0124 REAR HIGHLAND AVENUE - BPA-14-1021 The Commonwealth of Massachusetts
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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
Building Permit Number: Date Applied:
Building Official(Print Name) Signa a Date
SECTION 1:SITE INFORMATION
1.1 Property Address: \ 1.2 Assessors Map&Parcel Numbers
Ja� Q1or la a� , Kt<, _
L l a Is this an accepted street?ye _ no Map Number Parcel Number
1.3 Zoning Information: 1� tr� 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'o Rec rd:
Name(Print) � `O,.tJ� �,'e.. City,Stat—� e Z q bbl�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) E*. Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: I p x
Brief Description of Proposed Work : orc r 1-
A/PW c�eC L11 �a
cn nr*t
SECTION 4: ESTIMATED CONSTRUCTION COSTS 70
y rt
Item Estimated Costs: Official Use Only Q'
Labor and Materials
1.Building $ 6 � 1. Building Permit Fee:$ Indicate how fe¢js det ined:.'
❑Standard City/Town Application Fee ti
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ ��
4. Mechanical (IIVAC) $ List:
5.Mechanical (Fire $
Supression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 61 ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) L1060 r 1 /J)J)5
w1cl'ftJ �r.�sOr� License Number Expir ia�on ate d
Name of CSL Holder
150 K WiNoNO�- List CSL Type(see below) _
No.and Street Type Description
0 \ 1u , Unrestricted(Buildings u to 35,000 cu.ft.
TP wn,St T'� R Restricted 1&2 FamilyDwelling
Ci /Town,Sta e,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
1 SF Solid Fuel Burning Appliances
`1-71-'T S t--W 2,D I Insulation
Telephone Email address D Demolition
5.2 Registered d�ome Improvement Contractor(HIC)
�rn r e Cu t4-Spry /o79 �f
HIC Registratioo n Number Ex i ati Date
HIC S Com0 Name or HIC Re ' [rant Name
wi 101156. tT
N rd tree� Email address
Ci /Town,Slide,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 ..........29 No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
C�
I,as Owner of the subject property,hereby authorize 1� t t-i 1Gi c
to act on my behalf,in all matters relative to work authorized y this building pemrit application.
Print Owner's Name(Electronic Signature) Date
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 b t of my knowledge and understanding.
�,1111W.,2 �s� t ,may
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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/d s
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"maybe substituted for"Total Project Cost"
7�T�7U s T' INC.MEMBER BETTER BUSINESS BUREAU LAUGHLIIV HOMES C MA REG. # 161925
MEMBER CHAMBER OF COMMERCE FED ID # 4 1-20543 6 5
MEMBER SEVER LY KIWANIS
9 Charles Street/P.O. Box 252
� '
Beverly Massachusetts 01915 WARREN PEARSON CSL # CS40996
SINCE 1978 (978) 922-5579 • ( ) 828-3979 cell HIC LIC. # 107999
SPEECI�{CATIONS SU8MITTED T : PHONE
DATE
STREET
L- JOB NAME
��TE C &ZIP JOB LOCATION
�77.Y i
ARCHITECT DATE
S
NS JOBP
We her y ubmit specifics tionz ang.�siimat s f r: r
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Date work will begin: Date work sche u ed to be substantially c , lete �
Payment Schedule: Initial Payment: l (�
Payment 2: CG
Payment 3, due upon completion of contract:
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 02108 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 contraction-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 interest has been placed
}�onntthe residence.
Acceptance of Contract DO NOT SIGN THIS CONTRACT IF THERE ARE BLAN SPACES
L�-,�V"
The above prices.,specifications and conditions are satisfactory S'u./• �C"L —71i-) C%Xft
�
and are heresy accepted.You are author.elined abod to do the rk
as specified'%yment will be made as utv
Date of Acceptance B Si na re
J
On may cancel this agreement' it has been s' ned by a party thereto at a place other than an address of the seller,which maybe his main office or branch thereof,provided
-on not the seller in writing at his main of o:e or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following
he signing of this agreement. See attached Notice of Cancellation form for an explenation of this right. -
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Warren Pearson
Address: 150 R Winona St. ,
City/State/Zip: Peabody, MA 01960 Phone#:978-758-2938
Are you an employer?Check the appropriate box:
general contractor and I Type of project(required):
1.® I am a employer with 10 4. ® I am a g
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
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_ ®Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp, insurance.: 9. ®Building addition
required.] 5. ® We are a corporation and its 10.®Electrical repairs or additions
3.® 1 am a homeowner doing all work officers have exercised their 11.® Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.M Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.® Other
comp. insurance required.]
*Airy applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'wrap.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Travelers Insuarance
Policy#or Self-ins.Lie. #: U13613621316 Expiration Date:3/26/15
124 Rear Highland Ave. Salem, MA
Job Site Address: City/State/Zip:
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.
I do hereby certify under the pains and pen. so per that the information provided above is rue and correct.
Signature: ���//�-^.; — Date:
Phone#: 978-758-2936
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
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#:
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