B-19-1190 - 0009 ALLEN STREET - Building Permit The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
" " This Section.Foi;Official Use Only
Buildmg Permit Number Date Applied:
Building Officiat(Print,Name) �gnature Date
SECTION 1:;SITE INFORMATION
1.1 Property Address: AllP 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
a 1.3 Zoning Information: 1.4 Property Dimensions:
le �aN.
Loning#istrict Proposed se Lot Area(sq ft) Frontage(11)
B ding Setbacks(ft)
Front Yard Side Yards Rear Yard
;: - Reg!/ud Provided Required Provided Required Provided
=` I.6 Wa&r Supply: (M.G.L c.40,§54) 1.7 .Flood Zone Information: 1.8 Sewage Disposal System:
a) Zone: Outside Flood Zone?
Public.!, Private❑ — Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2:1 PROPERTY OWNERSHIP.'
...
2.1 Owner'ofRecord���� le M
P l + I M
Name(Print) City,State,ZIP
g ,�►��,� g 7�- 3�-spa 3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) He Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units her ❑ Specify:
Brief Description of Proposed WorkZ: }ri
SECTION 4 .ESTIMATED CONSTRUCTION'COSTS'_
Estimated Costs:
Item Official"Use'Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ : Indicate how feeds determined:'
2.Electrical $ ❑Standard City/Town Application Fee
❑.Total Project;Cose(Item 6)xmultiplier. x
3.Plumbing $ 2. Other Fees. $ '�
4.Mechanical (HVAC) $ List. '°
5.Mechanical (Fire $
Suppression Total All Fees $ ._ -
Check No = Check Amount Cash Amount.
777
6.Total Project Cost: $ l SO ❑Paid m Full ❑Outstanding Balance Due
cu., I (h 0-yo 6wy,�-"
SECTION 5: CONSTRUCTION SERVICES l
5.1 Construction Supervisor License(CSL) 4 6 91t 1
p1J j License Number Expiratioh Date
Name of CSL Holder
List CSL Type(see below)
ISO101 w 6—�C. Tye Description
No.and Street
n Unrestricted(Buildings up to 35,000 cu.ft.
h l R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�( SF Solid Fuel Burning Appliances
���'Z �J I Insulation
Telephone Email address D Demolition
5.2 Registered Ire I provement Contractor(HIC) 1 b
� <a Pi 1►�I� � HIC Registration Number Expi afion Date
HIC Company Name or HIC Registrant Name
1 So r Pi - ,>412) )C.
No.and Stre o 1.,
l� - �O Email address
Ci /Town,State, 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..........IM 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_" e,,l YP&J3 o,-J
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(ElectrbMc Signature) —�D to
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 and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) —� Date
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.mgLL.gov/oca v�Information on the Construction Supervisor License can be found at www.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 SMEitiI. NLkSSACHUSETTS
• BLn.DlING DEPART. lUNT
j 120 WASHINGTON STREET,Vo FLOOR
\ i0'f TEL (978)745-9595
FAX(978)740-9846
K1.% BERLEY DRISCOLL
T
MAYOR FLontAs ST.PIERRB
DIRECTOR OF PUBLIC PROPERT1l/BUUMLNG CO.NMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please PrintLeeffil
ga Name(BusineWOrnization/Individual): Wc� �NJ 1'0fSo
Address: ]so W. ,,Kw, S�
City/State/Zip: d�o � Phone i#: 9 �'Z S�"��►�
Are you an employer?Chec t he appropriate box: Type of project(required):
1.ElI am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet I ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL It.0 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' 13.❑Other
comp.insurance required.)
.Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
11 tomeowners who submit this affidavit indicating they are doing all work and that hire outside contractors must submit a new affidavit indicating such.
-Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that Is providing workers'compensation Insurance for my employees Below Is the policy and job site
information.
