139 OCEAN AVE W - BUILDING INSPECTION The Commonwealth of Massachusetts
R Board of Building Regulations and Standards CITY OF
�
Massachusetts State Building Code, 780 CMR SALEM✓ � Revised 2011
Mar
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ate Applied
�i.9t'T^n
Building Official(Print Name) Signatu Date
SECTION 1: SITE INFORMATION IV
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
/3� UCQ-a.J Ai✓ we5-r
L la Is this an accepted street?yes 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.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood-Zone? Municipal ❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City, State,ZIP
136 oCe-AN Ave_ cweST 6r? - 113 . 2&
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other lil Specify: (�/��tfL p/�t4tiTo�✓
Brief Description of Proposed Workz: C e-t v e9 {`.'-•--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building Ll
6;00 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost (Item 6)x multiplier, x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
C) Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 6 Q ❑Paid in Full ❑ Outstanding Balance Due:,:A 4o C0i l r4 j /
�7--
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) l o3i 7q Z3 2Gr�
JGo;�% '�AoyO-r-� License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Tye Description
Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town, Stat ,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
y
SF Solid Fuel Burning Appliances
_7� ( <Oy y4 0D7U I Insulation
Telephone Email address D Demolition
5.2 RegistMeed Home Improvement Contractor(HIC) /6 y�/�/ (Q 2/
2�� IiA1 HIC Registrations Number Expiration Date
HIC CompanyY Name or HIC Registrant Name
2�NvC2P.G✓5 L••./
N 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 .......... R� No ........... ❑
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.
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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 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.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/des
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"
b1/08/2012 02:217 17815955920 AMBROSE INSURANCE PAGE 02/08
�9�0-W- CERTIFICATE OF LIABILITY INSURANCE
^mnucee THIS CERTIFICATE; IS ISSUED AS A MATTER OF INFORMATION
Ambrose Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
56 Central Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
j Lynn, MA 01901 —"'—T—
-791-59278200 INSURERS AFFORDING COVERAGE - NAIC0
all Seasons Windows & Insulation INSURER A• SCOttBdaL,�,3& j
P. 0. Box 8229 wsuRERB Ar a Protection _
Lynn, MA 01904 INSURERc:
Trao®late
1NSURGR 0:
I INiLg6R 6: I —'
COVERAGES
THE ROL'CiES CF INSIIRA.NCE L:;v::o RI_!,CW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTAITHSTANDING
r.NY REOUREMENT, TERM OR C^_NiJITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
I.b1Y PERTAIN.THE INSUPANCF A.r:CRDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCW
;'OIJGIF_S AGG RECA TE LIMIT S>141-10 J MAY HAVE BEEN REDUCED BY PAID CLAIMS.
UOY EFFC TIVFrum 0 „ LCY�IROAATIYON UNIT _POLICY NU.NDCF
-N!YAL LIADILITv ^
1 EACH DDDURRBNDfi j q1 .000 . ^^D
' X COtiMSRCIAL OFIJERN.SIAD'LI^' VlGEOCQE-IOTIERTE
(--- ! PR M 9 ;Fa OttumPcnl f 50, OW! �_ G'.NMC MM1OE X CCpAr' WED E%p(Any OnB p4 aen) $ Cj 000
A. _. _. - CPP0058607 3/19/11 3119/12 PERSONAL3ADVINJURY '9 1 OOO OOO
Y� GF-Nr ER�L AGGRCGATF
C:<nn.PCfgcC;;TE!:MT.,ppi li'S^CR
- PRO PRODUCTS•COMP AP AGO S
PO :,,F r I.1C 21000 . 000
AUTOMOTLE UAAI.JrY '�--
M'YAUTO i COMBINED SINGLE LIMIT
—! (Ra acNdom) j$ 1,000,0001
ALL OVlNED AVIDf --�—`—
r'--. BODILY INJURY
SCHEDULED P.L'O , (Pp OMsor)
fi wREDALros i37797400001 15/15/11 5115112 B
' 'N0T40WNED/•UTOS : 1�DBccW ILYI PnURY S I
' PROPERTY UNAAQE i
CARACC:WGILITY
AUTO ONLY.EAACGDENT '$
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07HRRTHAN CAACC I%
AUTOONLY:
AGOif
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j OCCUR �!CI,VlA N.VJ)f
AGGREGATE
..._I'DEDUCTIOLC $
1 RETEN-ION f 1 S
L40RY, :,S COMPGNG.•TION All $
111PI OVPRS'LL1B'LITY ! TP0.VUFI TF !_. X �R
A.Y Vn'JPg1E,OR,PMTYO V/EaCLUr�:f
C On Iwe.uENaFq cLVB:;I E.L EACH ACCIDENT
i l!,,osm,-+c„unnw iBinder 112/15/11 12/'15/12 EL.DISFAFE-EA EMPLOYS s 500,000 SPL..IALPROVIEIONS bola.
