6 CHESTNUT ST - BUILDING INSPECTION (2) Ll 2-
The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards SALECITY M
p Maspoctl}tsetts State Building Code, 780 CMR Revised Mar12011
Buil4Pidi�"lk,' i'pplcicuafoPLTLoSConstruct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling o
((� 2 6 ection For Official Use Only P" rn
�— Building Permit Number: Date Ap 'ed:
I Building Official(Print Name) Signature
n to U'r
' rn
U , SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers W T
co Cf)
I 1.1 a Is this an accepted street?yes no Map Number Parcel Number
Fl 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 Owner of Record:
Jltin Me L
Name(Print) City,State,ZIP
6
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) rr Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : } — d
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 3 5 Q 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
G 2� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ L l 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) u 006 ,17
(A) cry O I wm Jt'I License Number Exp ratiod Date
Name of SL Holder
rL �
List CSL Type(see below)
DSO �IIAIY)ARA -
No.and Street Type Description
?�� - ,,n OcI60 U UnrestrictedFamily
(Buildings u el ing cu.ft.
r a A"tll ! R Restricted 1&2 Famil Dwelling
City/Town,Stake,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
q 7g-75'rf- I Insulation
Telephone Email address D Demolition
5.2 Registered H fr'
e Improvement Contractor(HIC) 1 o7el-0
t.- r i Yt1 w) HIC Registration Number Expirah_ Date
HIC Company Name or HIC Registrant Name
15b P ln)I�i rorrw_ S Y.
No.and Stre t Email address
pPca�no t u
City/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 ..........0 No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize &J^rft,N W,eur -JN1
to act on my behalf,in all matters relative to work authorized by this building permit application.
aZ� 2Z
PrV(Owner's Name(E omcSignature) l5die
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) to
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.gov/oca Information on the Construction Supervisor License can be found at www.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 halfibaths
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 S.-1 xm, INvLkSSACHLSETTS
BuumLNG DEPARTMEZ iT
p• 120 WASHINGTON STREET,3aa FLOOR
TV- (978) 745-9595
FAX(978) 740-9946
KI\BERLF-Y DRISCOLL
MAYOR T HoMAs ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L\BSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians✓Plumbers
Applicant Information ) Please Print Leeibly
Name (Business:Organization/individual): Wn r reP &22iJ
Address: ISO M W 1WaMP, SI' .
City/State/Zip: P°°dT MA OMO Phone#: q7$ 75et- 7 J�i7j
Are you an employer?Check>he appropriate box: Type of project(required):
1.0 1 am a employer with 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. Q New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7• Q Remodeling
ship and have no employees These sub-contractors have S. Q Demolition
working for me in any capacity. workers'comp.insurance. 9, [—] Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself.[No workers' comp. c. 152,g 1(4),and we have no 12.CSRoof repairs
insurance required.)t employees. [No workers' 13.Q Other
comp. insurance required.]
•Any appliram that=s box#l must also fill out the section below showing their workers'compensation policy information.
t I Inmeuwners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
:Cunrractors that check this box must attached an additional sheet showing the name of the mbeontrasbrs and their worker'comp.policy information.
I am an employer that is providing workers'compensadon insurance for my employees. Below Is the polley and job site
information. t—
insurance Company Name,_�
Policy#or Self-ins.Lie.M A re-;T ��O�i �I Expiration Date: llT_
Job Site Address: 6 Ck1-Nu3 54 . 4,4nw City/State/Zip:53�rri t
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 S250.00 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.
I do hereby certify under lite pains and penahles of perjury that the information provided above is true and correct
Si"attir Date'
Phoned: �7fr 7SR`-Z`1 3
Official use only. Do not write in this area,to be completed by city or town officiat
City or Town: Permit/hiccnse#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Cilyffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#'
PEARS-ON BUILDERS
Ylhmn A Prwssis
750Rwimna$ pbwre9l&751t•�BB -
HtP 6o4K,meww RK 9MA354M - .
af Massachusetts-Departinent of Public Safety
Board of Building Regulations and Standards
Can.,M.riaa Sapemis.-.-
License:CS4)40996
WABRSNAPSA$g0 '
isoR WINONA !� s
PEABODY MA
J.[.- fYi�a�`. 'r"`•a ` Expiration
Commissioner 04f1r M7
71
Coll 9e 7t�* �ril�eonb
o®cs ofc a�Lsact�mB _ 6�ere the a d> 1il xd�f�
i CONiRaCIOR Tom .pgkeefCm==wAffdm and BummaR os
- lndiiirduaf 19PwkPh®-2Wb5*170
Bmtm4MA02116
WARREN A
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150RVYfnons� ��' - '- 4yE%I/
P lf..t4A079M Notv"whwat _
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B LAUGHLIN 1957@GMIAL.COM # T ATT('�HLIN HOMES INC. �-5� MASS REG. # 103394
MEMBER BETTER BUSINESS BUREAU 1. 9 CV Street/P.O.
