63 OCEAN AVE - BUILDING INSPECTION J��L4 ob C<-R
The Commonwealth of Massachusetts
^ Board of Building Regulations and Standards CITY OF
4 ;I Massachusetts State Building Code, 780 CMR SALEM
t-= Revived Nlar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
"this Section For Official Use Only , 2S
m
Building Permit Number: Date App i d: < m
In,
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Building O fici fal(Print Name) , ignaf l (nDate •-
SECTION I:SITE INFORMATION the
LI Property Address: 1.2 Assessors iYlap& Parcel Numbers --
c�
L[a Is this an accepted street?yes no Map Number Parcel Numberco
rn
1.3 Zoning Information: 1.4 Property Dimensions: .
Zoning District Proposed Use lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Ruire eqd Provided
1.6 Water Supply:(M.O.L,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
✓Efcw M PA ((D
Nu ne(Print))y City,State,Z[P L � ��
�i l�+Ceu +... li✓'2 ' �J `F✓'z,ZU"'2ls�u E nm n t/CO-1i
No.and Strcet Telephone Enmil Address,
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:_
Brifef Descri tion of Proposed Work':
SECTION 4: ESTuNiATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ 1. Building Permit Fee: $_ Indicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application Fee
O Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ _
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire
Su>)ression) $ Fotal All Fees:
ele, Check No. Check Amount: Cash Amount:
(.Total Project Cost: $ 6' QQO ❑ Paid in Full ❑Outstanding Balance Due:
` 7/zq f03 Oc,�=-Pc�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
:=No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
City/Fown,State,ZIP R Restricted M2 Family Dwelling
M Masonry
'i RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
'Fele hope Email address D Demolition
. 5.2 Registered Home Improvement Contractor(f1IC)
HIC Registration Number Expimtion 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 .......... 13 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 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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) pate
NOTES:
I. 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 find under M.G.L. c. I42A.Other important information on the HIC Program can be found at
www.nmss.eov/oca Information on the Construction Supervisor License can be found at www.nass.eov/dos
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. 11.) Habitable room count
Number of fireplaces___ Number of bedrooms _
Number ofbathroorns _ Numberofhalf/baths
Type of heating system Number of decks/porches
"type ofcooling system _ Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
FILE No.: 20.3818
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THE tOCATION OF TIRE OWHOIC saw+ REGISTERED LAND CERTIFICATE OF nnE
DOS NOT FALL 111IION A SIEUM REGISTRATION BOOR: PAGE ASSESSORS MAP:
FLOOD HAZARD ZONE,EXCEPT AS MAY
BE OIDICATED. PLAN Nt1MBERt LOr(S) BLOC¢ LOT:
Co,ERAL 1DTM (1)BE LLOA"IM MAU ASM ARE ON Iff OASIS OF MY WNMOE.DSORIARON.NON BETIFF AS THE RESULT OF A MORTGAGE OSPECDON TAPE
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pEONiAl1O6 ARE MADE To THE ABOVE NAMED)OIENT ONLY AS OF THIS DATE(J)THIS PLAN WAS NOT MADE FOR!RECORDING PIRROSS,FOR USE IN PREPARING DEED
OESM906 OR FOR CONSi1RCTION.(4)VERIFICATIONS OF PROPERTY LK OIMENMrS BRNDNG OFFSETS.FENCES,OR VDT faNHORA1Wt!MAY BE AOWMPLSMED BY AN
ACORATE NNSTRWENT SURVEY ND RSOON9HRIIY IS AMMEI)HEREIN TO IRE LAM OWNER OR OCCUPANT. I
ISpy1P,t NJ 20MDo IaMe 6
CITY OF SALEM, MASSACHUSEM
Ki BUILDING DEPARTMENT
120WASHINGTON STREET,3" FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
Construction Debris Disposal Affidavit
(re_qu-ir-ed for aIWemoIiti.on_and-renovation-work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
—wino; C 0`l ( I( c:il Sr
(adbress of facility)
Signature of applicant
J
Dat
i
'j
QTY OF SALEM, MASSACHUSETTS
` BUILDING DEPARTMENT
120 WASHINGTON STREET,3"D FLOOR
TEL. (978) 745-9595
Frvc(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLMISSIONER
H� OM_EOWNE.R--LI-CEN.S.E;EXEM-PTION:n
PLEASE PRINT:
Date ( z ( ,I
Job Location (p :�) Oj^ -ea-- �4Cp � ISZ . V{/l H O ( Q :�0
Home Owner Address �a w D c, 5 <_> zl .,�
Present Mailing Address 5,.,.- w r4 c r.1,L.
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
� --
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR