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134 OCEAN AVE W - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Buildin g Code. 780 CMR, 7 edition OF SALEM Neri�rd Jmnnvv Building Permit Application To Construct, Repair. Renovate Or Demolish a One-or Two-Family Dwelling r This StctW For Official Use Onl Building Permit Nu ber. D r Signature: Buildin Cummissi /Inspmlw of Buil (}ate SECTI I:SITE INFORMATION 1.1 Property Address: 1.2 Assesso Map A Parcel Numbers J a y LXC!e1 tl � ZA-,eS r //n yd I.la Is this an aece ted streal?yes ' no IMAPNumbei Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: A P9S" 6ff Zoning District Propose)Use Lot vAm(sq 11) Frontage(11) 1.5 Building Setbacks(R) From 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 Pri,wc O Zone: _ Outside FI ?Cheek if Munieipal On site disposal system O es SECTION2: PROPERTY OWNERSHIP' 2.1 Ow r1 of Record: e,yiN Nome(Prim) Address fa Service: l— �.�-Z,/ g�� 7. �v�s s ���/9� '�3 Signature Telephone SECTION l: DESCRIPTION OF PROPOSED WORKr(check all that apply) New Construction O Existing BuildinfIx I OwgWOccupied XRepairs(s) 0 1 Alteration(s)YJ Addition Demolition -_A_ccessory Bld "Number of Unib 1. I Other O Specify: Brief Description of Proposed Work': _ a � AJS -/ r�svc� r N<t 2r) SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building is 300dQ 1. Building Permit Fee: S Indicate how fee is determined: 2. Electrical $ O Standard City/Town Application Fee O Total Project Costs(Item 6)x multiplier x 1. Plumbing S s©C� 2. Other Fen: S 4. Mechanical (NVAC) s />` List: 5. Mechanical lFire S � � Suppression) / Total All Fees:s Check No. Check Amount: Cash Amount: 6. Total Protect Cost: Sp Paid in Full 0 Outstanding Balance Due: r SECTION S: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) License Number Expiration Iyute N,mc of CSI.- Ituldcr List CSL type(saebelow) r Description \JJress U Cinmiricted u to JS,000 Cu.Ft. R Restricted IA2 Famil Dwellin Signature M M' Onl 1 RC Residential Routin C'overin I"elcphone WS Residential Window and Siding SF Residential Solid fuel Burning A liacee Installation D ResirkmiW Demolition 3.2 Registered Home Improvement Contractor(HIC) f IIC Cumpany Name or IIIC Registrant Name Registration Number Address Expiration Date Signature 'lrleplxare SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL f 25C(Q) Workers Compensation Insurance stTtdavit 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 ..........O No...........O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 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. Siwwurcofowner Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION rbehalE ,as Owner or Authorized Agent hereby declare and information on the foregoing application are we and accurate,to the best of my knowledge and Signature of(honer or Authorized Agent Data Si under the nuns and realties ofperjury) NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nol registered in the Home improvement Contractor IHIC)Program),will rig have access to the arbitration program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I0.R6 and I WAS, respectively. 2. When substantial work is planned,provide the information below: - Total floors area(Sq.Ft.) (including garage, finished basemenUanics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Numtxr orftreplaees Number of bedrooms Number of bathrooms Number of half/baths Type of healing system Number of decks/porches Type of cooling system Enclosed Open ). "Total Project Square Footage"may be substituted for-Total Project Cost" I i I I i i I 1 � J I REFERENCE -' - PLOT PLAN OF LAND LIFEii: REC. BK. PG. `ri _� PLAN: r'r ;. i; oc; f* � LOCATED IN I _'ERTIFY THAT THE BUILDING(S) �} L �/_Y HERFO,N ARE LOCATED ON THE GPOUN,9 A^ .-HOWN. rr _ . . r . ; •_, ;. PREPARED FOR it G. PROFESSIONAL LAND SURV SCALE_: 1 1 = 3! O T - 4 191 > V&jGLIL 051 o G—` NORTH SHORE SURVEY CORP. 09 WASHINGTON ST. - SALEM MA. SMITH :o No.330{3 0. 9 O o OFF F ss/0A'AL LAND SDI \ CITY OF SALEM .y a !i PUBLIC PROPRERTY DEPARTMENT 1111i II I20 Vf.\.ii II\G'1'ilN 5 f1<EFT * S.\I F.M. fit.\tii:\t.l It 'if.I I)V) 'fri:978-7Ji.9i95 ♦ FAX:978.74C,9846 Construction Debris Disposal Affidavit (required lur 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 N 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 I50A. The debris wiI I be transported by: jaLk J I.t)i S7�, (name of hauler) The debris will be disposed of in (name of faci ity) (address of facility) signature of{xnnit applicant Z z-'o date — ,Irlui+mi .,< CITY OF S.U.E.Ni PUBLIC PROPERTY DEPARTMENT w,a.a.stt wernu Vwroa I.VwADQMGW 1ltMW 9&RACK VAUAAILMM019.0 T11L 97L70-9599 9 F.ut 976.7469W HOMEOWNER LICENSE EXE.MMON Pfesse Enure Do@ ✓/d Job l,wAdos 13 �f�ic/ fh/z✓ E'si Home Owner Address L"5X0C-e—e17L1T Home Owner?elephone 7S/Y SS 33 7�/r/�33�/ �97�375 636 Present Mailing Address j,35t� GLe.4.t1 /fE& _ / The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire who,does not possess a license provided that the owner acts as supervisor. DEFINMON OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or Was structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "lameowner'sW submit to the BuildingOfficial,on a form table to the Building acceptable g Official, that he/she be responsible for all such work performed under the Building Permit The undersigned"homeowner'assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and Wquirements. HOMEOWNERS SIGNAM APPROVAL OF BUILDING CiSPECTOR See other side for state code CITY OF SALEM PUBLIC PROPRERTY ` DEPARTMENT .1,11:1 Nl 1'Y:)KM:s't I. \LNl tN 1 2�_WMI-ONsi I ON 5 i xELT • 5,\t ti M, MA SAO 11 SE I IN G1970 1l•.1.,978-7 3-9595 a 1'.vx. ,J73.74C-Ix46 Workers' Compensation Insurance At'17davit: Builders/Contractors/Electricians/Plumbers li y llicant information Please Print Le ihl Naine(aucuuath8aniratinrj✓I ndlvuluul): t G ,lddress:,Z City,Starci%ip:s �llt�! 0/970Monci': \re you an employer? Check the appropriate box: 'Type of project(required): I.PfI am a employer with 4. ❑ w I n a gen eral contractor and t G. ❑ New construction employces(full und/ur purt-time). have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. �RemoJeling ship and have no employees These sub-contractors have S. ❑ Demolirion working fior me in any capacity. workers' comp. insurance. 9. ❑ Building addition l No workers'comp. insurance 5. ❑ We are it corporation and its required.] otliccrs have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. (No workers' comp. c. 152, §I(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] -Ally ap phcasa Chet chucks box ill must alsu Jill out the vctiun hcluw slowing Choir workui cumpensusion Indiry iufurnutium ' I lumeownen who submit this affldavir indicating lhcy,are doing all work and don him oulside cumrxtors must suhmis a new afrdavil indi"ing%rich. -C'nnwscmrs that chuck this box must auchul.m addiliunai.,heal showing the name of the subromraaors and their workers'amp.rxshcy infumarion. l airr an employer that Is providing workers'c ompen.sadon insurance for my employees. Below is the policy and Jub site infonautiom Iruuraucc Company Name: __.... '_.-------.----.-- Policy Js or Sclf-ins. Lic. 0: .. _ .._ Expiration Date: Job Sitc ,iddress: _ C'ity;Stare/Zip: Attach It copy of the workers' compensation policy declaration pale (showing the policy number and expiration date). Failure by sccurc coverage as required under Sectiun 25A ul'>IGL c. 152 call lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprisoumcnt, as well as civil penalties in the furor of a STOP WORK ORDER and a fine of up to S250.00 N day aguinst the violator. He advised that a copy of this statement may be lurwarded to the OQice of Invesnguunns ul'thc UTA for insurance coveragu verification. l rlM herc•hy certif Muller the saisr. rr ies 'ury that the information provider/`above is true and correct. tii��:cuure' Bat^ 6: Official use only. Do star Ivrite in this area,to be completed by city or town official. I (.'ily or fn,vn: Pcrmit/l.iceme 0 hsuing,\ulhurily (circle one): _ _ - I. hoard of Ilvalth 2. Iuilding Ihpartutcut .3. Cilyi fowM Clerk 4. Liectrical Inspector 5• Plumbing Inspector b. Other L""bast Person: Phone Y: Information and Instructions ,lass.rchu,etts Gencral Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express Or implied, oral or written." An elnpluper is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more ,,r the tOregoing engaged in ajoint enterprise.and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,piumership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." `IGL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any :applicant who has not produced acceptable evidence:of,compliaace with the insurance coverage required." Additionally, hIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of connpliunce with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. if an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for continuation of insurance coverage. Also be sure to sign and duce the affidavit. The affidavit should he retumed to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain u workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate tine. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. 111zase be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pennio'license applications in any given year,need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address" the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new alfdavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he t)Ihce ul Investigations would like to thank YOU in advance fur your cooperation and Should YOU have any questions, l lea,e do nut hesitate to give us a call. The Ucparunent's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 -rel. k 617-727-4900 ext 406 or I-877-MASSAFE Fax # 617-727-7749 R.vi,cd i-26-05 www,mass.gov/dia