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3 OCEAN AVE - BUILDING INSPECTION } 1 � The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 C'MR, 7'edition OF SALkM I Revisw/lanmgt• Building Permit Application To Construct, Repair, Renovate Or Demolish a l One-or Two-Family Dwelling s Section For Official Use Only Building Permit Number: ?le Applied: /6 D Signature: Building C&x4missioncri Impect f nip Mee SECTION 1:SITE INFORMATION I.t Property AAddreas:/ /E 1.2 Assessors Map& Parcel Numbers I.la Is this an accepted street°yes no IMapNumber Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Luning District Proposed Use to Am(sit B) Frontage(I)) 1.5 Building Setbacks(ft) From Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40•§54) 1.1 Flood Zone informatio 1.8 Sewage Disposal System: n: Zone: _ Outside Flood Zone? Public O Private O Check if es0 Municipal O On site disposal system O SECTION 2: PROPERTY OWNERSHIP[ 2A,Owners of Rce rd. Y-Irl<_A/xQD� 04 �,yfyf�lF Nume(Print) Address for Service: } Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alteration(s) IVI Addition O Demolition O Accessory Bldg.0 Number of Units_ Other O Specify: Brief Description of Proposed Work': _-Z&, 7d CC a4 ///jg�L(l �1J17cL F/U SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Ofllclal Use Only Labor and Materials I. Building S / 7, 6LZ) Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee _. Electrical S 2 0': p Total Project Cost(Item 6)x multiplier x ). Plumbing 2. Other Fees: S 4. Mechanical (HVAC) $ List: In 5. Mechanical (Fire S Su ression Total All Fees:S Check No. Check Amount: Cash Amount: 6. 1 Project Cost: S p Paid in Full O Outstanding Balance Due: \1 �E/��t. '� V l Cyr''✓l�C SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) � /6 7 O/ �5 ! 0 I.iccrue Number I:.xpuanon Vale Name o'CSSII.- Ifolder L l.ist CSL T)pe(see below) f —Description Add U linreatricted u to 35,000 Co.Ft. R Restricted 132 FamilyDwelling Si azure LLv��e� ©/ p- M M. (MI 7�-p y/ d RC Residential RoutineCovering felephune WS Residential Window and Sidin SF I Residential Solid Fuel Burning Appliance Installation D I Residential Demolition 5. Is red Hom�e-Improv meet Contra (HIC) /5'066 2 — T N' N( Registnuion Number I IIC Com y Name or f IIC1R gtyr t N• q Addle 9 7ori 0O 7' Expiration Date Si 'relephune SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. f 25C(6)) Worker Compensation Insurance affidavit must be mpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the IssuanSeof the building permit. Signed Affidavit Attached? Yes ..........Me No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 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: OWNER'OR AUTHORIZED AGENT DECLARATION I. ]'�V) �Tr LZT: as Owner or Authorized Agent hereby declare that the statements and information on the foregoing applicat notes' are true and accurate,to the best of my knowledge and beha O. Print N �d t� Si atu Owner or ulh rized t flat Si under the pains and penalties of 'u 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 rapt have access to the arbitration 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 790 CMR Regulations 110.R6 and I I0.R5, 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 bathmoms Number of half7baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open ). "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEM ,01 r ` PUBLIC PROPRERTY DEPARTMENT -J]tlfl'RI.IiY DRISCOLL \t.�n,u 1?C W nsnlNc ION STRELT # SAL iM,M.wnci it svi i s 01970 978-745-9595 • FAX: 978.74.0--9S46 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 1,Pnlitant Information / nPlease Print Leeiblv flame t13u<rocssssi0irr-, nizatinNlndividuul): rn,a- (���(0± Address: � � c City/State,%ip: its d' 06S 76 Phone rl: S >i— d K- 00/F Are v an employer? Check the appropriate box: 'Type of (required): 4. ❑ I am a gcncral contractor and I G w construction am a employer with ❑ employees(full and/or part-time).' have hired the sub-contractors 7. Remodeling 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees 'these sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' cum insurance 5. ❑ We are a corporation and its I P• 10.