35 OCEAN AVE - BUILDING INSPECTION S'�
14 d 3 ,
The Commonwealth of Massachusetts
`\•/ Department of Public Safety
\�IItW i
NIassachusetts Slue Bu ld i I g Code(780 CN I R)
Building Permit Application for any Building other than aOne-or Two-Family Dwelling
("I tiesSection For Official Use Onh•)
Building{Permit Nuntbec _ Date Applied: Building Official: _.
SEC ION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/linen Zip Code Name of Buildinf;(if applicahle)
SECHON 2: PROPOSED WORK
Edition of NIA State Code used If New Construction check here❑or chuck all that apply in the two rotes below —
.Fx is IirV Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupanq, Cl Other ❑ Specify:___ _
At building plans and/or construct it'll docunten is being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? (' Yes ❑ Nu ❑
Brief Description of Proposed Work: plL �rt.e{ d Port)v__�C(,,r�
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(.):_ _
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Slories(include basement levels)&Area Per Floor(sq. ft.)
Total Aura (stl. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-I❑ A-5❑ 1 B: Business ❑ G Educational ❑
F: Facto F-I ❑ F2❑ H. Hi h Hazard H-1 ❑ H-2❑ 11-3 ❑ H-4❑ _ H-5❑
1: Institutional 1-1 ❑ 1-2 Eli-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-f❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
'rrench Permit•. Debris Removal:
Public❑ Check if outside 19onJ Zane❑ Indicate municipal ❑
A trench will not be Licensed Disposal Site❑
required ❑or trench
Private❑ or indenlilc Zone: "r un site system ❑ per mil is en,lased ❑
Railroad right-of-way: Ilazards to Air Navigation: �i t i�.k, , . 1, "� r'.. ,
Nut Appli,able❑ Is Slruct«re within airport approach area? Is lhcir revlet% inmpleted'
ur Consent lu Build enclosed ❑ Ni e.❑ or No❑ Yea❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: C'se Group(.): .____ IN IV"t COnalrn,tl"n: _______ Ckcupato Load por Flour: ...
Does the build ing,"nlain an Sprinkler System?.- _.._ Special Stipulations.
MC2�vs,S�'—
S par(/v\ �y,�l•r 'a3 I �
-I'ION9;'1'ROI'F.R'IYOWNI:Ii AUll101tIZA'I'ION _
:\Jdn•ssoi Pruprrlyt n v tr S&Lt
Name (Print) ------ -- No.andStree— -- City/Tutcn --- ---- -- — Zip
Prupertr Owner Contact Inlurmation:
Title _ -- Telephone No. (business) Telephone No, (cell) a-mail address
It applicable, the property o\vner hereby authorizes
Name Street ddr•ss City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this buildim mrinit a,,licatiun.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,0W cn ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town Stale Zip Discipline Expiration Date
10.2 General Contractor
Company Name C
Name of Person Responsible for Construction License No. and Type if Applicable
4� �,� �Qk 5-r c3 FAk— qua
_ rSt'r^eet Address City/Town State Z3ip9
Tele phone No. business Telephone No. cell -mail add rest
SECTION 11: lv ( unn11 \Si\HON INFUR:_\.VCI- \1 I II"',"[ M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the h1A Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)
.l. Plumbing $
Note: Alininmm fee=$ (contact music ility)
3. Mechanical Other S Enclose cheek payable to
h.To6d Cost S (c'onhut municipality)and write check number here_--- --
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my mane below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of nly knowledge and understanding`. r�
