136 OCEAN AVE W - BUILDING INSPECTION (3) .r
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--- I'lie C'onununwcallh ul M;usachuselts
(hoard ul Iluilding Regulations and Standards Cl l'1' of
1 61dinsp0c
Massachusetts State-Building C'ude. M C NIRSALli.11 lding Pcnnil Applicatiun 'fo Construct Repair. Renovate Or Demolish a
Um'-ur rtcn-Fuuull D%vvllin.Y
This Section Fur 011icial Use OnlNumber: Uateappliedl�'TIZ2�+��CilPrint Nwncl Signature Dutc
SECTION 1:SITE INFORMATION
1.1 Property Address: / 1.2 Assess-.Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Numhcr Parcel Nundxr
- • 1.3 Zoning Information: - 1.4 Property Dimensions.
Luninp District 11ropowd ilia • LoArco(sq 11) Frontage(11)
1.3 Building Setbecke(R)
From Yard Side Yams Rear Ya d
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Informal oat 1.3 Sewage Disposal System:
Ihrblic O .Privutc O Zone: Outside Flood Zone?Check if yc 0 Municipal O On site disposal s)srcm O
SECTIONS: PROPERTY OWNERSHIP'
2.1 Owners of Record:
ls7.t�f�54 17AG dA�� �i> t fs N i sSesGfu� t 4 z�147
Muna(Print) City.State.ZIP
il3& D�r-aN Ave, (c r 978.)4'o.4 1,1Lrn lf) .
No.and Street retephune Emuil Address ��y[
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction(3 E.risting Building C7 Owner-Occupied 0 Repairsis) O 1 Alteration(s) C3 I Addition C2
Demolition O 1 Accessory Bldg.C2 Number of Units Other O Spccily:
Brief Description of Proposed Work': a - v
i2� =
� rr
SECTION a: 11MATED CONSTRUCTION COSTS
hart Estimated Costs: OMNI Use Only
(Labur and llatcrials)
I. Building S 4&4V I. Building Permit Fee: S Indicate how lae is determined:
'. FIccirical S C]Standard Ciry,Tussn Application Fee
Cl Total Project('ost'I Item 6)% multiplier s
I'IumMng S *. Usher Fees: S_
J. \leeh.mical ill\
S total .\IlFcas: S\u vci5101 _
('hcck :\nunum: C,tuh \mourn:
n l'ulal Project Cost: 1 0 paid in Full — 0 Owst:mdiag 11al.mce Oue:
j. .
5ECHON5; CONSI'Rli("riONSERVI('F.S
5.1 C'onst rue tion Su pen isor license(CSL)
I'\pirawm Date
\,arse ul'C.\I. I Iu-Jer
I a+CS I. I)pels.¢helutsl.__.
- _..--- ---- I')PC Mseriptiun
Nu and Slrccl -"-_--- `—""' _
(I l (ILu ldi n s"'D It, 1 t.UIl0 cu. 1t.)
_ R licatricted I&?f.ul"I Dllellin
Citki loan..Slue.Lll' ..— ---.. . . INI \Lawn
.'K' RlMtin Clmerin
.,._. N'S N'indukr,aJSidin
SF Sulid Fuel llurning Appliances
I Insulution
1'elc hone 1411ail address D Demolition
S.2 Registered flume Improvement Contractor(HIC)
IIIC Registration Number Fkpiruliwn Dula
I IIC Compaq Name or I IIC I4gi.,IrunI NJllle
No.and Stme1 Email address
City/Town.Stnte ZIP rcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.§ 2SC(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..........O No...........0
SECTION 7m: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.
Print Owner's Nunte(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name low,I hereby attest under the pains and penalties of perjury that all of the infurmation
contained in t ' ap I t o is rue and accurate to the best of my knowledge and understanding.
i 6 ?
Prim 0E •r'. or wit ed.\gem'n N01114 Mccutilliq Sigmlturc) Dula
Nam:
I. An Owner%the obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(lot registered in the Hume Improvement Contmclur(HIC) Program),will nn have access to the arbitration
program or guaranty fund under M.G.L.c. 142.4. Other important information on the HIC Program can be Ihund at
wo.l 11.I11 ;Ok . I Information on the Construction Supervisor License can be found a1 w,kw nl.l.: �O, ,III,
2. \\'hen substanlial work is planned,provide the information below:
rwlal tloor area I t+ It.l . ____,._(including garage, finished basement attics,decks or pwrchl
Gross liking area lsy. IL1 ._,_. Habit.ibleruumcount
\unlhernl lircplaces .. Numbsr Nit hedrooms .. . .
\tlnlherol'hathnwnts . . . . . \unlhetof1mil,halhs
i I k pe wf healing s)+Icm .\unlhc!ol'dccks, pwrOws
I'k pc Pl e,4dlnl-' ik iteill I7nelw,pl (lpoll
1. "Id,li l'rwiccl Square Footage ,It1;Ik he wh,tittacd Inv"Total I'rljecl Cost"
CITY OF S.ULE.Nvf
PUBLIC PROPERTY
DEPART1dENT
u�a..u+r our•• --�
w,a � isov,r•w�ersnur•suaywwoRsrr7sots's
TIL 9'9-745-71N•F.A&9711-746764
HONEOWNE&LICENSE EXE.ti MON
S
Please "I
e`1
Date !o !
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Job Loeadaa 4Zd-N f�%IZW.P 0 e �'A 1
e-s T-
Home Owner Address b M�
Home Owner Telephone
prom Mailing Address I 4G�.e>,J �x
The current exemption of"Homan urns"was extended to include ownaroccupied
dwellings of two Units or less and A allow,such homeowmen to engage an individual for
hire who does not possess a .provided that the owner acts as supervises
DEFINMON OF HOMEOWNEIL,
Pe sons)who owns a pace!of Inns l on which hershe resides or intends to resides,on
which then is, or is intended to be,,a one or two family dweWn&attached or detached
structures accessory to such use mA or farm structures A person who constructs more
than one home in a two year period shag not be considered a homeowner, Sueh
"homeowner"shall submit to the Bur(ding OmciaL on a form acceptable to the Building
Official, that ho(sho be responsible f all such work performed under the Building
Permit
The undesigned"honteow"ce aMumes responsibility for compliance with the State
Building Code and other applicable bj,,,laws and regulations
j
The undersigned "homeowner"cerdfi that hNshe understands the City of Salem
Building Department minimum inspa on procedures and requirements and that hdshe
will comply with said procedures and uirem
H0�1E0-WYER$SJGYATL'RE U _ .
APPROVAL OF BUILDING INSPECTOR
See other side for state code
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CITY OF S.u.&a(, AUSACHUSETTS
UCtLOLVG DEP.IATtEVT
l I 'O WASHNGTON 3MI[r, )'FLCCA
M (973) 145-9591
lU J M fJtL.fiY D IILSCatl.
FAX(973) 1 49M
MAYOII J M40..%W ST.PQits
Dt C4CIPtxicPACPffATY1BCRDLYGCOSQIISJfONER
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Construction) Debris Disposal Affidavit
(required for demolition and renovation work)
In accordance with the sixth ed tllon of the State Building Cade, 130 CMR section 111.1
Debris, and the provision of MG o 40, S 34;
Building Permit a _ is issued with the condition that the dcbris resulting from
this work shah be disposed of in a Praperly licensed waste disposal facility as doBncd by NIGL c
11 I, S IJOA.
The
debris will be transported by:
The debris will be disposed of in :
(name oY fuiluy)
I,daraf, or•n,d �y)
P-IMIr
� ,O.INtG 1, pliC�nf