18 OCEAN TER - BUILDING INSPECTION (3) 2-7 Z - IOF
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY SALEM
r Massachusetts State Building Code, 780 CMR dM
RevisechL/arnr 201!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
2 Z One-or Tivo-Family Divelling
This Section For Official Use Only
Building Permit Number:
BiI'd ing Official(Print Na e . rgn Date
SECTION I:SITE INFORMATION
1.1 Pwpe Address: 1.2 Assessors Map&Parcel Numbers
66
I.1a 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(sq R) 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,EL Private❑ Zone: _ Outside Flood Zone? Municipal ER�On site disposal system ❑
Check if yesMP
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner[of Record:
6-r-'A 'R-e.•144 c« 'tgl",A ,) [/,7 , - i3Fvu�•�, ytq r�i�l;'
me(Print) City,State,ZIP
_Sb c_vw-ezr1 Av< , g7Y5,S 7ci(gL (Lf1 i lJ6)l2 lS e-
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building'&. Owner-Occupied ❑ Repairs(s)A Altemtion(s)a Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2:t r�e vino �� ' c r f 23
s/ L'/{� �n/ n`�N/S' F✓�2 COG`✓) 1✓i :-II 3 VIA ` :,N,'I'S re f u LT ?L'✓.✓r kRl
SECTION 4: ESTIMATED CONSTRUCTION COSTS '
Estimated Costs:
Item Official Use Only
Labor and Materials)
I. Building S ;�(�, pep 1. Building Permit Fee:$ indicate how fee is determined:
Electrical pa'J v.
❑Standard City/Town Application Fee
$ ��.
- ❑Total Project.Costs(item 6)x multiplier x
3. Plumbing S 3>'puJ 2. Other Fees: $
4. Mechanical (HVAC) S g poo List:
5. iNlechanical (Fire S
Slit I Total All Fees:$
Check No. - Check Amount: Cash Amount
6. Total Project Cost: $ 1 3 r 0 e 3 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES !
5.1 Construction Supervisor License(CSL)
�ipV�1✓� i-�, �rin</ License Number Expiration Date I
Name of CSL [folder / �] List CSL Type(see below) Uh✓e
30
No. and Street Type Description
e Va J( /°'1+ e �,� r U Unrestricted(Buildings u to 35,000 cu. 11.)
1 R Restricted 1&2 Family Dwelling
Citylrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
)- SF Solid Fuel Burning Appliances
111/Z d4i�✓O✓kj CtCOrtc,}l tc.t7 I I Insulation
Telephone Email address D Demolition
5.2 Registe ed Home Improv �ment/Contractor(HIC)
by(4I�lf r WmO/�5 7
,C i-e. HIC Registration Number Expiration Date
HIC Company
3oNam eor.A Registrant Name
C✓try f4 e CozC-,-) ,. t.
Nam,and St et � Email address
is -IVZ� } oi61) F),Q � i 7 J11 Z-
Ci /Town, State,ZIP Telephone
SECTION 6: WORKERS'CONIPENSATION INSURANCE AFFIDAVIT'(M,G.L,c: 152.§ 250(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 isAuance of the building permit.
Signed Affidavit Attached? Yes ..........1&(_ No...........❑
SECTION 72:OWNER AUTHORIZATION TOBE.COMPLETED WHEN
OWNER'S AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT:
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.
