136 OCEAN AVE W - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Board ol'Building Regulations and Standards CITY
8 m OFSALFM
Massachusetts State Building Cute, 780 C'MR, 7 edition
RevirrdJamnvs•
+ Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. :0061
f One-or Tv!—Family Dwelling
This Lion For Official Use Only
Building Permit N ber• Date Applied:
Signature: -1
Huildin ummissioner/In to of Buildings 15a1e
SECTION 1: SITE INFORMATION
I.1 P.1rope/r�ty Address: y� 1.2 Assessors Map& Parcel Numbers
/
I.I a Is this an acre ted strect?ycs no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Ama(sq 11) Frontage(11)
1.5 Building Setbacks(11)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.t.c.Ja,§54) 1.7 Flood Zone Information: 1.2 Sewage Disposal System:
Zone: Outside Flood Zane?
Public O Private O — Check if es0 Municipal El site disposal system O
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownfrr of Record. ,n �
M,_ Iilr<0. rQ 4 � Y�Yr/ 1 3 Gt"�-ay. AVehLtr �•✓�t—�-
Name(Print) Address ro Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building❑ Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O 1 Accessory Bid .O 1 Number of Units I Other O Specify:
Br Description of Proposed Wor : / .' a )7
SECTION 0: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building S ��-.a I. Building Permit Fee:S Indicate how fee is determined:
I. Electrical S 0O Standard City/Town Application Fee
O Total Project Costs(Item 6)x multiplier x
). Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
S. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S„/a I . p Paid in Full O Outstanding Balance Due:
0Wq 9d
r :
SECTION S: CONSTRUCTION SERVICES
5.1 Lice nsed Construction Supervisor(CSL) ;SL
J" l 3� y
e Number I:.apirrliun )ate
Name of('SI.•llu der I
Lfype(sce below)
Descri ion
Address /� llnmtriaed u to)3.000 Cu. Ft.CIA Cl/A t\AM�e Restricted IR2 Family Ducllinji
Signaly�,, ��1 -- M M (hJ
`"I gT62 �`��� RC I Residemial Roulin Covens
felepMme WS I Residential Window and Siding
SF Residential Solid Fuel BurningAppliance Installation
D Residemial Demolition
5.2 Registered Home Improvement Contractor(HIC) 10
I IIC Company Name O or IIIC Registrant Name Fegi ,ration Nuumber
AJJ // 7/rU,( rt )/�_ 1 / 6 n.\ .sr - Expiration Da
te
Signature 'rclephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL S 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 ........[r No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
/// OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
\Jy/�` authorize A/ to act on my behalf,in all matters
relative to work authorized by this buildih permit app cation. ''11
Z"-
siffAurc ofluAcr Z I Date
SECTION 7b: OWNER,OR AUTHORIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
7An
the sins and naltics or 'u
NOTES:
r who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
tered in the Home Improvement Contractor(HIC)Program),will W have access to the arbitration
or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 I O.R6 and I IO.R3,respectively.
2. stantial work is planned,provide the information below:
rea(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 baffirournsi Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substituted for"Total Project Cost"
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- Xlassi chusetts - Department ut Public Safcn
Board of Buildin Re,, latiuns and 'Stand:u ds
Construction Supervisor License
License: CS 54380
BRIAN J MOORE
34 SHIRLEY LANE
SHREWSBURY, MA 01545
Expiration: 7/24/2012
(lnnmissiuner - Tr#: 30572
CITY OF SALEM
'i PUBLIC PROPRERTY
' z:. , r' ,, DEPARTMENT
<--
I.IAII:.`R!.Ill'URIRs q.l.
12'WA.SHI.N(;I'O,N S'I RELT• SALI;.\4,M:\15Ac:i tl sii i iI 01970
fla.,978-145-9595 • P:\x:978-740.9846
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers
\pplicant Information Please Print Legibly
VOIme tl3usincssiorpanizatiotdlndivi(lual): I
A(wress: co
Cityistarei!-ip: 15 4 Phone ik. 1 /� (o ST 22-1 1
Are you an employer'.'Check the appropriate box: 'Type of project(required):
1.'®-1 ant a employer with �r 4. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-tinic).• have hired the sub-contractors Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workzrs' comp. insurance- 9. ❑ Building addition
To workers'comp. insurance 5. ❑ We are a corporation and its
CYN'CISeJ their required-] O 10.0 Electrical repairs or additions
officers have
3.❑ I am a homeowner doing all work S P P'
on exem ti right of per MGL I I.[] Plumbing repairs or additions
myself. [No workers' comp. c. 152,g 1(4),and we have no 12.❑ Rouf repairs
insurance required.j r employees. LNo workers' 13.0 Other
comp. insurance required.]
