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0080 WASHINGTON SQUARE EAST - BPA-14-715 -� o 19 The Commonwealth of Massachusetts INSPECTIONA L SEAVaR —i, Board of Building Regulations and Standards SALEM{t l Massachusetts State Building Code, 780 CNIR /1�.;,.,.,tei vol[ k"' r . 8m CIA 24 a Building Permit Application To Construct, Repair, Renovate Or emo is a t One-or Tivo-Family Divelling This Section Far Ot7icial Use Only . Building Permit Number. Date Applied: a 3 21A 1�} building official(Print Name). Signatu Da SECTION 1:SITE INFORJIATION 1.1 Property Address: _ 1.2 Assessors dlap&Parcel Number rocs ( 9r_Lly : So t- 1.1 a is this an acce ted street?yes ❑m M1lupNumber Parcel Number LJ Zoning Information: I.J Property Dimensions: Fronts a 11 \ Zoning District Proposed Use a Lut Area(sy R) g O FWater gSetbacks(ft) Front YarJ Site Yards Rear Yard Provided Required Provided Required Provided upply:(M.G.L c.q0,§Sq) F7 Flood Zone Information: 1,8 Sewage Disposal System: Zone: _ outside Flood Zone? Municipal❑ On site disposal system ❑ Private❑ Check if yesC3 SECTION 2: PROPERTY OWNERSH[Pt' 2.l Owncrt of Record: fie' do°�'�eLl City,State,ZIP - )me(Print) 6'0 C. vk 1 ' .S'A `.x rC Email Address No. and Street Telephone SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building l9' Owner•Occupied Q Repairs(s) Alteration(s) ❑ Addition ❑ Demolition (3Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed 1Vork': R e Al d k-fcC � SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Matcrials) I. Building S ' 1. Building Permit Fee:S Indicate how foe is determined: ❑Standard City/Town Application Fee 2. Electrical i ❑Total Project Costa(Item 6)x multiplier ```v 3. Plumbing .S 2. Other Fees: S 4.Mechanical (hIVAC) S List: / ICJ i.:\fshanw.d (Fire `i rotal All Fees:S Su n nression) Check No._Check Artiount: Cash Aolotuu:_ ti.Total Project Cost: .S /'tr b V ® ❑Paid in Full ❑Outsiandin Balance Due: Alt, Kul l Meat 4l3 u� An s SECTION 5: CONSTRUCTION SERVICES 2al.vrx? tan^rY��, 5.1 Construction Supervisor Liceme(CSL) CS — d d'. 1771 S�4d 'jYPla/'oD/'0-4 s1RY' ____ License Number Expiration Date Name ol'CSL[[older // List CSL'fype(see below) (� ri Q n .y 4 .e-.s G No. and Street Type Description ; U Unrestricted(Buildings to 35,000 cu. II. !f{�o � � ✓ u"" it I Restricted 1&2 Family Dwelling C'itylfown,S rite,ZIP bf Nlasonry O / ^7 G (o RC Rooting Covering WS Window and Siding SF Solid Fuel Buming Appliances I Insulation 'fele hone Email address U Demolition 5.2 Registered Home Improvement Contractor(HIC) 1 iixyo � '&o L Cn/.. s7 O ��' HIC Registration Number E.pirati n Date [IIC C rim u y Name ar[IIC Registrant None e / nn 1` ern M G4 •.-.L. J YraN © Y`oI�G CON$ 7/`a.c�.O A' No. m St Email L rnA of yG G 97�SYG >iav Emuitaddrcss Cit /T— own State,ZIP rele hone SECTION 6:WORKERS'CONIPENSATION 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 Is?;uance of the building permit. Signed Affidavit Attached? Yes .......... 2' No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN: OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER611T I,as Owner of the subject property,hereby authorize t9 act on nhal ,in all matters ti ad� to authorized by this building permit application. Print Owner's Nmne(Electronic lgn cure) 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. S/.' R/ ®c5 /.C— Yd ell 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 tine arbitration program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at n www.muss. ov'oca Information on the Construction Supervisor License can be found at sr raw.mass. �t�v'dL 2. Wbcn substantial work is planned,provide the information below: Total floor area(sq. P.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. It.) Habitable room count I Number of Fireplaces Number of bedrooms Number of bathrooms Number of led f/baths T,vpe of heating system Number of decks/porches . .fypeof Cooling sySteal Enclosed Open 1. "f01al Project Square Footage"wary be substinrtcd liar"fot.d Project Cost" POOLE o , CONSTRUCTION,..., \L Stan Poole \ One Farm Lane, Rockport,MA 01966 p:978-546-7120 f:978-546-3946 e:StanQPooleconstructioninc.com www.Poo]eConstructionlnc.com i General Contractors & Builders \\ 978.546.7120 Deslgn&BuRd•Property Management•ReSdentiM&Commerpal Leasing Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction SuperNisor License: CS-027771 STANLEY R POOL-`E- 196 ROCKPORTMA 01966 f�r � t �r J.