B-19-1268 - 0017 BOSTON STREET - Building Permit 1 � f
The Commonwealth of Massachusetts ,.,
Board of Building Regulations and Sta�da�'t _ :; CITY OF
Massachusetts State Building Co"de,`�780' IV r j1 V SALEM
Revised Mar 2011
Building Permit Application To Construct,Repa st n v t OrQeBio" kh a
One-or Two-Family Dwwi ,� g
This Secrion For Official.Use Only
Buildmg Permit Number Date Applied
Building Official(Print Name) Signature Date
SECT ION=1.SITE INFORMATION ;
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
?Art a
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed 1Ae 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 Owner'of Record:VCdb,& 1
Name(Print) City,State,ZIP�
17 too Sir. ��7-$
ol-
No.and Street Telephone Email Address
SECTION 3.pESCRIPTION.OF PROPOSED WORW,(check all that apply) ,
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: 4. o- mi- o 1 w�
fPJ h a S_ ' 1 ,N, P
,, SECTION 4':.ESTIMATED CONSTRUCTION COSTS_
Estimated Costs:
Item Official Use:Only
Labor and Materials ;,. .
1.Building $ �� q S 1 -Building Permit Fee $ Indicate how'fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3`(Iterri 6)x multiplier ' x
3.Plumbing $ 2-.0ther Fees $ ..
4.Mechanical (HVAC) $ ListI
5.Mechanical (Fire $
Suppression) Total All Fees $
Check No Check Amount: Cash Amount
6.Total Project Cost: $ !� qS o ❑Paid in-Full- Outstandirig Balance Due
SECTION 5: CONSTRUCTION SERVICES
5�1 Construction Supervisor License(CSL) Lf 07-7[ l
(N�� '1 Mt Oa License NI umber v ExpiratioA Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
1 ��/ Unrestricted(Buildings u to 35,000 cu.ft.
li , U R Restricted l&2 FamilyDwelling
City/Town,Stat ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�U_ SF Solid Fuel Burning Appliances
0 t I Insulation
Telephone Email address D Demolition
5.2�Registered Home Improvement Contractor(HIC) g
f CA1ei►l IJL HIC Pegistration Number 8xyiiati6n Date
Fut Corn any Name or HIC Re istrant Name
1 14��wbNt>L
N d Str et Email address
�, o t. , p lads g7�-Y -za31s
City/Town, ateS—IP Telephone
SECTION bt WORKERS':COMPENSATION INSURANCE AFFIDAVIT(M.GL.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 ..........91 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 6VArPt,/✓ Pror504
to act on my behalf,in all matters relative to work authorized by this building permit application.
1V 1�,Mk W 13/ 1 q
Print Owner's ame(Electronic Signature) Dfate
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.
15
� 1)113111
Print Owner's or Authorized 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 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"
OONDITq�J CITY OF SALEM,MASSACHUSETTS
Building Inspector
a. m 98 Washington Street,2"d Floor
pO�P Salem,Massachusetts 01970
i
_ LIME s '` �rz S5635
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Board Of Building Division of Professional Licensure
Commonwealth of Massachu Regulations and Standards
Cons
CS-040996 �f
WARREN A \ " ar ��ires:04/12/2021
" P.E/1lil4itf i#" -
16OR tMNO1VItz STREET
PEABODY MA�01989� "# r
_ Commissioner
.. •_
Office of Consumer Affairs&Business Regulation 9
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE:Corporation before the expiration date: If found return to:
Registration Expiration Office of Consumer Affairs and Business Regulatio
192811 08/16/2020 1000 Washington Street-Suite 710
PEARSON BUILDERS, INC. Boston, MA 02118
WARREN A. PEARSON
15OR WINONA ST Not valid without signature
WEST PEABODY, MA 01960 Undersecretary
CITY OF SALF.1�i, 1�I�'�SS�ICHUSETTS
• BUUML IG DEP3MWNT
` 120 WASHINGTON STREET,Yo FLOOR
TEL. (978) 745-9595
FA.r(978) 740-9846
KI.%,tBERLEY DRISCOLL
MAYOR T HoNw ST.PIERRB
DIRECTOR OF PUBLIC.PROPERTY/BUI DING CONWISSIONER
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 :
_ ofA
(nameVoof facility)
(address of facility)
signature of permit applicant
date
dcb6safEdoe
'� CITY OF SAL.EM 1 LNSSACHWSETTS
AuH DR40 DEPAR.tENT
+ 2b .ASHINGTON-STREET,'r FLOOR
TEL(978)74S-9595
Fur:-(978)7409846
KiaiBERLEY DRYSCOLL
MAYOR T HOblM ST.PIERRB
DIRECTOR OF PGBUC PROPERTY/Bl.'IIDI14G:CONLNMOVER
Workolrs'Compensation instiance Aft3davit:,Builders/Contractors/Electrcans/Ptumhers::
A" lica>zt lnforiiaahottt __ R!o"se'P 'nt Uefft
,ViTtt112(Business:Or�nizaaortllntt<vidustl): �U.�C'C�iJ 0�
Address -
CiCy/State/Zip:., v. dti� Phone:# / �
Are you-an
em t e 'Che: the,sP_ro 4it0 { 6�af
!7M iamacrnplayer wih II an,a! I contractorand I o act 4r e 9u
❑New cgnstructioi,.
