295 JEFFERSON AVE - BUILDING INSPECTION (2) q The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards longo ~
Massachusetts State Building Code, 780 CMR. 7'a edition Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a �
One- or Tiso-Famdr Dti efhng
This Section For Official UsaOnl
Building Permit Number: 14 Appikik
Signature: �( "N�Wi
Building C tsstoner/In toofauddjn Date
SECTIO 0 SITE INFORMATION
1.1 P Addp 1.2 Assessors Map& Parcel1.Io Is this an acc led street?yes no Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use- Lot Am(sq R) Frontage 1(l)
1.3 Building Setbacks(R)
Front Yard Side Yards Re er Yard
Required Provided Required Provided Required Provided
1.�Water Supply:(M.G.I.c.40.154) 1.7 Flood Zoos Information: 1.4 Sewage Disposal System:
Public O Private O Zorn: — Outside Flood Zone? - nieipsl O On site disposal system O
rleekffves
/ SECTION 2: PROPERTY OWNERSHIP'
Ow Hof Reto d:�yGY ev- ��✓'_�. jyf ,{
✓s-t r
Name(Pri 1. Address for Service:
46l7L te'29-5�
Signat(be Telephone
SECTION J: DESCRIPTION OF PROPOSED WORKS(cheek a0 that apply)
New Construction O Existing Building O Owner-Occupied O 1 Repsirs(s) O 1 Alterstion(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify'
Brief Description of Proposed Work
SECTION d:ESTIMATED CONSTRUCTION COSTS
Item auW
Official Use Only
I. Building . Building Permi:AFc*
Indicate how fee is determined:
Standard City/ n Fee
2 Electrical Total Project Coltiplier x
J Plumbing . Other Fees: S
a. Mechanical (HVist:
s Mechanical IFiretal All Fees: S
Su ressioneck No. Cash Amount:_A Total Project C Paid m Full ing Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervise (CSL)
,.W4,-Aen 4,rV5-0--1
L�,.e israse y Nluum�y�
Es not n Date
IJb Int `711%w4 " n
�
1L,,tCSLTypcli:vW-uw)_
A,Wrrss Type Description
U Unrestricted(up to J5.000 Cu. Ff
R Restricted 1,k2 Family Duelling
Sigrut re M .Ma Only
i I _ ill'J e
r3 RC Residential Roofing Covering
Telephone wS Rtsidential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
3.2 R freoHone mproereJ - ror(HI D Residential Demolition on
/ 1 t�—a-� 1 /� -2
��
HIC Co N HIC Registrant Name
/ Registration Number
/ (y r
Ache
��yy Expiration Date
Signatue Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2.12SC(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
1 Htir/ as Owner of the subject property hereby
authtrnze , 1 7" J` to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si antic ner Date
SECTION 71s:OWNNNEE�W OR AUTHORIZED AGENT DECLARATION
I, �IGIMlr2 lil�i eN�/ r7G< C [ri as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf. /lam
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of r
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 sg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I MRS.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. Ff.) Habitable room count
Number of fireplaces Number of bedrooms
Number of balhrooms Number of half baths
Type of hearing system Number of decks/porches
Typeof Cooling system Enclosed Open
1 "Tool Prgecl Square Footage"may he suh,muied for 'Total Project Cast'
02-16-'10 12:39 FROM- T-915 P002/009 F-665
GRANITE STATE INSURANEEiCOMPANY 0092241-00 WC 007-42-6452
13102 013-66-0309-00
PEARSON BUILNOVA ST INC OU9 w Member Companies of
Is ADODY.NMAA01960-0000 fIAR O u I m American International Group
��1lttn EXECUTIVE OFFICES:
70 PINE STREET. NEW YOM N.Y. 10270
SEE EXTENSION OF ITEM 1.OF THE INFORMATION PACE-WCOSUS10
LDM
PHIL RICHARD b ASSOCIATES INS INC
WORKERS COMPENSATION AND EMPLOYERS 491 MAPLE ST
LIABILITY POLICY INFORMATION PAGE STE 102
S. MA 0 2 -0000
INSURED IS PREVIOUS POLICY NUMBER
CORPORATION RENEWAL 0082.66872
DTMFR WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OP THE INFORMATION PAGE-WB990S10
eBa7 POUCYPEIa00s2tl A.MSLndardttmeatiheihsumd's
tbemns address FROM 03/17/09 To 03/17/10
ITEM A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Lew of the states listed
here
MA
a Employers LLebuity Insureneat Part Two of The policy applies to the work in each state listed in item S.A.
The limits of our liability, under Part Two are: Bodily Injury u W Accident S 100,000 each accldam
Bodily Injury by Disease S 500.000 policy limit
Bodily Injury by Disease $ - 100_,000 each employee
C. Other States Insurance. Pan Three of the policy applies to the states. if any. listed here
SEE ENDORSEMENT WC200306A
D. This policy inciudes these
SEE EXTENSION OF ITEM S.D. OF THE INFORMATION PAGE -WCSM12
'ITEM4 The premium for this policy will be determined by our Manuals of Rules, thassifidations.Rates and Rating Plans.
All Information required below is subject to verification and change by audit
rjUmafed TALI Rase Per erhm.1ad
CeSrlliWisns Colo N0.1m, Ramunerallon site OF Re. Premium
O.Annual❑3 Ye9r muneraflon Annual ❑3 Tow
SEE EXTENSION OF REM d. OF THE INFORMATION PAGE-WC7754
TAXES/ASSESSMENTS/SURCHARGES $188
EXPENSE CONSTANT(EXCEPT WNEREAPPUCAKE 0y STAfE1 18 MA
MINIMUM PREMIUM S50D MA TOTALESRMATEDPREMIUM S3.323
II hWk tad below,iamem adiustmenis al AMIKUM WWII bPmed.:
ElS.ml•Annually OuvtdAv Monthly OEPpsrr PREMIUM
03/24/09 ASSIGNED RISK 66
Nsud acne I"Wrrs ofll;m Auiheriaed RepresGMtim we a0 00 01
=07(Revd balm)
PEARSON BUILDERS
General Contactor
Warren A. Pearson
150 R.Winona St . Phone&Fax 978-535-6555
w.Peabody,MA 01960 Cell 978-758-2938
Massachusetts-Department of Public Safet}t ;
' Board of Building Regulations and Standards'
C53ds$tu' n Supervisor icense
WARE PEA 6Q W ''
)N PEAI33 .z 80
Expiration: 4112MI I
Comm�§ionei Trw. 13734 .
,/vcaSanda ..
Doard o[Burldrng'Regulan�and,Standards
_HOME IMPROVEMENT CONTRACTOR .
Regldl-410 ;107999
Esr irat�ian 1112010 Tr#:573
- WARREN A P
4WT
St
150R\%1908
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I'.IIP. N l k l IN Iv 'I 1
I'C VI'.%;nlmo;,IuSrNt[T 0 S.tnu, 59.t,i.0
l rl:v78.'4 9;95 ♦t'.ts:978J40-'1946
Construction Debris Disposal Af idavit
(required lur all denolition 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
S 150A.
The debris will be transported by: r
1 name of hauler)
The debris will be disposed of in
(mmne ul aci Ity)
f
plddrcss ul'licilityl
.ignature 1 *nnit applicant
plate