11 FORRESTER ST - BUILDING INSPECTION e. r
I'he C'umntumccalth of Iblussarhusdls
Board of Building Regulations and Standards C'I'1"1 OF
\Ma s) ssachusetts State Building Codc, 7SO C NIR S,\Ll:xf
Building Permit Application To Construct, Repair. Renovate Or Demolish u
011e-or Tn•o-fiuniA• Dtv dlill.V
This Section For Olfieial Uss;Onl
Building Permit Number: Date,\pplied: _
lull tiny 011icial(Pnnl wnc)
Signature Uotc
SECTION I:SITE INFORAIATION
1.1 Property Address: 1.2 Assessors Alep dt Parcel Numbers
1 Vw_ 2a e W 6t
I.la Is this an accepted street? es no Map Numhcr Purcel Numhcr
1.3 Zoning Information: 1.4 Property Dimensions:
/.oning District IrmposcJ tlsc Lot Area(sq II) frontage(Ill
1.1 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
e
1.6 Water Supply:(M.G.1.c.40.§Sq) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Iirblic❑ Private❑ Zone: _ Outside Flood Zone?
Check ifaC Municipal❑ On site disposal s)stem Cl
SECTION3: PROPERTY OWNERSHIP'
1.1 Owner'of Record; \ ��
nnt) t� City..Si I Z P
1 �treet a st
No.and Street clephune 3 a�hmuil AJdrcssAJdnas
SECTION]: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupie11 d ❑11 IN, I sU) ❑ Alteratk n(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specily:
Brief De iption of Proposed Work=:
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
((.ahor and.\laaerials) OMNI Use Only
1. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Flectrical S O Slandard City.•Tuan Application Fee
7 I'hunMng S ❑Total Project Cost'(liens 6)x multiplier -
_. Other Fees: S
J, Mccli.utical ill\ W) i List:
I Stw ue>sion) S - total .\II Fccs: S
G� r. l'utal Prn)jcct Cusl: i
❑P.)id m Full ❑Oulstandiog Bal.ulce Duc:
SECTIONS: CONSI'Mi rION SEHVI('BA
{ 'unstructimt Supcn'isor License iCSl.I /�
r'-- 1 Ic`�i I' Nuntcr I �pir;nim Urn¢
N,m 'alt'SI. Ilollde�r ) Q � Ilill'SI. I')Itelsecheival,__v
PA,.--'--- I)PC I)cicripliun
J strca U 14ncitrictcd I I)uildin s It' to 3!1.0 IU al. 11)
Kcatri.hJ Ia•_' P.Imil Dllcllin
klasoll
Cigt fanil.\Lie,LIP KC Kman covcrin
µ'$ duNv,Lnd Sdin
SF Solid fuel Homing,tpplialiccll
Iniululiun
a "C C ! 14nuil a11Jrc+s D Dcmoliliun
'I'ele belle d
S, egl red ume I gsruv'ement Cuntntctar(HIC)
IIIC' I egi9ratiao mlhcr Ifvpinllion Date
IIIC 'oil it Nat a or I ' (• hunt m
1, 1 J IiIT111faJJross
ci /Town,state --
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C. 163.1 3SCM)
Worken 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 ..........(3 No.........
SECTION ?a N
:OWER AUTHORIZATION TO BE COMPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
-Prin Ulmcr's Nwne(Elcelrunic Signulurl
SECTION 10;OWNERI OR AUTHORIZED AGENT DECLARATION
By entering Iny name below, 1 hereby attest under the pains and penalties of perjury that all of the information
d
co tain ' t is a plicati Is true and accurate to the best of my knowledge and understanding.G —(h . /Dow
I'ril )wlleisa nthoriieJ,\Lent'.+,Mile llilactrunic.............. iynaUeo)
NOTES:
I. ,fin Oaner Nvhu obtains a building permit to do his.her own work,or an owner who hires an unregistered cunirador
uwt registered in the Hunle Improvement Cuntractur I H ICI Program).Neill nu have access to the arbitration
program or guaranty t'uld unJcr M.G.L. e. I 4'_A.Other impurtant information on the HIC Program can be round m
�Nwa il,,l,. �„ ,•, I Informutiun un the Construction Supervisor License can be found at",N`� �lll`° >" 'IP`
+, \Phan substantial work is pl:nmeJ,provide the inl'u1 includition n garage. finished basement attic.Jerks or por0i)
rota) iluur arc.,liy Il.) . _---"— g g' b
Habitable/Mont count
(in,i; liNingMrealiy. 11.l _._.. ,umhcrufbeJnxnns
1 \unlbcrol'lireplaecs .. ... ._ .. —_ \unlbcrulhalfhaths .. .. .. . .
\unlhcral'hmhnwltls , , - . . \unlheral'Jecki- parches
I\pe of llc.ltlllg iN itelll I�ncldicd (ll,en
i
l\l+e ✓f�pP1111g iN ilelll
l'rolvGt tiyllare I'd,Llye 111;1N be .uh,tiuncJ for"I',n,ll l'rnfdel
CITY OF SM.&N4 N-LkSSACHLSEM
BLELDLNG DEPARTJtENT
a 120 WASHINGTON STREET,Ste FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYORTHOMAS ST.F[ERRS
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG CONMEWIONER
Workers' Compensation Insurance Affidavit: BuildersJContractors/ElectriciarWPlumbers
.Applicant Information Please Print Legibly
Name(BusincssOrganizalion/IndividualT
Address: n V I A�
City/State/Zip: �' v/-,o.-SS Phone 4: 7 $ Y 1�3�5 J
Are you an an employer?Cheek the appropriate box: Type of project(required):
1.4st'r arts a employer with 1.�=— 4. ❑ I am a general contractor and 1 ❑
employees(full and/or pan-time).
have hired the sub-comrzctors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employee These subcontractors have 8. ❑Demolition
working for me in any capacity. workers'camp.insurance. 9. ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers;have exercised their
3.® I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees. [No workers' 13.❑Other
comp.insurance required.]
'Any applicara that checks bra[Nt must also fi0 wt the scrim bclnw showing their worker•oarlDmtation policy infotnatioa
'ttnmeowrt0a who submit this affidavit indicating they are doing all work and then hire outside contmcom most submit a xv affidavit Wk nirtg etch.
{ontmt.Yon that check this box moat anachod an aWitiotul shxt showing the name of she n,b.eova..t.and their wo*m'comp,policy informadm.
l am an einployer that is providing workers'compenawlan insurance for my employees. Below is the pollty and fob site
Insurance Company
Insurance Company Name:
Policy#or Selbins.Lia#:"w C S �3 [Expiration Date:
Job Site Address: City/Statrizip:
Attach a copy of the workers'Compensation policy declaration page(showing the policy number and expiration[late).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1,300.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Invesligatiuns of the DIA for insurance coverage verification.
l do hereby rill d the ins and penaldes of perjury that the information provided a#ove is re and tarred
SiLnilture' )l Date: U
Phtme#: `3Z X `�44 Nam)
Officiaf use only. Do not write in this are%to he completed by city or towa off ciaL
City or Torn: Permit/I,leense#
Issuing Authority(circle one):
1. Board of lleallh 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6,Other
LM INSURANCE CORPORATION
P.O. Box 9090
Dover NH 03821-9090
LibertX Telephone: (800)653-7893
Mutu • Fax:(603)334-8162
Email: MISQLibertyMutual.com
September 6, 2012
PAUL NELSON DBA NELSON GENERAL CONTRACTING
108 WOODSIDE RD
HARVARD MA 01451
RE:WORKERS COMPENSATION INSURANCE
Insured: PAUL NELSON DBA NELSON GENERAL CONTRACTING
Policy Number: WC5-31S-323334-012
Effective Date: August 25, 2012
Dear Insured:
This confirms that as of the date of this letter, the above named entity PAUL NELSON DBA NELSON
GENERAL CONTRACTING 108 WOODSIDE RD HARVARD,MA 01451 has a valid workers compensation
policy,with coverage for the state of MA,effective from 08/25/2012 through 08/25/2013. The policy number
for this coverage is WC5-31S-323334-012.
Sincerely,
Debbie Derochemont
Commercial Service Operations
cc: EASTERN INSURANCE GROUP LLC
OT �o, na�u� ✓Gf
Office of Consumer Affairs&Business Regulation -
gHOME IMPROVEMENT CONTRACTOR
Registration 4111064 Type:
Expiration 1:1125/2012 DBA
PA L J NELSON GE ERAL CONTRACTING
PAUL NELSON
108 WOODSIDE RD `� ==a
HARVARD,MA 014511- ^>-
- '% Undersecretary
r
Massachusetts- Department of Public Safety
Board of Building Regulations anti Standards
Construction Supervisor License _
License: CS 36617
Restricted to: 00
PAULJ NELSON
r
108 WOODSIDE RD
HARVARD, MA 01451 g
Expiration: 3Y2J2012 C
('.mm�issi„nrr Tr#: 18441 E
CITY OF SALEM, N.LksSACHLSETTS
• BUIMLNG DEPARTU&NT
N 130 WASHINGTON STREET, 3nD FLOOR
"�•� T FL (978) 745-9595
FAX(978) 740-9M
KIN{gFRT FY RISCOLL
MAYORF- D DR THOAAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BU;ILDNG CO`L\IISSIONER
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.
Th ebris will be transported by:
(narric of hauler)
The debris will be disposed of in :
(name of facility)
_ �S-T C am-\�
(address of facility)
signature o ermit applicant
date
Jcbri>aif,Jce