136 OCEAN AVE W - BUILDING INSPECTION a ,
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts Stale Budding Code, 780 CMR. T"edition Building Dept
Oksompooft
Building Permit Application To Construct. Repair, Renovate Or Demolish a
One. or rwo-Fumilr Dis elling doom
This Section For Official Use Only
Building Permit um or Date Applied:
Signature:
Building Commissioner/Inspector of Buildings Date � 1
SECTION 1: SITE INFORMATION
1.1 Property Address: - /— 1.2 Assessors Map& Parcel Numbers
— /-' P✓�✓ 4/eN
1.Is Is this an accepted street?yes � no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning Disinct Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard I Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wage Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1 1.8 Sewage
/Disposal System:
/ Zone: _ Outside Flood
Public Private❑ Zone? Munici al Cl'On site disposal system ❑
® Cheek if es❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
C� ,�r��0.9�iCi>✓J 217�t� SAqy--2
Name(Print) Address for Service:
Signature Telephone
SECTION 2: DESCRIPTION OF PROPOSE WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Numberof Units_ Other ❑ Spetiry:
Brief Description of Proposed Work}: �au/ o
�]
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S O Total Project Cost(Item 6)x multiplier x
). Plumbing f 2. Other Fees: S
a. Mechanical (HVAC) S List:
t Mechanical (Fire S Total All Fees: S�
Su ression
Check No. _Check Amo nt: Cash Amount:_
6 Total Project Cost: S 3 '�!QJ 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 nsed Construction
�Supenisor(CSL) C9 7,0p,R
r, '� lG�rt�� ,J!/✓L-? C/\ L�.cn.e Num!/lx7r spout on Date
vrma of CSL 1191der Lot CSL Type(see hclow)
w,o 20
i I Description
ddress
U I Unrestricted luo to 35,000 Cu. Ft.
- R Restricted 1&2 Family D%ellinii
lgn:nure M Masonry Only
9`eO -?'gb-31 r 3 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
S.�� erect Home Improvement Coin ctor(�C) Z�2� 3 3
1 �r � U2✓I
HIC Compao Name ae HIC Regis rt ant Name 'Regiitrauon Number
� Z�
— Expintion Date
igmrure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. c. 152.1 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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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
ISilined under the gains and penalties ofperjury)
NOTES:
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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. I J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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
Tvpe of heating system Number of decks/ porches
Ty pe of cooling system Enclosed Open
1 "Total Project Syuare Footage' may he.uhstituted for 'Total Project Cost"
CITY OF S.0 E.`I, ,L-1SSACHUSETTS
BL'ILDIING DEP.IRTNMNT
120 WASHLSIGTON STREET, )'e FLOOR
TEX_ (971) 745-9595
FAX(978) 740-98"
Kl>IBERLEY DRISCOLL
MAYOR -I�tOAIAS ST.P[ERRS
DIRECTOR OF PUBLIC PROPERTY/BL'IIDLNG COWMSSIONFJI
Workers' Compensation Insurance Affidavit: Builders/Contrictor-WElectricfans/Plumbets
Anplicant Information Please Print Legibly
Naine (Busirwv Orttnizalion,Indtvidttal):
Address-
City/State/Zip: Phone *
,%re you to employer?Check the appropriate box: Type of project(required):
I.0 I am a employer with 4. 0 1 am a general contractor and 1
6. New COrlatrtictiOn
2.� employees(full and/or pan-time).• have hired the sub-contractor
1 am a sole proprietor or partner- listed on the attached sheet : ?• ❑ Remodeling
.hip and have no employees These sub-contractors have V. 0 Demolition
working for me in any capacity. workers'comp.insurance- 9, 0 Building addition
(No workers' comp. insurance S. 0 We are a corporation and its 10.❑Electrical repairs or additions
required,l officer have exercised their
3.0 I am a homeowner doing all wort right of exemption per MGL 1 I-❑Plumbing repairs or additions -
myself.(No workers'comp. c. 152.§l(4),and we have no 12.0 Roof repairs
insurance required.) t employees. two workers' 13.0 Other
comp. insurance required.)
Any applicant that afieckt boa al mull aim rill uat The section below showing their wOrken'co penaYion polity infurmmlon.
i I hvncowren who sudnit this affidavit indicating they are doing all work and then hire etmide contnctOrt tnat suhmit a new affidavit indicating suck
--(-,x tm:ton that chuck this Iws mud anachod an s thirml sheet showing the,,tune of dw suhavntracfon and their wuhan•camp,policy infwnouw. -
1 am an employer that is pravidinB)vorkers'compensadion Insurance jar my employees. Below is the pWi y and fob rife
informut(on.
Insurance Company Name:
Policy N or Self-ins. Lic. p: Expiration Date:
Job Sift Address: City/State/Zip:
,attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)6
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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 5230.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
I ncesitgat ions oldie DIA for insurance coverage verification.
mats
I do hereby cerri r pains mud penalties of perjury that the information provided above is true and carrecL
Win• r i it Dat : 1_/'_/jam 7
Phone 4:
iDfcial use o,dy. Do not write in this area,to be completed by city or town official
City or Tuwn: __. Permit/Llcense
Issuing Aulhurity (circle one):
I. hoard a(Health 2. Buifding Department 3. Cilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Unuact Person: _. .. __. _- Phone p:
i
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.i1111:� Rl ha!•Nht.I,I I.
\L`.l i tlt 120\X',\.il ll.\l 1'0N S rR LET 0 S.\I F.M. %I.\ii:\(.lit il I'i i
fr.i_478-74i-9i95 ♦ PAX:97S 740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR scction 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
--'
Inarne of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of Ixnnit applicant
/I/M
date
•L•6�I:�tn:,,
lg
1
136 OCEAN AVENUE WEST 261-10
GIS# ' 8746 _ COMMONWEALTH OF MASSACHUSETTS
Map � , 2C-1
Bioek CITY OF SALEM
Lot: ,-. 0139=„. r
Category `..RENOVATIONSh"
Pert# N 261_10 ,' BUILDING PERMIT
Proleet5" JS-2010 000378:'
Est Cost ;:,, $32,100.00
Fee Cha(ged: " ' $229.00
Balance Due': $.00 PERMISSION M HEREBY GRANTED TO:
Coast Class:' -�.cl�' f'-' ' License: Expires:
`Contractor: P
Use Group x. Richard Turner STATE-048918
Lot Stze(sgi tt.): 8049.888 I
Zoning "ij RZ , Owner: PAGLIARO MELISSA,PAGLIARO ROBERT
Units Gamed: Applicant: PAGLIARO MELISSA,PAGLIARO ROBERT
Units Lost: 01 li JAT. 136 OCEAN AVENUE WEST
Dig Safe#::,:
ISSUED ON: 05-Oct-2009 AMENDED ON: EXPIRES ON: 05-Mar-2010
TO PERFORM THE FOLLOWING WORK:
NEW ROOF, INTERIOR RENOVATIONS INCLUDING KITCHEN AND BATH
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-2010-000450 05-Oct-09 1439 $229.00
GcoTMSO 2011 Des Lauriers Municipal Solutions,Inc.