400 JEFFERSON AVE - BUILDING INSPECTION CIG I LA 63 28 er
The Commonwealth of Massachusetts v.
Board of Building Regulations and Standards "R'E'CEIVED CITY OF
Ulf Massachusetts State Building Code, 796-bRWTIONAL SERVI ES SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair, Renx�ke Dp�rpol'Sh�: b
f One-or Two-Family Dwelling rI ] WIT 1 A
O This Section For Official Use Only
Building Permit Number: Date A plied:
Ln Building Official(Print Name) - Signatu�r'e�e� Date
SECTION 1: SITE INFORMATION .
I 1.1 Property Address: q�tMy 1.2 Assessors Map&Parcel Numbers
-Te erGaN Vit•
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 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 Owne{t of Record:
J b r/ d- 5tAS u 4W A rw 4m PIA
Name(Print) City,State,ZIP
�jCk't T�ersol� At�2. 9?ts-ZIo`'1g�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) "
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 78 Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': M - o Salyut-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ a 3 1. Building Permit Fee:$ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ p Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ -
4.Mechanical (HVAC) S List: - � c
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. - Check Amount: Cash Amount:
6.Total Project Cost: $ t a 3- ❑Paid in Full ❑Outstanding Balance Due:
1151 20 1
awe
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) yoq$ 1� 7
- N License Number Expiration Date
W,4�K
Name of CSL Holder -
�� List CSL Type(see below)
No.and St ee Type Description
3GV& j MA t b Unrestricted Buildin s u to 35,000 cu.ft.
tA,y t "� U R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I--Insulation
Telephone Email address D Demolition
5.2 Via
Home Improvement Contractor(HIC) 107q`701
V is rreo fEea� HIC kegistration Number E n Date
HIC Company Na�e�or HIC Regisant Name
,1 SO (� V�li'NoN� �1
No.end Leit Email address
Ci /Town, Skate,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 ..........19 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 (/ M,/
to act on behalf,in all matters relative to work authorized by this building permit application.
ra 1S
/ 'Zyi
Print ❑(WY Name(Electronic Signature) 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 true anaccurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Ilate
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 atmny.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"maybe substituted for"Total Project Cost"
CITY OF S.UXA1, l/LkSSACHUSETTS
• El umING DEPART%MNT
120 W ASHINGTON STREET,3'n FLOOR
TEL. (978)745-9595
FAX(978) 740.9846
1CI.\(BERLEY DRISCOLL
MAYORTHOMAS ST.PIERRIii
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Nance (Busim.•ssiOrganizatioNlndividual): tyar&i`1 E&,\�
Address: 156 dz Wvjoi&. St
City/State/Zip: 1 fbbo�, MA O N D Phone
Atrre�you an employer?Cheek the appropriate box: Type of project(required):
1.Lel 1 am a employer with_� 4. 0 1 am a general contractor and 1 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
workingforme in an capacity. workers'comp.insurance.
Y P tY• 9. El Building addition
(No workers'comp. insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I LQ Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13%0 Other PC rC—�fyMR.
comp. insurance required.]
;Any applicant that chocks box#I must also fill out the section below showing their world='comla noon policy information-
1 r mteuwnas who submit this affidavit indicating they stn doing all work and them hue outside contractors roust submit a new Mdavit indicating such
lCommewn that chock this box most attached an additional sheet showing the name of the subcomracton and tel,wodars•comp,policy infonmtien.
I um an employer that isproviding workers'compensadon Insurance for my employee% Below Is the polley and job site
information. I I
Insurance Company Name: `^ ir4ilk
Policy#or Set&-ins.Lie.#: -AF-1- S Gy -7ZCr Q) Expiration Date: 3/,6
Job Site Address: �00 5er�nnl City/State/Zip: =�i)p_M Mme_
Attach a copy of the workers'compensation 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.
1 do hereby cenoyr under the pains and penalties of per/ary that the information provided above is true and correct.
Signature: ' so?4/ pate• o// S
Phone#: 9-7is•75e6- q31
Oficial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ Phone#
PEARS-ON BUILDERS
-
Werm A POWUM
150 2 NI4 ft Poate 97845$2939 - .
tlR PadfodY,MAD1960 fit 97857
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
• - %nnstrur8nn sunerrisor - - -
License: Cs- m*m -.'
WARRENAP$A) O
150R WINONA P
PEABODY MA 0196
Expiration
Commissioner 04/12/2017
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offimofcoe�a8s6a81zBegoh6m >a_e�:arregis0� -•. �rindrvidel�eonly
NPROV�AENT CONTRACTOR bemore the ewha6on d Iftb®d rdmn to:
-Offim of Co ASafrs nod Bosoms ReolkWo
rae in�vld� 10Park -saiinsno
Boston,MA 02116
WARRENA -
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MEMBER BETTER BUSINESS BUREAU L AVG 0-VIES INC. MA`REG. # 1619
MEMBER CHAMBER OF COMMERCE 9 +-'. S .P-0 Box 252 (�9—�2/� FED ID # 41-20543
MEMBER BEVERLY KIWANIS _ _
13e1 L'7IC''� 3 - 1 WARREN PEARSON CSL # G5409
SINCE 1976 78} 828-3979 cell HIC Lic. # 1079
SPECIFICATIONS S,UBMRTED
T !J Tom ' _ i
STREET O _� It / 1 i.
CITY STATE&ZIP JOB LOCATION �C f✓/-�i
OAF=Or PLAN^ / JOB PHO \ 9 _
We hereby submit specifications and es mates for: -- -
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Date work will begin: Date work scheduled to be substantiallyplet
Payment Schedule: _ Initial Payment: 0 / �7 j j
Payment 2:
Payment 3, due upon completion of contract:
The law requires that most home improvement contractors and subcontractors be registered with the Director of Home Improvement Contractor Registration.loa
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 1-800-223-093?
It is the contractor's obligation to obtain any and all necessary contruction-related permits,should the corner secure their own contruction-related permits or deal
_ unregistered contractors the owner shall he excluded from access to the guarantee fund. -
Unless otherwise noted in this document,the contract shall not imply that any lien or other security interest has been placed on the residence.
Acceptance of Contract DO NOT SIGN THIS CONTRACT IF THERE AREBLAN ACES
The above prices,specifications and conditions are satisfactory U WV� �(�
and are hereby accepted.You are authorized to do the work
rj S try Sig
as specified.Payment wi made as o ined above x/:20N
Date of Acceptance 16 / Y / Signa
- You mavcrocel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main oBfeJor branch thereof.pr
you notify the seller in writing at his main office or branch by ordinan mail posted tn-telegram sent or by delivem not later than midnight of the third business day fol
the signing of this agreement. Sce attached Notice of Cancellation farm for an espienation of this right
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