❑ Electrical repairs or additions required.] officers have exorcised their right of exemption per MGL I I.❑ Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work g P myself. [No workers' comp. c. 152, ¢1(4),and we have no 12.❑ Roof repairs insurance required.] t cmployces. LK'o workers' 13.❑ Other comp. insurance required.] 'Nry applicant that checks box#1 must alms lill out the section bcluw showing their w•orkans eompemation policy inliumatiun. ' I Wmeuwacra who wbmil this affidavit indicating Ihcy are doing all work and then him outside cuntmcton must submit a new affdavil indicating such. -Contractun that chuck this box main attached:m additional Acul howing the name of the sub�conlracian and their workers'comp.policy information. f out air ei nplayer that is providing workers'compensation insurance fur my employees Below is the puficy ant/job site iuforuration. _ Insurance Company Name; �(/�02� �5.�-.��V-4 -- - l Policy 4 or Self ins. Lie,ii�e6VC . _. --- ------ Expirution Date: ZjV0/,,l^^� Job Site Address: 2.d1U /a✓ City/State/zip:s� Attach it copy of the workers'compensation policy declaration page (showing the policy number and expiration date). Failure insecure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a Fine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Ile advised that a copy of this siatement may be forwarded to the Office of luvestigauons ol'thc DI, insurance o cra6e verification. l do hereby certi der th air i pe tolties of perjury that the infuriation provided butt is true and correct. Sienature: _ Dat • /110 �U IIt Ic •! Official use only. Do not write it:this area, tube cui npleted by city or town ojjfe•ird Citvor'fow•n: Permit/License'_--_-- .-- _ - Issuing.\ulhurily(circle one): 1. Board of health 2. Building Department 3. Cilyffotvn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Persow _.--- _. -. -- .._—. Phone tl: Information and Instructions I Massachusetts General Laws chapter 152 requires ail employers to provide workers' compensation for their employees. Pursuant to this statute, an etnpkgvee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." `4GL chapter 152, §s'25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." .additionally, vIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s),address(es)and phone nuntber(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retooled to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials _ Please be sure that the affidavit is complete and printed legibly. The Department has provided a.space at the bottom of the affidavit for you to till not in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current ' policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The OI I ice of Investigations "cold like to drank you in advance for your cooperation and should you have any questions, Please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia - { CITY OF SALEM ( 'a PUBLIC PROPRERTY l s.: DEPAR"I' IENT ',I .„ n I': \\.v.Iuv,. �lt!u:rr � l.�il \t. \L�.;v I. I . • :I'� _ Construction Debris Disposal Affidavit (required liu all demolition and renovation work) In accordance \ fill the sixth edition ofthe State Building Code, 7S0 CvIR section 111.5 Debris, and the provisions ot'%lGL c 40, S 54; Building Permit # is issued with the condition that the debris resulting front this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 1l1. S 150A. The debris will be transported by: /ems/ be CA furl nl (name of hauler) I he debris will be disposed of in (mine tit facility) ✓ gna try � per it , pphe nt :late y t 197,6'1. v 1 s 33" �-12" 24`�2' 24" 717," 39,,, 2 v —l2" 17' , 33" -- - IIIIR m ` W3336 W1242FW2442BUTWI242 WA2442L _ _ - A 204966 N J 612E 24.DISHWBF EZW � "- - - 48— z v m I OM, Supplied by contractor. o N - W W o < � A C O Lamby Residence Final design accepted by: d - � I diningroom 3 Ocean Ave Salem, Ma 01970 N w w 978 744 2549 Sunday, July 4_20T0___ jl c Kraftmaid Products a Haywood /Maple/Honey Spice j u Need to pick out sink hall B 2�RF TGAS-RANGE 2' L FWT.L _ . 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