23 NAPLES RD - BUILDING INSPECTION r
The Commonwealth of Massachusetts MOVED 4t, Board of Building Regulations and Standards (NSPEDTI NAISSM ►DES
Massachusetts State Building Code,780 CMR SALEM
R wised i t 28H -
Building Permit Application To Construct, Repair, Renovate Or Dem STR "Q 2 A 4F r G
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Y
l Building Official(Print Name) Signature Date
xP-�lL_/• SECTION 1:SITE INFORMATION
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1.1 Property Address, 1 1.2 Assessors Map&Parcel Numbers
h)aPles F�
L I a Is this an accepted street?yes y no Map Number Parcel Number
—� 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use 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:
Public. Private❑ Zone: _ Outside Flood Zone? Municipa On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTYOWNERSHtP'
2.1 Owner'of Record:
Laws 5egt�ar f SAL@iv, MA
Name(Print) City,State,ZIP
°)Srl g,D
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)(! 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description ofProposed Worl2: eeQl�r-taoc, 4-e a^'�44 i=lvur Ag-tti
N[O CE AD r�l� 'C Or S�fvnl n I C' 6a nee S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ a(7 000 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
2 o O Cb ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ V o 2. Other Fees: $ T
4. Mechanical (HVAC) S List: 1 (J
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 000 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C53-,)asl _ LPL
is^tr. ,^�o_.c) /7S0n License Number Ex ratio Date
Name of Holder
Cl List CSL Type(see below) fits`
— n fs /inn��)t..-- S'T
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
oa,l ye.cS M A- 01cm-3 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
q SF Solid Fuel Burning Appliances
'fc1Y) tJ0.wC�� (Ja��dcr��C 't'7"VIna•� I Insulation
Telephone Email address �C�^ D Demolition
5.2 Registered Home improvement Contractor(HIC)
11 /
ga ems— .7.s c
C^tag. 'D Ci.y r O50 r HIC Registration Number xpira ion Date
HIC Co mpp any Name or H[C Registrant Name
0y� /�-n0 >Je.r .9
No.and Street Email address
�4 nytr5 (h A- o )�, 3
City/To/Town, tate,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 .........C&-1 No ...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 1l r i a.n Dct v�0.&0^
to act on my behalf,�matutcrs to work authorized by this building permit application.
Prir's Namc Si DV
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.
QK�ZL n DCLOtcQson .-09- C*-- IJ ACi l
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"may be substituted for"Total Project Cost"
CITY OF S -1 .&M$ 1�'L�SS.�CHUSETTS
BUILDING DEPARTM&%T
130 WASHLNGTON STREET, 3'0 FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
K[.\(BERLEY DRISCOLL
MAYOR Txtmus ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BuumrNG Cmmasst0,iER
Construction Debris Disposal Affidavit
(required for 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# 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:
✓lq...� Tt.. �fL
(name of hauler)
The debris will be disposed of in :
(name of facility)
�c.n�ecs 2oL
(address of facility)
signature of permit applicant
� t
date
Jcbriuf7:Juc
f Massacnu efts - Dupor:r'it:n' vl P;,,�Ilc tnUlY
Board of Building Regulations ann ::,innti:fllM
Construction Super,i sm
License: CS-057251
BRIAN DAVIDSO;4
269 ANDOVER ST
DANVERS MA 01923
°xoi ra do
Commissioner 08/069015
f, n� (�J;hz��ZGCd -
-f NOT";..t
OFlice o( C;onsumcr Affairs and Business'Regulation
; F 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 171855
Type: Individual
Expiration: 412512016 Trk 252699
BRIAN DAVIDSON
BRIAN DAVIDSON __.__....--.------_.__...___......_.. . ..... ..
269 ANDOVER ST - ------- ._....._....... . . .. .. . __
DANVERS, MA 01923 --'— — ---- '-
Update Address and return card.Marie reason for change.
scat G soMAs/n .L [-I Address Renewal � ) Employment Lost Card
r•%ltr 1/nuNurrlrPrrr�/�r�( ��Uinrw.;r//;
Office ofConsumer Affairs&Business Regulation License or registration valid for individul use only
,13 .,AOME IMPROVEMENT CONTRACTOR before the expiration date. 1f found return to:
(?ice .. egistrati0n: 171855 Type: Office of Consumer Affairs and Business Regulation
!'Ex irati0n: 4/25/2016 Individual 10 Park Plaza-Suite 5170
P Boston,MA 02116
BRIAN DAVIDSON
BRIAN DAVIDSON '
269 ANDOVER ST
DANVERS,MA 01923 Undersecretary —Not valid without signature
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