Insurance Company Name:—<rw4e rs,
Policy#or Self-ins.Lie.#: ��'�` t) l S 1 Expiration Date:•
Job Site Address: A N )�C. City/State/Zip•_ �,1.e,11, 1'`1
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 e. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 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. He advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true
and correct
i gnature:—�C%�jS�,2 i+.y./C/ Date: f Z 1 r
Phone#
Ojjcial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/i.icense#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
WARREN.PEARSON CSL #CS40S
• �`SINCE l s7e, 8 8-3919
HIIc L11C. # 107S
SPECIFICATIONS1� 'T v ` +`-'�
SUBMITTED TO:. , PHONE:
STREET:
JOB NA
CITY,STATE,ZIP: .
JOB LOCATION:
ARCHTfECT:�UL%� D OF PLANS' J' JOB PHONE:
�: /
Installation of a complete
Shin le roof t
Color 99 '
d,, - lj .JI7 IM
I. IncludesInaudes strip all of shingles', w l all debris,clean' bslte thorou hl
g �< g and pay all dum fees. 66,A
r Includes Install: � - ���'�
ice and water membrane to main house eaves,.aroun -.ckumney a d is. Ileys �
-tarpaper base and flanges to stacks
8"aluminum dripedgeto all edges. Color:4411, �111flj&04)_
-.starter shingles to all rakes.and fascias-cobra ridge vent to al! heated ridge areas �
repair,reinforce as necessary andneatly seal 0/0�shing any step and apron flashin s.
-we procure permit, customer reimburses permit .cost. g
az
` ��141
option PL J Ae .74
Re- of: s specifi
o. gr
.1 e, and tarpaper baser
Col r:
Customer responsible,t cover
ltarp attic items and lean any res Ring debris-,in att
Ten Year workmanship guaranteeOF c f'
We Prop a hereby'#o furnish material and labor com lete in accordance.w' a specifications for the Sum of
Payment to be made as follows: _
1/3 start, 1omplete and balance upon completion. Thank you.
All material is guaranteed ro be as specified:All work robe completed in workmanlike manner
according ro standard praetitzs.Any alteration or deviation from above y !
extra costs will be executed on speciCeea ons mvolvin
only upon written orders.and wall become an extra charge over _ Authoriz
and above the estimate.All agreeatents wrttiagem upon stiilvs,accidents orddays beyond ow'. Signature.
con tmL Owner to prry fits tornado and.other ":,•» ��. . ' / i _
x
by workers compensation " 'gin'�"ance.Otv workers are coveted
ittsitiattce.
a iT ril "'
Owner agrees that.in the event of his breach Hof Uta contract befare work is started.Contractor may Lott;:This proposal'may be _
demand tweaty:five percent(25%)of the contract pnce as its stipulated damages for the bmach. withdrawn by us'if not accepted within
days:
Acceptance of Contract The above prices,specifications and conditions are satisfactory '
and are hereby accepted.You are authorized to do the work Signatur' trti
as specified.Pa
sP Payment will be made as outlined above. -
Dc.,':
Bate of Acce tan z
p cr I t �-s t i Signa
_ tr--
Yon may cancel this Agreement if it has not been consummated by'a party thereto at a place other than an address of the Seller,which may be his main office
or a branch thereof,provided you notify Seller in writing at his main office 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 agreement.
CITY OF SALENI, NWSACHUSEM
"• BuILDL�IG DEPkRT\IENT
' 130 W ASHINGTON STREET,3'FLOOR
.o� T EL (978)745-9595
FAX(978) 740-9W
KINiBERLEEY DRISCOLI.
MAYOR. T HoNw ST.PIi m
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
/J --
(name of facility)
(address of facility)
signature o permit applicant
ZJ124117
date
debrisaff.doc
x
Office of Consumer Affairs&Business Regulation e f HOME IMPROV MEIN CONTRACTOR r
TYPI.COMOration
�e f_ -1 ' EXoi
08/16/2020
PEARSON BUILD[F{_.
r;� y -
WARREN A.PEAk"
15OR WINONA ST
WIEST PEABODY,MA 01960
Unde~rs¢WPetary;
Commonweafth of Massachusetts
Division of Professional Licensure
J Board of Building Regulations and Standards
Cons� isor
v
CS-040996 y�_.t j 4,pires:04/12/2021
WARREN A `
150R WINOS =r: �
PEABODY
ICS33 �
Commissioner