238 LORING AVE - BUILDING INSPECTION e�d-W cw, 06
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR. T"edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One.or Tu'o-Fmnds,Du elling
This Section For Official Use Only
_ Building Permit Num c Dale Applied:
Signature:
Budding Commissioner/In to of Buildings Date
SECTION 1:SITE INFORMATION
L1 Pr a dress: 1.2 Assessors Map& Parcel Number
Ilia Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq(1) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,sSa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Cheek if es❑
SECTION 2: PROPERTY OWNERSHIP'
ored �� / �✓/ ilve
Name(Print) Address for Service:
�� —
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repi i W( ) ❑ Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': '
4- / ✓ ✓
fG SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofilclal Use Only
Item Labor and Materials
I. Budding f 1. Building Permit Fee: f Indicate�W,66
ermined:
❑Standard Ciry/Town Application Fee
2 Electrical f ❑Total Project Cost'(Item 6)x multiplier
3. Plumbing f 2. Other Fees: f
4. .Mechanical (HVAC) f List:
S Mechanical (Fire f Total All Fees: f
Su ression
Check No. _Check Amount: Cash Amaunt:_
6 Total Project Cost: f 3t(j( / 0 Paid m Full ❑Outsunding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CSf ali 6/ ;r 6 �j,
'' fOrlZ L.ccrise Number Espuuti n Dam
N.,poe ot'CSL Ilp�lyyr e �" Lut CSL Type(,cc below)
5
/.r57� /C GC7•�to"c.
�
Addre:� r e Dean rinn y �r'Z�� U Unrestricted(up to J3,000 Cu. Ft.
R Restricted 1&2 Family D%ellm
Signaturen,�/' N %lawnry Only
RC Restdennal Raofin Covenn
Telephone wS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 R }st r Home Improy melt ontra�(HIC) /a �c�4Q
HIC Company Na or Ii l�')tegistrani Nam �h Registration Number
Addn:we_ _ �/T7 / d JO Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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.........4 No........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize ��C' 9i,-��t. to act on my behalf,in all matters
relative to work authorized by this building permit application.
Jf &41,1-- ice,
Si nature of Owner Date
SECTION 7b:OWNEW ORrJAUUTHOfRII�ZED AGENT DECLARATION
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.6 ��f�3� �- �
Print Name`/��1� ��✓� —
Signature of Owner or Authorized Agent Dat
(Six,
i ned under the psins and penalties of perjury)
NOTES:
I. 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 ggj have access to the arbitration
program or guaranty fund under M.G.L. c. 111A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUattics, 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
Typeof cooling syvem Enclosed Open
3 "Total Project Square Footage" may he uhstituted for"Total Projcci Cost"
CITY OF SALEM
3!i PUBLIC PROPRERTY
1:; r � DEPARTMENT
�01P
::.1%W:KI I I Kht,01 I.
\I Uul< 120 W. ii IIN G!ON Srft ErT • SA I:M. %iAiiV IIt it I ii 19
Trt,978-.74i-9595 • FAX:978-74C19846
Construction Debris Disposal Affidavit
(required f'ur all demolition 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 t1 is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
1'3,�
(name of hauler)
The debris will be disposed of in
/liter
(name of face/ny)
_ S4t'
la dress of facility)
tature of permit applicant
T��e
"t CITY OF S.U.E.`I, L�SS.�CHL;SETTS
BL'IIDLYG DEPARTMENT
120 WASHINGTON STREET, )aa FLOOR
TE1_ (978) 745-959S
FAx(978) 740-9846
KISiBEXEY DRISCOL-L TlIOMAsST.PIFan
MAYOR
DIRECTOR OF PCBLIC PROPERTY/BCILDLVG COSLNrtSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r licant Information Please Print Legibly
Nalne Iausimv OrpniratiominJrvtdu+l)! / S
Address: /5-V /� lnr7
City/Statc/Zip: I�PI74 49 C) Phone N: 6 7✓��' ��
,Xre you to employer'Cheek the appropriate box: Type of project(requlred):
1. 1 am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the subctxuractors
2. 1 am a sole proprietor Or partner- listed an the attached shceL 7. ❑ Remodeling
ship and have no employee These subcontractors have 11. 0 Demolition
working for me in any capacity*
w r orke 'comp.insu ce.ran 9. 0 Building addition
INo workers' comp. insurance 5.,�We are a corporation and its -
required.)
