169 OCEAN AVE W - BUILDING INSPECTION (2) The Conmwmeealth of Massachusetts
Board of Building Regulations and Standards Fe>R
�Il'VR IIIAI.I'I Y
Massachusetts State Building Code. 780 CMR, 7°i edition I IS V J
•� j
Building Permit Application To Constiucl. Repair. Renovate Or Demolish a R, twd.h nna,1%
One- or Ttru-Fumilt, Duelling 'ul
This Section For Official Use Only
Building Permit Nw er: Date Applied:
Siflttaluie:
Building CUmmIID]RmCI"/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
LI Properh Address: 1.2 Assessors Map & Parcel Numbers
1(.9 C)ceah a)re rvK1. --
1.1 a Is this an accepted street? y'es_ no Nlap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
7.ovine Disl:=c; Proposed Use Lot Area(sq tt) Frontage (lt)
�1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
ReyuircJ Pn>viJcJ Required Provide) Required Provided
1.6 Water Supply: (M.G.L e. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public ❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record*�vn
aa5� /G c Gcea!, ate �-eS4 S41P y Mq_
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Cu nwuctwn ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': Ac�ck GO&A Rci,F_}_ EX•5 1��� Iso..f'P.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 'asoo„ / 1. Building Permit Fee: $ Indicate how fee is determined: j
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa (Item 6) x multiplier x
i
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: S
Check No. Check Amount: Cash :\moon:
b, Total Project Cost: $ aso0 ❑ Paid inFull ❑ Outstandins Balance Due:__-___-
d 5•J J
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSI.) C S C7 S Ff qS V,;IOA I o
r
o 1,,r ('.ct vva Y-- License Nullifier lisptr;unm Date
Nann•of CSL- Ilolder
C ,a Iyw rP rste f}- List CSL"fvpc lscr hcluwl _
l' ri c Desc i(ion
\ddrcss ) - Unrestricted tup to 35.000 Cu. I-(.1
_ R Restricted IRc'_ Family D%%clline
iauvc GG M Masonry Only
Q7&� —r�— (�7� RC Residential Rooting Casein¢
Telephone WS Residential Window and tiding
SF Residential Solid Fuel liurtune \ )>Inmce In.6111.HNI
D Revdeutial Demolition
5.2 Re slured Home Improvement Cgntractor(HIC)
J J C GPrs etgl Cc vs uir9(-1� r, Jok,
HIC Company Name or HIC Registrant Name Registration Ntlmlber
�—�Address Ce/k -S&O-91795 Expiration Date
�,<, namre Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6)) 1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pnwide
this affidavit will result in the denial of the Issuance of the building permit. J
Signed Affidavit Attached'? Yes .......... ❑ No ........... ❑
SECTION 7a: OWNER AUPHORIZATION TO BE COMPLETED RTIEN
_OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I X I v L t_ Viz-• I�O s'T- R- as Owner of the subject property hereby
authorize— CS w t r4Z to act on my behalf, in all matters
rcla.ive to work authorized by this building permit application.
Signature of Owner Date �—
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
I, 1C' •Aa- i of C T-" To 5-F,r Z , as Owper or Authorized Agent hereby decIate
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. /�,
X - /9 / o d T�P-
Pruit ,NaSnq
Signature of Owner or.Authorized Agent Date
(Signed under the 2ams Lind penalties of edu )
NOTES:
I. An Owner who obtains a building permit to do his/her own work or an owner who hires an unregistered contra:nx
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the at
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 730 CMR Regulations I IO.R6 and 1 I0.R5. respectively.
2. When substantial work is planned, provide the infomation below-
Total floors area(Sq. Ft.) — (including garage, finished basemenUettics, decks or porchi
Grass living area ISq. 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
Type of cooling system Enclosed _ Open
3. 'Total Project Square Footage- may be Substituted for "Total Project Cost"
CITY OF SALEM
Aa PUBLIC PROPRERTY
DEPARTMENT
\I i�tlt \ii II\i,.,`N si ..l TES.\I I'\t. \L
Construction Debris Disposal Aftidavit
(MILLired lix all demolition and renovation work)
In accordan
ce with the sixth edition of the State Building Code, 7S0 CMR section 1 1 1.5 _
Debris, and the provisions of MGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I It. S 150A.
The debris will be transported by:
(name of hauler)
I lie debris will be disposed of in
/VGA k r',4'e �9
(name ul laahty)
luddress u(facililyl
signature of permit applicant
late ___--
i
CITY OF S.;IX-M
PUBLIC PROPERTY
DEPARTMENT
C mum"Danco l
VAVM 130 wAswncrow S=XT•3AL M MA2A01L=M 0%VM
TPt.TW7459S"• FAx 978-74&964
HOMEOWNER LICENSE EXE..MFnON
Plea" filet C
Date ?
Job Location /6 9 OCPc Jc-e • w er+
Home Owner Address /(D 5 C)Cen Ac-e 4�e f+
Home Owner Telephone `7 7 - 6G- O GOB{
Present Mailing Address IGzy o r oo Ac-e r
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be. a one or two Emily dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HO,MEOWNJERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code