52-54 OCEAN AVE - BUILDING INSPECTION LAB '513
N The Commonwealth of Massachusetts IWSPECTO,rIvUUfa fCE
n Board of Building Regulations and Standards
60 Massachusetts State Building Code,780 CMR �j 5 SALEM
Building Permit Application To Construct,Repair,Renovate Or Demo s �� Rglvrse I v12pJ
—• One-or Two-Family Dwelling F' G UU
( This Section For Official Use Only
Building Permit Number: Date Applied:
J
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:52-54 Ocean Ave. 1.2 Assessors Map-&Parcel Numbers
Lla Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
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 li
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8Sewage Disposal System:
Public M Private❑ Zone: _ Outside Flood Zone? Municipal N On site disposal system -❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ronald Merritt Deerfield NH 03037
Name(Print) City,State,ZIP
15 Haynes Rd. (603)490-2864 merkoni@aoi.com
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building IN Owner-Occupied ❑ Repairs(s) 30 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units 2 1 Other ❑ Specify:
Brief Description of Proposed Work': Tear off the two existing_courses of asphalt roofing.
Install IKO Weather Shield rubber membrane above all eves including all valleys.
In I Ol .Felt Dri Rid v I lifetime tranghingles
Front Porch flat roof:Fiber oard Insu ation Dri ed a and Rubber membrane roof
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 11,000.00 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g ❑Standard Citytrown Application Fee
D Total Project Cosh(Item 6)x multiplier x
3.Plumbing $ - 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 11,000.00 ❑Paid in Full ❑Outstanding Balance Due:
vl^.0 vT I O c1
SECTION 5: CONSTRUCTION SERVICES
'1 5.1 Construction Supervisor License(CSL) _CS-061160 05/15/2017
Ronald Merritt License Number Expiration Date
Name ofCSL Holder
LisiCSL Type(see below) 1J
15 Haines Rd. Type Description
No.and Street
Deerfield—H 03037 U Unrestricted(Buildingsto 35,000 cu.a.
R Restricted 1&2 Family Dwelling
City/rown,State,ZIP M Masonry
RC Ranting Covering-
WS Window and Siding
SF Solid Fuel Burning Appliances
(603)490-2864 merkonl(awl.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Daze
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..........19 No...........❑
.SECTION 7a: OWNER AUTHORIZATION 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.
Print Owner's Name(Electronic Signal=) 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
contained in this application is tr/u/e/,/$,(�,t�d accurate to the bi;.k&t1�,Ig8,:�(ellowlcdge and understanding.
/,�.,j(/ d / emasl�anMml@aoLcan.mUS
Ronald Merrritt / =p a� �� 10/05/2015
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hiresan 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. og v/oca information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide theinformation 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"
i CITY OF & .EMI, N-LNSSACHLSET M
BUILDING DEpARTairT
120 WASHINGTON STREET,3'n FLOOR
TEL (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOII
MAYORTttOMAS Sr.PtERae
DIRECTOR OF PI:BLIC PROPERTY/BUMDING COMMMIONER
Workers' Compensation insurance Affidavit: Buildersicontractors/Electricians/Plumbers
Applicant Information Please Print Leeibiv
Name(Businesiorganiration/Individual): Ronald Merritt
Andress: 15 Haynes Rd.
City/State/Zip: Deerfield NH 03037 Phone #: (603)490-2864
Are you an employer?Cheek the appropriate box: Type or project(required):
1.0 1 am a employer with 4. 0 I am a general contractor and 1 - 6. []New construction
employees(full and/or part-time).• have hired the subcontractors
2.® I am a sole proprietor or partner- listed on the attached sheet.: 7• 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. [].Building addition
[No workers comp,insurance S. 0 We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.® 1 am a homeowner doing all work right of exemption per MGL 11:0 Plumbing repairs or additions
myself.[No workers'comp. C. 152,§44),and we have no 12.®Roof repairs
insurance required)t employees.[No workers'
comp.insurance required.] 13.❑Other
'Any applicom then sheclm box el mual also fill out the serum below showing their workers'mmprnration policy informatim.
'l Imreawtwa who submit this aptdi vu indicating they am doing all work and then hire outside contractors mut=limit a new affidavit iedica ing arch.
:C.mtractwa that check this box mart anaMed an additional droet showing the name of the su i.c mraatma and their woken•comp,policy infammam.
fam an emphryer that is prmiding workers'compensation harurance jar my employees. Below is the ptdley and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 52-54 Ocean Ave. Cityistate/Zip. Salem Ma. 01970
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 S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lawmigations of the DIA for insurance coverage verification.
do hereby certify nder the palm and jxXq!1aq rperJary that the information provided above is true and correet
Sienature le�e 10/05/2017
Phone#: (603)490-2864
Official use ordy. Donor write in this area,to be completed by city or town nfcial
City or Town: Permit/I.1cense#
Issuing Authority(circle one):
1. Board or Health 2.Building Department 3.Cilyffown Clerk 4.Electrical.Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
Massachusetts -Department of Public Safety
Board of Building Regulations andStandards
k� Corci��i.:nn Sunen�.cor - .�
License: CS-061160
RONALD C MEROT,
13 HAYNES RID
DEERFIELD NEF
�..f~�ll�6f¢•.��-�u�a Expiration
Commissioner O 1512617