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82 OCEAN AVE - BUILDING INSPECTION (4) The Commonwealth Of Massachusetts Board of Building Regulations and Standards CITY OF l/�� Massachusetts State Building Code, 780 CNIR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised,tlor 2011 One-or Two-Family Dwelling This Section For Official Use only Building Permit Number: p Date Applied: W�1ar� Buddmg OQtcml(Print Name), . Date SECTION L•SITE INFORt11AT10N L1 Property Address: 1.2 Assessors Map St Parcel Numbers I.la Is this an accepted street?yes_ 110_ Map Number , L3 Zoning Information: I arcel Number LJ Property Dimensions: ' Toning D�— Proposed Ua— e Lot Area(sy tt) o Frntage 01) L5 Building Setbacks(ft) Front Yard Side Yards Provided Re Required Provide) Rear Yard Reyuired aired y Provided 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: Public ElPrivate❑ Zone: 1.8 Sewage Disposal System: _ Outside Flood Zone? Check ifyes❑ Municipal❑ On site disposal system ❑ j,I OwnertafRecor SECTION 1: PROPERTY OWNERSHIP! d: N�hme(Prmt) ( `rS5/Qpj � � .� uty,State,ZIP rvo. m,d Stn,ct M Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED 1VORK*(check all that apply) New Construction❑ Existing Building Owner-Occupied Re airs s Demolition El Bldg. ❑ Number of Units ) P O Altemtion(s) ❑ Addition ❑ Brief Description of Proposed Work': r Other ❑ Specify: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only I. Building $ I. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee 3. Plumbing $ ❑Total Project Costa(Item 6)x multiplier x 2. Other Fees: $ T`. 4. Mechanical (flVr1C) $ List; 5, Mechanical (Fire Su ression) $ Total All Fees:S 6. Total Project Cost: $ S9� Check No._Check — Cash Amount: ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES rFi3 �, 5.1 Construction Supervisor License(CSL) Ltttnoc yum cr--J---- Eepiration to N:une of CSLHolder { List CSL Type(see but ow)�— L -rye- i/(V Type Description - No.laid C U Unrestricted Buildin s u to"",0 cu. RJ R Restricted I&2 Famil "welling M Mason Cityfrown,State,ZIP RC Rooting covering WS Window and Man, SF Solid Fuel Burning Appliances 3C6Lnl� r��kK- ( Insulation t,YI D Demolition Tcic bona Email ada.s vement Contractor(HIC) 5.2 Registered dome Impro f�yf�o_ /��— s trution Dute � r HlC Regislranon Number P TIC Company Name orb C Regis�P t ame Email a dress No.a d Stre t ''I%e/ Telephone e Y Tele honene Ci /Town,State,ZIP N INSURANCE AFFIDAVIT(MlG G C.152. l re SECTION 6:WORKERS'COdIPENSATIO application. Fail to Workers Compensation Insurance affidavit must be completed and sue milted with this ure to provide this affidavit will result in the denial of the Is§uance of the building p Signed Affidavit Attached? :Yes CTION HORIZATION TO SE 7a:OWNER AUT BE COMPLETED W HEN. APPLIES FOR BUILDING PERMIT OWNER'S AGENT OR CONTRACTOR I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Date Print owner's Name(Electronic Signature) SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION s of perjury that all of the information By entering my name below, I hereby attest under the pains and penaltie contained in this a ' tion is true and accurate to the best of my�kn l knowledge and understanding. ' &big Date Print owner's or Authoriz Agen Name(Electronic Signature I. An Owner who obtains a building permit to do less/her own word,or an owner it havveho tac ess t ires an nthe arbitration (not registered in the Home Improvement Contractor(FIIC) Program),, pv,vsv�mt_ or guarality Inform tilon on he Construction Supervosor Li efnse can be l undation on the la[C Program n_ 't.�"o`'�'It'—s and�t 2. \Vhen substantial work is planned,provide the info lntliodinggarage finished basement/attics,decks or porch) 'total floor area(sq. ft.) Habitable room count Gross living area(sq. ft.) Number of bedrooms Number of fireplaces Number of half/baths Number of bathrooms Number of decks/porches Type of heating system Enclosed __Open Type of cooling system 3 "Total project Square Footage"may be substituted for"fotut Project Cost" CITY OF Siv.ENf, ;tii USACHUSETTS BL'IMLNG DEPAM-M&YT 120 W-ASHNGTON STREET, 3.e FLOOR TEL (978) 745-9595 Fla(978) 740-9846 Kl\tBE1tLEY DRISCOI.L NL-%YOx THo.Nw ST.P[£RRE DIRECTOR OF PUBLIC PROPERTY/BUILOLNG CO\pttJSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section l 11.5 Debris, and the provisions of MQL c 40, S 54; Building Permit lk is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by 11vfGL c 111, S 150A. The debris will be transported by: (name of hauler) flte debris will be disposed Orin : — (narne of facility) — ---(address of facility) signa mit applicant t214o )F!,5 — The Commonwealth ofMassaehusetas Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wtlw.mass govldia Workers' Compensation Insurance Af davit: Builders/Contractors/Electrlcimm/Plumbers Applicant Information Please Print lnftly Name(Buaiossrotgeaixationandividua): ( Ci o.kICIL omE ( CMCDC`Llk6 CJ/ yp Address: 2SD1 T RP/YLf 1. &17� BF)D t 6,ga r City/StateMp: Phone#: Arc an employer?Check the appropriate box: Type of project(required): 1.Mam a employer with IS, 4. O 1 am a general contractor and 1 C ❑New construction employees(full and/or part-brie).• have hired the subaonuactors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t ?• Remodeling ship and have no employees These subcontractors have S. ❑Demolition working for me in any capacity.. workers'comp.insurance. 9. ❑ Building addition [No workers'camp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL . I Ln Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4).and we have no 12.[}:Roof repairs insurance required]t employees.[No workers' 13.0 Other comp.insurance required] - 'Any sWi�t that cheda box of man else an not the sectim below snowing dwir sotirm rompemsttm policy Wbonatioo.. - t Homeownm who submit this xMdavit indimting they ate doing all work and then hie oowke emuecmrs maa sobmn a new dfidssh 4diatiog mfi. rCantmcnon that cask that box norm atread>A additioml slier showing me more of t)rcub-omtreuam and tlieir+vo[kas'comp.polio mformadon.)'am an employer that is providing workers'eampensation insurance for my employees. Below Is the paltry and Job site information. Insurance Company Name. l4A K i.-E S1l)LLE�r /1 doe-CF—STW— .�I�/s C--d Polity Nor Self-inc.Lic.a:. W` ©0 C3©6 0 a�3_/ 7_/6 Expiration Date, 101J / _ Job Site Addres City/Statellip. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Fai lure to secure coverage as required under Section 2SA of MOL a 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 y Istor. Be advised that a copy of this gtatemeat may be forwarded to the Office of Investigations o the D for coverage verification. I do hereby c un er epM7affler ofpedury that the Information provided above is true and correct Phone ?7 y-ZS'y- u6 -3 Ofeibl use only. Do not write in this area,to be completed by city or town official City or Town: _PermiUlJeente a Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: CERTIFIED U Factor(U.Si/9-P) Solar Heat Gain Coefficient i 1 -VisibletTransmittance - Contlensation:Resistance 1 ri�>> �+!s{`r�°�"J9TFryt ����r`y'� jy�,.v{���}a is �'•�11sJ� S�.e�N 1i��j�C 9a.�....�..� ) + i;. la� d��,•,��((,, f.,aa .", A'1 ,;IRIF �9d . x'.0F Aliz- '•9Fkr�:sr sJ.,M r .t. .w, {; ra =�S "7 '�°!'?;.k Ic f r Pf �i Mtop;�y ,ay. •+s- f *+�'1'_� MI'7tt ,6+y-�' I .a tiyl}.'21<.' '(''- . k! I.L�.r}"7. ,4`e'fit z. .' `+ q rk , ...i.. '6.Et c+t^,.1 k.....�... f s y�1 �."`-gt h�'ry?y+i7, 1�.4., C . , q Xn4}.'4 "/, '�. _.yr•-`VII 3'd+ h �M14r W ` l �•wa.. y' � i gc - 1GYTiI` (Y1� I