100 JACKSON ST - BUILDING INSPECTION $2-31 cv- 1-qc�—)1
The Commonwealth of Massachu? {�s RECEtVEO
Department of Public Safety dPECTIONAE SERVICES
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-ojXV,%4 e
.15
(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 available)
-ILU
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 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 Review required? Yes ❑ No ❑
Brief Description of Proposed Work: F- poAr e,,T%< irA M�
p SN3w `,
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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) ❑
Existing Use Group(s): Proposed Use Group(*
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❑ B: Business ❑ E: Educational ❑
F. Facto F-1 ❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-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 fx CONSTRUCTION TYPE(Check as applicable)
IA IBD IIA ❑ IIB13 IIIAO 1IIB1:1 IV O 1 VA ❑ VB ❑
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:
I
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner \
S�a� ANaSjAS /6y S"a5"1 � �0� 1{� 1 iD 9 70....
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 roperty owner hereby authorizes G, \ M
MriYN tt.a-eic�nl IsorW1'JyoNn /'• VieA7�
Name Street Address City/Tow State Zip
to act 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)
f building is less than 35,000 cu.8,of enclosed space and or not under Construction Control then check here 0 and skiE 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
&�'i R jt�,)
Company Name 1
We.rreN Pal SatJ �OG1� � �INlIM�Cd
Name of Person Res onsible for Cons�ction License No. and Type if Applicable
Street Address City/Town— State Zip
2C, 34S
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 the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Z. Building Permit Fee=Total Construction Cost x (hvsert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (I VAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
Z �/t
6.Total Cost $ - 1 W U (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 owledge and understanding. r
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Please p ' t and sign name Title Telephone No. Date
Street Address City/Town."
ity/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF S.u.E.NI, IN'LxSSACHUSETTS
a
B11LDIING DEPARTNtEvT
130 WASHINGTON STREET, 3�FLOOR
TEL. (978)745-9595
FA.4(978) 740-9846
(O�tgFRr RY DRISCOLL
MAYOR THomm ST.Pmm
DIRECTOR OF PUBLIC PROPERLY/BumDLNG coNMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
1n 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:
14, k-
(name of hauler)
The debris will be disposed of in :
C tIHN\
ZC M
(name of facility)
e'6411 V M
(address of facility)
signature of permit applicant
date
JcbriwfLdce
CITY OF S�1LEM� 2UNSSACHUSEM
13UUDLNG DEPARTMENT
• 120 W 1SHINGTON STREET,3a'FLOOR
TEL (978) 745-9595
FAX(978) 740-9946
KIMBERLEY DRISCOLL
MAYOR DIRECTOR
Sr.P1xRR8 DIRECTOR OF PUBLIC PROPERTY/BUIIDIING COMLNQSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business.Organization/individual): C a e g
Address: I So f7(L w Nznl No. nSI -
City/State/Zip: 061 ),1u 01_l 6 Phone #: q 7 $- S�' Z �l 27
Are you an employer?Check the appropriate box: Type of project(required):
I M 1 am a employer with '-f 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: �- ❑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
required.]
officers have exercised their ME] Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LC]Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp. insurance required.)
•Any applicant that ch%*s box#I most also rill out the section below showing their workers'compensation policy information,
1 tomeowners who submit this affidavit indicating they ate doing an work and then hire outside contractors must submit a new affidavit indicating suds
=Conuauton that check this box most attached an addidoml sheet showing the name of the subcontnactont and their workers'comp.policy information.
I am an employer that to providing workers'compensation insurance for my employees. Below is the pollay and job site
information.
Insurance Company dame: U}17A !�7i r--YP
Policy#or Self-ins. Lic.#: A t T S O LJ -7�-O-�O- 01 Expiration Date: Z
Job Sire Address: /OD �C�SoN S� City/State/Zip: S, Wi NIA 0Iq '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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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 pal annd penalties of perjury that the information provided above is true and correct.
Sirmntre: lr. .� � mot/ Date-
phone#:
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#:
PEARSON BUILDERS
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Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
. Construcfira Sune,—d;sor .
License: CS1140996
WARREN AP$A$5o '--
15OR WINONA !�
PEABODY MA 0196
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Expiration
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J..G.-•�1J�fiGJc� P ..
