0282 WASHINGTON STREET - BPA-15-1060 REPAIR/REPLACE INSPECTIONAL SERVICES
1 2015 OCT -2 A 11: 31 1
The Commonwealth of Massachusetts D
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Department of Public Sa(ety MassachumitsStateBuilding Code 780CMR
Q Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Only)
1^ Budding Permit Number: Date Applied: Z Building Official:
tJ / "Building
1:LOCATION(Please indicate Block#an Lot#for Iocallons for which a street address is not available)
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City/Town Zip Code Name of Building(if applicable)
I SECTION 2 PROPOSED WORK
te Code used_ If New Construction check here❑or check a6 that apply in the two rows below
❑ Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No IC
Is an Iru ependentStructural Engincerin Per Review required? I Yes ❑ No ❑
Brigf��ription of Proposed Work
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor.(.sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTIONS.,USE CROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business Q E: Educational ❑
F. Facto F-1❑ F2❑ - H: Hi h Merc Hazard H-1❑. H-2❑ H-3 ❑ H-4❑ H-5 El
1: Institutional 1-1 Cl 1-2❑ 1-3❑ ❑14 M: antile O R: Residential R-1❑ R-2❑ R-3 O R4❑
S: Storage S-1 ❑ - S-2❑ U: Utility❑ Special Use❑and please describe below.'
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licabie)
IA ❑ IB ❑ IIA ❑ 1111 ❑ lit\ ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check.'(outside Flood Zune❑ Indicate municipal❑ A trench will not be
required O or trench or specify:
Private❑ or indentify,Zune: or on site system❑ permit is enclosed❑
Railroad right-of-way: 11"ards to Air Navigation: NIA I listorf< e.r.l'n,:gq<:
Not Applicable t5- Is Structure within airport roach area? Is their review completed7 rr
or Consent to Budd enclosed❑ Yes❑ or Nuap Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Coda: Use Group(s): Type of Construction: (kcupaut Load per Flour:
Does the building contain ar Sprinkler System?: _ - Special Stipulations:
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SECTION 9., PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
(Y1-5 5m,A- 212 Wt5'" Sale. MA iq R
Name(Print) No.and Street - City/Town Zip
Property Owner Contact Information:
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Title Telephone No. (business) Telephone No. (cell) mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and or not tinder Construction Control then check here O and skip Section 10.1
10.1Registered Professional Responsible for Construction Control
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( 06 ' S �a�(C¢/ 3J&- YX 4 1 f S c5Wn)(C".340 I- C5-.yyf-koo
Name(Registrant) Telephone�.10. mail address Registration Nmnber
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Street Addrss City/Town State Zip Discipline Expirf Lion ate
10.2 General Contractor
�ro Ma�49 otie ti�
Com " Name
OP.,/ Goo
Name of Person Responsible for Construction License No. and Type if Applicable
9' w, ( d r, .s i -�e�T P" C k-b h /1 e-23 C I
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:FVORKER.S'COM PENSA LION INSURANCE AFYIUAVII' M.C.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes M No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor - 30 r7
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ vo '�
Building Permit Fee=Total Construction Cost�(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost 5 Dc, (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 Yowledge and understanding.
Please print and sign name Title Telephone No. Date
R WE 1�-0d SdrFEY
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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Date: October 2, 2015
Invoice # [13098] '
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Pro-Management Design and Construction TO: Tristan Smith
43 Village Road 282 Washington St
Raynham, MA 02767 Salem MA
Phone: 508-944-6115 Phone: 9784068808
Fax 508-584-0988 Customer ID
Email: cswalker3@comcast.net 282Wash
I
SALESPERSON JOB .i PAYMENTTFRMS DUG DATE
i
Carl Reframe and repair wall with sheetrock Due on Receipt 10/1/2015
... ,._ANT UNIT PRICE SUPPLIES
I QUITY DESCRIPTION LABOR COST LINE TOTAL
Flat rate
1 Refra me and repair wall with 'h"sheetrock $300.00 $300.00
I
Permit $50.00 $50.00
Subtotal $350.00
Total $350.00
I
Make all checks payable to: Pro-Management Design and Construction
We warranty our work for a period of one year from the date of substantial completion.
Thank you for your business.
li Massachusetts -Department of Public Safety
`-` Board of Building Regulations and Standards
t Lastrucuon,wpert i,at.
License: CS-086600
11
CARL S WALKED '
8 WILDER ST *,
• BROCKTON iylA
s
Expiration
Commissioner 01/13/2016
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991m)of
i enclosed space.
Failure to possess a current edition of the Massachusetts
i( State Building Code is cause for revocation of this license. +
1 For DPS www.Mass.Gov/DPS
Licensing information visit:
1t
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
I..
Home Improvement Contractor Registration
Registration: 146306
Type: Individual
Expiration: 4/12/2017 - Tr# 262968
CARL S. WALKER III : sx�
CARL WALKER ; )
8 WILDER ST '§ �= s
BROCKTON, MA 02301 � "Update Address and return.card.Mark reason for change.
SCA 1 C� 20M�a`.J11 Address [-j Renewal Employment Lost Card
�e�manneoazarea�llc o�0'd�rrau�c�r�edeCGi -.,--•-�--.-•.� .. _�.-- -
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
E IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistra0on r145306 Type: Office of Consumer Affairs and Business Regulation
erxpiration 4/12/2017 Individual 10 Park Plaza-Suite 5170
1 Boston,MA 02116
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CARL S.WALKER I 1 gip-
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CARL WALKER
8 WILDER ST ":..f ::;y. '+r' _\L..c-z•i•{,�.-.._
BROCKTON,MA 02301 Uadcrsccrctary Not Wd w(tDadf signature
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