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48 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts ° Board of Building Regulations and Standards rt Massachusetts State Building Code, 780 CMR, 7u'edition Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised N, - One- Two-Family Dwelling A �i115, 2009 __- ` This ection For Officiif Use Only JBuilding PermitNum er: pplied: t , \ Signature: Building mtnissioner/ ct . Buildings Date Q SECTION 1: SITE INFORMATION 1.1 Pro erty AtMr 1.2 Assessors Map&Parcel Numbers CkG/�®n 1.1 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 ft) Frontage(ft) L5 Building.Setbacks(R) rto' 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.'�L,'t Zone: Outside Flood Zone? Public❑ Private❑ — Check if yes❑ Municipal❑ On site disposals`ystern ❑ ' SECTION 2: PROPERTY OWNERSHIP'. 2.1 O ner'o�RCcord e-,� ^G �E Address for Service: - Signature ,d - Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply) y New Consteuct ort❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition,.O Demolition ❑ AccessoryBldg. ❑ Number of Units_ Other ❑ S�ecify: - Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Labor and MatePials JOfficial Use Only a t 1. Building Permit Fee: $ Indicate how fee is determined. 1.Building $ g t ❑ Standard City/Town Application Fee 2.Electrical $ 4 ❑Total Project Costa(Item 6)x mulflplier x �,. 3.,Plumbing $ ° 2.'OtherFees: $ / s+ '^ •4.Mechanical (HVAC) $ List: - a.x Mecha - $ ..` Su cessi nical (Fire on Total All Fees: $ F' *4 o� CheckNo. Check Amount 4 Cash Amount, 6. Tot`al Project Cost: $ `l q©D ❑paid in Full ❑Outstanding Balance Due: :.r^•r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) ,,�! �•5'�Yo9�'G ! 2 /jt/' �j1Sj jh License Number E pira ion Date Nam� f CSL- olde // ` � ����^��, List CSL Type(see below) Address a Description - - U Unrestricted u to 35,000 Cu.Ft.) ��/ - . .. R . Restricted 1&2 FamilyDwelling Si lure �� � M- Masonry Only RC - Residential Roofing Covenn Telephone WS Residential Window and Siding • SF Residential Solid Fuel Burning Appliance Installation D I Residential Demolition - 5.2 Re is ered Home vement Contractor(HIC) �a HIC Company Nii j or C egistrant Name - Registration Number` - - /L Address r/(i �7� ' 2L76 Expiration Date Signature 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........... 0 , SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN + OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT w I, lXklLh , as Owner of Oe subject property hereby authorize /� G ice✓r� i; to act on my behalf, in all matters I " relative to w rk authorized by this building permit application. y e:Signature'of&<nor - SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION �"O 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 ► l ' Print Name/// Signature- of O�r"-ot�ed Agent Dam , (Signed under the, airs and penalties of a 'u 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 and t { Construction Supervisor'Licensing(CSL) can be found in 786 CMR Regulations 110.R6 and 110.R5,respectively. 2. 'When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics,decks or porch) Gross living area(Sq.Ft.) Habitable room count 'Number of fireplaces Number of bedrooms Number,ofbathrooms Number:of,half/baths Type of heating system Number of�lccks/poro)tes Type of cooling system Enclosed > Open 3. , "Total Project Square Footage"maybe substituted for"Total Project Cost,' : . t 04-08-'11 13:43 FROM-Richards Insurance 1-978-774-1318 T-132 P0001/0001 F-198 A�OR[7' E RAMOOTYM CERTIFICATE OF LIABILITY INSURANCE DAr04/08/11 THIS CERTIFICATE IS.ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND-OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and Conditions of the policy,certain policies may require an endorsement A statement on this Certificate does not confer rights to the certificate holder In lieu of such endomeman s. PRODUCER 97B•7744338 .. CON FACT Phil Richard&Assoc Ins.,Inc 978-774-1316 PHONE 27 Garden Street Unit 10 AIc xo (AID,No): Danvers,MA 01923 EMAIL Diane Famiglien ADDRESS:i - PRO ER C SDu MERIDP.PEARS-1 a - INSURE b AFFOROINOCOVERAOE NAIC9 INSURED, Pearson Builders Inc INSURER A:Arbella Protection 95OR Winona Street INSURERS:Travelers Insurance 10647 Peabody, MA 01960 1 INSURERC:Ace Group INSURER 0: INSURER S INSURER P: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L TYPEOFINSURANCE POLICY NUMBER MMI�D� POLICY LIMITS r GENERALLIABILITY EACH OCCURRENCE $ 1,000,00 B COMMERCIALGENERiLLLIABILI7Y 680565M5386 11128/10 1128/11 REMISES MEce enm $ 300,00 CLAIMSMAOE ❑OCCUR MED EXP(Any one pereoN S 5,00 x SuStnessOWnen; - PERSONAL&ADV INJURY S 1.000,00 GENERALAGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO t 2,000,00 POLICY PRO- -L, g A PMO'LBRE 11A011JT' COMBINED SINGLE LIMIT $ A ANY AUTO T 3T262400001 07118/10 07118/11 lEa eoceenU - �- BODILY INJURY(Per parson) S 250,00 ALLOWNEDAUTOS BODILY INJURY(Pel accident) 3 500,00 X SCHEDULED AUTOS PROPERTY DAMAGE HIREDAUTOS (PBTawwnU 3' 100,0 00 NONAWNEWA17T09 3 ' UMBRELLA LIPS OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE, $ cF—DEDUCTIBLE S 'RETENTION S S _x ORKERS COMPENSATION WC STATU- OTH op f.MPLOYERS'LIABILITY YIN C ANV PROPRIETOWPARNI;RIE%ECUTNE O N(A WC002502555 0317111 03/17/12 E.L.EACH ACCIDENT S 100,00 OMNI den 1MNN E%CLUDE01 f.L DISEASE•EA EMPLOYEE $ 1 OO OO ( as 1 It yes.OesoilN under DESCRIPTION OF OPERATIONS bebw E.I.DISEASE-POLICY LIMIT $ 500,00 OEACIUMON OF OPERATIONS I LOCATIONS I VEHICLES JAnach ACORO 10%Addilienal ReMft$p&edNIC B TON 00400 Is MQUIrull Evidence of Insurance CERTIFICATE HOLDER CANCELLATION i SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE. DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTTHHOR990 REPRESENTATIVE I ' 01938-2009 ACCIRD CORPORATION. All rights reserved. ACORD_Z5 2009109 The ACORD name and logo are registered marks ofACORID Printed with pdfFactory Pro trial version - purchase at www.pciffactory.com The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): - Address: City/State/Zip: U Phone#: Are you an employer?Check the appropriate box: Type of project(required): L❑ 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.❑ listed on the attached sheet. 7. ❑Remodeling I am a sole proprietor or partner- ship and have no employeesThese sub-contractors have g• ❑Demolition workingfor mein an capacity. employees and have workers' Y p tY• 9: ❑B�11thug addition. [No workers' comp.insurance comp. a torpor t e e' tr , required.] 5 We are a corporation and its " 10:❑Electrical repairs or additions 3.❑ I am a homeowner.doing all work officers have exercised their 11.0 Plumbing repairs or additions . myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs 'eirw ance d re q uire t c. 152, §1(4),and we have no ] . employees. [No workers' 13.❑ Other ` comp.insurance required.] *Any applicant that checks box ill must also fill out the section below showing their workers'compensatiou policy information. - t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indcicating 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 most provide their workers'comp.policy number. r �Z am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: r,,'/' Policy#or Self-ins.fLiic..