41 FRANKLIN ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
C� Building Permit Number: " Date A ied:
t Building Official(Print Name) Signature _ Date
`� SECTION 1: SITE INFORMATION
( 1.1 Property Alrrs: 1.2 Assessors Map&Parcel Numbers
1r�a1Jk�,'ni �t. .
Fo I.Ia Is this an accepted street?yes no Map Number Parcel Number
I 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:
hr, Sk Na 4 Dtm, 5,, eQ l l MP\ CM70
Name(Print) fI� c City,State,ZIP
Z11 - 57a-0
No.and Street Telephone Email Address
SECTIONS: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 12 1 Alteration(s) 19 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Num 2. Other ❑ Specify:
Brief Description of Proposed Work" a rn M S,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ `] 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier k x
3.Plumbing $ 2. Other Fees":"$
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire "
Suppression) $ Total All Fees: $
Check No. Check Amount A Cash Amount:
6.Total Project Cost: $ '❑Paid in Full ❑Outstanding Balance Due:
M to i t_ -I--0
MD"lukEp 3� FCo
" -SECTION 5:sCONSTRUCTION SERVICES'
5.1 Construction Supervisor License(CSL) qq �( ' )7
1`r•P td �� License Number Expi ation Date
t Name of CSL Holder
List CSL Type(see below)
w
P
Noand Street :. Type '.=y Description
Unrestricted(Buildings up to 35,000 cu.ft.
t6 Co�V� 1 u t 00 11 Restricted 1&2 Family Dwelling
City/Town,State, M Maio
RC Roofing Covering
WS Window and Siding
/ O ✓ //5 I� �3� SF Solid Fuel Burning Appliances
L 1 Insulation
Telephone Email address D Demolifion
5.2 Registered Ho"prrovvement Contractor(HIC)
sn
�AfAr— �l 1 e z�ti HIC Regis ,tion Number Explatibate
HIC C m any ame o IC Registrant Name
N� get
Email address
��ldy , MA O H60 T'��-z1v
City/Town,State+,ZIP 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 ...........( 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 IMat f,ed U r-S oPJ
to act on m ehalf, in all matter r IaNve to work authorized by this building permit application.
/ 3
EI )1�1� 16
Print Owner's Name ignature) Date
SECTION 7b: 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 in this application is true and accurate to the best of my knowledge and understanding.
L b
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.mass. o¢ v/oca Information on the Construction Supervisor License can be found at www.mass. og v/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 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 S�U .Mit i L-kSSACHUSETTS
• BUILDING DEPARnt&NT
a 120 W'+SHINGTON STREET, Y"FLOOR
°j TEL. (978) 745-9595
FAX(978) 740-9846
KIJiBFRt GGY DRISCOu
I
MAYOR t tOM,\s ST.PIERRIi
DIRECTOR OF PUBLIC PROPERTY/BCaDING cosmaSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information /t Please Print Leeibly
NaMe (Busitxss:OrganizatioNlndivriduul):V/^fArfft� Wd!75-0/t)
l
Address: O W j Atolv'&-
City/State/Zip: e o 0 Phone #: q C-T el
Arela you an employer?Check the appropriate box: Type or project(required):
1.Ste'1 am a employer with S 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.. 7• ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and is 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I Z Plumbing repairs or additions
myself.(No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' 13 ❑Other
comp. insurance required.]
•Any applirua that checks box#1 most also fill out the section below slowing Their workers'wmpemadon policy information.
*1It—owners who submit this affidavit indicating they am doing all work and then hire outside comracimi;most submit a new affidavit indie sing such
=Cone non that check this box most anached an additional shag showing it,name of the sub- mutroeon and their wodmn'comp.policy information.