of cer have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL 1 I.0 Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4).and we have no 12.0 Roof repairs
insurance required.)r employ*:$. two workers' 13.0 Other
comp. insurance required.)
'Any applicata than chocks Don NI must also fill en the section below,showing their worker'c m;M Whm policy inrurmadems
'h l muowoes who submit this aftldsvit indicating they aka doing dl work and than hits ataride coom urnor m W suhmil a new,affidavit indiosing suck
T.miracion thst chock this boa mud anachd an a klititmal shows showing ate name of the mbesttnKjM and tho4 workers'a^p.policy infomauw. -
1 am an employer that Ira pravid/nx workers'co pelssadon Insurance jar my employers Be/aw/s the poOry oad Job irUa
information. 471 // /j
Insurance Company Name: r/l �/ '^� �� l�G/�i
Policy N or SelUins.Lic.N: G` 5 1 I _XL . l Expiralion Date:Q a�/
Job Site Address: 7 Lov,-Ysl City/State/Zip:
,attack a copy of the workers'Compensation policy declaration page(showing the policy numbor and expiration data}
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to S I.500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and fine
Of up to 5250.00 a Jay against the violator. Be advised that a copy of this statement may be letrwarded-to the Office of
InvcsitxattuM ul'ilt: DIA for Insurance coverage verification. .
I do hereby certify ueJ/r the paid pe les of perjury t the informaton provided above is true and carrecL
'Zn_nvure:
iO riel use may. Da not wrife in thin area, to be romp/sled by city or town gpt-iaL
Cory or fuwn: __ Pcrmit/Llcense N _
Issuing Aulhunty (circle onc): - - - — - --
I. Iluard of Ileallh 2. Ruilding Department 3. Cily/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone N•
A CERTIFICATE OF LIABILITY INSURANCE �TB`3�i6 09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Phil Richard & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
491 Maple Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 102
Danvers, MA 01923 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA SCOTTSDALE INSURANCE COMPANY
Pearson Builders, Inc. INSURER B: Arbella Protection
150R Winona Street INSURERG Granite State Ins AIG
Peabody, MA 01960 INSURERD.
INSURER E'
COVERAGES
THE POLICIES 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 TOALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION UNITS
GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000
A X COMMERCIAL GENE RAL LIABILITY CLS1445653 11/28/08 11/28/09 PREEMISE C TOREN rrence $ 100,000
CLAIMS MADE 1XI OCCUR MED EXP(Arry one persm) $ 5,000
PERSONAL&ADVINJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-COMP(OP AGG $ 2,000,000
X POLICY M PRO- LOC
AUTOMOBILE LIABILITY
$ COMBINED SINGLE LIMIT $
ANY AUTO 37262400001 7/18/08 7/16/09
(Eaaccidenl)
ALLOWNEDAUTOS
BODILY INJURY $ 250,000
X SCHEDULED AUTOS (Perpvson)
HIREDAUTOS BODILY INJURY
NON-OWNEDAUTOS (PeraWdenl) $ SDD,DDD
PROPERTY DAMAGE $ 100,000
(Peracdtlenp
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANYAUTO OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESS/UMBRELLALIABIUTY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE - $
RETENTION $
WORKERS COMPENSATION X I WC STATLI OTH-
AND EMPLOYERS'UABILITY
C AWPROPRIETORPARTNERIEXECUTIVIE YTBD 3/17/09 3/17/10 E.L.EACHACODENT $ 100 000-.
