Loading...
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 i 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 - . . - Wamm Pearson NQ —� - �_ tsazwnmrrast. Pyr.MA 019M _ - - `- - - :=t . . - NetvaGd W1fl1nH[ nre i �Cctit /inJ S ✓^ s f. /tt�fi .f G 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: -- - ... .......:............. .........-.--.. .-.-.- ---.......-.-.-....::.....---:............. ....................-. ........ .... . ... . . a/6�C�?s.....� 1-. . ....�� 7✓-.f ..0 E �. ....fI-LJQ......G ......... . ......'�-7� . f�y r) .../..lJ..... . .... .rti-............. .r%.../. .. ... .....--. ........................ f�< -c- - ............-/�- .�...... �- z.. ...... 41 .. . ... r.....F�- - �.�r .... `...... .�.....¢.. ....r�r..... v...... lL.. r:�... �� .... . .. .-J 'z` ..... -cls-... ....... ....cc�'......� �� P�� - Awl. ... ....... ... . /... ... ... . . . .. . . ............ ............... . . . . ( . ... ....... �....... �.... � c. y � ...: � c. . .-. z.... 4� r ..............�.a�7.... 7..`7.✓........��...' <!�t�[ ..... '... .....Gi/Y/�<✓ r. , �r..... ............G' .,-........... ........................................... :::::........ :: :: .:::::;: ::::::G; % :......:: .......... ............................................................................ . -. ................ ................................................:..........................:................................................ .... .. ... 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 v w r c�2 Irk 8 //S Com) S11104A Z1"1 moo f