163 OCEAN AVE W - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
ao� / W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
= � This Section For,Offic' se Only
Building Permit Number: Da /Applied:;. 4
$uitdmgOfficial(PrintName) "` '„ Signature Date
SECTION 1: SITE INFORMATIONj�,�
,P�operty Address; _ ' u �� 1.2 Assessors Map&Parcel Numbers
L l as Is this Vann aaccep�ted 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 isposal System:
Public 11/ po
Private ❑ Zone: _ Outside Flood pone? Municipal Sewage
site disposal system ❑
Check if yesgr
"SECTION 2 PROPERTY OWYERSffiP
2.1 Ow cri of Rec
rR y >�L4AJ 01900
Name(Print) City, State,ZIP
No.and Street Telephone Email Address
SECTION 3-DESCRIPTION OF PROPOSED WORK (check all that apply)t
New Construction VFx1sting Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition E/
Demolition ❑ I Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2: 'I i
_. SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: a
Item OfficialUse Onlq
Labor and Materials
1.Building E sBuilding PermitFroee $ Indicate how fee is determined:
ElStandard City/Town Application Fee
2.Electrical $ a U ❑Total ProOec Coss(Item6)
x multiplier. xr
3. Plumbing $ 2 Other Fees $ Jr
4. Mechanical (HVAC) $ List: h
5. Mechanical (Fire $ Y
Suppression) Total All Fees $ �- s
Check No Check Amount •.'Cash Amount
6. Total Project Cost: $ in
�� ❑Paid Full _�,� ❑Outstanding Balance Due F ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street 'Type ' ' 'Description .
U Unrestricted(Buildings u2 to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
H
HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. e. 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 .......... ❑ No........... ❑
SECTION 7ii OWNER AUTHORIZATIONITO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILI)ING 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 O ner's N me ectr is Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION, }z
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
Nvwwanass."owoca Information on the Construction Supervisor License can be found at www.mass.eov dps
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"
s
CITY OF S.ULE.NI
PUBLIC PROPERTY
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HOMEOWNER LICENSE EXE.MMON
Plan"I
Date c o
lob[acatlas /63 nC,7A,, A--e kzwt-
Hom 0woer Addrear
Home Owaeat?eleghone
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or few and to allow such homeowners to eagage an individual for
hire who don not posuss a lianas,provided that the owner acts as suporviow.
DpxjNMON OF HOMEOWNER
Persona)who owns a parcel offend on which hdsbe reolda or lntende to resider on
which there is, or is intended to be,a one or two fltmily dwelling atteched or daubed
strictures accessory to such use and/or rum structures. A pawn who constructs more
than one home in a two year period shall not be considered a homeowner. Such
--homeowner"shall submit to the Building 0®ci4 on a form acceptable to the Building
Official, that he/she be responsible rot all such work performed under the Building
Permit
The undersigned"homeowner"assumes responsibility for compliance with the State
Building Code and other applicable bylaws and regulations,
The undenignod "homeowner"certifies that helshe understands the City of Salem
Building Department minimum inspection procedures and requirements and that hedshe
Will comply with said procedures and requirements,
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECTOR
See other side far state code
L'
CITY OF SAI.E.LM, i.iASSACHUSETTS
BULDNG DEPARTM&NIT
P. 120 CYASHL,IGTON STREET, P FLOOR '
TES.. (978) 745-9595
FA.x(978) 740-9846
Kl,,tBERT F.Y DRISCOLL
T
MAYOR l-[OhtAS ST.PtERRH
DIRECTOR OF PUBLIC 0ROPERTY/BUMD0JG CONLMISSIONER
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:
�,
(name of hauler)
The debris will bee disposed of in
(name of facility)
(address of facility)
jF s/natu,&of permit applicai t
date
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