33 HAZEL ST - BUILDING INSPECTION (5) The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family DWllin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for.which a street address is not avai%able)
,- '-3 NI-Zt°I ';� MIN
No.and Street City/Town Zip Code Name of Building(if applica e)
\:.J. SECTION 2 PROPOSED WORK ..
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rovWbelo va
PP Y we
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ .No ❑
Is an Independent Structural Engineering Peer Rev' required? a Yes ❑ No ❑
Brief Description of Proposed Work: �c n 5� d�`N G
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6.CONSTRUCTION TYPE(Check as applicable)
L4 O IB O IIA O IIB ❑ ILIA O IIIB ❑ 1 IV O VA O VB O
SECTION 7,SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit:
Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑ or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation MA Historic Commission Review Process.
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
M1=1(L-c-: J_-�> TO Gc , bIZ)
SECTION 4 PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner Z
CM,1tl S)g a 33 g� �i S� kM MA
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
-
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the�property owner hereby authorizes ll � N1 n
40✓19Lr{N 1'�e^M0PJ ) SO R. Inl PNoNrn -SN , N 1 o
Name Street Address CityCi y/T—F�m To n State Zip
to acf on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
1rJu rrL r Pm sad
Company Name �p rA / / 1
UJa,,e.N \ edf5a� -109-1�t7 N R."ft<fI` Ye
Name of Person Responsible for Construction License No. and Type if Applicable
)so fZ 4 mtl\ 1T
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of a issuance of the building permit.
Is a signed Affidavit submitted with this a lication? Yes No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ f (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT -
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.
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Please print and si name t, Title Telephone No. ate
<ep
Street Address City/Town State Zip l
Municipal Inspector to fill out this section upon application approval: �!
Name V Date
i� CITY OF S.0 UN1$ , NSSACHL'SETTS
• BUILDING DEPART%MNT
120 WASHINGTON STREET, 3a'FLOOR
0 TEL (978)745-9595
FAX(978) 740-9846
KiNiBFRT RY DRISCOLL
NMAYOR THoMAs ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUIIDLNG CONWISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information 9 Please Print Leeibly
Name(Business:Organizadom tindividual): d" rrC1'i irk t'1J
Address: K0 TZ- (r1.l i`nt7Ntn >
City/State/Zip: Pi e,�n �Lv A O 1160 Phone #:_
Are you an employer?Check the appropriate box:
Type of project(required):
L E3 lam a employer with_ 5 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 S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I EI 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' Il.�Other, 5idr 1
comp. insurance required.]
;Any uppliautl that checks box#I most also rill out the section below showing their workme compensation policy information.
1 I Inmeownm who submit this affidavit indicating they are doing all work and then hire outside contrattoB must submit a new affidavit indicming such
=Contructors that check this box must anachod an additional sheet showing the name of the sub-conttocters and their workm'comp.policy informative.
I am an employer that Is providing workers'compensadon Insurancefor my employees: Below Is the policy and Job site
information. r
Insurance Company Name: U 1—[Pm 44
Policy#or Self-ins. Lin.#: Q tL-� l>ox,\ -7 z-oq y I Expiration Date: 3/ d)I7
Job Site Address: NG7Z` City/StatetZip: �4 KM i LVA _
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 the ppaiaiinnnss and penaties of perjury that the information provided above is true and correct.
Date:
Phone#; 97I_7 4��'—
Official use only. Donor write in this area,to be completed by city or town official.
City or Town: Permit/I.icense#
Issuing Authority(circle one):
I. hoard of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone#•
PEARSON BUILDERS
G®neml Camactw - --
VVattlMt a Pearson
t�RNritlaw St PLoele 978-75f�08 -
+Ai Peabadld,MAor960 pm 97841354= _
l�1 Massachusetts -Department of Public Safety
�f Board of Building Regulations and Standards
Constriaction sope�—'sor - Aim, -
License: CS40409W
WARREN A PBA"C = '.-
150R WINONA SMSWWF s
PBABODY MA M96d `
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Expiration
Commissioner 0411212017
offimorCo�vAt6tns&B BeptaSon - la registration FifforhuNwiftimeoW
t MPROVEW3ff CONTRWMR before the toe
Z _ Type; -OffieofCoosomwAffim and) Regalladem
Ea6aBn- Inrtlreiial IOFarkPbm-biteS171t - -
-����� Boston,MA02116
WARREN A.P-
twi$�i'�j.F
Warren Peamon
150R Wl nona St
Pesb6tly.,MA019W i NotVamwNioutswastere -
1
MEMBER,B=E:R BUSINESS BUREAU LAUV ilO1V1L'J LLV Ii,�L L Ej-' /0.� - - MA REG. # 161 92!
MEMBER CHAMBER OF COMMERCE 9 Charles:Street/P.0: Box 252 .' - - FED ID # 41-205436!
EMBER-B,EVERLY KIWAN IS -
ft - Beverly Massachuse S'.01915 'WARREN PEARSON'CSL.# CS4099t
H SING t97H -{978)828-3979 cell �Z/f1/// r IC LIC. # 10799s,
. . SPECIFICATIONS SUBMI17M O: - HONE- 4An
CITY,STATE., 7JP _ OB O TI
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DATEOFREANS JOBPHONE
We hereby su13'mrt spe/c'rfyd ttq,n d esttmates., r / /4�' -•�
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Daie,'Ark will begin: Date work scheduled to be substautiat�y`tomp2'e -
Payment Schedule: . Initial-Payment - ' C VC
Payment 2: Jr /.
Payment 3;due upon completion ojcontract: A ``:.N.
The law requites that most home imprnvemeat contractors and:subcontractors be registered With the Director of nome:im 'Couha�or n.You maV
inquire about a eoatroetW registration by writing to the Director at OneAshbarn Place,Room:13B1,Boston,MA 021�or_ by caging 61x - Mt or 1-SOC-22MM.
It is the contractor's obligation to obtain any and all neeetsary wntrnction related-peemtts,should the owner secure their own contructlon-related 'or deal Wittunregistered contractors the-oanershall be excluded Gum access to theguarantee fond. - permits .
Unless otherwise noted in this document,the conttactshall not imptit Vint any Hen or other seeurity interest has been placed an the M ideas
Acceptance of Contract DO NOT SIGN THIS CONTRACT•ly THERE ARE BLANK SgpC)3
The above prices,specifications and conditions are satisfactory. 1rn'�j/// •/—/ -^.
and are hereby accepted You are authorized.to do the work
as specified Payment wi�l"l made is outlined abo''v``e''_ - -
Date ofAcceptance ,rf�J�- I Si
You may cancel this"ent if it has been signed bv.a patty thereto at a place other than an address of the selley which may be mom office or branch thereof,prarid,
Sally Murtagh ° L4 (A
From: EMILY SHEA <emily.shea@me.com>
Sent: Wednesday, June 15, 2016 12:22 PM
To: Sally Murtagh
Subject: Condos at 33 Hazel St Approving Permit Request
Good Afternoon,
I am writing to say that the Renaissance Condominium Association, located at 33 Hazel Street, approves the
Vinyl siding job being completed by Laughlin Homes.
Please let me know if you need any additional information.
Thank you,
Emily Shea 03
(978) 821-6133
emily.shea@me.com
t