136 OCEAN AVE W - BUILDING INSPECTION (2) The Conuuom%ealth of NIaSSIIChUSetI.S
Bouid of Budding RcgulationS :111d Standards
,�, \IIVII'll'.\I.fil '
t. 9 Massachusetts State Building Code. 780 CNIR. 7 edition til[
Buildin_ Permu Application To C011SI ICt. Repair, Renosate Or Dc'nolish a R, d Amit:;n
— p)le- or Fits -1-*(I tilr Dvrlling 1, iris
'phis Section For Ofticial Use Only.
Buildings Permi N mhcr. r Dote applied: 0 CJ
Bill thug C'ununn.ioned liupei nx of 13uddines DutySEC] [ON 1: SIT(: INFORMATION —
Ll Property Address: 1.2 :Assessors Nlap & Parcel Numbers
I.I;t Is this an accepted sutet yes_ nu__ ::Alap\unihcr P:urrl :\'umhcr --
1.3 "Zoning Information: 1_4 Property Dimensions:
Zonis-' D110i❑ Proposed Use Lot Area(sy It) Fnn!ta,,e (Ill
1.5 Building Setbacks (ft)
j Front Yard Side Yard., Rear Yard
! Rcyuired Provided Required Pruci Jed Required Pis),Jed
I
1.6 Water Supply: 0.1 G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone! Municipal ❑ On site disposal +y,ten ❑
Public ❑ Pri%ate❑ Cheek if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O v er'of Record: n eo /� I / vapqo /)(0 WeS
Nwnc(Print) Address tor Service:
�Z�� 6 0 I, -
SWIlatnre Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Emy ng Building ❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
r6 p - ray�,KDQ If
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item
(Labor and Materials)
I. BwlJing S - I. Building Permit Fee: S_�Z r
Indicate hut% fee is deter
St:mdard Cityfl own Application Fee
?. ElectricalS ❑Total Ploject Cost (Item 6) .r multiplier .% _
I
1. Plumbing -. Other Fecs: 'S
.l. Mechanical IHVAC) b List: ----
i. Mechanical (Fire 5
Su��rcminnl Total :AII Fees: 'S
Cheek No. __Cheek :Amount ('doh AM()Llrt
j 0. ToUd Project Cost: S aid in full ❑ Outst:mdin�' BaltmeC
J
SECTION 5: CONSTRUCTION SERVICES
5.1 1 i eased Construction Su ervisor(CSI.) Y
License Nunibcr Fxpinawn Date
N:une of CyS"L- Jdy1 n sI CSL T%pe (see below) _
Descri loon
f t,IIrC5(Ileled III l IU 35,t 1t 1O(�n. FIJ
R Re.uictcd .2 Fanuh D,�cllinc
gmtnrecS
RC Rr>idenual IL ndine Cosrn ne
Telephone A1'S Residenu:d Wmd, ,ind Si.linp __
SP Rcsidrnual SuliJ Furl Burninc 1Lhh.inee lu.tallam ni
D Rcbidcuu:t Drnwhu"n
5.2 Kegisti�edomeiWrpycnent 'un[,r nctu 27 6yr
HIC mirrn�zu eor Reentrant Name R>eeulruur/n Num irr
F..vpuauun D:LLc
Signature
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25CI6))
Workers Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... ❑ No ........... ❑
SECTION 7a: 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.
Sienamre of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 v L G as Owner or Authorized Agent hereby declare
that the statements and infor ation on the foregoing application are true and accurate, to the best of my knowled`g,'e and
beha r
✓ �� G/
Print Name
Sienature of Owner or Authorized Agent Date
(Signed under the dins and penalties of eQtn))
NOTES:
1. An Owner who obtains a building permit to do his/her own souk, or an owner who hires an unregiSlered Contractor
(not registered in the Home Improvement Contractor (HIC) program), will nnt have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important infnnnmion on the HIC Proeram :tnd
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5. respectively.
_'. When substantial work is planned, provide the information below:
Total floors area (Sq; Ft.) (including garage, finished bnsemenl/uoks, decks nr pnrchl
Gross living area (Sq. Ft.) Habitable room count
Number of rirrplaces Number of bedroom.
Number of bathrooms Number of hal —
fvpc of heating System Number of Icck,l porches
l ype of cooling system L`ncloscd Upen
1, "Total project Square Footage" may be xtbstituted lot -total Project Co,(-
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\[A:� 'lt I'� \t �sl it N,�f��]1,;t Ltl • �.\i:-\1, \[\�iq, II. ii I i _1'1--
v'y-?i;_•t;,t; • F vs, v-g.74.-'%8a6
NN'orkers' Compensation Insurance Aflid at,it: Builders/Contrastors/Electricians/Plumbers
> tlicant Information Please Print Leaibl
Name t lt,r un•s ttrgdnl<an��lt li,d,v•�lu,ll:
\ddre,s: //J7
City,Statellip 6 —%//�> J Z, Phone:
Are ou an eployer:' Check the appropriate b
m F,]' Type of project (required):
I. I :un a cmployer with - 4.0KI ani a general contractor and 1 6. ❑ New construction
employees (full andlor part-tinlc).' have hired the sub-contractors
1 ❑m a sole proprietor or partner- listed on the attached sheet.
