9-11 OCEAN TERRACE - BUILDING INSPECTION ' rhe Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
I(7 hlassachuseus State Building Code. 780 CMR. 7'"edition OF SALLM
XerisetlJurrtxrrt'
IUI Building Permit Applitatiun'ro Construct, Repair,Renovate Or Demolish a
One-or Two-Fomilv Divelling
This Section For Official Use Only
Building Permit Nu er: Date Applied: '2 '2
Signature: Z� !
Building Cummissioderrap6cpr1of Buildings Date --
SECTION 1:SITE INFORMATION
I.1 Property Address: 1.2 Assessors Map At Parcel Numbers
`I- If GGe�w �
1.1a is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Ztuting District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(D)
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:
Zone: _ Outside Flood Zone?
Public fat' Private Q Check it' es❑ Municipal ClOnsite disposal system Q
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert f Record:
iff �lt o C��,�ko I-/l 4, Ce4 14,
Name(Print) Address for Service:
Ala+d-/Vew, IS V ?-8�S— lc �t
Signuture Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building Q Owner-Occupied Q 1 Repairs(s) Cl Altcration(s) Q Addition ❑
Demolition ❑ Accessory Bldg.13 Number of Units_ Other Q Specify:
Brief Description of Proposed Workr: p -!,t ri �✓ o/t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
L Building I. Building Permit Fee:S Indicate how ree is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost}(Item 6)x multiplier x
3. Plumbing S /✓ft — 2, Other Fees: S
4.Mechanical (IIVAC) S List:
5. Mechanical (Fire
Suppression) S Total All Fees:S
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S leA2N ❑Paid in Full ❑Outstanding Balance Due:
�Iknl �z� °�--(( 0�-�"✓�
SECTION S: CONSTRUCTION SERVICES
5,I Licensed Construction Supervisor(CSL) f .�; 7 p L ,' /-( -
J
_( _J o C-SPA 19 /J„�& l.ieense Number Expiration Date
Name of CSL. Ifolder List CSL f)pelice below)
a Al �ti/✓r$ C-<cr r, Description
rens j_ _ tt I orestricteai JLip to 35.000 Cu.Ft.)
,7 R Restricted 1&2 Family Ihsellin
'gnuture Ft Maven Only
P'7(,1,k5,5—& RC Residential Routing Co%crin
I'dephone WS ResiJentiai Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
1) 1 Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) f 2 f�3
I IIC Company Name or 111 Registrant Name Registration Number
Mossrd�/� t ao /r
A Jrcs .
E xpimuun )are
sig a ure "refephonr
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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..........❑ No...--...0
SECTION 7a:OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signal=torr of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, 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.
Print Name O//
Signature of owner or Authorised Agent !Pate
(Signed under the pains andpenalticsofperjury)
NOTES:
1. An Owner who obtains a building permit to Jo 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 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 !lours area(Sq. Ft.) 3 (including garage. finished basemcnUattics,decks or porch)
Gross living area(Sq. Ft.) Yeg 0 d, d 1labitable room count I S
Number of fireplaces 4A41ty Number of bedrooms
Number of bathrooms .3 Number ofhaiflboths
Type of heating system 3 Number of Jocks/porches
Type of cooling system Enclosed Open
3. "Tota) Project Square Footage'may he substituted for"Total Project Cost"
CITY OF S' .E.NI, NL-uSACHUSETTS
BLWLNG DEPAR-HENT
120 WMHLNGTON STRM. 3"'FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI\BERLEY DRISCOLL
MAYOR THOMAS ST.P11.1"
DIRECTOR OF PLBLIC PROPERTY/BI:UMLN.G CO\L%IMIOVER
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 1 l 1.5
Debris,and the provisions of MGL a 40, S 54;
Building Permit# 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
I 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
i (name of facility)
(addre s of facility)
signature of p��r
���O��
!late
Abn�1 ,x
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I N u cat I M WA\thMaU\5'i'xEbT s SAI t H,M.u\ar.I It it I IN Jt97.^,
ll•.i:)4713•9593 is F%x. 9 11.74- cat
Workers' Compensation insurance affidavit: builders/Contractorsik:lectricians/Plumbers
tioglicant information p �j 4!�/ Please Print Leribly
NatnCtiivataussiOrgamratioNMdavutvul}; ) 6 S,-",04 / 4,,
,Address: 4,1JLn2/1 A � V
City;Sratci/sip
Arc you an employer?Check the appropriate box: 'I'ypa of project(required):
4. t am a general contractor and t
1.❑ t am a employer with (). (3 New construction
cntployces(full antilor part-tine).• have hired the suh•contracwrs
?, �l"a{n a Tote pmpricutr or partner-
listed on the attached shcet. • J. ❑Remodeling
ship and have no empluycos These sub-contractors have S. ❑Demolition
working for me in any capacity, workers' comp. insurance. 9• ❑ Building addition
li I No worriers'camp. insurance 5. Cl We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ i ant a hoof owner doing ail work right of exemption per NIGL t I.❑ plumbing repairs car additions
myself. (No workers'comp. c. 152,q I(4),and we have no 12.C] Rtwt'repuirs
Insurance required.)t .mployccs.[No workeri 13.[]Other
comp. insurance rcquircd.J
•any xpphaaut that chucks b#01 must alga ilii caw the necuw{ttclaw showing their w•wkmi cunipunwaiws pulicy minrina;u
'1lumaowtwn who euumil this Affidavit indicating they are doing all work aur then him outside cpnrxtors must.uhmis a naw 4if4avit indicating awh.
