15 OCEAN AVE - BUILDING INSPECTION (2) 4
The Commonwealth of Massachusetts
Board of Building Regulations and Standards H)R
kBuildingMassachusetts State Building Code. 780 CMR, 7'" editionMl .Nlcili ,\LI'fl
l of
ng Perini[ Application To Construct. Repair, Renovate Or Demolish a HrrurJ hunu,
One- ur Tivo-Famil Dm ellingThis Sec -Fur Official Use Only
Date Applied:
Signature:
Budding Comm ssioner/ Inspector o ings Date
SECTION I: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
i5 t)t�arN eV
I.la Is this an accepted street?yes_ no_ Map Number Parcel Nwntxr
1.3 Zoning_
Information: lA Property Dimensions:
Zoning District Proposed Use Lot Area(sq fll Frontage(ti)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Require) 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?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: .
MNI,iit"\c+ a z1 ara 1 5 oce ,.� 9�
N aw(p,ri` ,1 Address for Service:
q.ZQn- 'Is(nG • L5'�1
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied )R I Repairs(s) )q I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units—!-- I Other ❑ Specify:
Brief Description of Proposed Work': sr Ltie exsak-s r h R.-e_ imcc_ .Ls1rr
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ORicial Use Only
(Labor and Materials)
I. Building $ a5pp 1. Building Permit Fee: E Indicate haw fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
*Total
S 2. Other Fees: S
(HVAC) S List:
(Fire S
Suppression) Total All Fees: S
Check No. Check Amount Cash :\mount:
ct Cost: S a . 0� 13 Paid in Full 0 Outstanding Balance Due:
r.
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
License Number Ezp(rwu n�Dute
Nms of CSL- (holder List CSL Type(see below)
T Dcscri non
Address U Unrestnaed( to 35.000 Cu. Ft.i
R Restricted 1 2 Farad D..ellm
Signature N Mason nl
RC Rcs(de (al Rowlin Cusrnn
Tel phone wS Res( noal %Vmdo, jnd Sidra
SF R• idenual Sold Fuel ljuuune 1 r rh:m.. Im(.illawm
D aidennal Deuuthuun
5.2 Registered dome Improvement Contractor(HIC)
HIC Company Nainc or HIC Re ,tram Nance Regutrauu wntxr
Address Ezp( icon Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. 1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pruwde
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No ........... O
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.
Si nature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1 , as Owner or Authorized Agent hereIdeclarethat the statements and information on the foregoing application are true and accurate, to the best of my kn
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ams and penalties of du )
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner w=angistered contractor(not registered in the Home Improvement Contractor(HIC) Program), will no!ha arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information onm andConstruction Supervisor Licensing (CSL)can be found in 780 CMR Regulations .RS. respecnsely.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage. finished basement/anics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/buths _
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open i
3. 'Total Project Square Footage" may be substituted for"Total Project Cost"
a
CITY OF SMEM
PUBLIC PROPERTY
DEPARTMENT
K„o>
MAYOL 130 WA94NCTON SMEET•SALEK MASSACHUSE S 01970
TEL 976.74S.MS• FAY 979.7-1&9"
HOMEOWNER LICENSE EXE.MMON
Please Print
Date (-A:! ti_ - o=b
Job Location i ocear� a�
Home Owner Address 15 0 d.w
Home Owner Telephone Al-es - -A�-6 . 2 S I i
Present Mailing Address 15 ac- . � a."
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 who does not possess a license,provided that the owner acts as supervisor.
DEFINMON 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE 1' I1`0\c
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 WASI]ING!ONStRLI'T ♦ SAIFS4, NIASSAk:I II il I IS
f I'l,918-7-Ii-9595 ♦ FAX:918-740-9846
Construction Debris Disposal Affidavit
(MILIii-ed for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions ofMGL c 40, S 54;
Building Permit It is issued with the condition that the debt-is resulting front
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name orliaLIlCr)
The debris will be disposed of in
(name of luility)
(address of't'acility)
Signatule orpermit'4pplicyalt
Mod lz\ Z'0.0 es
(late