13 OCEAN AVE - BUILDING INSPECTION (2) a�
1'11c Commonwealth of vlassachusetts CITY OF
Board of Building Regulations and Standards SALEM
14 Massachusetts State Building Code, 730 CNIR Revised.Llur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number; Date Applied:
Building 011iciul(Print Name).
Signature' - Date
SECTION 1:SITE INFORMATION
I,i Property Address: 1.2 Assessors Map&Parcel Numbers
J UGC/f!�'J
M1fa Number Parcel Number
n
I,I a is this a accepted street?yes no P
1.3 Zoning Information: 1.4.Property Dimensions:
illFrontage(It)
Lot Arcs(s
Zoning District Proposed Use q
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:
Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTIONS: PROPERTY OWNERSHIP,
2.1 Ow,er/of Record: /10 �
`G2✓ p�1/�iC `>
bme(Pnnt) O City�v- P7 L/� ,/`
/ Telephone
Email Address
No. and Street
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altention(s) ❑ Addition ❑
Demolition ❑ 1AccessoryBidg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and blalerials)
I. Building .'$ I. Building Permit Fee:S Indicate now rue is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
d.Slcch:utical (IIVAC) S List:
i.;\lech:mie:d (Fire futal All Fees:3
Su ression)
Check Nu._Check Amount: Cash:\nunmt
6, fatal Project Cost: 0 Paid in Full ❑Outstanding Balance Duc:
SECTION 5: CONSTRucTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E.xpiru[ion Dote
Name of CSL Holder
List CSL'fype(see below)
No. and Street Type -, ' Description
U Unrestricted (Buildings tip to 35,000 cu. II.)
R Restricted 1&2 Family Dwelling
Cityll'own,State,ZIP M Nfasonry
ItC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances r
I Insulation
"role hone Email address D Demolition
5.2 Registered Home Improvement C ntractor(HIC)
HIC Registmuon Number Expiration Date
HIC Company Nt e or 111C Registr, lmne
No.and Street L`/� � �� Email address
City/Town,State ZIP C' Telephone
SECTION 6:WORKERS'COM1IPENSAT[ON INSURANCE AFFIDAVIT(M.G.[ c.152.g 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 ..........0 No...........❑
SECTION 7a:OWNER AUTHORIZATION T NIPLETEDWHEN.,
CT
OWNER'S AGENT OR CONTRAOR S RBUILDINGPERMIT
I,as Owner of the sub' r pe y authorize
t9 act on my beh al relative to work authorized by this building permit application.
L
Print Ownc s e(Electronic Signature) Date
I
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under�the i �'�tld penalties of perjury that all of the information
'contained' tl ' appi • no ue and ac•a� St of my knowledge and understanding.
Nin Owner'sorAuthnrizedAgent'sName(ElvetronicSignature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(trot registered in the Hone Improvement Contractor(HIC) Program),will no have access to the arbitration
program or guaranty Fund under,LG.L.c. I42A.Other important information on the HIC Program can be found at
kaww.masS.eov:'oc❑Information on the Construction Supervisor License can be round at wvvw.mass.,,ov/dlts
2. When substantial work is planned,provide the information below•.
Total fluor area(sq. It.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number or fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
'fypeofcoolingSystem, r_uclosed Open,
1. "Total Project Square Footage'may be substituted fir"Total Project Cost"
�u, rniantonmea(.G£ / is%uae(Ce.OW. elgistration:
fice of Consumer A o/
ffairs&Business Regulal�oo
ME IMPROVEMENT CONTRACTOR
135734 e TYPeiration g/4/2016- DBA -
PATRICK A.CHASSE�SR" F- --Owl
PC SASH
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PATRICK CHASSE �'� F /F� €•
14 CLEVELAND ST.
SALEM,MA 01970
Undersecretary,!
6 t Massachusetts;-DepartmCA of Public Safety _'
f- 8oafd of Building Regulation;and Standards:„
t Cunstruriiiin Sup6n Aso" ' '`
1 ' (
a License: CS-0850410
s ,.
s PATRICK A CHASE
14,CLEVELANDSIT19w
SALEM MA 01970
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/ < `%�.— � n ro "+ , Expvation ;,.
+ ' .. Commissioner,a•,
* 11/28/2014r
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