7. ❑ Remodeling
These sub-contractors have 8. ❑ Denutlilion
ship :Ind have no employees
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' comp. insurance 5, ❑ We are it corporation and its 10.0 Electrical repairs or additions
reyuircd.J officers have exercised their
right of exemption per MC,L I I.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work c ght o 1(4), and we have no �.
myself. [No workers' comp. I_ ❑ Roof repairs
insurance required.] employees. [No workers' I3.❑ Other
comp. Insurance required.]
•;\„y,,pplica,u,hat checks box RI nuut also till cut the section below showing their workers'compensation policy info miaiion.
' I Ionn•Owners who suhmir this affidavit indicating they:ue doing all work and then hire Outside contractors must submit a new affidavit indicating such.
$'nntractury that check,his box nmst attached an addiuunal sheet showing the name of the sub-cuntractnrs and their workers'comp. policy information
I am an employer that is providing workers'compensull.un 'r.surunce forU1,
loyees. Below is the policy and job site
injurnration. ,rt l — Jnlf-Insurance ('ompany Name: V/ / v
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site .Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure co\erage as required under Section 25A of,INIGL c. 152 can lead to the imposition of criminal penalties of a
line op to SI,S00,00 and/or one-year imprisonment, as well as civil penalties in the torm of it STOP WORK ORDER and a fine
to S250.00 a d:ry against the violator. Ile advised that a copy of this statement may be tiliwarded to the Office of
Im-csti_;uions o(Ihc DIA tit insurance c)\crage Oct flcalion.
I do hereby rrrri/i' under the pubo cord pec�c%_i!C.ry=r' hat the itiprmation prueided uboce is true and cr next.
t� Date:
1p_n.lture:
ojjh iul use onlr, no nut write in this area, to be c'onnpleted by city jr loon official
(Cin or
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. 01lter ---- _- --
Contact Person: --- —_.—.----- Phone #:
Information and Instructions
\Ia S>aC h l a to t is General Laces chapter I>' rcqu it" all entp lo%crs to pros ide workers' annpensat ion fix their cliff plo)ces.
Pursuant to this statute. .all rnyrL!rce is detin.cd as cycr% person in the Scn ice of another under anv contract of hire,
c�press or implied. oral or
\n einplorer is defined as "an ind:�:dual. pa rntrrship. ;association, corporation or other legal entity. or any two or more
,,(rile lolcgoing engaged in ajoint enterprise, and including the legal repre>ell(a I es of a deceased employer. or the
recei%cr or u-u f stce o an individual, purtncr.hip, association or other Icgal entity, cntploy ing employees. l loweyer the
o•,�Let- ordw
elling house having not ;pore than three apartments and who res:des therein. or the occupant of the
J��elling house of another w% ho employs persons to do maintenance, construction or repair work on Such dwelling house
or on the _rounds or building appurtenant thereto shall not because of 9UCI7 employment be deemed to be an emplo}tlr."
\IGL chapter 15_', �25C(6) also states that "every state or local licensing agency shalt 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 compliance with the insurance coverage required."
Wditionally, NIGL chapter 152 �25C(7) states 'NviQter the commonwealth nor any ofits political subdivisions shall
enter into any contract for die performance of public work until acceptable ec idence of compliance with the insurance
requircmentS of this chapter Mace 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) mmne(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 attidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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 a 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 line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of nhe affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please he sure to fill in the permitilicense number which will be used as a reference number. In addition, an applicant -
that must Submit multiple permit/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. r\ new affidavit 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. a Jog license or permit to burn leaves etc.) said person is \'oT required to complete this attidavit.
The Office of Investigations would like to thank you in adwncc for your cooperation and should you Race any questions,
please do not hesitate to vice us a call.
I he I)cpartnrnnt's address, telephone and F,tx number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oftace of Investigations
600 Washington Street
Boston, MA 02111
Tel. 0 617-727-4900 ext 406 or 1-877-MASSAFE
I(cciscd 5-_'6-t)5 Fax it 617-727-7749
www.mass.gov/dia
136 OCEAN AVENUE WEST 928-08
Gs# s7a6 ; . COMMONWEALTH OF MASSACHUSETTS
Map 24 ,
Block:
CITY OF SALEM
Lot: , �0139
Category ,. REPABt REPLACE
BUILDING PERMIT
Project# 7S 2008-001489
Est Cost: $0.00
Fee Charged: $20.00 ,
Balance Due: $.00 PERMISSIONIS HEREBY GRANTED TO:
Const. Class: on
License: Expires:
Use Group: .. r ..m J;p C.Castle STATE-054882
Lot Size(sq.ft.): 8049.888
Zoning: R2
Owner. PAGLIARO MELISSA,PAGLIARO ROBERT
Units Gained: Applicant: A-.C.Castle
Units Lost:.. AT. 136 OCEAN AVENUE WEST
Dig Safe#:
ISSUED ON. 17-Apr-2008 AMENDED ON: EXPIRES ON. 17-Sep-2008
TO PERFORM THE FOLLOWING WORK:
RUBBER ROOF REPAIR NO CHARGE jhb
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# - Smoke:
Water. Alarm:
Assessor Treasury:
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2008-001890 17-Apr-08 cash $20.00
GeoTMS®2011 Des Lauriers Municipal Solutions,Inc.