I um an employer that Is providing workers'compensation lnsurance for my employees. Below is the policy and fob site
information. r
Insurance Company Name:_U t y 1(q f-1`r'IQ r�
Policy&ur Self-ins.Lic. < `/ Expiration Date:
Job Site Address: � I�� City/Statetzip: -,< )PM D A-70
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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
i Ln t ire• -��.�+-+ � Date' 3I171� 6
Phone#�
Official use only. Do not write in this urea,to be completed by city or town ojrciaL
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF S.U.& I, IN'LkSSACHUSETTS
• 13UILDLNG DEPART\tE2NT
120 WASHNGTON STREET, Yo FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KjStgER1EY DRISCOLL
MAYOR T Homm ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BI:II Nr.comNaSSIONER
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:
& L�z
(name of hauler)
The debris will be disposed of in
(name of facility) /
(address of facility)
siinanir of pe itit applicant
to
JcbtiulT.Jce
PEARS-ON BUILDERS
ieml Can aWur
Winn a Pearson
,midst rhow9784 M
at MA019M Fmr 9784OS450
Massachusetts -Department of Public Safety
Board or Building Regulations and Standards
- :.on;truc:ion Suner.-;srr .G _ -
License: CS4)40996
'.I s ri4>
WARRBN A PK:jr
15M VMONA
PEABODY MA 6196dfi
v
Expiration
Commissioner 0411212017 .
' Y
t - Cu-ofl�o� .ctlmomare,..: _ ---
Lievrregistrslioa dibriodividnlmeoniq
om�arcea�rat &s��s�r+roa ..
E IR_PROVEMM CONTRACTOR before the expiation date Iffo®d return ix
0fflm ofCommmwAffm and Basmm RgFd w2
n 71rpa 10ParkP�-Slofe5l�
� ox IndMdua! Baston,]ffiA02116
WARREN A PEAR _ -
peabodp.l9A019ti0 - - i Netvandwhhoutskestam
�I
cfh X-AJ ! !'L - IVAI, -Jyzl u Gd rl
MEMBER BETTER BUSINESS BUREAU LAUGHLIN HOMES INC. o6-n� ` MA REG. # 1s�5
M€MBER CHAMBER .9 Charles Street/P.O. BOX 252 r( - FED ID # 41-2054365
M.EM BER B CY K IIWANI`S�^'/�y Beverly Massachusetts 01915 WARREN PEARSON CSL # CS40996
SINCE 19 OL J f'J '✓�/ - ' 82g-3979 CBII HIC LIG. # 107999
SEE91PICATIONS SUBMITTED TO: iv
N ` / o—/ DATE
STREET !O NAME t.�r
CITY,STATE,At ZIP JOB LOCA�
`w7ld! r /✓
ARCHITEg DATE O PLANS HONE
b /
We hereby submit specifications and estimates or: —
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Date work will begin: Date work scheduled to be substand In to
Payment Schedule: Initial Payment: o
Payment 2:
Payment 3, due upon completion ofcontract:
The law requires that most home improvement contractors and subcontractors be registered with the Director of Home Improvement Contractor Registration.You may
inquire about a contractor registration by writing to the Director at One Ashburn Place,Room 1301,Boston,MA 0210E or by calling 617-727-3200 or 1-800-223-0933.
It is the contractor's obligation to obtain any and all necessary contruction-related permits,should the owner secure their own contruction-related permits or deal with
unregistered contractors the owner shall be excluded from access to the guarantee fund.
Unless otherwise noted in this document,the contract shall not imply that any lien or other security in h s b n placed on tie neiiih%ce.
Acceptance of Contract DO NOT SIGN THIS CONTRACT IF THERE ARE BL P CES
The above prices,specifications and conditions are satisfactory
and are hereby accepted.You are authorized to do the work Signa�
as specified Paymeitwill-be'made asoutlined -�-- --- ---- ---- ---
Date ofAcceptance C1 Signature
You may cancel this agreement if it has been signed by arty thereto at a place other than an address of the seller,which may be his main office or branch thereof,provided
you notify the 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. See attached Notice of Cancellation form for an explenation of this right.