13 OCEAN AVE - BUILDING INSPECTION ,t
The Commonwealth of Massachusetts
Board Of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CN1R SALGM
1, Ki•risrd.I lur 201 l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For O iat Use O
Building Permit Number: ate App ' d:
Building 011icial(Prinl Nmne) Signature Date y'
SECTION l:SI INF TION
1.1 Property Address: 1.2 Assessors Map&t Parcel Numbers
t:s fX�stn AV
I.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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards
Rear Yard Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
1.4eOwngr'o�f�Reco{ v�
2 KXas� S� �m Mfg cli [g 90
Nmne(Print) City.State,ZIP
I 13 00ai1 Aot .YCria," 778Ty �jb¢aUpi y lZsn .
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
PNe ❑ Existing Building❑ Owner
-Occupied I Repairs(s) l� Alteration(s) ❑ Addition ❑
❑ .4ecessory Bldg. ❑ Number of Units_ Other ❑ Specify:
f Proposed Work':
r n rn
Y u
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Onl(LaborandMaterials) y
5 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical 5 Cl Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x _
1. Plumbing S 2. Other Fees: 5
4. \Icchanical (11\':\C) S List:
5. .\Icchanical (Fire - ---_--_----__--
tiu.1resiionl 5 Total :\II Fees:S
Check No, Check Amount: Cash amount:
G. Total Project Cost: S III Sty -------
❑ Paid in Full 0 Outstanding Balance Duc:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor '•mse(C'SL)
-'-t----�-
---- --------
)Zi'w-�fil License Number Ifcpimuon I me
Nuntc o(C'SI. Ilulder -__---
1I �.C4� w"C_ LiuCSI.1)pe(see below)
No. and Street - --- - h)Pe Description
_S_+- I-tr•^ / - Re,triridcd 2Family
amn n u' el ing cu. tl.l
r __ _ R Restricted IK2 Pumil � Dwellin
Cigi fort n.State.ZIP M Masonry
RC Roolin g Covering
- WS Window and Siding
SF Solid Fuel Burning Appliances
�Vc�3Gf lz 8112 (-'fq(/ltyoQ(7VMf 05 — -co
Insulation
'felt hone Email address D Demolition
5.2�Reg�is�te�red Home Improvement Contractor(HIC) 0/gyp)
IIIC Registration Number lispoauun Dale
IIIC Company Nnnte or I IIC I egistrunt Nmnc
(/ dG=�
Nu. 14 t5cc' c ^N Eve �7J 2 �!l ,Z. Email address
Ci )Tow/n.State.ZIP 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 4 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 WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
` n. /_
�i L I B/PiJ�I� vz�� ✓Zl/r� —1 ' /I
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' 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 t the my now dge and understanding.
Print Ottner's or Authorized Agent's Name Electronic.Sigi tire) Dale
No'rEs:
I. An Owner who obtains a building permit to do is;her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will rIof have access to the arbitration
program or guaranty fund under\I.G.L. c. 142A.Other important information on the HIC Program can be Found at
watt nni�..g��t. ".:.t Information on the Construction Supervisor License can be found at -0�\ dps
'. W'hen substantial work is planned, provide the information below:
Total flour area(sq. ft.) (including garage, finished basentent'attics,decks or porch)
Gross living area Isq. Il.) -_ _ Habitable room count
\umber of fireplaces.--_- Number of bedrooms
Number of bathrooms Number of half baths
f)pe of healing s)stem __ — N'untberof decks, porches --
I t pc ofiouling ststenl -__- _ )inclosed ___Open
), "fowl Project Square Footage-mak be substituted fix"fo(al Project Cost*'
1
1
b CITY OF sm.E.Nf, 1YWs.-kCHUSETTS
BLILDNG DEP.IRMLENT