J 25 1. FED ID # 41-2054365
MEMBER BEVERLY CHAMBER OF COMMERCE 9 Charles StTeet/P.O. BOX ZSZ
MEMBER BEVERLY KIWANIS Beverly Massachnse S WARREN PEARSON CSL # CS40996
SINCE 1978- ---(9.Z8}92.3-53-}9 (978) 828-3979 HIC LIC. # 107999
SPECIFICATIONS SUBMITTED TO: y PHONE: r
STREET: ' _S 1 /1%/ L�' 7" • JOB NAME: /J 26 U r C.,C C < —7
CITY,STATE,ZIP: Cc_•�. .- p / L JOB LOCATION:
ARCHITECT: - /�/ i_ 'i//. DATE OF PLANf/) q J JOB PHONE:
e'q .tr0�,v�* 77� 1,e /4 .t/ de-
Installation of a complete Certainteed / f/ i"i t Shingle roof to the entire house. /ec_" ��—
Color:
I. Includes strip all old shingles, we haul all debris, clean jobsite thoroughly and pay all dump fees.
Includes Install:
- ice and water membrane to main house eaves, around chimney and in valleys <�7j �t'l.-C f-r S
- tarpaper base and flanges—stacks,
- 8" aluminum dripedge to all edges. Color: Z tlh/ X-C
- starter shingles to all rakes and fascias a
- cobra ridge vent to all heated ridge areas CI c.r 1. /L� 6
- repair, reinforce as necessary and neatly seal ebinr=y_flashings, any stMand€aproi flashings.C^
- we procure permit, customer reimburses permit cost. 7s G 7
C <
&' k e,�fV lc v�i i ivsf ?cf�x
` �` ao< 2 r
S aCYCr' fit' iol/f -)11" /CX_ t ,4 IG/<i
optio�'11 �N ae� IC/Ce (.e/Ci r LJl
Res CD same rspecificatiORs-as-above, but-we will-go aver{ne- t#pping)-the existing-roof-and-excludes-ice-and water
me�r bra e and tarpaper base.
G 1or:
J//G / '" 4 Q/ Iq v?6 c N -G/ V'/'1 /G✓/i y-/ly- ,
S—G 0 c/J /4.1 G/L
Customer responsible to cover/tarp attic items and clean any resulting debris in attic. f f
Ten Year workmanship guarantee
We Propose hereby to fucni material and labor-comp-e-e n accordance with abdvk specifications for the sum of:
Payment to be made as follows:-
1/3 start, j3.at ktalfzt=pletg and balance upon completion:Thank you. r—
All maler al is pronounced to be as specified.All work to be completed in workmanlike manner i
ite .�-. _ . ....
cord costs
to illl b6 ca practices,Anyalteration or deviation from above involvingextr .- r '- AUthOriQl_.ad
rods will stment..med a on wontin ant u ansttw,e,accidents
a or de charge overo
and above the estimate.All agreementsmadeando Cher nec upon strikes,ce,O r or delays,cover our Signature:
control.Owner to nstair n in tornado and ocher necessary insurance.Our workers are covered by workers compensetidn insurance.
i Note:This proposal maybe
Owner agrees that in the event of M1ii breach or this contract before work is almost.Conrcacbr may withdrawn by us if not 9 mar d wnbin days.
demand manly five peon[(25%)ofthe,mimact price as its alipalated damages for the breach
1
( t
Acceptance of Contract {)
The l above prices,;specifications and conditions are satisfactory
andare�hereby accepted.� ou are authorized to do the work Signature
as specified.Paymeht will be rnede as outlined above.
Date of Acceptance r u Signature
I
You may cancel this Agreement if it has not been consummated by a party thereto at a.plaee other than an address of the Seller,which may be his main office
or a branch thereof,provided you notify Seller in writing a his main office or branch by ordinary mail posted,by telegram sent,or by delivery,not later than
midnight of the third ibusiness day following thesigning.ef this agreement.
Ia ,