I U!HT-R E.L.DISEASE.POLICYLIMIT f 500 000
!ifC!;4iPTICN'Cf OP ERATIONS/LCCAI'IQUN/v!9 PCLEOI E:,C,.v6,O,S ACDrO BY ENDORSEAIGN I/SPECIAL PRQVISIONS
Carpentry/Insulation/ lectrical -
I
I
CERTIFICATE HOLDER CANCELLATION —
. City Of Salem, SHOULD ANY OF THE ABOVE OESCRIGOD POLICIES BE CANCELLED OWCRE THE FY,P;RAT1pN ;
Attn. : Building Dept-. DATC THEREOF, THE ISSUING INSURER WILL GNOEAVOR TO MAIL 20 DAYS LVRIttE!1
City Hall NOTICE TO THE CERTIFICATE HOLDER NAMED TO TN5 LEFT,OUT ENLUAE TO DO So SHMLL
Salem, MA Q 1970 IMPOSE NO OBLIGATION OR LIABILITY Y KIND UPON THE INSURER. ITS AGENTS Ci
ROPREBENTAT S,
AVTHOR,=, T
1 ZQRO 2512001/051
(DACORO CORPORATION 1988
i CITY OF S.UEM, NL' sSACHUSETTS
• BUILDING DEPART,%IEUNT
120 WASHINGTON STREET, Yo FLOOR
b TEL (978) 745-9595
FAX(978) 740-98"
iCMBERLEY DRISCOLL
'I
c�1tYYOR 3toI+tAs ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/lIVILDNG CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information n / J Please Print Legibly
Name i�usirnss<Organirat(i�oMinclividual): 7Y�/ friri-SUw'S t�rrNGpPC✓ t� �_✓y 5' /QirO�^� LLC
Address: �D 3,0 )0 B 2 2_(2i
City/State/Zip: M log Phone
Are yo an employer?Check the appropriate box: Type of project(required):
1.L'9I am a employer with 4. [1 1 am a general contractor and 1 6. 0 New construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ l am a sole proprietor or partner. listed on the attached sheet. 7• El Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. 0 Building addition
[No workers'comp. insurance 5. We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.C1 I am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurancerequind.J 13.0f her 2f✓IOR7�nP2��4
'Any applic:an itht checks box 61 must also till out the section below showing thcir workers'compensmion policy intetmatioa.
f I h>tr+euwnt rs who subatit this affidavit indicating they are doing all work and then hire outside contractors most submit anew afdavil indicating such.
=Contnactors that check this box mw-t auaehed art additions)sheet showing the rauna or)ba subcentmctora and their wo*,m comp.policy intotmation.
1 am as employer that is providing workers'compensation Insurance for ray employees. Below Is the pulley and Job site
information.
