37 OCEAN AVE - BUILDING INSPECTION Q The Con,nionwealth of Massachusetts
D i Board of Building Regulations and Standards I )R
Massachusetts State Building Code, 780 CMR. 7 edition
I'SI{
Building Permit Application To Construct. Repair. Renovate Or Demolish a /l� ivol lamem
DOne- or Tnv-Fumih Dwellin,it =uns
\ This Section For Official Use Only
Building Perin umber, ate Applied:
l3 �8
signature:
Building Cunvniuioned Inspector of Br t J tgs Date
SECTION 1: SITE INFORMATION
Ll Pr erly Address: 1.2 Assessors Map & Parcel Numbers
to
I.la Is this an accepted street? yes no Map Number P:urel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy Io Frontage(it)
LS Building Setbacks (ft)
Front Yard Side Yards Rear Yard
ReyuirrJ 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?
m ❑
Public ❑ Private ❑ Check if yes❑ Municipal ❑ On site disposal syste
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:
t t Ytk In leu lP.
Name (Prino Address for Service: _
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': Sd--r-�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
i
3. Plumbing $ 2. Other Fees:
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
�7 G, [� Check No. Check Amount: Cash Amount: _
Total Project Cost: $ �V I � I ❑ Paid in Full ❑ Outstandine Bcd:mce Due:__.____
i
�a
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) C S q--/a% t ^y / 1
C- r -- �.--�1-�V� License Number I 'I i,w i Dala v-�
Name of 'L- Milder,//
List CSl_ 'rype(see M1eluu ^ , ,) U
"1' c Descri pion
1J ..
C CnrestncicJ 1 u i pt 15.(N)0 Cu. Pt.i
R Restricted I&'_ Family Dsselhne
lQ/ _%1 .\lasonn Onlv
1 [ ' V�' i RC ResiJell[ial Ruolinc Cos en ne
Telephonc WS ReSlJeolial \Vnuluw an,! SiJui!
SF Rnidelloal Sated Fur! l;uniin. \pphunce Insi.ilI.Won
D IZenidenlial Deniuluuo
5.2 Registers edy Y—9!r�eSttent Conlr��(lilC) ( 3- S--�G
HIC Company Name or IC Ree�s!ru�iittiii• Registration Number
Ad ssZZ
14 Expiration(Date
II Signature Telephone
SECT/ON 6: WORKERS' :FF DAV!T (M.{ :L. s, tcy e
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide 1
this affidavit will result in the denial of the Issuance `Che building permit.
Signed Affidavit Attached'? Yes ......... No ........_. ❑
SECTION 7a: OWNER AUTHORIZ TION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DEC LA RATION
C
1, {��Dt'--� L�-r✓y�C , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name s-
Signature of Owner�orizcdAgent Date
(Signed under the 2ains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(nut 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 730 C'MR Regulations 1 I0.116 and 110.R5. respectively.
When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished base ment/:utics, decks or porch)
Gross living area tSq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms _ Number of half/baths
C7pe of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage- may be substituted for "Total Project Cost"
._� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
J
. ....� \L\�, n I`: \11.1�:`. •:,,� i:!:Ill a <\;! ll, \I1..4 !.• .: � . _Il :
I'. t. •t-g-'t'-;;[ a l-l\. 1-g.-i_ •t$i„
N orkers' Compensation Insurance .�1'tiila\it: Builders/ContractorsiElectricians/Plumbers
Please Print Legibly
\ ) tltaant Information
`.1111� I Ifu.lnrs, I h'yam el n,�n In.LI iduel I:
,q �
\dlfe5i: 7
City State.Zip 2 v� l`i hone �P I f? 2L_
'ire you an employer? Chuck t e appropriate has: of project(required):box: `-
1_ .In a empluyer w iIh 4. ❑ 1 am a contractor eontraer and I ❑\ew cunstruetiun
CIl1p 1Uy'ees(toll anll'Ur part-tulle).e lla\'e hired the sub-contractors 7. ❑ Remodeling
listed on the attached sheet.
_'.❑ I in, a sole proprietor or partner- I hese suib-contractors hall: Y. ❑ Demolition
ship and hale no employees workers' comp. insurance. y, ❑ Building addition
lvorking for me in at capacity. 5. ❑ We are a corporation and its
)No workers' comp. insurance 10.0 Electrical repairs or additions }
required) officers have exercised their
I I. repairs or additions y.
{.❑ I am a homeowner doing all work right of exemption per [l1GL ❑ Plumbing
c. 152, }I(J), and we have no I oof repairs
myself. [No workers'comp. employees. [No workers'
insurance required.) 13.❑ Other
Bump. insurance required.]
