64 OCEAN AVE - BUILDING INSPECTION r
\t1
a The Commonwealth of Massachusetts CITY
of Building Regulations and Standards
Board g g
m OF SALEM
I Massachusetts State Building Code, 780 CMR, 7 edition
�i Revixrd January
Building Permit Application To Construct, Repair, Renovate Or Demolish a �• =(/t�Y
i One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number Date Applied:
� _ /I 1
Signature: `" � ('/ /110
Building Commissioned Insficutor of Buildings Nate
SECTION 1:SITE INFORMATION
1. ,Prope Address: 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes_ no Map Number _ Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(tt)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of rd: 44 `Fc- ) \LS��`,Ks4t!, #a) C..
UU W
Name(Print) Address for Service:
�i?a- '7LJ`f 5 37
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief DescripPtion of Proposed Wor ':
jc
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlRcial Use Only
Labor and Materials
1. Building S (9(g O C7 1. Building Permit Fee: S Indicate how tee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S &(0 6 ❑Paid in Full ❑Outstanding Balance Due:
C lyg *Y7 ��`f l'la�re o��
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) -Zp,•{-7 9 —7
License Number Exp:;1iop Date
Namr,}�;l'L�1.-Ilu er (�' ( .i1 t 1 1
1.� �r r�ICYYJtCYt List CSL I'Ype(sec below)
AJJ ss�� \ _ Tsn Pe Uescri Lo ft.
Unrestricted u to J5,000 Cu.C ..
J�\J R Restricted IB2 FamilyDwellin
Sig u (^ \ M Masonry Onlyi
URC I Residential Rooting Covering
telephone WS I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Regl tered Home Imp�oveAngpt Co t Jtor(HIC) U Sd�'7
It 0. ,,Ac�� �t
III N• a or I k e istmnt Re istration Number
Ad
Eapirati6 n Date
Sign a 'relephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... 0 No...........O
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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, �J�"^-`� ✓Llar_�_ ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name bo
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 fW have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
l
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
•CN tlkt'T •).0 I]l. W a I..:I'l :
V .�•a fr1:-171.74y1}95 Plat:'17t•NS'lt
construc
tion Debris Disposal AtTidavit
(n,.yuimd lur all demolition altd mmovatiun work)
In accurda"ce with the sixth edition of the Slate Building Code. 7so CMR section 11 I.s
Debris. and the provisions of MGL a .S 54;
is issued with the condition that the debris resulting from
Building Permit M rl Licensed waste disposal facility as defined by MGL c
This work shall he disposed of in props Y
111. 5 130A. ,
The debris will be transpoRcd by.
t nemt ur hauler) .
'1'li )debris
)will
bbeQ disposed ofin
(Haan of xi Ity -
I j drae of l'xllily) (�(
.gaalure n rmit�pylicant
' Jate
CITY OF S.UXiN(, WSACHUSETTS
BL'mmm DETAtrT iuNT
120 W.tsm&4GTON STuirr. )"FtOOR
nos. (978)745.9399
R.�x(971n 1,149fii�
KJt®EA"Y ORMOLL TllobwST•PQ2tRi
MAYOR Dllltt,CMR OF/L SLIC PWPRATy/11CRDLVG CO%MaSSIOrER
Workers' Compenastlots Insurance AI1ldsvih guilders/Contractors/Electrlclsnslplumberr
innllcant Information '(�� �/� r PTesr Print La�6tlt
Valve Iauane+rOrggytuanavlrwbrrauall: J"� • IGG� ��Y'v e�=c��( -
Address
city/stateizip: '� pm.s. T
tre oats employer'Chock the approprlaft beat Typr,of project(rsgL*O*
I I am a employer with d. Q 1 am a Faced eoaaoeaor and 1 tr ❑New construction
i .mpleyeas(fallaad/apatatime).• have hired tboadocsWacers
).Q I.a a sole proprietor rx partner-
listed m the attached ahM l 7. Qf4lt aMline
m
:hip and have no employees Thaw sub cowmwun have a. �dmolitiae
worting; far me in any capacity. workers'comp.Inaussee. 9. (3 3wilding addition
I No worker'cornµ insurance S. Q We an a corperadee NW its I O.Q Electrical repair of additiorra
r gairo&l oflkms hove exercised tlrk
J.Q 1 am a homeowner doing all wait right of complaints par MO. I I.Q Plumbing repairs or additions
myself(No workero'comp. a 13%/1(4),afd we Itsw no 12.(3 Roof repairs
insurance requirtd.l► emp .). LNe wmkan' 13.0 Other
cornµ imunna regMited.l
'•'krl'Mtra"W rhw does"to Of wan site tla We-rrr MUM telow anus aVr watae'm"pets�w vrNrf iadWwtWaa
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in�era.ellaa 7
In%urrnce Company Name: Z�gt_ _ C{
Policy 0 w Self•iru.Lie.M: �' � a` �� 1 Eapiratioo Datr r/ r v
fish Sire Arhlnat: C_ City/SutsV2ip:
.%nach a copy of lbe worbon'compsesaden policy declaration pap(showing iba polley sumber,mad explrstleo daft)6
F4aue to socun coverage so required undso Soctlm 25A of.%4GL e. 172 can lead to the imposkim of criminal penalties of
fine up to S I.S00.00 and/or one-year imprisonmortt,air well an civil peoalties is the form of a STOP WORK ORDER and a fine
Of up to $230.00 a day iWinsi the violator. Ile adviaal that a copy of this siaternent may be forwarded to the 0171ce of
luresneutiorr ut'rbe n1A far insurance coverage vcnek:aioa
/J�Aeeft No the pl%M on,lW xooklgH rj0�-�"r/agWAN A*infMMdew periled ubrw i raw Word:N►rd
,•u rt rre'�-7�Q ov " I— Disler l t V
P`nre a: l0l Gt 3q OOL-LC.)
FI *
D"nN widein this rirot n 0/.urwp/e/d•y Wi yor townn//ilf."
win: Pr►mit/Lleenree whoray (circle onorpofIlrullb L Huddlaa pcpjrtmenf ). cigtrown Clerk t. fled►ical finprctor S. Plumbmgl Impostor
Phone e: