180 OCEAN AVE W - BUILDING INSPECTION 2- S� CK, i o03
The Commonwealth of Massachusetts INS P AL SERVICES
Board of Building Regulations and Standards SALEM
q � Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish ja 3' 32
One-or Two-Family Dwelling
n This Section For-Official Use Only
r Building PermitNumber Date Applied:
Duilding Otticial(Print Name) Signature: Date
L�J4 SECTION 1:SITE INFORMATION
I,y 1.1 Property Address: 1.2 Assessors Alap& Parcel Numbers
r Ma Number - Parcel Number
I.I a Is this an acce ted street?yes_ nUJ
o P
1.3 Zoning Information: IA Property Dimensions:
"Coning District Proposed Use Lot Area Is
t1) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yaiils Rear Yard -
Repired Provided Required Provided- Requited' " - Provided
-"Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System;'
Zone: _ Outride Flood Zone? MunicipalPo❑ On site die sol system (3Public❑ Private❑ Check If es❑
SECTION 2: PROPERTYOWNERSHW
2.1 Owner'of Record:
time ring _ M,/4r-
city,
I D Q prxA,) PyjA to 171.12HD '1 60 -'it du'
No.and Street Telephone Email Address
SECTION.3:DESCRIPTION OF PROPOSED WORK°(check all that apply)
New Construction O Existing Building❑ Owner-Occupied O Repairs(s) (3Alieration(s) O 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: ,�M �c A i �7 )S 1-k E
SECTION 4:ESTIMATED CONSTRUCTION COSTS
licnt Estimated Costs: - OfRefal Use Only
Labor and Materials
I. Building S ZS 1. Building Permit Fee:& Indicate how ree is determined:
❑Standard Cityrrown Application Fee
2. Electrical S ❑Total project cost'(Item 6)x multiplier s
3.Plumbing S P Qther Fees: S
4.Mechanical (HVAC) S List:
5.\lechanle11 (Fire S total All Fees:S
Stipprcssiat)
Check No. Check Amount: Cash Amount:
6.Tutu Project Cust S Z�j b r70 ❑Paid in Full 13 Outstanding Balance Due:
MAit.� rte 11. (D i2�15
SECTION 5: CONSTRUCTION SERVICES , (,
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Mulder List CSL Type(see below)
-Type - Description
No.and Street -
U Unrestricted(Buildings tip-to 35,000 cu.Il.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M ismay
RC Roolinit Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D I Demolition
5.2 Registered dome Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.attd Street Email address
Cit /Town State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I c.152.§2$C(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 Isivance of the building permit.
Signed Affidavit Attached? Yes ..........0 No...........O
SECTION lap OWNER AUTHORIZATION:TOBE COhIPLETED.W HEN.'
OWNERS AGENT OR CONT[tACTOR APPLIES FOR BUILDING PERMIT
1,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) Dale
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.
x C A-1 6- :1b DWIAS �� L20 i
Print Owner's or Authorized Agent's Name(Electronic Si ature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
knot registered inthe Home.Improvemenl Contractor(HIC)Program);will nu have access to the arbitration
program or guaranty fund under bI.G.L.c. 1412A.Other important mformanon on the HICProgramcan be-flown d at
ww.v.mass.cov:'oca Information on the Construction Supervisor License can be found at AAAAII ss.eov,'dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) N (including garage, finished basement/attics,decks or porch)
Gross living area(sq. fl.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
FE rot Projcct Square Footage'may be substituted for"'rural Project Cost"
QTY OF SALEM, MASSACHUSETTS
I BUILDING DEPARTMENT
~' 120 WASHINGTON STREET 3 FLOOR
TEL. (978) 745-9595
FAX(978)740-9846
KIMBERLEY DRISC DLL
MAYOR n-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ) 2 1 1� _) 20 1t
Job Location IUO.G�— �4 AvrV
Home Owner Address
Present Mailing Address t P 1 Y I J7 C) ) q D
The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that 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 "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements. `
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR