30 WILSON ST - BUILDING INSPECTION 133 C�� � 025
The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALEM
\ Massachusetts State Building Code,780 CMR p�
CYC .':I�F�Q�I 33
Building Permit Application To Construct,Repair,Renovate Or Demolish a JG�dy
tBl
One-or Trvo-Family Dwelling
t •This S.,erdioinl'cr0ffit�•Use,
Bu Ging Permi<-;Number- Date plied:
iy
Idrog olei ( t ➢ sigfleane Bate
�-- __iiC_UONT$ITISH!ti(ORMAfIDN'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
3c („r
l.la Is this an accepted street?yes V no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
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: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system 13Public❑ Private❑ Check if yes13
SECTION 2: PROPER9TYOWNERS1ItPt
2.1 Owner'of Record: Sad?. !MCS r
S05a, SCCn 2G� 7
Name(Print) City,State,ZIP
?0 4,ldrer 51' L 508- Od-7—q 6
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK;(glteck all that aPPly)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Re pai-s(s) q Alteration(s) 1k Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work"
n 46
SECTION 4:ESITMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1.Building $ t�,60'0, v6 1• Buikling For;*—Feu:$ Ii3dlcate haw fee is detuninedi
13 Standard City/rovm Application Fee
2.Electrical $ "z 3 °V. ` ° Q Total Project COSts(item 6)x multiplier x
3.Plumbing $ - 11700100 2.List,
Other Fees: $ _
4.Mechanical (HVAC) $
5.Mechanical (Fire $ Total AB Fees:$
Suppression) -
Check No. Geek Amount: Cash Amount; .
6.Total Project Cost: $ /R2 700 ,00 ❑Paid in Full ❑Outstanding Balance Due:
of I I -L M 4t t_EYq
10 t-1 7 z"D Porn LT — r1_6 C) M lkmjz�,D .
SECTIONS- CONSTRUCTION SERVICES
5.1 Construction Supervisor Licen/se(CSL)
7Ol OY��y 11- 2Z-/6 r.
ocL s- 6I '/// �.0✓�Y.L License Number Expiration Date
Name of CSL Holder
��- Lis[CSL Type(see below)�•
No.and Street
npuU /1!1 �/1g--(s �1 f/r U Unrestricted din to 35,000 cu ft
R I Restricted)&2Family Dwelling
City/town,State,ZIP masonry
RC
Roofing Covering
WS Wmdow and Siding
SF Solid Fuel Burning Appliances
779 b57 ?Sc/ � C-Q^^�S4 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) IZ-� 2Z3
/✓lti a)i a C', ZiAc HIC Registration Wu-tuber 'on Date
HIC Company Name orLHIC Registrant Name
C ��wn Jl.�7 _:_.ah2i
No.and Street Email address
�
iU`f� YYi�-SJ
Ci /Town tate Z1P Tel hone
SEC9IOI4 6:WORKERS°'COMFENSATTON I SURANACE ARWAVIT(M.G.L c 152.3 2 f )
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 ..........❑ No...........❑
72:OWNER AUTHORIM TO BE C()WI M WHEN
OWNER'S A NT OR C9 OR AP1PIJES
.E _ :.. ). INGPER-MU_
I,as Owner of the subject property,hereby authorize it a ,�"
to act on my behalf,in all matters relative to work authorized by this building permit application.
5CJ50/I SGC/1?la in t l 'd ?0' 6'Print Owner's Name(Electronic Signature) Date
SECTION lb-OWNEW 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
dinythis application is true and accurate to the best of my knowledge and understanding.
/!/lal+✓aJ �Pw <-pin4 IT1f
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOUS;
I. 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
3nMAIMLgov.'oca Information on the Construction Supervisor License can be found at wmr.mass.gov/dos
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 haWbaths
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"
J
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards '-
Construction Supen isor I &z h'am11y
License: CSFA-048684
111 . i
THOMAS IN M BERUBE
15STEWARTAVE
BEVERLY MA 01915
pyi
eyExh�
Commmissioissio
Coner .riwr•—
Q
vusiness
Office of Consumer Affairs and Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
-= Registration: 123223
Type: Private Corporation
Expiration: 1/7/2017 Tr# 262068
THOMAS W.M. BERUBE CONTRACTING I
THOMAS BERUBE
15 STEWART AVE
BEVERLY, MA 01915
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
DPS-CAI 0 50W(14106�G101216
!t?.-� Otfice foame� ei`rs&Bofioesls��{gu`iatio License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
F.Registration: 123223 Type: - `Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170 -
>=_ Expiration 1R@017 Private Corporation Boston,MA 02116
THOMAS W.M.BERUBE CONTRACTING,INC
THOMAS
15 STEWART AVEC.
BEVERLY,MA 01915 Undersecretary Not valid wnhout sigaature
t
QrTYof SALE14 MASSAQ3USEr1n,
BanMDBrA MOff
IMWA9DWMSnM7s3=ftDM
1>n:(118)745-9595.
