�5-���6'Z�7� I Insulation
Telephone Email address D Demolition
5.2 Registered HoeI_rnprovement Contractor(HIC) lo— �y G
pt-3.W�N HIC Registration/Number Exim' n Date
HIC Company Name ,r HIC Registr t Name
1 � �- �J i'NbNa ��'
No.�Vp d Stree Email address
MAI.L, . 1"1 Ol140 G-7rs-7 Sg--
City/Town, Slate,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 ..........I5 No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize Pd tIYA/
to act on my behalf,in all matters relative to work authorized by this building permit application.
1ZM JltrL�A �/IS
Print Owner's Name(Electronic Signature) ' Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest ander 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.
Print Owner's or'A� utgorized Agent's Name(Electronic Signature) ate
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. og v/oca Information on the Construction Supervisor License can be found atnLNny.mass.gov/dps
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"
CITY OF S�U. INI, NNWSACHUSEM
BUILDING DEPAR'MENT
120 WASHINGTON STREET, r FLOOR
df
�
TEL 97 745-9595
FAX(978) 740-9846
KINiBERLEY DRISCOLL
i1dAYOR -l�tOMAs ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUU DING CONMUSSIONER
Workers' Compensation Insurance Affidavits Builders/Contractors/ElectriciansJPlumbers
Applicant Information Please Print Lealbiv
Name (Busirhms;OrgatizatioNlndividual):
Address: 1 S o F- 'Nome,
City/State/Zip: 1 ea� ON U IUPhone 1#:
Are you an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with_ 5 4. ❑ t am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' l3.®Other. 5i '
comp. insurance required.)
•Any applicant thatch a box AI most also fill out the section below showing their worker'compensation policy inrotm dce,
'I lomeowner who submit this affidavit indicating they ase doing all work and than hire outside contractors roust submit a new andavit indicating such.
=Contractors that check this box must attached an additional street showing the name of the subsontnwto a and their workers'camp.policy m1brinatica,
1 am an employer that it providing workers'compensallon Insurance for my employees. Below Is the pallcy and fob site
information. '
Insurance Company Name:�_Tj roN- Y't-c5 4 7 '
Policy Nor Self-ins. Lie.
�#-7��'� SO-17�� (2.1 Expiration Dater/
Job Site Address: �Z IG, Slt�M - City/State/Zip: lCMt
Attach a copy of the workers'compensado policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties 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 fine
of up to 5250.00 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.
!do hereby certify
�fyunder rhe pains and penaltles of perjury that the informatlan provided above is true and correct
Siannittre: '�/�,n Z/02Q Date: l a1III S
Phone#: X17
Official use only. Do not write in this area,to be completed by city or town ofJlciai
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other,
Contact Person• Phone#:
PEARSON BUILDERS
1Af nm A.Pews=
150 R Vvffl a SG i9wne 978-75B-D38 - .
VLF Wfad% lAffl%0 Rot 9
}�[ Massachusetts-Departinent of Public Safety
�f Board of Building Regulations and Standards
cun,trucunn S:ner kr.-
License: CS-040996
errs
WARREN A PEARJSO '-
_ 1508 WINONAST F
PEADODY MA lft% �
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y,
Expiration
Commissioner W12/2017
018eeofCoasomsAfiain&IHegaLBm
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befarethe espua6en da& U-%md vdwn to
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CONTRACTOR ' .OffimofCooeamrAffeisand Dmm3mReButabos
Indmduai _ - 10PmkPh=-Suite 5178
Bestm,MA 02n6
WARRENA '. '
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t:
Warren Pearson
15OR Wlnani SL
Pesbody..MA019w 1 Netvalidwhhontsigaed re
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MEMBER BET-rER BUSINESS BUREAU LAUGHLIN HOMES INC. - - MA REG. # 161925
MEMBER CHAMBER OF COMMERCE 9 Charles Street/P.O. BOX 252 FED ID # 41-2054365
MEMBER BEVERLY KIWANIS
BeverlyMassach WARREN PEARSON CSL # CS40996
SINCE 1978 78) 828-3979 cell HIC LIC. # 107999
SP (CATIONS SUBMITTED TO: ONE r
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. I DATE
ME
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""" /t G;s� l�_.Jszic Y I hog ra JOB NA
CIN, ATE/ARZIP JOB LOCATION
ARCH( D`%E P JOB PHONE ^1
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We hereby submit specifications and estimates f
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Date wor w egin: Date work scheduled to be substantially comple e f v
Payment Schedule: Initial Payment: altA-e i
Payment 2: e o 0
Payment 3,due upon completion of contract:
The law requites that most home improvement contractors and subcontractors be registered with the Director of Home Improvement Contractor Registration.You may
inquire about a contractor registration by writing to the Director at One Ashburn Place,Room 1301,Boston,MA 02108 or by calling 617-727-3200 or 1-800-223-0933.
It is the contractor's obligation to obta: any and all necessary contruction-related permits,should the owner secure their own contruction-related permits or deal with
unregistered contractors the owner sha be excluded from access to the guarantee fund.
Unless otherwise n. t .his document,the contract shall not imply that any Ben or other security interest has been placed on the residence.
Acceptance of Contrac, )O NOT SIGN THIS CONTRACT IF THERE ARE BLANK SP ES
The above prices,specific am ions are satisfactory I �1
and are hereby accepted at 'to do the work SignaAIT,fA �
as specified.Payment v ned above.
Date of Acceptance 7" Signa
You may cancel this agr. .signed by a party thereto at a place other than an address of the seller,which may be his main office or branch thereof,provided
you notify the seller in:. trice or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following
the signing of this agmer. Notice of Cancellation form for an explenation of this right. - -