Plea ,rin and S l I;n n a me �� I'it c Tclep urn• �. Date
e 1
--a --��-� -gip-
titrcct Idr"S Cit\'/town State Zip
l
municipal Inspector to fill out this section upon application appruv _ _ ` r- _
Nan e hate
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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I!:\pMMI,\laU�ilx[t:T a S,ul•.u, M.u�al.ut v I I,JI')7:
(c1: 97/.11i'li'lS � P 1x Y7N41C.6yM
Workers' Compensation Insurunce ,witfavit: Builders/Cuntracturs/Electricians/Plumbers
► llicant Inrunnution
PI as Print Le lbl
V:11T1O1IhnuN;,il)rganuarin,vindlv�duull: �. o� T
Address: o 4--
Cilpsrarc,zip -------------
lr��ke ��� 9�1 �(C1Dltb�iveil:
.\re)ou an cngrloyer:'Check the apprnpriale box:
I 1. I "m a cm lu yr with 4. 1'7M of pro)uct(nyulred):
P ) ❑ I am a general contractor and 1
Lrvqu
yccN(fullantYurputt-lime) huvu hint lhu xuh•amuaelors (r' ❑Nvw cwtrltrttctiun
sole pmpricntr or partner- listed on theartacheJ shcet t y ❑ RetnoJeling
nd have no empluyurll These sub-contractors have
ng tiff me in any capacity, workers'comp, insurance. g' Dernolirion
orkers'cutup, insurance S. ❑ We are a colparetinn and its 9' ❑ DutWing addition
J.) oBiccits have uYureird their lo.(]Electrieal repairs or additions
hnmwavnw Juing all work right of csemption p.r b(CL t 1.❑ Plumbing rcpuirs or aJJitinne.(No workers'annp. c. 152,it(i)•and% hnvv noce required.) r :InpluyccN. (No workers' 12 0 Rwrl'npain
comp Ill unnlwttyuind.) 13.(�Utber ha.l( }
•4rp.q""McN ihW vhuche Ws el Nr11e1 atw rill g the arahan"w awwinN,helr wwhwe'cun,INmrwiun Idicy inrivmwiwa
. IluN+w,wan wIW ualmil this NlTeevil inetmip Ilrer ap JY11111 di Wore ana be,hills viols rpN(Nrlew TWI•Yhnk a„ew,alrlaera IMIIW:Ne VN'h.
'r lllll 11Nr Ihel aMtik Ihie hex T°N Jllitbe.(e rllalllw4t nllgl,huwiNN IIMI naNM Grille
f tM lue•ceMnrtole and(ht,r au(keNr'mills.lwdky,"Ism anus
/uxr un elup/eyer that Is pruvld/ng IvorAers cumpenrndvn inrurnnar/rrr ely emplrryers. Belmv 4 the pu/Isy turd/ub.rig
/njor/nutGns
Policy Y or SulGins. Lie.d: Expiration Due:
Job Sily Address:
�`�` "'r CnylSlater"Cols:
\stitch is copy of file workers'cumpulnatlun pulley ductarullua page(showing the policy nuntbur and expiration date).
1+"'lure lu Yccuro curernge as required under Secliun_JA of ML c. 152 eau lead to tht imposition o(eriminal penalties of a
tTn.up m.S LSnO.t)n"nll/ur ono-yea hnprisnumunt, "s wc11"s civil penuhla:s in lhv form of a STOP WORK ORDER irtd a Pint
of up m i?itl.t)n a Jay.Illuinal file vialamr. Ile advi.scJ thus a copy of this autununi may be lurw"rdvJ lu the Uilicc of
Inr,.hg"urns ol'lhv I)1,1 for m,urarsec"over"gu lcriticahun.
/Ile hvreby tvrri/y ruder the p(lins,old pen(ddes of per`lloy tbet the in/prlsrw/len provided above it true(slid carreelt
��
r)//lrial we on/y. Oo noI s•rite in thlr urr•u, lu be rvurp/cled by citrrolvo/ii.y o / i
('ily ur l'nwnt Pcnnit/Llcrnw s !
h,vins Authurily (circle site):
II. RI,"rJ of Ilrallll 2. Iluddio". Dcp:lrtnlcul I. (:il):'I'u,ul Clerk J. Uccl!6cal lorpcatur :. PlumbinN In,peeror
6. Olhvr
Pitonu Y:
Information and Instructions
1:on in the service of another under:Illy cunlroct of hire.
\I:Issachusetts Ueneral Laws chapter 152 ictiulres all elllplo)ers to provide workers' compensation for their cnlp oyees.
I'urzu.uI1 o lilis .latura.in empA Akre is defined as,, every pe'. _
%press or implied, oral of written."
