146 LAFAYETTE ST - BUILDING INSPECTION (2) TfS � - nos 2. b 1 ,5
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR RECFAVE,0M
W?E V WYNE
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling IM 121 A %
This Section For Official Use Only
Building Permit Number: Date Applied:
i
Building Official(Print Name) Si afore Dat
SECTION 1:SITE INFORMATION
1.1 Property Add sa: 1.2 Assessors Map& Parcel Numbers
I.Ia Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed se 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:
Zone: Outside Flood Zone?
Public❑ Private❑ — Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner of j�rd-
�fb M �e
Name(Print) City,State,ZIP
ILI LGFae S�, 1te- my-663b
No.and Street U Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 19 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : t te, c ,¢F &W W-1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ Cexb 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
\ Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ b,U� ❑Paid in Full ❑Outstanding Balance Due:
5-rt4L;- -TVA t S W'.—_ �G
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -=��
Artyp ,I//LII.,0 License Number Exp ho Date
Name of CSL Holder c,.
S� it- i NoN^� J'. List CSL Type(see below) U
No.and Street Type Description
Unrestricted(Buildings u to 35,000 cu.ft.)
R
City/Town,S Restricted 1&2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
6 a SF Solid Fuel Burning Appliances
C47g-75B'L L37J I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
LA I,,,?t-) 0-A rc4,A HIC Registration Number E i 'on Date
HIC Company Name or HIC Regir4 Name
No. d Stre t Email address
eg 0A
City/Town,State,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 ..........01 No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize " e,N &'.)-
to act on my behalf in all matters relative to work authorized by this building permit application.
arG,N 2ns lof lqg
Print O�Namd(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 best of my knowledge and understanding.
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. o� v/oca Information on the Construction Supervisor License can be found at)nny.mass.gov/dps
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"
PEARSON BUILDERS
General Contractor
Warren A.Pearson
warrenpearsord9mmost.net
150 R.Winona St Phone 9787W2938
W.Peabody,MA 01960 Fax 9784356555 -
Massachusetts -Department of Public Safety
hoard of Buildiiig:Regulations and Standards
Comtruction Suptn isor
License: CS4)40996
WARREN A PEA100N
' 15MM140NASTRE-V _
W PEAEM MA Ol i
e '
Expiration
Commissioner 04/1212015
�'. �a Wor�rrraaueaersll�eo�P/lr✓aa�aclsu�eCL�-.' •.. -m� —_
OITee of Coosomer AlTairs&Business Regulation Lieens@ or registration Y-'f,d for individul use only
WExplratlon;�-�-;V-
ME IMPROVEMENT CONTRACTOR - _ before the expiration date. If found return to:
istration �Q/9gg - -_ Type: Office of Consumer Affairs and Business Regulation
1if11Q Individual 10 Park Plana-Sane 5170
Boston,MA 02116 _
WARREN A.PEARSbF `G',.,!"�`
Warren Pearson ��
Winona
S S
150R t '•ti 1�•
Peabody,MA 01960 Uaeisecremr '- ' Not valid without signature -
MEMBER BETTER BUSINESS BUREAU LAUGHLIIV H INC ��^ -V MA REG. # 161925
MEMBER CHAMBER OF COMMERCE �� ../(/�-�'� FE[yID # 41-2054365
I _w 9 Charles Street P.O. Box 252 ) oC�\/ � 4/
MEMBER BEVERLY KIwANis p/l/�( -
0 `" J1 v � Beverly MassachD WARREN PEARSON CSL # CS40996
SINCE 197a %l% tl ` ! (978) 922-5579 ( 1 8) 828-3979 cell Hlc uc. # 107999
SPECIFICATIONS SUBM EDTO: P ON
7 J -I DATE
I
62�ci r 6 LL .
STREET
CITY.STATE&ZIPSI 106 LOCATION
ARCHIT"C� I DATE OF ANS JOB PHONE
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We hereby submit specifications and estimate s�lir
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Date work will Date work scheduled to be substantialWeompleted:
Payment Sc i Initial Payment: �J ter✓ T� hr ���
Payment 2. `" ) : , /c 1: -c l"�
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 mal
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 1-500-223-0933.
It is the contractors obligation to obtain amp and all necessary contraction-related permits,should the owner secure their own contraction-related permits or deal will
unregistered contractors the owner shall be excluded from access to the guNiFantee fund.
Unless otherwise noted in this document,the cwffract shall not imply that any lien or other security interest has been placed on the residence.
DO NOT S N THIS CONTRACT IF THERE ARE BLANK ES
Acceptance of Contract
The abo•e prices,sppecifications and conditions ore sa sfettory '
and aye hereby acce led.You are authorized to do the ork
as speu6ed. Payment will be trade as outlin above. y� �—
v
Date of Acceptance !£ � ° - - _ Signature
You may cancel this agreement if it has been signed a party ere[d at a place other than an address of the seller,which may be his main office or branch thereof,provid
you notify the seller in writing at his main office or branch by rdinary mail posted,be telegram sent or by delivery,not later than midnight of the third business day followi
the signing of this agreement. See attached Notice of Cancel) tion form for an explenation of this right.
Y'4J�4ee -�- tf/ � /,Y,-
\= The Commonwealth of Massachusetts
Wers' Cont
Department of Industrial Accidents
Office of Investigations
600 Washington Street, 7h Floor
Boston,Mass. 02111
pensation Insurance Affidavit:Building/Plumbing/Electrical Contractors
ADDlica'nt`information: Please PRINT legibly
name: WctrCCJ �x.l^SOJJ y
address: S� i NONJG ''AA b city Peabt,;y statelMA zip: 011k phone# 11it'7 T��K- L 2
work site location(full address):
❑ I am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel
❑ I am a sole proprietor and have no one working in any capacity. El Building Addition
F
® I am an employer providing workers' compensation for my employees
.working on this job.
company name• r/d/ .Ul tRPI��+-S ,jj�,
address: 1/.il t `0/iln� K (A)i�4f )1
city � �I ,{ f P d �y , 1 II'1 phone#• 1 2-n �S 1 Xi
insurance co. I(d�r-t,Y f S . L_.A/�ll.ra rJ('e. policy# UL6 6 Q67.-31 L
i 1
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
company name:
address:
city phone#•
insurance co. Policy#
company name:
address:
city phone#•
insurance co. policy#
fAtfach additional sheet if uecessa_ry f
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$l M 00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may he forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the�p�paJs and penalties of perjury that the iritonnation provided above is true and correct.
Signature 4j�j Date I n)2��1 t1
Print name �asrGrl TPedSol,) Phone# 4'ec-'ISt-2A3
official use only do not write in this men to be completed by city or town official
city or town: permil/license# ❑Boilding Department
[]Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone#; ❑Other
(revised S PL 20N)