110 W.uHLVGTON STxm, 3i0 FLOOR
Tt+s. (978) 74S-9S95
FAX(978) 740-98"
KIJ®FJtLEY DRLSCOLL
MAYOR THoaus ST.Pmsitst
DIRECTOR OF PLIXIC PROPERTY/HLILDNG COMMISSIONER
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 c 40, 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 disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
(name of haular)
The debris will be disposed of in
(name of facility) —�—
Si5 te�) M
(address of facility)
vgna re of permit app
t
- CITY OF SALEM
/r PUBLIC PROPRERTY
DEPARTMENT
vlir,st
11:\{rAwn.\ice il.�)Ix EL•1'• 5,11 L•.N, hS.Uh.11.111 V I nv177„
Ihl: '/7L.'ISvi'r3 a hr.v v7N•7rr•'ly*
Workers' Compensation Insurance :%tOduvit: Builders/Cuntracturs/Eiectricians/Plumbers
\ t )Meant Inrorinalion
All
Name llhnuN�s;t)raanvniaminJmvuluull: Tit%/?6jp� (� �-)•- ..._r LLG
Address: /9' wr/)/'4s S�_
City,Slaw,Zip: �j�l��se-� .! "2/30 Phuneik �Gt Gt3Z
\re)nu an vutployerl Check the appropriate box;
I I.❑ I ant a emPlu)er with 4. un a gununi cJA
tor and 1 1 SPe°f Project rrequired):
enlpluyeex(lull anLvur Part-time).• have hired the hlractors 6' ❑New construction
2.0 I.un a tole pmprictor or partner. listed on rho anahcut. : 7• ❑ Retnodeling
chip;imtil have no umnpluyuus These sub-contractorshave g. Demolirion
working lie me in any capacity, worken'camp• ce.
I No worken•cutup, insurance 5. 0 we are a cmporsd its 9• ❑ Building addition
3.0reyuin:J.) utTlcen have esetheir 10.0 Electrical repairs or additions
1 ❑nr a homeowner doing ill work right ofevemptioIOL 11.0 Plumbing repairs or additions
myself. IN'o workers'comp. c. 152,41(4),andvo noilrsuranco required.) m cinPluyeeN. (No w ' 12.0 Ruul'repairs
ctnnp insuranccrtJ.) IJ.ODUter
�y yrill"A a,"clxeks ti"NI mum:Jw till oum did w tin WOW mtxmwiny"I"A �Mu.ivwkui ciMrlWrtaaGwr Immaiey nr6umlWmiwx
'I t�niw,wmwn "Amur this arlldavil indiuming jr," joint,all.wrk arse iMm him oWaiG euwrmwters mum.ulrrtll a nNw alndsril inaiWing rn,k•
•f„nmrwtmN•i ihW thcek this box mild amlahmNl an aaaimiuryl..hYh Jtnwine tha name Or this rse,..mIWIma and thew%,*M-camp,INANy innxmatimr
/urn all eluployrr that/r prut•ldlnx rvwArrr'rarnprnrallon I/1.tur/rncelur my r/np/ayrr& Be/mY Is thr pul/ity and job xife
iulunnufGrn,
Insuranuu Company Vmne: //1/F!/lj,�4.-y/ ..mom-5--7
1'4)licy k of Sclf•ins. Lic.rr;
. . .. _ Expiration Dune:
lop Site Addres !s: 6 3 06,je,- s�l
C1ty'slaterZip:— P. w
\ttacA It copy of time worken'cumpensatlon poiley doclaroNon Page(showing rho policy number and expiration date).Pamluro to xcuro coserage as required under Scctiun 25A ul'.%IGL c. 152 eau lead to the imposition of criminal penalties of a
tine uP III S 1 500.0f)eniVur une-year imprixlmmcnt• a.t well Al civil Pcnaltics in the 1•onn ofa STOP WORK ORDER and a fine
ofuP to i250.00 a Jay igainxl file violater. He advitcd that a copy urlhih amlusnunt may be I'urwarJuJ to the 011ice ul
Im vahg,mluI's of tliv DIA for ur.ur.u'ce aoveragu icrilicauun.
1,10 hereby r • slider 1/1 ,ern slIJ prnu/fief u�prr/nry/her rhr in/bnnur/on yrvviJaJ uburr is true uud rorrrra
�i,. r file• � - I(
r)�/Ia'iu/IrN tut/y. "O nor�Yrire in U�Jt urea, /Y AO rYIIIpIt'/fl/ey Clry Yr tamYn a/�lrruL
(it.v ar 1'nwitt Pcnnir/Lltente M I
1-uing.\urhurity (circle aoc): i
i1. Ilm�,rrdmrlhvltJt 1. Ihuldumq Ikp:irtumcnt 1. Cil):'fuirn Clerk J. Llcctriral luvpcctur ;, Plumbing Invpecror
6. Othee
l',ul.mcl Vvr%uu:
I'hunc .y:
Information and Instructions ur their enlpiOyees.
on in the service of another under any conlMet of hire.
