180 OCEAN AVE W - BUILDING INSPECTION (2) c�S� � 38olou
fheContmonw fMasc�tG$elfs LIVE CITY OF
i Board ofOuildingRegµ �ts�� rt, ?EC_ EWICULENi
Massachusetts State Buhl ing Code, 780 C 1 5 ReviseJ.(d,r 1011
Building Permit Application To Construc � p1Q f{kaov2(R ?oljs�t ap 3
One-or Two-Famr y welling L �17, q8 Jt L
This Section For Official Use Only
11 Building Permit Number. DateApplie'd.
DuildingOlticial(PrintName) - , Signature` ) Date
SECTION L SITE INFORv1AT10N'
1.1 opertxAddress: 1.2 Assessors 61ap&Parcel Numbers
—} I D ()��ir�N y� 1l�fs�
I.to Is this an accepted street?yes 110 Mop Number Parcel Number
1.3 'Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ElPublic❑ Private❑ Check if yesCl
SECTION2: PROPERTY OW ERSFIW
2.1 Ownerl of Record: S ���� u A
r) me(Print) City,State,ZIP T
o�g R� IA) - bl �`tb- o� cf'Nnot,t,tas
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alterntion(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.(3 Number of Units Other ❑ Specify:6x''6 fiyzeFLACC
Brief Description of Proposed Work-:
GOcS >=iYt�Pt-�C.
SECTION 4: ESTLNIATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials -
I. Building S I. Building Permit Fee:-$ Indicate how fee is determined:
❑Standard City/Town Application Fee
1. Electrical S ❑Total Project Cosh(Item 6)x multiplier s
3. Plumbing S P Qther Fees: S
d.Mcchanical (hIVAC) S - List:
5. Mechanical (Fire S 'fatal DUI Fees:S
Suppression
Check No._Check Amount: Cash Amount:
6.Total Project Cost: S 4O ❑Paid in Full ❑Outstanding Balance Due:
i�na t I— To N. o d' MaD -M S(--Po
7xS = 3�
SECTION 5: CONSTRUCTION SERVICES
5.1 Cunstruction Supervisor License(CSL)
License Number Expiration Dale
-
Name of CSL [[older
List CSL'rype(see below) �I
No. ;md Street Type - Description .
U Unrestricted[(Buildings tip-to 35,000 cu. 11.
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 I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
[TIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town,State ZIP Telephone
SECTION 6.WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15L$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 Isluance of the building permit.
Signed Affidavit Attached? Yes ..........❑ 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNEW 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 know) a and understanding.
�R RI Fr Tl�o wt S Z'l 20 15
Print Owner's or Authorized Agent's Name(Wc uonic Signature) Mile
NOTES:
I. 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 nut 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, �o� y:W Information on the Construction Supervisor License can be [found at wjyAjl as�
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) ' .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) - Habitable roam count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heating system Number of decks/porches
'rypeof cooling-system Enclosed Open
3. "Total Project Square Footage"may be substituted for"'rut ii Project Cost"
- - .r -• - ,� � , - - - QTY OF SALEM, MASSACHUSETTS -
BUILDING DEPARTMENT`
120 WASI-BNGTONSTREET,3R Rom
t TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR TYHOINAS STTIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMv USSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
22
Job Location 6 V I ✓jj1 U RD a v)n 1 (�
Home Owner Address �Tl DC_rG'� ) A v f l�. 1 e tM MA D 1 Iq
—7 D
Present Mailing Address l SP M-e>
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that 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-family 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE L—l 's� —� C��(� F T�b�✓1
APPROVAL OF BUILDING INSPECTOR
CITY OF SALEg MASSAcHus s
Bur DUINGDEPARTAaNT
120WAS}IINCTONS7REET,3 0FLooR
7kL(978)745-9595.
KB&ERLEYDRISODLL FAX(978)740-9846
MAYOR I)i M STYIERRE
DIRECTOR OP PtwucPROPERTY/BUIIAm omamsgomit
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 c40, 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 deposit facility as defined by MGL c 111, 5150A.
The debris will bepp transported by:
-&CV' \4A CAI
(name of hauler) —�
The debris will be disposed of in:
Lick too,r A o�
(nam of facility)
(address o facility)
Signature of applicant
ate