10 OCEAN AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a I, 2008
One-or Two-Family Dwelling
This Secfion Fot OElicial Use'`Only
BuildingPermit Number: ba
t ate A he3"
Pm Nb pip
` Signature:
.�� Building Co 4 issioner/Inspector of Buildings ,D"ateC
SECTION li,SITE` NFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
D ll ��/l-4 U
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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTIONS: PROPERTY,,OWNERS1IIPi1:
2.1 Ow erg of Record:
/�r'n /5 e p�/n try O ! if arc 4�
Name ' t) Address for Service:
U y26 -
Si tore Telephone
SECTION;3:DE5 ION OF PROPOSEIYWQRK2(cheek all that apply)
New Construction❑ Existing Bui ' g❑ Owner-Occupied)lf I Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units 2 1 Other ❑ Specify:
Brief Description of Proposed Work2:
I GtI/ f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official U
Labor and Materials + seOnl- _y
1.Building $ 1. Flee:.,$ 'Indicate how fee is determined:
2.Electrical $ :❑Standard City/Town Application Fee -
❑�TotalPro)ebt Costa(Item 6)x multiplier x
3.Plumbing $ 2. ,Other Fees: $
4.Mechanical (HVAC) $ List:.
5.Mechanical (Fire
Sup ression) $ e,Tot aI AlkFees $
_ "Check No Ch&k Amount: Cash Amount:
6. Total Project Cost: $
bG ❑Paid in Full ❑ Outstanding Balance Due:
SECTION:5` CONSTRUCTION SERVICES s r
.r ..
5.1 Licensed Construction Supervisor(CSL)
M L �' �ti I°6s-- License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) y
/'S,f-PV11
Address =°De'scri tion
Ly. U Unrestricted u to 35,000 Cu.Ft.
, .v�-�CX_ R Restricted 1&2 Family Dwelling
Signature i / M Masonry Only
-:n--'7 S 3 RC Residential Roofing Coverin
Telephone WS Residential Window and Siding '
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re isterell Hq to I tprovement Contract r(HIC)
HIC Coon
jName or HIC Regrt ne Registration Number
AddresG L ` � 7k-741( 3;3 Expiration Date
Signature / 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 .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED W,HENa
,,OWNERIS:AGENT OR CONTRACTOR-APPLIES�FOR BUILDING PERMIT
I, 1 cf- ��A.K as Owner of the subject property hereby
authorize �rE to act on my behalf,in all matters
relative to work authorized by this building permit application.62
D r v
Si nature of Owner Date
n" SEC 7bE OWN
N+E�R O ,THORIZE1)1AGENTDECLARATION
I, as Owner or Authorized Agent hereby declare
that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L
Print Name
Signature of Owner or Authorized Agent'' Date
Si ned under the giqs and penalties of r'u
N0
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.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 bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"