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) 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 M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.L�ov;'= Information on the Construction Supervisor License can be found at www.ntnss.itov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 0 (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces 2 Number of bedrooms q
Number of bathrooms MRNumber of half/baths
Type of heating system 1 ✓tc-- Number of decks/porches
Type of cooling system Enclosed Open 6
3. "Total Project Square Footage"stay be substituted for"Total Project Cost'
J /a� CITY OF siu.l:.m LVL']SSACHUSET 1S
BL'ILDLNG DEPART'M&NT
aa� - y 120 WASHLNGTON STREET,3-FLOOR
TES. (918) 745-9595
Ruc(978) 740-9846
KIJ[DERL EY DRISCOLL TFioa4ts 5T.1?tEaR13
MAYO& DimuoR OF PUBLIC PROPERTY/Bt:ILDIING COSLMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
NamelBusina+yGrganiratiorvindividuul):
Address: 3Q �✓e s ��•� Ai'L
City/Statc/Zip:_ 3e`�(A�s /t — phoneM:
Are you an employer?Check the appropriate box: Type of project(required):
i.a l am es employer with 2- 4. ❑ I am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time).* have hired the sub-contractors
2.Ellam a sole proprietor or partner- listed on the attached.rhaot.t 7• (�}ttemadeling
ship and have no employees These subcontractors have a. ❑Demolition
working.fur me in an capacity. workers'comp.insurance.
Y P ry• ❑Building addition
(No workers'comp.insurance 5.'0 We are a corporation and its
required.) officers have exercised their IOr®Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I SPlumhing repairs or additions
myself.(No workers'camp. C. 152,$1(4),and we have no 12.(A-Roof repairs
insurance required.]t employees.[No workers, lJ.❑Other
comp insurancercquircd.j.
•Any appllcaM that chadn box 01 most also fill uui ihv sectloo below showing their waken'compensation policy inriamotlen
'I h"ttuaim"who,ubmit this uTldavit indleaing they an doing all work and thus him"tilde eontrunum marl submit a mnr arddavit indicting ruck
=(:nntrx um that chcslt this box meat attached on additlund shows showing the,name orthe subeantracton and their wurken'comp.pulley infosnotion.
1 um an employer drat is pravidbig workers'compeusadon btturance jar my employees. Barlow!x dre pollay and fob site
infonnudam
Insurance Company vane: I !-ayz�r-rS
Policy 4 ur Self-ins.Lic. 4: Los 1 SSAa- Expiration Date:
lab Site Address: Cily/Smtr/Zip:
,\tracts a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of,%,IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of STOP WORK ORDER and a line
of up to 5250.00 a day against ilia violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investiguiimts ut'lhe DIA Fur insurance coverage vcriticatiun.
/du hereby verrljy Wider r/ tut and penulliet ujperfury that flit hiforinutlon provided above is true and correct.
Si'nvurc•• iy Date: 07Y/J3
Phone,/, 1-78, ej�-7 I/ lz
OJficial use wily. Ou not write in thir arra,to be conrplered by city or town oJJlelat
It
City orTuwn: Permit/ .1censepLssainp Auillority(circle one):
1. Qoard of health 2. nuildintl Dulmrtmmat 3.City/rown Clerk 4. Electrical Inspector i. Plumbing Inspector
6.other —
Cuntact Person: _. Phone th
i
`rr CITY OF SAL.EM, N- ASSACHUSETTS
• BUILDDvG DEPART\tE.vT
N 130 WASIALNGTON STREET, 3" FLooit
TF.t. (978) 745-9595
Fax(978) 740-9846
KIMBER.LEY DRISCOLI
tii.'tYOR THo\[as ST.PtERAs
DIRECTOR OF PUBLIC PROPERTY/BCII.DDVG CO\12MnSSIONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting fromthis 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:
(name of hauler)
The debris
{will be disposed of in
(name of facility)
�Slti<,„ t�af R! . -'Oleo
(address of facility)
signature of permit applicant
date
s Ofrice fCon uncr fiIjjrsAu£iness Rcgura olion
HOME IMPROVEMENT CONTRACTOR r
-Registration 1, 1.51188 Type:
Expiration 5/23/2014
:HA TON WORKS ? `
RICHARD TURNER �t�'qy�
t 30 C4ESENT AVE� � �r /� �o
BEVERLY, MA'01915 i�-�-�,��' Undersecretary -
lk 'i
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
Cunstructiun Supen isor
License: CS-093798 `
ON, o
RICHARD H TFJ�tNER
30 CRESCEIWT AVER
BEVERLYIYJA 015 '+�' =,
i
enJ �t
Commissioner
Expiration
02/12/2074
,