40 OCEAN AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
CITY OF
a Board of Building Regulations and Standards
NI
Massachusetts State Building Code, 780 CMR S
Revisedd U Marar 2011
Building Permit Application To Construct, Repair, Ren ate Or coolish a
One-or Tivo-Family Dwelling
17.
This Section For'Official Ui Only
Building V'rmit Numberr; Date A i
c ;
Building Official(Print Name) Signature e
SECTION I: SITE INFORiV ION
1.1 Property e�ddress: 1.2 Assessors Nlap& Parcel Numbers
UD orae. .2 3W04SO
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 �loningInformation: 1.4 PfyjtyDimensions:
—ems
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2:, PROPERTY
�OWNERSH7Pi' l.,
2.1 Ownert fRecord: � JV k 01970
[-r �ltl r PtM�
Nam Print) _j(\ City,State,ZIP.�/ -
\ ({U ()Cftn Ay_ 6t7—wo—( U-s � 0l,rr�t. 1i(tfMCp41M�c(n
No,and Street Telephone Email Addres4
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply),
New Construction ❑ Existing Build ng❑ Owner-Occupied ❑ Repairs(s)X I Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTENUTED CONSTRUCTION COSTS-
It
em11
Item Official Use Only
1. Building 1 Building Permit Fee S Indicate how fee is determined:
❑ Standard.City/'Gown Application Fee
2. Electrical i❑ Coral Project Cost ,(Item 6)x multiplier x
2. OtherFees: S ``C) Lisf: C4 M_\lechanical (Fire
sion) otalAll Fees: SCheck N0. Check r\mount: Cash :\mount:l Project Cust:' ❑ Paul in Full ❑Outstaiulin,
613alutce Diw:
^(11 ""'00� � Olri o
SECTION 5: Co,4sTRUCrION SERVICES
5.1 Construction Supervisor License(CSL)
License n ber Expiration Date
Name of CSL holder
List CSL Type(see below)
— Type Description
No. and Street
U Unrestricted Duildin s u to 35,000 cu. tt.
R Restricted 1&2 Family Dwellin
City/Town,State, ZIP ivI Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
[ Insulation
"role hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
IIIC Registration Number Expiration Date
IIIC Company Name or IIIC Registrant Name
No.and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 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 Ovvnet of the subject property,hereby authorize
to act on my behal f,, in all matters relative to work authorized by this building permit application.
Print Owner's Na ne(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, [ 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 my knowledge and understanding.
_ IOn ier's mthon
Print Os tcr's or Autltori al:\gents Name(Electronic Signature) Data
NOTES:
1. :\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not 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 can be found at
tvww.mass.,,ov.oca Information on the Construction Supervisor License can be found at www.mass,!L) dL
2. When substantial work is planned,provide the information below:
Total tloor area(sq. R.)" _(including garage, finished basement/attics, decks or porch)
Gros living:uca(Sq. ft.l Habitable room count
Number of tlreplaces Number of bedrooms -_--
Nuntberofbathrooms Numberofltalrbaths
I cpu of heating system - --_ __- --_-- Number ofdecks/ porches
----------
fppe of Cooling sy;lein __-- F:ncloSed -- --Opcn _
1. "feral flower tiyu,u"e Puot i limy he sub;titutcd Cor l ot-tl 1'1u1ut Cost"
CITY o I:. Iti
FS �r
PUBLIC PROPERTY
DEPARTMENT
u.,auafr o�euxa.
7UwwaTd hoar•UL04 VAVA04L=M Q19V.
ML 9-9.145.9s" •v.a 93.71e.9e4
HOMEOWNER LICLNSB EXE.tit 10M
Plesse "I
Date —`— U$
lobLocadae 40 Duc, fie. DIg7d
Home Owner Add4eae 40 DurA� 0970
Home Owner Telepbow 1V7-7(0—
Presed Mailing Addrew c M
T U current exemption of"Homeowners"was extended to include ownw-occupied
dweUingo of two Units or fees and to allow such hemaowners to enpp an individual for
hire who.does not possess a Ueens4 provided that the owner acts as wpervisor.
DERNMON OF HOMEOWNMt
Persons) who owns a parcel of Lod on which hdsbe reaida of intends to reaidsy on
which there ir, or is intended to be4 a one or two family dweW & attached or detached
strneturee accessory to such use usd/er rarm sWxrwea A person who constructs more
than one home in a two year period sW not be considered a homeowner. Such
"homeownee shall submit to the Building 00164 on a form aaceptabls to the Building
OfllciaL that he/she be responsible for all such work performed under the Building
Permit
The urtdersiZnW "homcowncs'assumes responsibility for compliance with the Stars=
Building Code and other applicable bylaws uW regulations
The undersigned "homeowner"certifies that hehhe undentands the City of Salem
Building Department minimum inspection procedures and requirements and that helshe
Will comply with said procedures and requirements
HOMEOWNERS S[GNArLW
APPROVAL OF BUILDING OiSPECTOR /41 ,,
See other side for state code
I
d
CITY OF Si1LYM) NL LSSACHUSFTTS
BUff-MG DEPAR:n NT
120 WASNLNGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.L.e(978) 740-9246
lCI�tBEAL.EY DRISCOLL
"ILWOR THO.%GU ST.PIERIM
DI.2ECTOR OF PLBLIC PROP ERTY/BLILDLNIG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work
In accordance with the sixth edition Of the State Building Code, 730 CMR section It 1.5
Debris, and the provisions of tNIGL c 40, S 54;
Building Permit ht 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 hauler)
The debris will be disposed of in
-- (name ot'racility)
(address ot'racility)
siy11 a *fit5;icant
��9-2oi3
dafe -
fi
i
1