Commissioner 0411212017
O�rsarCoscemmA6airs&li®ans lieph5on ld. vr reghhgtions��r mdwidet n9e Oraly _
t ITAPRO CONTRACTOR" before the expb*lam date 1flamd eturn toc
Tym 0SM efConsmmwABafirs and Bmmm Ragukbm
Exji Inrtividual 18 Park P�-bbifeS1711
-r Bostm4 MA 02116
WARREN A-PEAKl
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Wanen Peanmm
t50RWmonaSt.
P y.MA 0196D - : i- NatwNwihoutsommre - -
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>kmber sew eustue 1 e� MaWReW 8 1[61%5
Aim6wcbwdwgfcauuwm 9cliarfns BOX2S1 FeaeotID#4120S66 t
6BEVERLY.MA o1915 Waata1?kwLsttnCSL CU0996 ;
(97 SZ?PSM WL978487839W Ew1jr-9187999
Sk=1978
1 S cayn rt\� 6U Kd'e- le6
C1AIM#CPMQ4nM Bob Ws cell- 978-828-3979
r ff Ptiftl4ii.02SRAMOD0307 A Bryan.781-392-MUS ji/
U Proposal Suter To: i = Phone: lt978-741-577C,
Anastas Qualfty Fund Reeky Corp
Stma job Wmd,loa Damageg
mil►.Swe&Zip.- etch i.oratitirt. �.t=
1
Salem, MA 91970 Same / Z
}Architect Bob L Daze lof Plans:317116 job ne A .G
CLM REP:Allbon Mee_, .dO X 23D7118
We hereby seta t specifications and estimates for. ✓•R%l
�Ql' S 4
Due to the eaareme weight of;ast wi imes ice and snow several areas ofthe roof Vvere
mepaial*damagect crashing themsulaabon board uplifting seems '
a)Therearpo tonapplvffimateip82'wide by445'is ioo percentdamaged;strip and remove
etstmgtubher roofand modified underneath and mstaIl atop W insidetian btlard with sawis
and plats and a fift adhered "O rnhher roof(aipin=�.37.
1NCLUDESRemoveandReplaceandmatertdst `-:
b)Repair,replace seamtape,Sap sealantas necessatpand mai tenance plan to approximate
g 70-75 syuamarea-__.___. -.___
e
( Pi
7/Ngl Rebuild f21 aver refii�ration units no yiceasyet
Payme�nt Schedule. PaymentCA" k-t�i j-rl
" 1,kj �r�ilwf'i ent 2.
on ofeonzwcr -4Azr
The law requires Wat most home imprwemeot matrarcors and subcontractors be registered�sith We 1)bector oFnome I
inquire aboat a Contact-re�4stion by.rilingto the DbecmrataueAshhexn Place.Room 13gl.nnwon,MA 021gg or , Curoven �or Registrathon.Yone
by calfivg 617-7ET-3=or 1-g00.7734"33.
its the motraUm"s obuzothso to obtain arty and an awry coxdrudioa.r its]permih,should the owner secure their own mntrurt l red permits or deal a
mreg¢lffed mntrartors the aweer ahan be excluded item ages to the guarantee f.&
Doles otherwise oohed in this document. he®tractshen net®ply shot my r.or other security mteresthas been placed on the Midec¢
Acceptance of Coffiact 1l0 NOT SIGN THIS CON'I7(ACC IFTEMMARE BLANK SP
The abosp.ppcet,spedSgtions gad wmhuoos are cze_ f
and are haehy arsxpte L YOU are do dw fang �� Sigtsb .
asspedfiN- t as ea above S'�e
Date ofAcm.pianre j r Sigoame
Yon may n this affeesne6 if it 14.b—siVIM by a puts thereto eta plain other than an address;of the seller,which may be hie main onme or branch thereof,peas
you notify the senv to wridog at his main oHite or hnnh,by ordi,,ry one posted,by telessam senior byderwery,nottater Wan midnight of the third boa.dry fono
Weskoiog ofthis agreentenL See attached No6eeofCae vent®u ram Ur m e:p4oallon,Ftba riOL