Insurance Company dame: R �
Polio #orSelf-ins.Lie.#: 6,P'�Ps2Date:—
Job
Y Expiration
Site Address: 139 OC e4 ..✓ I¢t/ t^�5T— Cuy/State/Zip:f&^r/'-&1'4 .A�4
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of,4IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may b: forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby crrnfy a r th7e�pai�ns ansd penalties of perjury that the btforinatlon provided above is true and correct
Si>n.lttre� .71H 44 t/"l/t/V Date'
Phone#:
Official use only. Do not write in this urea,to be completed by city or town official
City or Town: Permit/I.icense#
(..suing Authority(circle one):
1. Board of health 2. Building Department 3.Cityhfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other__
Contact Person. ___. Phone#'
r CITY OF SAL&M, tiIASS.kcHusETTS
• BL LDNG DEPARTMENT
• 120 W.%sHLNGTON STREET, 31D FLOOR
TEL (978) 745-9595
Fns(978) 740-9845
KltitBERLEY DIUSCOLL
MAYOR THo"ST.PtE n
DIRECTOR OF P[BLIC PROPERTY/HUUMING CONIMSSIO,YER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
I T916ty.N 5`7 to -T V
(name of mauler)
The debris will be disposed of in :
Ly,'1,N MA
�i (name of facility)
(address of faciiit
n of ermit app nt
-3
date
Jct)riwiY doe
Massachusetts Department of Public Safety
Board of Buii`ding Regulations and Standards
%1 �_constructlo�Supdrvisor License '1
_.Li"6$d:,Cs 1934744i 4,i
Restncted�to� uupp�,.� fli
d aq 6 {� bl; 1'' t�tA d 7`t
JEFFREY MAYOTTEIi 1
29 ANDREWS'ii
LN �1) �
EAtt
ST KINGSTON, IJH 0.3627
Expiration: 1/2312013
Tr#: 103474
O<<ce�t coaTsumer A airs�$�ne" ss Regul Looms � _
VEY
HOME IMPROVEMENT CONTRACTORRegistration ,164564 Type:
Expiration t0/2J(2013 Individual MAYOTIT [S i
JEFFREY MAYOTTE
29ANDREWS LN ' " I
EAST KINGSTON NH Q. Undeoerretary I'
I ACTION, INC � O .
47 Washington Street
Gloucester, MA 01930 � , - / _
Tat YP slf� OQ7'39A 13�j V iP �` I O
Agency: NSCAP NGRID A,ppticatitn
PROGRAM: D0.t"j I
.1013 NUMBER: 0
DOE Work Order#=Air0flcan
0
Fork Order Date: U'•S.C.performed? No
2/29/12
Primary Contractor: Window,&InsulationOther Contractor: NA #Bulbs installed . rt
Clicnt: Steven R.Fiaeberg `� ""^ Cost a'Bulbs 40.OU
Street: 139OceanAvenueWestIn<P`fi�750in;vfav 'tO.00
City;StSte;Zip: Salem; M4 Otherin�Mud
OY970 Electticul work _
Telephone: (611):91:3.2738 $J.00
R Amount I,'a,Span
Blower Door Test; 9�.Amourn National Grid
. yes
Inspect Knob&Tube: An Other Utility SO,W) .
Date JobComplcted: EatimtWIRepafrtotal 1,0.00
YJeatherixetion ActualRcpair totul g0.90;
Door kit Estimated Actual Cost Est Cost
Act Cost
Regular doer sweep $43.00
Auromaticddoor swcc $15.00
Air sneling2- an fadrd fper noun
3
$22.00
.Vua tireuliatt:.aaitlpam(a6m„e $75.00 $225:00
wcuthcrstri .window $7$.00
(per side Seal ducts-mastic $5.00
Seal duct $62.00 ~•
returns•inash'c 562.o0
ivlS&insulate nnic hatch R30 1
i. $30.00 $30.00
s0:o0
$0.00
( $0.00 1
Wea6crization Total: $0-00
S2$5.00 $0An
lnsalation Estimated Actual
Attie Her R,_B bG.^n Cost Bst Cos[ Act Cast
.Attic f!arR30 o n 51.40
.Auicflar/sl c1L0reshic 51.30
tcd
400 $1.41 $$64.00�
Themtodatnc
Aaic knccwal R R Fr. S f%,00
A'tiC kneewrp R IS Ecllniafc w/p,��j�� $1.,25
Ante knecwall floor R30'stnctcd S 1.65
Insulate attic stairs&walls i $1,41
Sidewails_vin i Rl5 DP $130.00 _
tntcriarwaii-ploster Rl5Dp -- $1,70 i
1"rY 'dfb n KWslo s/cl+ceks 490 $1.81
Duct insulation R5&seat seams $1.85 $906.50)
1 droNQ i ,instil to 1"RS $`95
Steam i.^!, 150 $3.25 -r•
. usul to 1.25"RS $48, 50
D11W i ms1uatl0nR5 $5.25
�Jnsulatd4cxr- 1^ri id board R7
$2.50
,Sit) 1?-part foam wi,PG butt R lg
insulation Total:
S4958.00 50.00