18 OCEAN TER - BUILDING INSPECTION l
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
I kµ { Massachusetts OF nua
EM
Mhetts State Building Code, 780 CMR, 7s edition
J Revised dJa Jwunry
Building Permit Application To Construct, Repair, Renovate Or Demolish a I• =/)ox
One-or Two-Fumily Dwelling
s Sect on For Official Onl
Building Permit Nu bee r: Date plied: 1
Signature: - J , `�'`t" ��a7 / /d
Building Commissioner/Inspect d Date
SEC 1 N 1:SITE INFORMATION
1.1 Property ddress: 1.2 Assess MaMaR reel Numbers
C/ Y
1.12 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 11) Frontage(11)
1.5 Building Setbacks III)
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 Sewage Disposal System:
Public Private❑ P �"1 po y Zone: _ Outside Flood Zone? Munici al Lyon site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) Address for Service:
O
Si a�gn Ca2— ~� Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building O I Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: ) J
4.Mechanical (IIVAC) S List:
5. Mechanical (Fire _S Total All Fees: S
Su ression
V Check No. Check Amount: Cash Amount:
6.Total Project Cost: S (/vt� ❑Paid in Full ❑Outstanding Balance Due:
00
r 1
)
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor /'YC' /{lA7C r �-� JU
d1 ' / o -� (I.iccnseGNum✓ber IisQpiratiun I ute
Name of C"L• ul /
S. n List C'SL'1'ype(see below)
.4JJ s T Description
Unrestricted u to 35,000 Cu.Ft.
���� Restricted l&2 FamilyDwelling
Signatt 7 W M Mason Only
CC// RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
3.2 Reg � dl1lrgQrove mC{ntra (HIC)Rn7o �rva � I/
I IIC CumpanmI egiltat Name egistralw'n N�umb�erN
Expiration Date
Signal Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 2SC(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 .......... O No...........13
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTgO/R� APPLIES FOR BUILDING PERMIT
1, <E (— y4 fQV -S 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.
' 25�2 �7, 2�1
Signature of Owner Date
n SECTION 7b:OWNEW O1R AUTHORIZED AGENT DECLARATION
V e5a5 'k VR �^y ,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. N
Q
Print Nam
Signature o ne Authorized Agent Date
(Signed on r he sins and nalties of 'u
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 Maj have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I 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"
i
r *
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
pit, "Mlv H I
I_'C�t'.,aufrl'v%4•JylyN •P�rc:vlt�+S/11M I .:I'�':
Construction Debris Disposal A17Mdavit
(required lur all demolition mul runuvaliun work)
790 CMR section 1 11.S
In accurd:Incc with the si_tlt edition of the State 13uilding Code,
Debris,and the provisions of MGL c 40,S 34;
is issued with the condition that the debris resulting from
ouilding Permit M—�; rl licertd�d waste disposal facility as defined by MGL c
I work shall he disposed of Ina grope Y
l 11. S I30A.
The debris will be transported by:
(nalrA Of Miller)
The debris will be disposed of in
to one i
a
to o l Iwrmit applicant
/,/,7hz) _
,late
r CITY OF S.U.E.N[, IONSSACHUSEM
BLMDLVG DPP.\RTMENT
120 W.13HMTON ST118R. Y FLOOR
TEL (979)745-9599
FAx(973) 740.98"
K).m®EJ"Y DRISCOLL -aw ASST-MRAs
yL/►YOl DIRSCroa OE PL sLIC PROPEhTY/K MDL% G CO-%L%oSStoa EA
Workers' Compenseltott Insurance Allldevit: Ouilders/ContractorviEloctriciansiPlumbers
aunlleant Information Meow FrintL.eiibly
vatne le„r,.e,.at,nrratiar.ln,r.rmL.n: —./mac %�J4,l�yYQ-/��
Address:
Cityistste/rp:� _ ,� Phone A 27b 92e - -L2
.\re yen as employee?Ckseb the appropriate boar 'typo of proiete(requlrea
1.4p� 1 arts a=player with -3 s. 0 1 me a getter tae s)comme and 1 K ❑Now conscrixWoe
"etnployeve(Adl and/or pan-tier).• have hired this at►srracsors
2.0 1 am a tela pmpries err Pmuwr�
listed on tea hsaehrd AkVL= y�RemaNling
,hip and have no employto Thor suk-coateeown have S.
Damolitiaa
worklng for me its any capacity. workers'comp`invarsom 9. ❑Duaity addWoe
I No workare'comp.insurance S. Owe am a carpondm Well is
onk'rs haw t cardsed their 10.0 Electrical repairs or ddiristr
3.C3r` o ri of MGL I L Plamin r additions
1 a am m a homeowner doing aU wont YM �►�par 0 bt+repairs c myself live workers'comp. C. 1 S2r L 101 Mod we have no 12.0 Roof repairs
insurance required.)► :mpl 3 ens iNe worYrs' U.❑Oeror
Comp6 insurance regsimdl
•her,trpter nen dww am Of MOM airs Its qa tlr reeen tarty M ft M*vn 'M'mtgree kw ptakey i.1t..ur.
't hwvarwww.le submit take aeldvis indleYq they an deft as wrtk ad then hlr.uriamaterwa rod snots a nor alerkek irdlaaiea M&
:(',err�trrradMv ttdW r.wr,a ar1eWa•sWriw•I.hr'Mt'aa.M~erlhe w►rennowere ad dhdr warren'damp.p ily:eareaWkO,
/am aft rtty(oyt►tAar k prdl/nK rnrRrrs'eenrprtnrdre/ fbr t4 ra'p/eptea Srtile d nkepa/ky aft/�e1 stir
insra.rriea 7 ;� �, C,
In,rrrrrtce Company.Name: �/'Q�l� - � v_ d
enlicy s dw Self•ins.Lie.M: Eapiratioa Dow. ,(�� J� J)
Jub Sire Address: x? / /��R J� e✓ City/StaWlip /�'' -e) 7
.\each a cop of the workers'compausdoe paltry dstbntbe pap(abewlag Ike palky sembw and esplrstlee dsaa)v
Failure to socun coverage an required under Salioo 2SA o(NGL e. 152 can lead to the imposition of criminal penalties of a
fine up to SI.500.00 and/or one-year imprisonmi nL as wall as civil penalties is the form are STOP WORK ORDER and a Qos
of up to 5230.o0 a day aQainat the violator. Ilo adviaud'hat a cup of this statement maybe forwarded to the 0171ce of
Invarrsmiuru ul'dte f71A fr inar✓anct coverage ra41f)caliarL
1,16 hereby aOMO enAer tee pei ve end yrwe/Nov%er/ory tAN tAe injraret/oe provi"t0ew is raw dnI earrra'a
•tntura pate
pare k
OQ/i'id ate mr/y: Oe n eke wrim ice this eras\to be•erep/efird eke r;y er,torn gla.iw
City or fume: _ ecrtnit/Licestee__
I%wint.\uthorrly(circle nne►: -
I. lluard u(Ilaaltb 1. 9uddlna Mpartmrns ). Citytfowo Clerk 1. Electrical lnrprctor 9. rlumbine Impecror
h. Other
l . rtaet renen: _ Phone 0•