88 OCEAN AVE - BUILDING INSPECTION 389 ' y /3 -7 D CK
r
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALENI
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dvelling
This Section For Official Use Only
Building Permit Number: Date lied:
Building Official(Print Name), Signature Da e
SECTION I:SITE INFORMATION
I.1 Property Address:A,r 1.2 Assessors blip 8r Parcel Numbers
n 98 Qcmd"A' kles N tii
1
I.I n Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy 11) Frontage(11)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check ifyes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
.byvt o T 7—tar-1-4X1NT'rU4- P48 bi�Y _ Ind ot'14o
�hme(Print) City,State,
21 Tbaeg,✓ eo.A-,d- 1176 535-7840
No.and Street 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) erlAlteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: KrAso✓L I
PoaG (�.t5 uNA22 le.00f alit,e .ru5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 12 OG6� 1. Building Permit Fee:S Indicate how ree is determined:
Electrical g ❑Standard City/Town Application Fee
2. ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) $ List:
5. Mechanical (Fire S
Su ression) Total All Fees:S
Check No. Check Amount: Cash Amount
6. "Futal Project Cost: S ❑Paid in Full 13 Outstanding Balance Due:
/3 �r, l 4d 491141A e,
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) .4 9 Ste_ ?
44e, r T WOW License Number Expiration Date
Nance oFCSL[folder
List CSL'fype(see below) V
/6 Schoatiu fee a -,
No.and Street type ' Description
� �- Unrestricted(Buildings u to 35,000 cu.It.)
R Restricted I&2 Family Dwelling
Citylrown,Stale,Zip iM Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Bunting Appliances
2l9 IftrAi.izaio I Insulation
'fBe hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) / 2 S+`i
1—' /e`t T llyAll k HIC Registration Number Expiration Date
MC Company Name or HIC Registrant j�tme
1D SC6Fe90Nf2 G 11 uetl A7A-0-3 z't^MS/V 0%
N'o"�nd Street Email address
City/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.,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..........f9-' 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 L*iet;e
t9 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.
L�reY T h�/i ir- 11 -t 3
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 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 iM.G.L.c. I42A.Other important information on the HIC Program can be found at
www.nrtSS.^ov.'oca Information on the Construction Supervisor License can be found at www.mass.,,ov:!d ss
2. When substantial work is planned,provide the information below:
Total floor area(sq. fl.) (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 ofcoolingsystem Enclosed Open
3. "total Project Square Footage"may be substituted for 4,rot:d Project Cost"
'A
t.
CITY OF S uEms AXSSACHUSETTS
KILDNG DEPARTNW-NT
p< 120 WASHNGTON STREET, 3aa FLOOR
TET_ (978) 745-9595
F.mx(978) 740-9846
KINfBERt FY DRISCOLL
T
MAYOR Eloetrs St.PIE.eRE
DIRECTOR OF PUBLIC PROPERTY/BUMDNG CO',L`.IISSIONER
Workers` Compensation insurance Affidavit: Builders/Contractors/Electricians/Pl umbers
Applicant Information Please Print Legibly
Name (nusincsaOrganization,`Individual): L.ti" Y 'r
Address: !4 5'e-".PArrz / 4�
City/State/Zip: 014aki cko"f IV/4 aff-Yf Phone iE: 41i2 "F�5� — ►Z"S
Are you an employer?Check the appropriate box: Type of project(required):
I. ►❑''I am a employer with 2-. 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I ran a sole proprietor or partner- listed on the attached sheet,t 7. ❑ Remodeling
ship and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
(No worker comp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
c. 152, '1(4),and we have no
myself.[No workers'comp. 9 12.❑ Roof repairs
insurance required.)t employees. (No workers' IJ.❑ Other
camp. insurance required.)
•Any applicant cut chucks box BI most also fill oonhe section bclow showing their workers'compensatiun policy nub mation.
r I tomahwners+vho huh nit this affidavit indicating thty ace doing all work and then hire outside contractors most submit anew affidavit indicating such.
=, ntmewn that chuck this box most anachoci an addiliuoal shut showing the none of the subtontmetom and their workers'camp,policy information.
uni an employer that is providing workers'confpeasation in.ucrance for my employees. Below Is the policy andfob site
information. A
Insurance Company Name:
Policy A or Self-iris. Lic, 0: W C Y Oo -4,?0,._Z6 Z Expiration Date: M3-1�}h
Job Site Address: $g D C t.¢Nr /`/'•1/=i✓u� City/State/Zip: 5i�_, //l/7
Attach a copy of the worirers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofNIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be, forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
i do hereby certify uu r re pair and penalries of perjury that the infarination provided above is true and correct.
; .,n,t lr Date: // —/3
Phone,l- Ll __75,a — EGGs - - --
Official use only. Do not write in this area,to be completed by city or lawn official
Issuing Authority(circle one):
1. Bourd of Health 2, Building Department ].City/Town Clerk a. Electrical Inspector 5. Plumbing Inspector
Contact Person: ._..,____ Phone il:
CITY OF S.U.E\d, tiL-us.kCHUSETTS
j. * . a l7ULMLNG DEPARTMENT
130 WASHCYGTON STREET, 3'FLoOR
u TEL (978) 745-9595
FA.Y(978) 740-9846
KIJfBERL.EY DRISCOLL
INLAYOR THo.%w ST.FiERRa
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG CONNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition 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 c 40, S 54;
Building Permit k# 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 MGL c
111, S 150A.
The debris will be transported by:
G sPe'�a L
(namc of hauler)
The debris will be disposed of in
(name of facility)
1 riv�v w.� Y L Y.viv Al 4-
(addressof facility)
- signatur of permit applicant
date
Irbn:ai�,I,x -
F
88 OCEAN AVENUE 389-14
GIs 5017 COMMONWEALTH OF MASSACHUSETTS
rM�p 33
IBlock: CITY OF SALEM
Lot: 0067
Category: REPAIR/REPLACE
LI'eln,it# 389.14 BUILDING PERMIT
Pro;iect# JS-2014-000849
;Est. Cost: $12,066.00
;Fee Charged: �$137.00
�Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO:
,Cons1 Class: -Contractor: License: Expires:
Larry Hudak General Contractor-049536
LotSize(sq ft.): 5708.1024 Zoning . ...I
��Owner: KINSELLA DAVID E,KINSELLA TERESA B
._ B4 G Units Gained: _ ,'�'
`, '1 v s7Applicant: Larry Hudak
Units Lost: a AT: 88 OCEAN AVENUE
Dig Safe# ZI
ISSUED ON: 12-Nov-2013 AMENDED ON: EXPIRES ON: 12-May-2014
TO PERFORM THE FOLLOWING WORK:
REMOVE&REPLACE THREE(3) 6X12 PORCHES UNDER ROOF OVERHANG
POST THIS CARD SO 1T IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Unde eround: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rougln Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chinmey:
D.P.W. Fire Health
Insulation:
Meter Oil:
Final:
House 9 Smoke:
Water: Alarm: Assessor Treasury:
Seger: Sprinklers: Final:
,THIS.PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: [)are Paid: Check No: Amount:
BUILDING RLC-2014-000858 12-Nov-13 13771 S137.00
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