21 FRANCIS ROAD - BPA r �
L
U ' The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
U 7s'1 Massachusetts State Building Code, 780 CMR, 7m SALEM
edition
Revised Jurungv
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
This tion For Offl ial Use Only
Building Permit Nu er: Da Applied:
Signature: is M&2
Building Cummissi /Inspector of Buiyi#PDate
SECTIO :'SITE INFORMATION
1.1zop V 1.2 Assessors Map& Parcel Numbers
L l 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 11) 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.I.c.40.§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ -
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow ?�f RecgM/; �
i rtif>'40 ,I P/G,rrPi.;S
Name2rintl Address for Service:
Si ature ' Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
.Ere' Ali :PY
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S Q I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (fIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
f'� Check No. Check Amount: Cash Amount:
6. Total Project Cost: S $�fy 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /'5-
G`0
2 (p
�_+ L W2 License Number _ lispiraliun Uate
Name ul CS -lit I er List CSL Type(see below) Pit_
r.pe Description
Addre U llnrcstrictetl up to 35.000 Cu.Ft.
R Restricted I&2 Family Dwelling
SignaI n M Maso Only
0' RC Residential Routing Covering
relephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
S.2 R b ered Home Fdvement Contractor(HIC) �.�Wdy e?
M=�r
I IIC Company - cot
IIC Registrant Name / /J Registration Number
Addres s Expiration Date
Signature 'rcitphone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 4 2SC(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 ..........ET No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. V 6t/1-e fa/q , as Owner of the subject property hereby
authorize (I.( w✓'i` Lag to act on my behalf, in all matters
relative to work authorized by this building permit application.
lea f,
Si tore oAwn!r Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I t �yyrpyt / ? ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.R , y�r ������ A j,
Print Name 4
Signature of wner or Authorized Agent Date
Si ed under the pains and penalties ofperjury)
NOTES:
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 fful have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and I IO.RS, respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUamics,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"
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
.ty
www.mass ov/dia
g
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I Please Print Legibly
NanIC (Basineis//Organization/Individaal): i"��se�
Address:
City/State/Zip: 011' ei Phone
Are you an employer? Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and I 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. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, Q Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• 9. ❑Building addition
[No workers' comp.insurance comp. ins rance t
ed.] 5..�We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I required.]
quva homeowner.doing all work officers have exercised their l l.❑Plumbing repairs or additions .
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
camp.insurance required_]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compeasation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contactors and state whether or not those entities have
employees. If the sub-contactors have employees,they must provide their workers'comp.policy number.
I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site
information. / / 7�
Insurance Company Name:_/"! 1 r�` z`h c,;.
Policy#or Self-ins.Lie.#_ Cz S �y Jr3—Z Expiration Date:
Job Site Address: City/State/Zip: '/�Jett:'--
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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
.1 do hereby certify under the ains _d penald ofperjury that the information providedabove is true and correct.
S_iimatum: i/G %y�v L /� v"�' / Date: d 6 y
Phone#' 'h
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permlt/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City)Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
04-12`10 10:30 FROM- T-552 P001/001 F-313
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD°"Y'/'
4/12 10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Phil Richard s Associates - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
491 Maple Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Suite 102 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers, MA 01923 ,INSURERS AFFORDING COVERAGE NAIC0
IN$UR® / INSURERx SCOTTSDALE INSURANCE COMPANY
Pearson Builders, Inc. ,{p CJ�S``S�JS INSURER B: Arbella Protection
150R Winona Street � `� INSURERC: Granite State Ins AIG
Peabody, MA 01960. - INBUMRo
INSURER E:
COVERAGES
THE POLICIESOF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED.NOTWfTHBTANDI NO
ANY REOUREMENI.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AW'L POLICYEM.C"VE POUCYE IRXMON '-
WE OF INSURANCE POLICT NUMBER LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X COMMERCWL GE NERAL LIAR ILITY CLS1445653-2 tOANWGE TO RENTED
11/28/09 11/28/1Q FREMI• $ 100,000
CLAIMS MADE an(rUR I WD EXP(Amare e m $ 5,000
I'ERSONLLAADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN•LAGGREGATELMITAPPLIE$PER PRODUCTS-COMPKIPpGG 3 2,000.000
POLICY PR t LOC I
AUTOMOBILE LIABILITY
B ANvpuTO 137262400001 7/18/09: 7/18/10 eo 1COW6lNED 0)INGLELMR $
KL O W.0 AUTO$
X ' SC9EDULEDAUT06 BODILYINJURY
BO Pcs S 250,000
m)
HIREDADTOS
BODILY INJURY
i NONOWNEOAVTOS (P�amdaml $ 500,000
PROPERTYOAMAGE $ 100 0QQ
. tpP 60tiQanD
GARAGELJABILITY AUTO ONLY-FAACCIDENT S
ANYAUTO I OTHER THAN FAACC S
I AUTO ONLY: AGG S
RDEC
SS/UMBRELLAIJABILITY' ' EACHOCCURRENCE $
OCCUR CLAMS MAOE AGGREGATE I g
I$
OLTIB LE
-
a
TI N $ $
NORKEIS COMPENSATION WC STATIJ- OTH- -
ANDEMPLOYERS'LIABILITY YIN X
C ANYPROPRIETORJGARTNER/EXECUTNE TED 3/17/10' 3/17/11; E.L.EACHACOLENT 3 100,000
OFRCEWNEMBEREXCLLOEDT �I
(maMabry It,NMI E.L.DI S EASE-EA EMPLOYEE 6 100,000
SPEC)AL PRO VISION SEdaw I E.L.DISEASE-POLICY LIMIT S 500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICI6S I EXCLUSIONS AVOW BY ENDORSEMENT/SPECIAL PROVISIONS
EVIDENCE OF INSURANCE .
