90 OCEAN AVE - BUILDING INSPECTION l
The Commonwealth of Massachusetts
R Board ul'Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C'MR, T"edition OF SALEM
r RrvurJJunarvv
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• .aAr
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dale Applied: Seg
Signature:
Nuilding Cummissionvr/Inspects of ffuildinss Ome
SECTION 1:SITE INFORMATION
1.1 Property Address: � v 1.2 Assnson Map& Parcel Numbers
2
I.la Is this an accepted street?yes I,'- no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use La Area(sq 11) Frontage(11)
1.5 Building Setbacks(it)
From 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 Sewsga Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
IZ, e IT Is f2.n m A-N O vi 7-Z 9::2
/l C ev�nJ i9 y
Name(Print) Address for Service:
Signatre Telephone '
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck a4 that apply)
New Construction❑ Existing Buildin Owner-Occupied Repairs(s Alterations) O 1 AdditionJ
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other CISpecify:
Brief Description of Proposed Work: o
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical S ❑Total Project Cost(Item 6)x multiplier x
). Plumbing S 2. Other Fen: S
M
4. Mechanical (HVAC) S List:
J. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cosf: S 0 Paid in Full 0 Outstanding Balance Due:
1
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
1.iccnse Number lixpiration lluic
Name of l'SL•I luldcr I.isl CSL Type(see below)
f Description
Address U IlnreuricteJ to 13,000 Co.Ft.
R Restricted Id2 Familyt)%ellin
signature M M Only
RC Residemial Roolin Coverin
I dephone WS Residential Window and Sidin
SF Residential Solid Fuel ll min A liance Installation
D Residential Demolition
3.2 RegbIcred Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address Expiration Date
Signature TelepMate
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS7.123 OD
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 AfTtdsvit Attached? Yes ..........O No...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , as Ow net of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
re of0wrWr Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of owner or Authorized Agent Date
Si utukr the aina and penalties ofperjury)
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 M 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 790 CMR Regulations I IO.R6 and I IO.R3,respectively.
2. Whcn lislamial work is planned,provide the information below:
Total IT
area(Sq. Ft.) (including garage, finished basement/aeics,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
). "Total Project Square Footage"may he substituted for"Total Project Cost"
CITY OF S.U.E.M
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICENSE EXEMPTION
P1ew "I
Dab Sep?
Job Location `O oCeiyy p9 y e—
Home Owner Addrew 9n D r Qi4ti A- y e
Home Owner Telephone 2-2 Q-
Present Mailing Address 9n e7 C e.ate./ 4-v e—
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
him who.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 "homeowne^assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE ' 1�,eql �z
APPROVAL OF BUILDING INSPECTOR
See other side for state code
y ,y CITY OF SALEM
ji. PUBLIC PROPRERTY
' DEP ART'.10ENT
:.,I . i. ��: \\ r.rll�i... •.�I�LI r • 1.\I I \I. )L\"\ .. ,. I . :1'I -
Construction Debris Disposal Affidavit
(required lix all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 780 CMR section 1 1 L5
Debris, and the provisions of AGL c 40. S 54;
Building Permit B is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
11 t. S 150A.
The d 'hris will be transported by:
I name of hauler) �)
fhe debris will be disposed of in
(name ul laci ity)
(address ul'Iac1mv)
,leoature of permit .Ippllcaut
date