employees(full and/or part-amp).' have hued the sub-contractars .
Z Q I ata a sok proptieor or parnter, ltsted.ori che-attached sheet:I Q Itentodeling
`chip.and have no cmployeex These sub-contractors Nava I. Q pemoliiioa
working 'for me iA any;capacity wor xrn cow tos."urame: 9. Q S.utldtng addition
[No workers'comp tnsetrance_ S: Q We are a corporatiott and:its
rrdutred'a officers havti,exerctstid they
10 Q filectrical repatrs hr additions
3.❑,i®m a h6mcowner�domg;all work agltt of exeinptton per,MGL 1 l Q Plumbing repairs or.additions
myself (No woilit;rs',comp:, a 1.52.§l(4) and we have no 12 Q Roof rc go
»zsurance`rcqucted.)? - em to ees t\'a workers' (�
comp.imranee mquicdJ .
'Any appliistnt tfust cFiacks boz fvt must also tiU uut the seetioa below ahowinQ their aorlcua`eornpensanon goiiry mtu+mcuion ""
t,1 tcwneownea who submit this afliQavtt ind,nting they us acing ail work attd tha►hua ouai.. coniooata onlii 016it a new,atlidavtt ua3imong sued
=Cuntiai tort that dieck.ttiu'box must anacisod'an sdditionat meet shnariag the came of the sub-contractW atti!their wotitara'-wtnp.;poi�ry information:
m any oyer that is provlding^'workers'compensatrou lnsu�ance fot-my eaipluyee .Below!a the pallcy and}ob slta
in
fnstaance Coinpaay Name
Policy*or-Self ins.LiC,# I '� "' f 75 Eitpuation Date; v �-
Sob Sice Address:. :��� City/StateJZtp:
�% taeh a.copy oi'the workers'compen anon po.Ilcy declaration page(slowing the policy aiitnlDer and expl tloa date).
}:allure to s�xure tzoverage as requiredun`�lt:r Secton,25A of MGL c 1S2 can lead to the iriposition of`tiriminti!penalties`of.a
fine up to S 1,501).00 asid/or one-year imprl$onmesnt,as well as civil penalties to.the'form of a STOP WORK ORDER and a fine:
of up to S250:00.a day a .ltnst ttit;'violatorz Be advised that a Ampy.of.this statement tray be forwarded to the Office;of
nti�uoiu'if the DIA for insucan.'ce coverage vc'riftuition:;
«5
l:r<ohireby emit y.under tl+r p+elns a+id eaaltics of perjuty,that t&e!n/urinptTon provided above is rare and correct'
Sia at-ttrel
Phonc
Official*F only,Da not write in this;area,to.Ae cornpkted by cuy or.(of m ofJwwi
City or-Totivn:. Pcrmit/iacense ti
Issulitg�i uthortty(circle oneP.