�• �iSf .. „ "` Expiration Commissioner 0 7/2 412 01 5 �� ((uuuoiraienl/�r j�'lllulrrc�rr, :� Office of Consumer Affairs&Business Regulation , ,TOME IMPROVEMENT CONTRACTOR egistration -112409 Type: xpiratton _3/25/2015:. Private Corporatir POOLE CONSTRUCT,ION CO INC r STANLEY POOLE ` - 1 FARM LN. --- ' ROCKPORT,MA 01966,s" _ir_;, Underses CITY OF SiU.EiNA, NLNSSACHLSETTS Buu_DacG DEPARTMEINT OT r s� 120 WASHLNGTON STREET, 3m FLOOR �2¢e TEL (978) 745-9595 F.A_x(978) 7.10-•98.36 KI.%tBEIu.EY DRISCOLL �gAYOR THontAs ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUIr.DrN'G CO\LUISSIONER Workers' Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amilicant Information Please Print Legibly Vain L' (13 usinesGrngan izatioNlndividual): /&o,0 /t Cd-- -/ Ccs, rw G Address: 4 u-- e* �_,ro City/State/Zip: /24� G Ce Phone tE: !) �5—Y 6 7 X D Are you an employer?Check the appropriate box: Type of project(required): I.2rI am a employer with S 4. D J am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors ` 2.0 1 ran a sole proprietor or partner- listed on the attached sheet. t 7• Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. Building addition [No workers comp. insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp.insurance required.i •Any applicunl dot checks bus 01 moat alau fill out the section below showing their worken'cumNnsalion policy infi)madorc I I lomcuwmxs who submit This atfldnvit indicating they ore doing all work and then hire oulside contractors mmt mihrnil a new affidavit indi"ing such. :Gmuactom shot check This box muss atlachod an addiliuml ahec t showing ow name of the subtwuractun and their worken'cump.policy infia"ation. l art an employer that is providing workers'campeusailon insurance for my employees. Below is the policy mtd job slid information. ) �/� L� Insurance Company Name: thh S'v Ss�`ti ._s . �"" OL Policy A or Self-ins. Lic.d: Expiration Date: Job Site Address: 9 .9 w ;z4sZ'VfU City/State/Zip: ��l•`^+ /1au ®/97v 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,`vIGL c. 152 can lead to the imposition ofcriminal penalties of a tine up to SI.500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this,statement may be furwardcd to the Office of Invesligations ofthe DIA for insurance coverage verification. f do hereby certify under thhee ppoins rand penahies of perjury that rise infonnatiar provided abuvo is true and correct ii,lrlturn' Phone 4 Officiul use only. Do nor write in this area, tithe connpleted by city ur town afficiul City or Town: __._.. .__ Permit/License Issuing Authority (circle one): i. L'ourd of I1ealth 2, Building Department .1.Citylfowo Clerk 4, F,lech'ical Impcctur 5, Plumbing Inspector 6.Other . . .-._ Contact Person:_ ... . .— Phone _-- /hvf CITY OF JiU. Nfj LY.Ia-USACHUSL' 11J t ' BUILONG DEPART\t&NT 120 WASI-INGTON STREET, P FLOOR TEL (978) 745-9595 FAX(978) 740-9844 tu\mE1uEy oRlscoLL �{AYO t T2-toads ST.PtERRs DnmcroR OF PUBLIC PROPERTY/BCILDLNG CO\LMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of NIGL 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 tNIGL c 111, S 150A. The debris will be transported by: CerndoJ-t,rn (name of hauler) The debris will be disposed of in (name of ractlity) (addres.s ortacility) signature ut permit applicant ,i. to I i ' I I i I �I I o El El El El 0 LL I QD Q1XID � QU El i ' O i I I I Note Phis drawing is an artistic '"`ty°�^��tfJ`,,,�, Designed 3/21/2014 it interpretation ofthe general 2O�o0arl Printed:3/21/2014 appearance of the design. It is not meant to be an enact rendition. • I. P IIoole. L_ I 711 , L N - -_- . L�.J.%t..9 _. .6 .__.. P g .b All dimensions-size designations This is an onmal desin and must Des med:3/21/2014 given are subject to verification on i«neowmta not be released or copied unless Pnnted'3/21/2014 �� job site and adjustment to fitjob applicable fee has been paid orjob - - conditions. order placed. i Poole Countertops Drawing N: 1 No Scale. r w I i i i i i I \ I f f I I \� ® oo i A I I II II Note:This drawing is an artistic r�/`0/'� -� Designed.3/21/2014 '. interpretation of the general rLV �esr+9� printed:3/21/2014 appearance of the design. It is -- not meant to be an enact rendition. i. (Poole_ i i . �I I ' I I 99 , I 2„ 27" 15" 30" I 44 - ._..._ T - 27 1 5 �� 1 n It �� i � I 2911 1511 3011 1 24it I I ; -7 n' 7 ,k� I ✓ i s "t`t"� v d t i 9 �,�a � iy >> k 4� i a iuYG '� t Yutr r a4d32k.wYwH�e W ss4 i` u.vbti.ueVW{fi)V� ay2` i4 dT.u:r� »'�+6 a..a:xm5�a�f F 2W2718 W1530- 2W3030 2W2415 30L-REF DB15 P1 „24-RANGE mm Ni ` - _ ..... I I ,I 'I All dimensions size designations M[��y This is an original design and most Designed 3/21/'20[it 4 given are subject to verification on i ei�u`oC°a not be released or copied unless Printed:3/21/2014 1, job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. i i Poole All All Drawing B: I No Scale.