#: 4/p� �ZS�/�25�� Expiration Date: 2— Job Site Address: 7 0 3� ��f��`//< 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 r a f 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifyy under the pains and alSes ofperju that the information provide odd above is true and correct. Siehature // �k r Date: `Phone# /b� � �:Z - Official use only. Do not write in this area, to be completed by city or town of City or Town: Permit/License# 1 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#: PEARSON BUILDERS General Contractor - Warren A. Pearson 150 R.Winona St Phone&Fax 978-535-6555 W.Peabody,MA 01960 Cell 978-756-2938 Massachusetts—Deportment of Public Safety" Board of Building Regulations and Standards sCu n Supervisor License .license:.as ' 40996 . aU�(ARR PEABO Eicpiratfon: 4/102014— . "Gominisaiover `:. ".` Tr#: 13734 ^ - ✓/se 'Pianvnra�zuiea�/ o�./�aaeac�igaeCla License or registration valid for individul use only Office of Consumer Affairs&BYsmess Regulation HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: . 07999 Type: Office of Consumer Affairs and Business Regulation " 10 Park Plaza-Suite 5170 Expiration: .�8r=2012 Individual Boston,MA 02116 IFEN A.PEA �� - OIRS°4 Warren Pearson \ I" a 150R Winona St. 4� ��= ,Qom_ Peabody, ell MA 01966�' � Undersecretarysignature - �,�.�' " Undersecreta Not valid without a - - TT � f u MEMBER BETTER BUSINESS BUREAU LAUGHLIN,HOMES /y IeI9,2,,:�:;, 9 Charles Street/P.O. Box 252 MASS REG. a B�3 MEMBER BEVER LV CHAMBER OF COMMERCE MEMBER BEVE,RRLY KIWANIS Beverly Massachusetts 01915 SINCE 1978 ® ✓ Flo CS'7�0 (978) 922-5579 4c-e-S 6 17 DATE SPECIFICATIONS SUBMITTED TO:�1.�/��t � ,( fir/ PHON STREET: � d0 1..9iv/i �/,1(G ���•2r JOB NA E: - _ CITY, STATE, ZIP: L //.!���n O/'/i BLOC 0 - ARCHITECT: DATE OF PLANS: JOB PHONE: �GI/�/l��-Comet/�/ ��C�E/ ✓! Installation of omp ete Certainteed �� ��� Shingle roof the entire house. Color: . C ri. -k1a C Q ��-/� , I. Includes strip all of shingles, we haul all debris, clean jobsite thoroughly and pay all dump and permit fees, oN Includes Install: mb L ai •- ice and water membrane to main house eaves, around chimney and in valleys �/ s -tarpaper base and flanges to stacks � ✓ 8"-aluminum-dripedge.So.all-edges-Color_-,c3�6Le"., - ✓ ✓ d_ ''JJ`` t starter shingles to all rakes and fascias ' m-1n/ clr, -,,repair, reinforce as necessary and neatly seal chimney flashings, any step and apron ashings. C,�/���el- opt' el- op5aft 11 : e specifications-esabsuertwywe wil ) the axisiigQ reef artd-excludesase-aad.water- s . , and�� or :-^ Customer responsible to cover/tarp attic items and clean any resulting debris in attic. - Ten Year workmanship guarantee We Propos hereby to furnish material and labor-complete in accordance with above specifications for the sum of: � /' /} -�'iJk-� �Y lu,1 a�,�/ �' oars $ TilD o� ) Payment to be made as followsSa-"^""` - 1/3 start, 1 nd balance upon completion.Thank you. All material is goeranlsed to be as specified.All work to be completed in workmanlike manner according 0 standard Minices.Any alteration or deviation!roan above specifications involving Authorize costs will be casamed only area written orders,and will become an came charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beymd our Signature: control.Owner to carry fit.,mmade mcf.her necessary immance.Om wmkers are covered by workers compensation insurance. Owner agrees that in the event of his breach ofthis contract before work is started Contractor may Note:This proposal may be demand overly five percent(25%)or the conerse,pose ne its stipulated damages fat the b¢ach. withdrawn by os if not accepted within days. Acceptance of Contract The above prices,,specifications and conditions are satisfactory and are hereby accepted.You are authorize o do the w k Signa as specified.Payment will be made as ou ned above. /{ Date of Acceptance / Signature You may cancel this Agreement if 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,provided 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