d'ontrxnas Ihai check ibis bas must aaachud an addaimal A"l ou,wing the nano of tha sub.omractars and their wurkvnt'tromp.policy information.
t torr an emptoyar that Is pravidi"Ar]Porkers'compensation btsurauce jar my ourpioyees. Below is the pulky,and job site
hifornration. p <
Insurance Company Naine: V r2� V 1� e2! G d A,
Policy it or SciGins. Lic.rt: ._ . .._ Expiration Date:
lob Sitc Address: C'ityrSlate/ZIp:
.much it copy of list workers'coiniensatiun policy dceiaruiion pulse(showing the policy number and expiration date).
i'ailute tea secure covcntge as required uudcr Section 25R ot•.LIG1•c. 152 can lead to the imposition oteriminal penalties of a
tine up ro 51.5110.00 and/or wle•year iniprix.unnent, Js well as civil penalties in the loon of a STOP WORK ORDER and a fine
of tip to 5250.00 it day against tilt violator. !!c advia d that a copy uCthis slat meso may be forwarded to the Of Lice cat
lit\'da11gJ11011a of the DIA Ior nitnraiwe cover44L' curd rc Jhan,
!do hereby certify ander the pains and petudties u/perjury that the information provided abovir is true and correct
�t,•:,awre' -- —. � i;/- bate'
1'I: tsar � Tbfl
t)ficial use only. Do not write in this arra,to be cussipleted by city or town gJiciat
CRY or Dorn: Pvrtnitft.lceme is
litsuing.ituthorily(circle one): i
1. hoard of health 2. Iluili ing Department .1. t:ityi(•gnu Clerk 4. Electrical luspecror 5. Plumbing; Inspector
6. Other .— .--
C'satactMrsou:
Information and Instructions
.\fassachuseas General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this saatute,an rnrplt;rre is defined as"..,every person in the service of another under any contract of hire,
etpress or implied.oral or written."
An einplul,er is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
.+i the toregoing engaged in a joint enterprise,and including tht legal representatives of a deceased employer,or the
teceiver or trustee of,m individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
,Iwclling Iiuuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, 425C(6)also states that"every state or local licensing agency shalt withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, NIGL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please GII out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
:accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The atIldavit should
he returned to the city or town that the application for the pennit or license is being requested, not the Department of
industriul Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate Zinc.
City or Town Officials
Plcnse be sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom
of the affidavit for you to till not in the event the Office of Investigations has to contact you regarding the applicant.
I'Icax be sure to till in the permit/license numbur which will be used as a reference number. in addition,an applicant
that muss submit multiple pennitilicense applications in any given year,need only submit one affidavit indicating current
policy information of necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of.the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.c.it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lic rklice of investigations would tike to thank you in advance fur your cooperation and should you have.uty questions,
please du not hesitate to give us a call.
The Licpanmou's address, telephone and fax number
The Commonwealth of Massachusetts
Department of industrial Accidents
Me of Investigations
600 Washington Street
Boston, MA 02111
Tei, #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia