42 OCEAN AVE - BUILDING INSPECTION The Coo unomrealth oI Nlassachusetis
t y Mould of Btill&q: Regulations and `tdlldtlt'ds
r Massachusetts State luilding ('ode. 780 ('A1R. 7" eJiti,at
Building Permit Application To Consuurt. Repair, Reno%ale Or Drnlulish a R, I I, 'Jl llll, r
One- Nr rot o-Valnilr lhr(lling 'nns
tV This Section For Official Use OrilY ---i
-per BwlJing Prrmil N ih Date Applied._ —"--�
Si�n:nurc:
Bw Jiug(aim �n In>perklr of BuiIJmFs Ua e —/�(-DU__ __-
i
SECTION 1: SITE INFY)KNI:\'1'11)N
�1-1��rI. Add�®rpes�s: �-_—_- _— 1.2 Assessors Nlnp & Parcel .Numbers --- --- --'-- --
I.la Is Ihts :In accepted '.;reel° %CS no i Mop IVunther I"J"Cl Nulnbcl'
1.3 'Zoning Information: —, II.» Property Dimensions:
i I
�1 t Building SeU)r ks (f-1 _-- - _------{
Front Yard �— -.— Side Yards Roar }'arJ I
Required I Proeided ReywreJ
_ Pn!vIJrJ Required Pn ,IJrJ
r1.6-W—atter Supply: (MC. I_c. 40. §5J) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
ic ❑ Pri%ate ❑ zone: "— Outside Flood Zone:'
Check ityrs❑ ,tihmicipal ❑ On site disl>,)sal s}smm ❑ 1
_ SECTION 3: PROPERTY OWNERSHIP' 1
2.1 Own rt of Reco d
Address lirr Seri i/cJe:''')
Telrphune
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑UEL�Lslmgilding F7 ( net-Occupied�Repwrs(s) ❑ Alteranon(s) ❑?emulitiun ❑ ldg. ❑ Number of Urns_ Other ❑ Sperlly: j
Brie! Description of Proposed WorAt: --- -----_—
SECTION d: ESTIN1ATED CONSTRUCTION COSTS
Estimated Costs:
II` n _ Official Use Only
(Lahur and Materials)
I. BuilJine S �O 06 I i. Building Permit Fee: $ Indicate ho' lac I. delerinl-
'. Electrical ,S ❑ Standard City/Tuwn :\pplicahun Fee
❑Total Project Coal' (I(em G) .x multiplier
3. Plumbing 5 . Other Fees:
1. .Mechanic31 HVAC) S Lim: /
i. Mechanical (Fire � II
Suppression) ) II Fatal All Fees: S -- -----
1 b fatal Project Cost 5 �"� QU i Check No. __Check :\mount: __(',uh :)onou,tc-- - -
__ ❑ Paid In Full ❑ Ouisl'mJin„ Balan e Due
t
t•
SECTION 5: CONSTRUCTION SERVICES
r5.711,ice�nsed Construction Supervisor 1C'SLI
�P� Ueense Nunlh.r 1`spleauoil Date
\aiur a Z'SI- IIuIJcr ! I-u( CSL l\pe Iscr hrluts l �__
.1.1 t, Deserl lion _
WJ. C I, estnetcJ I u i nl ?.IN)0
R RcsurctcJ I�_' F.uwh D��:Ilene
S enauue \1 \I:no[In Onls ---�
RC Re.IJ:nllul Runtime
\\'S Re.idcnnal
I'rlrphnnc _ _ —
- - SF 12rvJenu.11 Solid Fuel ISuuunu \pl,lienc Im1.J l.unu ;I
p ReaJenllal Ueinulnion --- __---j
to Im ro\'ement Contractor (111C)
i e istere P --- -
Reguuunun Vunahr�
HIC Cennpa❑ la or F IC Re srf:u IN mac
m F ` ^ 6';L --
Addr .s �3J' ITN y^ Fx puatiun U:a;
'relephune
SI al
SECTION 6: WORKERS' CON]PENSAS ION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure nl pr„�IJe
this affidavit will result in the denial 01 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
as Owner of the subject property hereby
to act on my behalf. in all maulers
authorize -
i
.elative to w•.nk authorized by this building permit application.
------ Date ------—-------1
Si nature ul Owner —II
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
P _ / , as Owner or Authorized Agent hereby declare
h s v
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
Print Nat
Date
Signatt e I Owner or Aut ¢ed Agent
(Si ned under die Pains and Penalties of PCr a 'I NOTES: - —I -
L An Owner who obtains a building permit to du his/her own work, or an owner who hires an unre„
Iaerad c„°tr:t`1'"
(nut registered in the Hume improvement Contractor (HIC) Pnlgraml, will o�rt have access n, me :uhitrauon
program or guaranty fund under M.G.L. c. 112A. Other important information on the HIC Program and
Construction Supervisor I_ieensmg 1CSL1 can be found in 780 CMR Regulations I IO.RG and I I010, tcspecmek.
When substantial work is planne pro
d, vide the information below:
Total flours area(Sq. Ft.a (including garage, finished busemenUaulcs, decks nr ptrehl
Habitable room coum
Gnus living area ISq. Ft.) Number of hedronms _.--__----------
Numberottoeplaces Number of hal tih,uhs --- ------
I Number M hathioon's Numberlitdecks/ p,a,hcs _-- -.---- -
fcpe of healing system I.I1.h'seJ —
Type of cn,4mg system —
7. "Total Project Square Footage' may be substituted tier "fold Project Cost"
CITY OF SALEM
;. � PUBLIC PROPRERTY
DEPART'vIENT
•,) ,,,,: I u n,i u>,,..,,N s::u.r r • >.ti i m. \I 1
Construction Debris Disposal Affidavit
(required litr all demolition and renovation work)
In accordance %%ith the sixth-edition of the State Building Code, 780 CNIR section I 1 1.5 --
Debris, and the provisions of%1GL c 40, S 54;
Building Permit f is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
A� �2n�� f�v"� Go �7Zvc�c
(nutne of hauler) \
I lie
debris will be disposed of in
( tame of facility)
(address of facility) _
re of penult:yt{ ant
_ CY Z—
date
• •,�.•,•. , •-%/,.• tl.I){I)e.i)tUJ:'lllf%Jy(`I, ��U3✓:'�JJ 4J6�J•-.,.
I ty Bmwd of building RN U19000, and�iundn-dc�tl HOME IMPRO\EMENTC(NaTRACTOR. �
s.
Repleirxion 100733
Exp,ryt-an
fy�r fnw�•«Ccrfx: abinr
0. CARNP'S. INQ".
vry (,.af 'as
9 4rrnnar.;d 'still Rd.
R'Cf[C, MA 01921 0clin1t Atim nim Liar
Board of[Wilding Regulations mitt Stnudardi
Construction Supervisor License
License: CS 66139
}[( Expiration: 1 11 41201 0 Tr# 12130i
YY...
Restriction: 00
KENNETH R CARNES
* b DORIS STD ''✓i
GROVELAND. MA 01834 Commissioner
ACsUM CERTIFICATE OF LIABILITY INSURANCE o)izsizo ee'
rwaucca (751)4)S-Suou PALE (78I 43S-SO TTHISCERTMATEIStSSU£O ASA1tATTEROP INFORMATION
New England t!erttage Mrsurance Agency GroJG. Tut. 7NLYANOCOKF6RSNORIGHTS UPON'THE CEK91rICATG
Its main Stroat M 'N W-OER 13 Ct•RMCAr.-DOES SO r AMEND,EXTENO OR t
� ALTER THE COVERAGE AFFDRDEi;SY TkE PO�i:IES BEt0
Storwhim. MA O23D0
INSORERSAFFORIMID COVERAGE HAICM
anuxeo'•A B rnes.Int. -- -- ucrLA ESSex IttsurAlsx Co,--
so Arrowhead Farr) Rd, !:r`-p!s;E rTC C1FR1CXV iNTEq."rL �.Ri3:i+
SroY4ord. HA 0142I
'a,M1lwenR I
COVERAOEe
r'RSF I PM1Y 20PR+9.'T,-":MRt`:M:.Et CC titi1 Wfl.=OF:F'- +- zK:ypmc
:fr A.7 f,Ka:sM ;.:tY:=En2a7i0%-A' wD3E I S;SMj�ini
W PS:rA WENYRn9CC4 As0F 6mE2C= eE.FC: Ta A c FAv I tiMC5 O$C � NFw i.A:M ,
E1'a:;(,�''.W^CAE6A'E LIba55N9YVp YA[.lilc 5F[:wrG..:Eft 9+aA ':AIM:i. '
• rrf:twF.O;cxci _•_ -v I.-Y MROi_-'r ._ 'd yt - W.*R:.
as:eaalvme.•-r •BO 03l SS�6 Gas j�1�pD? tm,•+c�r>xaa..�+i.c s 1.000.