CERTIFICATE HOLDER CANCELLATION'
SHOULD ANY OFT KEABOVE DESCRIBED POLICIES BECANCELLEO BEFORE THEEXPIRATION
DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 OAYs W nTrEN
TO WHOM IT MAY CONCERN -NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 0060 SHALL
IMPOSE NO OBLIGATON OR LIABILITY OF ANY KIND UPON THE INSURER,ns AGENTS OR
REPRESENTATIVES.
AUTHORQED REPRESENTATIVE
STEPHEN TURNER
ACORD 26(2009101) - 01988.2009 ACORD CORPORATION. All rights resor d.
The ACORD Tame and logo are registered marks of ACORD
PEARSON BUILDERS .
General Contractor
Warren A.Pearson -
150 R.Winona St Phone 1£Fax 978-635-6555
W.Peabody,MA 01960 Cell 978-75B-293B
lYf-,ssachusetts—Deportment of Public Safct.t. ;
Boai`d of 13tnlding Regulations and Standards'
aC It supervisor License.
idiinsm CS 40998 .. .
WARR a
45pR VI -
`i: . a 60:•
PFO
�,.G`_ �y r , • -: Eicpfration: 4/12/2011
Cnmmi4d'wuei '` Tr#: 13734
�/ee �iomvrrza�eeaaaae� License or registration valid for individul use only
Office of Consumer Affairs&B smess Regulation
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
- '�1 Office of Consumer Affairs and Business Regulation
Registration 07999 Type-
On
' 10 Park Plaza-Suite 5170
Expiration: A12012 Individual Boston,MA 02116
W FENA. PEART, o
00
Warren Pearson
150R Winona St.
Peabody,MA 01960�` ���-,�% Undersecretary - Not valid without signature
t_✓
Y
LAUGHLIN HOMES /
MASS REG. # 703394 �
c-: ISE o= COMMER^E 9 Charles Street/D,O. Box 252
" SINGE 1978
— v
K 'AN!' Beverly Massachusetts 01915
(978) 922-5579
` DATE
PHONE:
_ W
.. ., <.�-'. ' _ JOB NAB
S .. t, Lip_ JOB LOCH ION:
,4r.;.I- /'. % DATE OF PLANS: JOB PHONE~`
/ / n
:nstaJa for of a complete Certarteed Shingle roof to the entire heill �
COIO
I. includes _tr z;G „id shingles, we haul al-I'debris, clear`jobsite thoroughly and pay all dump and permit fees.
includes Instail: -
j - ice and water membrane to main house eaves_ around chimney and in valleys , '` <"� C✓'- �%
- tzrpzper base and flanges to stacks
G .jn-. c ;pedge to all edges. Color:
starter sNircles t^ all rakes and fasclzs
i - cobra ridge vent to al; heated ridge areas
- repa: . .rf;,roc as necessary and neatly sea! rrn-rney flashings. any step and apron flashings. �'&L,/ .- <i !
/ j/v._* _ /_..� !> _ ._,i—. /—,._�— VJ' � _ �%-• ice_ '_
Optioh-/ ,. _'✓�/ _:Ili !'/ /:,/ �_
,Rd-roof;sarte spec+*, C a b �ecbail��^ ^ sT�p l Lne-exist-ae-roof-and exc`1utdes-ise:and-water
I mefntSae��ape=base _
I
r-� p
C"Sio.' :espOnalbie to cover/farp attic items and clean any resulting debris in attic.
Ter. Year w ship guarantee J f C- v N/ .. G C;
pege,hereo tumis6 material and labor-complete in accordance with above specifications for the at of y`
-'� ._; .- - ��,•��F E ;�� �����d,`��� --dollars !$
I
Payment tore .,race as `glows:
"!13s;a,—;;3--at ha,faorrc�le`- " � �oirpte:ler+-7 an ot7
d.41'- e PI tl A I'Y rcr /
Authonzed
< q'I ea n Sl atures {/✓ {", �� ' /
e cP^eree
_ Note:This proposal may be
.:fix ram._ a_ -n; I' b h '.conrrtc bcrc c••0 A', d
--.,.—. •.�.`-�,r« -r-'liar<orR.,<1ia rc.^-as-�,s�r++ee-a �o�aao"
. ., f withdrawn by us if not accepted within days.
—
-,kcccPt tarice,o. Contract
I e abo ices specifications and conditions are satisfactory
and are n-en, accepted.You are authorized to do the work Signatur 7 ,�
as Specified_Payment:will be made as f utlined bola
Date nfAccemance
Signature-
You!nay cancel this Agreemedif 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.prici ided 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,
/
ec-