74 PROCTOR ST - BUILDING INSPECTION -Fi3 - I LJ 1-2
-
IL The Commonwealth of Massachusetts INS ECTIONAL.SER ICES'
•
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Buil ' Pe itNu er: Date pphe
- BEildifig Off5cial(Print Name) ,.Signature . Dar
SECTION 1:SITE INFORMATION
1.1 Pro rtyAddress: 1.2 Assessors Map&Parcel Numbers
L l a Is this an accepted street?yeses 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(it)
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 E( Private❑ Zone: _ Outside Flood Zone? Municipal!a On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
1.1 Owner of Record: ,
DO .1
hA l' t Co Sralem , r4a 01970
Name(Print) City,State,ZIP
�yi-7
7y tp1\oekor $4reeT /�776-375' /
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) V I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: RemOvt- Kr- ry eWa�dt
O'r " kc. house anol to sla 11 nt-J RirQ 'Tyvek
1-1nu se wra n
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only '
Labor and Materials
1.Building $ y 2 D D.0 d 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: (,y
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:.
6.Total Project Cost: $ y 200,00 ❑Paid in Full ❑Outstanding Balance Due:
5c►sr -1-b R'(3- 5113
i SECTION 5: CONSTRUCTION SERVICES'
5.1 Construction Supervisor License(CSL)
1 �t1 CS -o59(033 it o Doty '.
ROD'e\ rT k 1VQASon License Numb e Expiration Date
Name of CSL11H\\older 1 t t
91 '3 TYQVer�t1` g� List CSL Type(see below) IwyeskrleledV
Noo.and Street Type Description -
Ro Loll Y . Ma 0k 9 (09 U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
978- 9g9-5/25 r-k ncl so. 2tit E? wl( I Insulation
• Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Nclsov� Cow .ArucAto� /12g58 5
R. K . Co
to i5
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
gl'3 1{g\ t11 iskr«rt rknalSor+ 29 @ 4 Vria _Com
No.and Street Email a dress
AotJluj Ma o►9109 978 918 5125
Ci /Town,Stale,ZIP Tele hone
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...........❑
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
to act on my behalf,
�i/n,Jall matters relative to work authorized by this building permit application.M;;t4A t't-// O /0 /
Print Owner's Nam lectronic Signature) I Date
SECTION 7b:OWNEW 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 inn this application is true and accurate to the best of my knowledge and understanding.
RobcrT k WJSon — 0/
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.gov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dns
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 hearing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i CITY OF S.U.EN1, !Nv'LkSSACHL'SETTS
J BUILDING DEPARTMEINT
.• ` 120 WASHINGTON STREET,3w FLOOR
TEL (978)745-9595
FA..c(978)740-9946
KI\iBERLF-Y DRISCOLL
MAYOR THOMAS ST.PIERIM
DIRECTOR OF PUBLIC PROPERTY/BCBDLNG CO.%MSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A»nlicant information 1 Please Print Legibly
Nalne(Busim Organaalion/mdividual): R, l< . NcJ jo y-\ ��I�SSt f UG� \O✓�
Address: 81'3 V\Uv i r( M ST
City/State/Zip: Mot 019 ln9 Phone#: 97 0 — c'`/8 - S ) 2 S
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. 0 I am a general contractor and 1 6. 0 New construction
employees(full and/or part-time).* have hired the stab-
contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself.(No workers'comp. c. 152,§10),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.0Other
•Any applica t due checks boa Il l must also fill ma the seclimm below showing their workm'compensation policy intatmatioa
I lomemenns who submit this affidavit indicating they arc doing all wok atd then hire outside wnttaCots must submit a new affidavit indicating such.
Cminacton that cheek this box must amachad an additional sheet showing the name of the suhcontrectors and the*workers'comp,policy information.
I am an employer that Is providing workers'compensadon insurance for my employees. Below is the policy and Jab site
information.
Insurance Company Name: Fo r yyN FA m 1,�j \Y)S .
Policy#or Self-ins.Lic.#: 2-00 S WCe tg 9 6 Expiration Date: 1,2�/15
7`/Job Site Address: rrpc4or Slrr.-+ City/State/Zip: SaA cm , Ma 0lg70
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
fine up to S 1,500.00 and/or one-year imprisonmem as well as civil penalties in the form of a STOP WORK ORDER and a foe
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investiguiions of the DIA for insurance coverage verification.
I do hereby certify under the pains and penaties of perjury that tine information provided above is true and correce
Sil:na urc•�z Date, 8 9�/`/
Phone#; 978 - 9y8 S/2s Cc1l 978-979 -2110
Official use only. Do not write in this area,is be completed by city or town oJJkiat
City or Town: Permitfldcense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department J.Cityifown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other.
Contact Person' Phone#:
CS-059633
ROBERT K NELSON
813 ItAVERHILL ST
ROWLEY MA 01969
92,
11/10/2014
Office of Consumer Affairs&Business Regulation
'-'`�!�Z-jHOME IMPROVEMENT CONTRACTOR
Registration: 112958 Type:
.i&piratici 51612015 DBA
R.K.NELSON CONSTRUCTION
ROBERT NELSON
813 HAVERHILL ST.
ROWLEY,MA 01969 Undersecretary
Unrestricted -Buildings of any use group which
contain less than 35,000 cubic feet (99 Im")of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS Licensing information visit: wwwMass.Gov/DPS
CITY OF S' .ENl, LxsSACHUSETTS
BURDLNG DEPARTMENT
P 130 WASHNGTON STREET,3"'FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KIN
LBERIEY DRISCOLL
MAYOR THOAtAS ST.PIERRE
DIRECTOR OF PL:BLIC PROPERTY/BUILDING CO\L\MIONER
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:
Q• 1� ` e\SoYI co"-S4ruC�loY-
(name of hauler)
The debris will be disposed of in :
Sq\\ -'M Aro,n4r,- (No4hSAt,
(name of facility)
S L')Q m ip scc)�A '9DA '2 1M", Aa of 4�0
(address of facility)
signature of permit applicant
date
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