\LUy1GIluSGllb taCneral Laws ChapiCr I JZ ItiyW(C$aII Clllploye0 to provide workers' compensulun t
111,r5u:L1r it)till$ autute, an emplerte is defined a$"..every pen
♦Preis Or implied, oral or written." legal Or illytwo or Inure
.fin etnplupar I+defined as"an individual, Partntnhip.associanua,corporation ur otherac,:enhry,
A ei f:regmng engaged ,n a iulnt enterprise, and ineluding the legal representatives of a deceased offs. yc4 or the
tether or trulee of.m individual. p
rsmenhlp,assoelauon or other legal amity,employing employee$.ant NoJ However the
owner of a dwelling house the
heving not more than three apartments and who resides therein.or the occup
dwefhng house of another who employs apet sons to do shall notntcrtunbecause c n Is employment be deemed tupail work on cbe dwelling e+nQluyet
or on Flit grounds or building app
In he gingtrationagallis for any
�IGL chapter f 52. g2SC(6) also states that"every$rate or local licensing agency shall withhold the Issuance or
usiness Or
construct bu
renewal of repel ant It olicense
has not prod or porr uced acceptable fair an operate a bevidence of cumpllance wltb theslnsurantcoverage ubdivisions
\d llcanl ly, g bag not I S]. 15C(7)status"Neither the commonwealth not any of its political subdivisions shall
under into any contraChapterct for the perfomwnce ul'public work until acceptable evidence ufculupliasr, with the insurance
requirements of this chapter have been presented to the contracting authorit
Applicants to our situation and,if
Please fill oat the workers' compensation affidavit completely,by checking the boxes that apply Y
Of
necc$sary,supply sub-contruclor(s)name($),uddre$$(cs)and phone null' ar(s)along with than with no employees)other
insurance. Limited Liability Companies(LLCw or orkers'tcom compensed Liability ation insurance.(If an)LLC or LLP does have
than the
mmnben ur Partners,are not required to carry be submitted to the Department of Industrial
enlpenyees,a policy is required. ad advised that this anldavit Also be re 19 sign davit s of
hi,ccie rodents for con to the airy or town thatt h cC Coverage'appl c Lion for the pens sure
license is being requested-toot the porke should
Indusrial Acuidtnta. Should you have any questions regarding the law or if you are cared ed to obtain u workers'
culnpensation policy,please call the Department st the number listed below. Self-in$tarnd companies should enter their
self-insurance license number on the a ro riato lino.
city,or Town Officials
,+f a.s affidavit for you f ti11 out in the event the ORSea of Investigations has to contact you regarding the in applicant
llleasC be iU(C that 1hO afTidavlt t$eO1nQICtO;end printed legibly. The Department contact
provided u space at Chu bottom
111:aso be sure to fill in the pormit/licellsa nuanbe cwhich
will been ea r'needrefeonl club submit nee number. trtT davit addition,
gtcururent
Olaf inuat submit multiple Pannit'liceltse applications
Y g y y Lit of
ss"the
Policy informariof Ile ufflduvirtythst lies been offlrialty md under-job Site oped or marked bytile city or town)tnay be provided to they
YY
town). .A cop$
applicant as proof that a valid affidavit is on file for fLttsre peg-mill,or licenses. Anew affidavit must ss or m lilted out each
°era dug Where hu ne permitowner
or citizen is to bum leaves Obtaining J license or
r Y rinit not
aired toelate complete omplete this to any cafftdav immercinl venture
nse
I hu UI)iue ,F)Investigations would like to Chunk you in advance for your cooptratioa and shuuld you hase:uly yutblous,
lease du nut hesitate to give u$a call.
p
f he U:panmaub addri I$. telcphune and The C number:
of Masmaehusetts
Department of Industrial Accidents
ollfee of Invesdgadons
600 Washington Street
Boston, MA 02111
'fee. p 617.727-4900 ext 406 or 1.877-MASSAFE
Fax M 617-727-7749
d ;.+fLus www.mus.gov/dia