SIA�ERI�YD ,
MAYOR 71�nr�sS7.Pf8asE
DmscrtatcFrusut FFXF at Y/autuMoMraM
Construction Debris DisposW Affidavit
(required fora!! demolition and,.renovition work)
In accordance with the sba edition of the State Building Code, 780 CMR, Sect W 111.5 Debris,
and the provisions of MGL coo,S 54; Buil Permit B Is►std with the
condition that the debris resulting from this work shall be disposed of In a properly ra:ensed
waste deposit fadfity as defined by MGL c 111,S 156A.
The debris will be transported by.
-
/.Y//171Z is
(name of hiuled
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature/ of applicant
�nnAA zee /S
Date
z
The CommonweAM ofMaysachuseM
Department ofiWNsoiaAcc denis
I CongressS74m4 Suite 100
Boston,AL¢02114-2017
WWW.massgov/dia
Workers'Compensation Insurance Affidavit Builders/Contractors/Eleebicians/Plumbers.
TO BE FILED 87TH THE PERRMTJNG AUINORrI Y.
Applicant hbMation Please hid IetiAly
Nam(Basmessiogammtion/lnuivdal):
Address:
City/State/Zip,: Phone M
Are yea an tmpbysYt Oedt the aypreprAft bm:
I.OIam a e V10ya WM Je -en*YM(full-dlmPsn bs)•* 7. O New construction
2.Olam4aok popaimrapataership aoQ save ao.empbXym tvo7ifma taameio 8: Remodelim
m] y [Fla kaa' tioutoce"tel 9. ODemalitiow
3.q lam a aomeovmerdoiog ag workmysa[No wwkes camp.invmancem9!me fl t
4.61®a Eomtowaermd will be airing emaactm to cma daall Volk on mypopeny. I wdl 1 O Q Bm7dmg addi7ion. .
emoetbat all conasams eidw have workers'compevol"M iosomce acre sole 11.0 Electrical repairs or additions
Nsp?ratms web aoempaoyeen' - 12:0Ph>mbmgi0aus ai'tulditi( "s
5.0 lam a gmeral ceatodm and have aced the sul4cearseem lilted ad do a]1ee6edshwL 13. Roofr s
7bow my-cmase[®We mooym and lave wbalm'con*-neu• MI . .�. -
6.0 we are acoryontianaedit.offiewsasveeserciaedil�rilmofumptiaoperMOLa 14.[]Other .
152.4](4),and we aai+em enwloyeas:IND wwik 'cWmp:iorivanm=Of&) -
. •pnyappliuMffim eaeeto<baa til must also M.omPoelaCOa babwsaowktg Poet warloeia Pobe]'
r Nomeowms woo suEvnd Pob alldatitibdi - amammt ssLmas newat6davitiodinfing ouch:
1Conoasmr do caeck dw bm new wed ao-aMdoml shed1showmg tae naaftofdw subconueomsmd sme'waeffierw sol Ihme mopes We .
employee. Xf�6ub- saeve.emPloY�.�.'mo$tpawide&ev woTkae'eomR lmbcY�e<-- ,, . :
Iama>aeofployerlhatirpropidiagworkers't:ompenaapionmsararrcejor�ayea . Behnaiathepohryandfobsife
lnjtirmatlen.
Insurance Company Name:
Policy#or Self-ins.Jac:M Expiration Date:
Job Site Address: " . Cit3'/State(zip. -
Attack a copy of the workers'compensation policy declaration page(showing t1ke policy number and expiration date).
Failure to am=coverage as required under MGI.c. 152,§254 is a taint' a]violation punishable by a fine up to$1,500.00
and/or one-year mi nFi c' mit,as well es civP penalties in the torm da STOP WORK ORbER and a fine of up to 5250.00 a
day against the violator.A copy oftbis stateiixnt'rmy be forwarded to the Office oflavestigatic aB of the DIA fcr insurance
coverage verification. '
Ido hereby ceamo ua�ndertbepains anndd penakiees ojperjury that the information provided abbow it frue and corned
Doe: 6
Phone#
O,frcial use only. Do not write in this area,to be coWleted by Elly or town official.
City or Town: PermitMIcense#
Issuing Authority(circle one):
I.Board of Health I Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone M
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hive,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local lieensiug agency shall withhold the issuance or
renewal of a license or permit to operate a badness or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,125C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the worker'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other then the
members or partners,are not required to carry workers'compensation instance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insuredcompanies should enter their
self-insurance license number on the appropriate line.
City or Town O1Ldals
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the peratillicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating cument
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in=(city or
town):'A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit mast be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017.
Tel.4 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia