134 OCEAN AVE W - BUILDING INSPECTION OF
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY M
\
Massachusetts State Building Code,780 CMR SALERevised Mar 2011
/ Building Permit Application To Construct, Repair, Renovate Or Demo ish a
One-or Two-Family Dwelling ButldingPermttNuinber�r
L. . ... �'SECIFON lF SITE.INFORM41x 1r � � x t
1.1 Property Address: 1.2 Assessors ap&Parcel Numbers
13q p eig dt/e We-s i
1.1 a Is this an accepted street?yes V, 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(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 00,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
Sl C �01v 2 ,g1t0 RT `6PCNEI2S�'sw
2..1/OwnerrofRecord: _ /! _ � 26)
\>(/ Name(Print) City,State,ZIP
I'� h--Lx3�S r
o.and Street Telephone Email Address
r , SECTION 3D1 SCY2IPION Ok PZtOEOSDMOIZT{ �check all that apl }
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : .v N
'e,
SFCTION4 ES ITMAPED CtLVSTi1 C TIOk COS CS � �� z T
Estimated Costs:
Item Labor and Materials � ,. Officta ?TTse�nl ? *
S F af. § { XLr 1 9'
1. Building $ ed
1 Build iigPerree $ � rdreate hod fee�sfidetermmed
$tuafd �tp oyyn phcafionFe t�
2.Electrical $ �� � �s; 's,�`�*• �,�>` "� �„ � z = . I
3.Plumbing $ � �ber }ae
r' Lsf"4
4. Mechanical (HVAC) $ s
5. Mechanical (Fire � � �
Suppression) $ I
Oheok o �CleckomC"ash Amount
6. Total Project Cost: $ x;
O���• �❑Fa�rd rn�ull �, �Ouc�tandmg�alance Due�, , r, ���,;,,
T
i
SECTION5 CONSTRUCTION SERVICES"
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street Type = n - • Description'
U Unrestricted(Buildings u 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
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contrac •(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant N e
No.and Street Email address
City/Town, State,ZIP Telephone
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 .......... Cl No ........... ❑
SECTIONS 7a: OWNER ATTTHORIZArIONTO`BE COMPLETED
OWNER'S AGENT'OR CONTRACTOR APPLIES FOR BULLDING 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.
Print Owner's Name(Electronic Signature) 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
containe is application is t e d cc to to the best of my knowledge and understanddiinng.
/
Prin wner's or Auth e Agent's Name(Electronic Signature) Date
z- " ,NOTES: �:_x _ ,,
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.inass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov;'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 heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.UYEN(
PUBLIC PROPERTY
DEPART:,iENT
u.o.aas+ro•ura�i
Varese t�v�o.rr.-roM l►.aa•s�u�y wa,.oauns m f-o
TIM 9'6745-95"•FAX f7a7469646
HOMEOWNER LICENSE EXE.MMON
Pfew "I
Date
Jots Loeatios /'R y 0CPl�i iC) ffc/� G��s i
Home Owner Address , t"
Home Owner Telephone V2 - -? V! - 5.T73 3
Presort Mailing Address S/:V~
The cunvnt exemption of"Homeowners"was extended to include owner-occupied
dwellings ottwo Units or lees and to allow such homeowners to cupp an individual for
hire who doe not possess a license;provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Ptason(a)who owns a parcel otland on which hdshe reside or Intends to reside6 on
which there is, or is intended to bq,a one or two firmly dwelling, attached or detached
structures accessory to such use and/or farm strtsctutva A person who constructs more
than on@ home in a two year period shall not be considered a homeowner. Such
"homeownd'shall submit to the Building Official,on a form acceptable to the Building
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 uirementt
HOMEOWNERS SIGNATLRE
APPROVAL OF SUILDENG NSPECTOR
See other side far state code
CITY OF S.U�EM, NWSACHLSETTS
• BUIMNG DEPARTMENT
N 130 WASI-INGTON STREET, 3" FLOOR
TEL (978) 745-9595
FA.r(978) 740-9846
Kl.%,tBFRt RY DRISCOLL
MAYOR DIRECTOR
ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COJL\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.
The Idebri's/wiill be transported by:
/UCH Q` &
(name of hauler)
The debris will be disposed of.in :
(name of facility)
(address of facility)
signature of permit applicant
date
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