OFFICE MMEMBER EXCLtDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OFTHEABOVE DESCRIBEDPOLICIES BECANCELLED BEFORE THEEXPIRAT"
TO WHOM IT MAY CONCERN DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR to MAIL 15. DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDERNAMED TO THE LEFT,BUT FAILURE'TO„DO SO SHALL
.IMPOSE NO OBLIGATION OR LIABILITY OF ANY:KIND UPON THE,INSUPAKA'S AGEWrS OR
REPRESENTATNES.
AUTHORRED RE PRESENTATIYQ
ACORD 26.riZ ID- 986-2009 AC ORPORAT110N. All rights T Y►d.
The AtORD name and 19000 W marks of*A�NI 00
PEARSON BUILDERS
-- - - General Contractor - -
Warren A. Pearson
150 R.Winona St. Phone&Fax 978-535-6555
W.Peabody,MA 01960 Cell 978-758-2938
�I
Massachusetts-Department of Public Srfetj4
Board of Building Regulations and Standards
�GdhsjjuE(fpn Supervisor License
,Lticense:.CS ' 40996 �•=., .. .
Rg' rded 00
;WARREN PEARSON .
150R W IN�� --TjRE
-V11 PEAIWDY 'P/IPs 96& N -
Expiration: 41121MI I
Tr#: 13734
- ✓fie Tooa�+�,r��f .ryO > _.
board o[Building�Regula6dns and
_ _ HOME IMPROVEMENT CONTRACTOR `
Regist%uo .107699 -Tr# 27�A'ry'
u
Expiration 11I2010
. i i7�7e ° rQual x
P
yy.
v"�amen Pearson
.I 150R Winona
Pe pSdy,t'!)-A:01960 r ".A1Mr .
d.!`��LCC.C-.G�sC--+ Cf7/L/i" / �'-�':� . _ �.1 Lid✓ '�./-_/=-��-� ,�" Z.ZE_ii(-LT��f __..__._—._____._..__
Page No. ---f Pa es
Lz ryc(✓ z
tAL JH HOSES INC. 16/q2>
MEMBER BETTER BUSINE=c B,�Rc_,-_ � 7 ,. MASS REG. # ('�
MEMBER BEVERLY' CHAMS=F CF CGi•i'/ER-E 9 Aarle St'eei P.O. Box 252 -y/- G"Y/•P�/ SINCE) 1/978
MEMBER BEVERLY KiVC.\-S B .1'erh l3 i1 .�:� 0191� OR EM AN S *OR C •f z'/(J y 9Ee
PROPOSAL SU ITTEp TO:�
STREET✓J
CITY,STA?E&ZIP
ARCHITECT / DATE OF P NS JOB PHONE
/ ereby submit specifications and eaimates for: i
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_We Propose hereby to fuini material and labor—complete m a otdance with ab e sp�eci tcati
L ✓ir'i-Vdollars ($ C� Y
Ir Payment to made as follows: /
All material is aranteed to be as Sp cified.All work to be completed in a workmanlike man-
net according to standard practices.Any alteration or deviation from above specifications in- Authorized
volving extra costs will be executed only upon written orders, and will become an e)[rz Signature
charge over and above the estimate.All agreements contingent upon strikes,accidents or de.
lays beyond our control. Owner to carry fire, tornado and other ne ry insurance. Our
keys are covered by Workman's C mpens��w Insurance. fit t Note:This proposal may be
� /��� 30 0 A n thdrawn by us ifnot accepted within days.
Owner agrees that in event of his breach of tiSis contract before woik is started,Contractor may demand twenty-five(25%)percent of the contract price as its
stipulated damages for the breach.
Acceptance Of Proposal -The above prices,specifications and condi- Signaturd� l
tions are satisfactory and are hereby accepted.You a authorized to do the work ,
specified.Payment will be made as oudin above. oil
y (
U. (G Signat .� ty
Date of Acceptance
You may cancel this Agreement if it has not been consummated by a parry 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.