52-54 OCEAN AVE - BUILDING INSPECTION (2) $-7 The Commonwealth of Massachusetts "3
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IF�.
e Board of Building Regulations and Standards CITY O ', O1
Massachusetts State Building Code,780 CMR SALEI 01
Revised MarV I I 9,
Building Permit Application To Construct,Repair,Renovate Or Demolish a rr:'
One-or Two-Family Dwelling UJ .
'' nn This Section For Official U,se,Only r<
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Building Perini[Number: Date A lied: CA
Budding Official(Print Name) Signature D 't"
1 SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
52-54 Ocean Ave.
!I Lla Is this an accepted street?yes X no Map Number Parcel Number
ry 1 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
From 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:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal N On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ronald&Patricia Merritt Deerfield NH. 03037
Name(Print) City,State,ZIP
15 Haynes Rd. (603)490-2864 merkon](&aol.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building N Owner-Occupied ❑ Repairs(s) IN I Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units 2 Other ❑ Specify:
Brief Description of Proposed Work': Vinyl Siding Paint trim
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 10,500.00 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 0 ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 0 2. Other Fees: $
4.Mechanical (HVAC) $ 0 List:
5. Mechanical (Fire $ `
Suppression) 0 Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1Q,500.00 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
L.�
5.1 Construction Supervisor License(CSL) CS-061160 05/15/2017
Ronald C. Merritt License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) j T
15 Haynes Rd.
No.and Street Type Description
U Unrestricted uildin s u to 35,000 cu.ft.
Deerfield NH. 03037 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(603)490-2864 merkon I(&aol.com 1 Insulation
Telephone - Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC 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..........ffi No...........❑
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain this application is true i1 �3�p the best of my knowledge and understanding.
�— 1'`DI�1 ftn,o,oµ em !i-me onlMol.mm,r-US
f Date:201605.o20G1 S5 W 05/02/2016
Print Owner's or Authorized Agent's Name(Electronic Signature) Date .
NOTES:
1. An 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type 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"
aMassachusetts -Department of Public Safety
Board of Buiiding Regulations and Standards
ion+ir ud'.ou$ulry uirr eaw�.�ra=.xis
License: CS-061160 k
RONALD C MER;tY1T '�'
I5 HAYNES RD % - de c '
DEERFIELD NEF0307,
Expiration
Commissioner 05/15/2017
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name: Ronald Merritt
Address: 15 Haynes Rd.
City/State/Zip: Deerfield NH 03037 Phone#: (603)463-5790
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
or part-time)." 6. ❑Restaurant/Bar/Eating Establishment
2.® I am a sole proprietor or partnership and have no
7. ❑Office and/or Sales(incl,real estate,auto,etc.)
employees working forme in any capacity.
[No workers'comp.insurance required] S. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp.insurance required]* 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees.(No workers'comp.insurance req.] 12.❑Other
'Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
•-If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an'
organimtion should check box H I.
t am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#ovSelf-ins.Lic.# Expiration Date:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised.that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby cert' under lice pains and penalties of perjury that she information provided above is true and correct.
Sienalum: e 44 � Date: 0 5102/2 0 1 6
Phone# (603) 463-5790
Official use only. Do not write in this area,to be completed by city or town official
City or Town: - Permit/License#
Issuing Authority(circle one): ,
1.Board of Health 2. Building Department 3.Citytrown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gmv/dia