-.Any::p plicant Ibut chucks box ill must alsu till out the action Ixluw showing thou wurkurs'compunwriun policy information.
' I lemeuwncn whu submit this atYdavir indicating they are doing all work and then biro outside coininteton must auhnnit a new of ldavit indicating such.
Contract,,s Ihal check this box must aaachcd an addiliunal..hcet showing Ilse name of the sub-contractors and their workers'comp:policy information.
lain can employer that is providing workers'compensation insurance for my employees. Below is the policy ant!job site
inforatathln.
Insurance Company Name:'— .1/ 5.3._. . ._._ r/V`1S`. __-._._ _...------
Policy 4 or Self-ins. Lie.I;: _ �.�)____...._._/n.�wv.� Expiration Date: �l ^ �/
Job Site Address: 13 V2 o cea � 7" H � I Cityistate/Zip: C Aj= l� K
Attach 11 copy of the workers' compensation policy declaration page(showing the policy nu nber and expiration date).
I;ailurc to secure coverage as required under Section 25A uf.vlGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 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 dry against the violalor. 13e advised that a copy of this statement may be forwarded to the Office of
Inwsligauons uhthc [AA for insurance coverage veritianiun.
I do hereby elcrd y Harder the pains and penaGics of perjury that the information provided above is true anal correct.
)1 L':11111ire: 61VV/
PhUl:e Fr:
ojJic•ial use only. Do not write in this area, to be completed by city or town oJJic•iaL
Citv or 7-own: __ - . . Permit/License d—__-
Issuing Authority (circle one):
1.,Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Counsel Person: __-- -. - _ __.-- Phone#: -
y !1
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplgree is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,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."
b1GL 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 compliance with the insurance coverage required."
Additionally, 11-IGL 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 compliunce 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 nunmber(s)along with their certificate(s)of
insm ance. 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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The aff idavit 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 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.
Please be Sure to till in the permit/license 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. A new affidavit must be tilled 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
fhc OI f Ice of lovestrgatnons would like to thank you in advance for your cooperation and should you have any question,
please do not hesitate to give us a call
the Department's address, telephone and fax number:
The Commonwealth of Massachusetts g
Department of Industrial Accidents o m
Office of Investigations 9 co
600 Washington Street ceo am
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE v r"'o
Fax #617-727-7749
Revised 5-26-05 - <
www.mass.gov/(iia c, rn
J= cn
CITY OF SALEM
PUBLIC PROPRERTY
T�DEPAR NTENT
12" A,N'lll%i.,0Nsisi:i r # s.m m, %t\,i\t
I I I 974-74n-9;95 # FAN: 9,8.174-,9846
Construction Debris Disposal Affidavit
(I-CCILlit ed lor all demolition and renovation work)
In accordance with It the sixth edition of the State Building Code, 7 SO CNIR section 111.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit it - 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
I 11. S 150A.
The debris will be transported by:
(name of hauler)
I lie debris will be disposed of in
(name of facility)
(address of facility)
NILlialul C of pmIli, all(
date
m ','MQ5kday, August 02, 2010 Z14 PM WILMINGTON INSURANCE AGEN 9786575724 C.01
CERTIFICATE OF LIABILITY INSURANCE DATE(BWlaawrn
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THIN ORRYIPICAYFITP49 CIRTIFICATE HOLDER.
CERTIFICATE DOEO NOT AFFIRMATIVELY OR NBOAT IVELY AMEND,EXTEND OR ALTER THE COVER AMR AFFORDED BY THE PO LIVER
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURE R(S)•AUTHORIZED
REP RESENTATWE OR PRODUCER,AND THE CERTIFICATE MOLDER. Q�r�q
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cenificate holder in lieu of such andoreement(s).
Wilmington Inauxaace Agency N
Five M1641esCx Avenue. Vnit 14R. 0. Box 1010
Wilmington 161E 171887-0580
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE AGOVL 050CMID POLICIES 91 CANOGLLLD GGFORG
COI�f^1 THE I!XPIMT ION DATE THEREOF.NOTICE WILL EE CELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
COMM OE 14ASSAC8IISET'TS AUIM;U=R PRFBENTA NE
Division of occupational Sa£et y
19 Stani£oxd etxaet' 2nd Flx 'h
Boston MA 02114
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