•;lay applicant That checks box 01 must also till our the section below showing their workers'compensation policy infunnanun.
t I lomeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Coutracmrs,hat.heck this box most antic hed an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I mn in employer that is providing workers'compensation insurance for uty employees. Below is the policy unJjob site
infurrnulion.
Iluurance Company Name:—_
Policy d or Self-ins. Lic. a: A `�J St I J(,l� Expiration Data: 3 2�
.�`� � � t1��� City,State/Zip: —✓�-�"'x ,�/ �(.`)�/v
Job Site Address: -- `
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure co\'erage as required under Section 25A of 1\IGL c. 152 can lead,to the imposition-of criminal penalties of a
line up to S 1.5oom() and'or one-year imprisonment. is well :ts civil penalties in the firm of a STOP WORK ORDER and a tine
,It till to )2�If.l ll).1 day :ICaltbt Ihc' llo:ator. He a l'I?Cd that a Copy of illls Staterient may be forwarded to the Office of
I I;\c,u_:pions of the DI:\ for insurance mere \enficauon.
l Jo hereby rerii/i- nder the it ins unJ p• dtice of perjnr}' dose due inJirrnrutian pros idr is rue wrJ a orrect
Date
gyl,nurd.
l'r.„tie
Y-
�olliciol use pulp, no tutu ,trite in thus urea, lu he aa till)leted by city or to It, ofjiciuL
.. Permit/License ri
hsuint; \uthorih (circle one):
I. Board of health 2. Building Department 1. Cith,-l'own Clerk J. Electrical inspector 5. Plumbing Inspector
6. 01her -' -- ----
---- --- —
Information and Instructions
I!u,cus (kncraI I a%%. :hcgrtcr I requtw, all employers to pro%Ide workers' congicnsauon for their cniplovvcs.
I'll].u.urt Ill tills .I.nute, .lit rvnplowe a delin.ed as ' c%cry per.,nl In the ,cry i:c of an,nhcr under .in% :owracl of lure.
s l�Ic�s or implied, oral or wrncn." .. ..
\^ emplUfer Is dctined is ...in :ndlt:dual. pamicr,hgt. a„oc 1,11 Ions aorporanon or other Icgal cinity. or am hvo or store
of [Ile fnlc aOulg engaged In ajoint cntcrprse. and Including the Ic_al reprc•senlatry cs of a dc:e.l,ed eniph»er, or the
c:cn cr or nu,tee of in Inds idual. panncnhip, .',,ocianun or other legal runty, cngilo)uig cniplovices. I lowev er die
„%%liar of a dlvcllulg IiJn,e hay Ing not More than three apartinentS and %%ho reside, therein. or the occupant of the
diyci!mg llou,e of another who employ, persons to do ni.untcnance. :onstrucuon or repair Mork on such dwelling house
,-i ,ii the_founds or building appuren.un thereto .hall not he:ause of loch employ nicm he deemed to be an cntployer. •
\It il- :hapicr I5', IN al,o .tales that 'every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable cv idence of compliance with the insurance coverage required."
Additionally. .MOL chapter 152. j25( 1-) ,late, "Neither the conunom%callh nor any of Its political subdivisions ,hall
cnlcr into any contract for the perGuniance of public work until acceptable ey idence of compliance with the insurance
rcquxenients of this chapter have been presented to (lie contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) nanie(s), addressles) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships I LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP dues have
employees, a policy-is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents.fbr confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
Ile returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fix you to till out in the event file Office of finestigations has to contact you regarding the applicant.
Please be sure to till in the permit,license number which will be used as a reference number. In addition, an applicant
that must submit multiple pemtitilicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address" the applicant should write -all locations in (city or
nov W.- A copy of the affidavit that has been officially ,tamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
tear. kli,here a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves cte.),aid person is NOT required to complete this affidavit.
Ilse 1 mice of Investigations would like nl thank Nou in advance fix your cooperation and should you hdve any questions,
ple.t,e do nol hesrtate to give us a :all.
I he D) patnnent , address, telephone and fa.s number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
O(IIce of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. q 617-727-4900 ext 406 or 1-877-MASSAFE
u:•.I,:d -'o-u5 Fax 111 6 1 7-727-7749
www.mass.gov/dia
{ *�, CITY OF SALEM
s h�
' PUBLIC PROPRERTY
DEPARTMENT
%\-.Nil ll.`:, iIN SI It IJ'T 0 SAI I M, \IA iiAI !II Il .I'I
Construction Debris Disposal Affidavit
(required lur all demolition and rcnovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 9 - _ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal lacility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed o^fin :: Q
(name of facility)
(address of facility) "
sienature of permit applicant
le
4oln,.,If dw