1 Board ui 1[e tlth 2.;Builtlin(;Dcp rttueat 3 OY/Town Clerk 4-Electr#cal Inspector. g.,.I'tumbiitg Ins pecto''r
G.:Othec .
Gtidfict Person I'Aone#:
CIS' OF 5MINI, MASSACHUSETT
BLILDL`G DEP..Ri`LE.>1T
t 1 2W W SHiIJ.GTON STREET,' Ft:OOR
fez
FAX(978)740-9846'.
KI,.%tBERIEYDRISCOLL
MAYQR: T oz`us ST PMRRB
DT 44TOtt OF PUBLIC PROPERTY/,B MDL;G cO 4$IQNER
Workers'•Compensation Insurance AMdgvit Builders/Conti-actors/EIectricians/Ptnmbera
Anglicant:infor nahoo_ . _ _ Ptesse,Print Lek1bty
Name(sW4 ss fpn.iza'tiowindividwal)� ("t"P �j I• :a(�
w)
.:Address::_ .'A
City7State%Zip.'
,ire you au:etnpbyer?.Check the appropriate box. Type of project{required)
z ;
d. l am a to er with 4 (] l alit a general contractor contractor
'mP Y . , 6. ❑New have hired the svb-c'ontractois coh-strut tion
einploytars(full aad/orpart-ttmc).
7-
(]:Remodeling
2❑ I am a sok proprietor or.partrter:' listed on the attached sht:et.
ship anti.have no omploycez;, 'These sttb-contractors have IQ Demolition'
working'.forme;in any capacity.: workers'comp tnwmnoe. 9 0 Building-4dditton
f,No workers comp,insurance 5: ❑ We.ai+e a corporatism and its
'required,]'
officers haire:exercised then l0.[ `Electrical repairs or addiftons
3 [].`l am a homeowner doing all work right of exemption per MGL l 1 0 plumbingrcpairs or;tddiftons
myself-.jNo.workers'comp; c. 1.52,§t(4),and we have no g 2; Rsiof repairs
i isuranca equ ied*j`a emptbyees.jl`o workers' i 3.Q.Other
comp.iriseirancesequired"
Any opplitarit ihat:cli� tins itmWIdIso Gil aui the section haloes s6%fill ihClr WolkeiS aompenaatuM policy irefonmadon.
*;1 iarnuw- who submit this affidavit indicating ifuy are fining all wodt and ihco hire outride eoairs rtiust'4b&ft anew.ailIil W iad'e rtg spccb.
=Gonir dots that c o&ties box inwwa tN n&ne of ttie aitb ritrattors bed ihelra ortietn'eatttp:policy;intaitmtion:, ,
lam oR eiap/oyer that fs pros dlri�g workers'ro npensadon,insrrraiice for rely 0016yeem Mow,is the pogey and,job site
Information.
In-surance Company Name;
i'ol icy.#ortelVins Lic:fl Z C j 0 S Expiration Date:-
rob Site.Address: >_, = . Cityistate%ztp +
t
Attach avopy of the.workers'compensation p0110.4eciarztlon page,(showing the poll¢y number and expInflon dates.
Failure to smu v ge covera as required under Section Z5A of 4IGL C:_152'can lead to tho:inipositii nn 6f critninal p=nalties;of a.
fnc up to S 1,,00.00 and/or one-year imprisonment,as well ass civil penalties in'tke form of a STOP WORK ORDER and a Rite
of up to S250.00 a flay against the violator. rite;advised that,a copy of this sateihoht may he:forwarded io.the Office of
investig:tttoris..uf the Dlkforinsui"ance edvOd varifteatioti.
do Jiereby rertJfy under tJie prslhs uriQ tallfes bjperJury"/hat the njor.»iatfpn provided uGtr've Js trae;and eorretL
Date" a
Phone#.
orkiaJ Lse auly Do.not write io{lees orrery to be cyinp,10 d,..by ctry or tows o ctatl
Cityve Toivni 'Peknit/i,lconse
Issuing Authority'(clrele one)?
6.Other of`1lealtfw 2:BuildinL t)e part ment 3 C ly%fovrn;Cterk 4.Electrtca)inspector:5.l'lpmbin,g taspe;tgr
Contact Petson:: Phoine#i