XTeeY>eLae+l ea,o�ualnf:n+' C..,.c >.•a6rrr' �-SO GOi.
rFi1]WE tAOV wnwY- S1.000.004
co•.LaA:.acalpnE s 2,000 OEA
6[ta:A;clxultdu.::srvrlCst�a >sr.•s..•.x.ccnva:o.:,G F 1,C00,GO
- AVEorurac lrearrr - --� �� � ;r�amxtofwrac usr :>
! AVY wro r rah+.!
u IOMErNnnx a(Ir_I:YlWon'
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1 lib YDs/,I r
9AaMiE.IA6ltW- � A:TOCh. la t.l d;M.
Ab WITC
-rLL'rSYvxlxKN JEIiNra' ��•------ iFGM1.',••.:t101aFCE A6t' f '—
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,Yo+ala.eon+ewnF:wSE Are MF S4t-:A-ibi 9;;t sL L2:l9R • 03r31/z409 _ ,�aT.-a• i �r�."--_
Eluay.Ews weam i _a`i�xt.rxrs� e.-F._— 1 000 0
S axr x_r:xZrvr.AEnEer.Y1`aa-Y j
�ocv.�ar¢-yca xcws;, � .cl`o.ase-cA CMnme�e 1.000,00
C WaLAi.•'N•
SOr:�^OMP'01'flh'Yld'tM.r•10'4`/r'SMLi 6d•mICS•-to toms. oudi wo ;F ep rN:sev.i15
nntractor Sub)e[! to teE•6;, condit;c+n:', endorselr4e:C anG tI['.'l uRl'Ja on the P4T rcy.
Q*Rl*CATE ER J__. -__ CANCELLATN]N
I f�.NLRIICfM rE�\Y_F�:ZtBc7r01.•�RC4aCEl�EO dttCREYrE �
Lq�11A SN JA?CTK4FPF•T,YKF.•M WViLG M:a IxaY.nY:%x rO FA'[
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I OlTf.v:uxL IU YAi_tvt�wt•IEi:_$AE:XfDg?l-OallGtl.Ox[xE_•.•„T
"vRO[S OF 11NSURAKE COVERJSCE 0!1LY'•• .xox•x:mv m:_.s_.�.sun-:x e>»Esr:on x:=w+ercrArm~ _
SPECIMEN COPY ONLY ``urwoartw f[ra�cYrAT+s -
ACORO261U01lM ' ACORD CORPORATION 1880
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CITY OF SALEM
PUBLIC PROPRERTY DEPARTMENT
. _ ..\1 s• �.., . t: I \1s.i�. .,.., � i.ail • � 1, . sL \I ,�., , . _, t .
Ill /'g.'1:. ,iJ: • t ,\. 1_.'0.14„
Workers' Compensation insurance Aflidasit: Builders/ContractorsiElect 15e ns/PlPrint Legibly
13licant htfornlation
N,IlllcAddl
c It slatc.zi
it re y uu an er r. Check the appropriate box: Type of project(required):
I I a employer vv ith 4. ❑ I on a general contractor and I h. ❑ New construction
hace (tired doe sub-contraclorS ❑ Remodeling
employees (full and'ur part-tone)." t -
'.❑ I alit a sole proprietor or partner-
lured on the attached sheet. Demolition
,hip and have no employees I hese sub-contractors have 8. ❑
working 6a me in any capacity.
workers' comp. insurance. y. ❑ Budding addition
[No workers' comp. insurance 5, ❑ We are it corporation and its 10 ❑ Electrical repairs or additions
require
d.) „Ificers have exercised their
q ] ri ,ht of exemption per h1GL 11.0 Plumbing repairs or additions
}.❑ i am a homeowner doing all work c SI5_ 1 4 , and w have no
myself. [Nu workers' cutup. � a ( 3 I_'.❑ Roof repairs
insurance required.] t employees. (No workers' I3,0 Other
comp. insurance required.)
•:\ny.11,1)1 icanI Ihit checks bun NI must at,,)till out the see on below..how Ing their workers'tompen.sution pulicy information.
t I lasit eowneis who submit I is affidavit indicating They are doing all work and'then hire outside contracfurs must submit a new affidavit indicating such.