�n empluper li dcrincJ as"an individual,purtnenhip.issocianoa, :Orporaiiun or other legal curtry,or any two or more
a the loreguold engaged m a joint enterprise,and nlcludmlgl the legal ry J welly.cols to in deceased
«s.I Hcv.cvcr the
,ecelver or Irublea ul'in individual,ptumership,;,ssp,c1a1100 Of other legal enury,employ g ' P )
owner of a dwelling{house having{not more than three apartments and wh uclion of repair work On such dwo resides therein,or the occupant of thehouse
tenance
,Iwelling house of another who employs appurtenant thereto shall notnbecause of such employment be deemed to be ineempl employer
or an the grounds ar building,apP
�IGL chaplet 132. $23C(6) also $tates thug"every slate or local licensing agngs 1 shall withhold the Issuance
any
usiness Or to construct
renewal Of It license or Part
has not produced ace ptabl nit go operate a Aavldonce of cumpllaace wills the Insurance coverage0 he lrequiredr
\dJltiunully. �141 chapter l 3_', §33C(7)slutes"Neither the commonwealth nor any of its political subdivisions shall
enter into any connect for the performance of Pit work until acceptable evidence ofcunlpli uue with the insurance
requirements of this chapter have been presented to the contracting
authority."
Applicants
compensation at'Rdavit completely,by checking the boxes that apply to your situation and,i
please fill out the workers' cumpe es rod bona numbers)along{with their cartiflcillWO of
necessary.supply su�contructor(s)nume(,$),address(Limito P with no
Insurance. Limited Liability Companies(LLCworkea teomgxnsa od Liability n iluurance,l f an)LLC or LLP does have
oyees other than the
member or purtners, are not required to carry affidavit.t Tote a Industrial
should
is required. Be advised that this rtfldavit may be subm d dale the Depaavit. t it Industrial
employees,u policy taft"
:\ccidents for confirmation of inatuaneo coverage.atson for the permitsor license isbeing requested,not the p,pattmcat of
he returned to the city or town that the upp questions regarding the law or it'you are required to obtain u workers'
Industral Accidamts. Should you have lurY q
compensation policy, please,call the DepaM.cut at the number listed below. Self-insure)companies should enter then
self•insurancs license number on the a ro nato line.
City or Town Offtclals vil
complete;uld printed
y. The Department
rPcha affiJuv i for you to Idl11 nutsin the event the Office toggle Investigations ons has to cuntrct you regarding the applprovided u space at the ipplicR
it(til a fr .lure to till in the permit license mmtM:r which will be used to a reference number. In addition,an applicant
That must submit multiple pennib'licelule applications in any given year,need only submit one at7iduvit indicating current o
of the uHlJuvit that has been offleiully stamped ur marked by the city or town nay bu provided o the
policy information of necessary)and under"Job Site Address'the applicant ihould write"all lucutons in (cry or
town)." \cuDY
applicant as proof that a valid affidavit is on file for More permits of licenses. ss or A now affidavit must commercial tilled nut eau
to any busine
y ear e. ,��KR ensa or pW toil w citizen is
leaves ate.) W pets ining a n�is NOTit not required o complete th at'fidavit venture
I I1C t It glee tit 111vorigatiun3l would like W think you it, adv:rllee fur your cooperation and should you have any yuebuons.
please do nut hesitao to give us a call.
f he Ucpanment's aJdresa, telcphune and Nat,number
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMC#of Investigations
600 Washington Street
Batton, MA 02111
fag. N 617-727.4900 ext 406 or 1.877-MASSAFE
Fax 0 617-727-7749
www.mus.govldia
CITY OF S.V.E.NI, ,LvL-kSS.ICHUSETTS
BLILDLNG DEPARTMENT
120 W.i•SHLHGTON STREET, 3�FLOOR
7-EL (978) 745-959S
FAX(978) 740-9846
KIJBE LUY DRWOLL
MAYOR THomu ST.Pmxaa
DIRECTOR OP PLBLIC PR0PERTY/9t:MDLNG COSNISSIONER
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 I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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:
�\ 1
(name of hauler)
The debris will be disposed of in :
(name of facility)
(Oil ress of facility)
signature o ermit applican
ate
Iahnulf J•w
Nlassachusetts- Department of Public Safetc
4 llw rd of RuildimJ Regulations and St ndarils
Construction Supervisor tic8nse
License: CS 83589
DANIEL J OLEARY
202 OAK ST
WAKEFIELD, MA 01880.
Expiration: 8/6/2012
('u u un iss lun r r T r#: 396
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Office of Consumer Affnits&Business-Regulstfou.
HOME IMPROVEMENTCONTRACTOR
'! Regfstration�. 159516'
Explratlon 5/2/2612- TrN 294791 4r_
F F i
Type I Indiv tlual�c
}i Vic. ya i ` i
DANIEL J..O LEARY I�CARPENTRY �
DANIEL O'LEAR`PY �
202
WAKEFIELD MA 01680 " s UodersecreTSQ�ry--a '!