27 JAPONICA ST - BUILDING INSPECTION Fold �
fisBuilding Dept
The Commonwealth of Massachusetts
QBoard of Building Regulations and Standards Tom
t
t � Massachusetts State Building Code, 780 CMR, 7'"edition
Building Permit Application To Construct, Repair, Renovate Or Demolish a #
One- or Ato-Fund.' c mg
- This Section ForOAcial Y se O I
Building Permit Number:: '/n DaiopI
Signature: " . � - / �5
Building Commissioner/16fpector of Buildin s ate
SECTION KSITEIKFORMATION
I.1 oggrt ress: 1.2 Assessors Map& Parcel Numbers
I.]a 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(R)
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.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private El Zone: ❑ On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Or'of Record:
!#/ o g� awiC-!4
�a 1� 77 3�P
Name nnt) Address for Service:
_ �26`-7V5-- -2`7-33
i nature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)fie Aiteration(s) ❑ Addition E3Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work:
Ari m Ve
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OffIclal Use Only
Labor and Materials
1. Building 5 e D 1. Building Permit Fee: f Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) S List:
5. .Mechanical (Fire S
ression Total All Fees: S
Su
�OD1J Check No. _Check Amount: Cash Amount:
h. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
'' - Liceroc Number Expiration Date
r
N4roc u(CSL Helder List CSL Type(ace beluw)
L
T Descn tion
Address
U Unrestncted l(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwellin
Signature M Masonry Only
RC Residential Roofing Covering
TelephoneWS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
- Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 .......... ❑ No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. 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.
Si nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I, p� 4 /L) 11�0 rs& , 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. �d / r, 13
Print Name
Signature of Owner or Authorized Agent
Si ned under the pains and penalties of fu
NOTES:
I. An O7ch who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not ered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
progr guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Conson Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and I IO.RS, respectively..
2. Whetantial work is planned, provide the information below:
Total flooa(Sq. Ft.) (including garage, finished basement/attics.decks or porch)
Gross livia(Sq. Ft.) Habitable room count
Number olaces .Number of bedrooms
Number orooms Number of half/baths
Type of hsystem Number of decks/ porches
Type of csystem Enclosed Open
3. 'Total Project Square Footage' may he substituted for"Total Project Cost'
CITY OF S.UFENf
PUBLIC PROPERTY
DEPART74MENT
K1IUIFJILY rvwvv
WYOn 137 WAS UNG ON MEW•SQM NAZACHLSMS 01970
TEL 978.74S•9S" • FAz 97&740.9646
HOMEOWNER LICENSE EXEMPTION
Plesse Print
Date 11 / 0
Job Location 7 3f�ow, c� ST f<
Home Owner Address 77 "Tiofp --j cW ST S4
Home Owner Telephone 9-7 -7V- - Z-"3
Present Mailing Address70cm,i c49 57- 1444
The current exemption of"Homeowner"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowner to engage an individual for
hire 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 "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeownee'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
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
•,� ., ,: ...
III '1'8,'; \. `)'8.'4_ '1.14..
Construction Debris Disposal Affidavit
(rciluired fix all demolition and renovation woi k)
In accordance ttith the sixth edition of the State Building Code, 780 CNIR section 111,5
Dcbiis, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting front
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 he transported by:
,Ldw Ce 3a
I name Of haular)
I he debris will be disposed of in
lYI i)j1 ----
(namr ul facility)
laddrrs. of facllilvl � �
'1gualule UtI 111111 applicant
�� date