.(\),,tractors hit check this box must anac tied an additional sheet,huwing the name of the sub-contractors and their worker'comp policy information.
/oar an employer that is providing nv rkers'romperhsation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: � , j
Policy # or Self-ins. Lic. d: Expiration Date:
f
Job Site Address: J a �� � City,State/zip:
.\roach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section _'SA of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up ro S I.Si)o o 1 and'or one-year imprison) rent. ,is %veil as cis it penalties m the lorm of a STOP WORK ORDER and a fine
„I ip to S_250 00.1 day •t_L'altut the v iolam le ads iced that a copy of this slatement may be forwarded to the Office of
Im e,n n.uwn; of dlc DI:\ for insur.III coverage vcnlicarton.
/Ju hereby n•rri/i.turder the ra mId penaltiev of perjary that the information prn-ided abate it true and correct.
Date 6 2
N,in,tll l rc.
P_I_o 3 3 3
olliciol a,e unll•, no not ,rite in this area. to be ruagteted by city ar rown official
( its or fovvnt __. ..—
hsuing \uthnrity (circle one):
I. Board of Ilcalth 1. Building; Department 3. ('iht fawn (lerk J. Eleorical Inspector 5. Plumbing Inspector
b. other _ _ -- --- - ---- -- - - -
( intact 1'ervon: _.-- -- Phone _—._--
Information and Instructions
\I.i.,.l.I•.tncn, lisncr.rl I aw,,h.gner I �' Icyuu c, Al employ ct, to pros ide Isorkers onq,cu,anOn for Ihcir cmplu�ecs.,.
I'.ii.ii.ull to Ihs ,[.little. ,m rurpfuree t, JcilneJ .i, cn� person if the ,ens Ice .0 m of under .i ,ontrio of lure..
:slv c., or :ny,!,c& oral or Il been .
rngdorer I, do I iucd .IS .un In dit:,lua I. pm m:cr,hl p. .L,act.0 non, auporanon or other !c_al cnnn. or in Ihso or more
I the fotc_omg en_.tged In a joint cwcipn,e. .Ind utclulmg the Ie_al rcprescnt.nne, III decca,cd employer. or the
I.Cry cr or nu,lce of an mdry IJuJI. p.unternhlp, a„oc Ltnon or other Icgal anuy, cmplo�Ine cntpl u%cc., I Iolscser die
,.•.,tier or i .Iw el hng house hay utg Sol it thin three .tpartmcros and Is It,, re,Idc, d;creln. or the oce spa nt of the
,k\ci!Ilie hou,e „I .Inot her who clop Itn, per,on, to do nt:nntenancc. con,irucnon or repair I%ark on such dwelling house
.a .tit the uouu,ls or hu11Jmg aliputten.Iut thereto ,h;Ill not hecause ot,uch cjnI los mcnt he deemed to he an cmplo,�er.
\I(A. ehafncr 1>2, ,,'Sl.till also ,tale, th,t 'csery state or local licensing agency, %hall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commomsealth for any
applicant Ishii has fit)( produced acceptable es idence of compliance with the insurance cuserage required."
\d.hhonally. MOL chapter 152, j2'( (-) ,rates 'Neither the conunomvealth nor any of its polmcal suhdiv t,tons shall
enter Into any contract far the per tonnance of public Iyork unit acceptable c%idence of comps iauce with the insurance
rcyuucmcnts of this chapter have been presented to the contracting authority."
\ppiicants
Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(v), address(es) and phone numbers) 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 on LLC or LLP dues have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be 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
,elf-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 afttdavlt for you to fill nut in the event the Office of Insestigations has to contact you regarding the applicant.
Please be sure to.fdl In the permnL license number which will be used as a reference number. In.addltion,an applicant
that must submit multiple pemniblicense 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
tossn).•' A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
Applicant as proof that a valid affidavit is on the for future permits or licenses. A new affidavit trust be filled out each
ear. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
I i e. a Jog license or permit to burn leases etc.) ,aid person is NOT required to complete this affidavit.
I lie f Slice of Im estigations would like u, thank )ou in .id%ance for your cooperation and should you hase any questions,
plca,e do not he,rtatc to tine us a call.
I he D,p.utntcnt', address. rclephone and tax number
The Commonwealth of Massachusens
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Inc•. ,ed �-'u-ui
Fax # 617-727-7749
www.mass.gov/dia