2 JAPONICA AVE - BUILDING INSPECTION 0,1,Y (,)I
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PUBLIC PROJTAT�
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APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT
ALL STRUCTURES EXCEPT I AND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE INFORM�YO�
Location Name 4AOOrBuilding
Map# I
Property Address
Located in: Conservation Area Y/N Historic district Y/N
Use Groups
(check one)
Residential(3 or more Units) P-2
Type of improvement Residential (hotel/motel RI —
(check one) Assembly(churches) Al —New Building Assembly(nightclubs etc) A2—Addition Assembly(restaurants, recreation) A3—Alteration V- Business B
Repair/Replacement Educational E
Demolition— Factory(moderate hazard) F1 —Move/Relocate Factory (low hazard) F2—Foundation Only High Hazard If—
Accessory Building Institutional (residential care) 11 —
Other(describe) Institutional(incapacitated) 12—Institutional(restrained) 13
Mercantile M
Storage(moderate hazard) Sl
Storage(low hazard) S2—
OWNERS111P UNFORMA'I ION(Please type or Print Clearly)
OWNER Name
Address
Telephone
MSCRIP FJON OF WORK TO HE PERFORMED
ESTIMA FED CONSTRUCTION COST
^ G 1
Y
CONTRACTOR INFORMATION
Name
Address
Telephone
Construction Supervisor's Lic #
Home Improvement Contractor#
ARCHITECT/ENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Residential est. cost x $7/$1,000 + $5.00 =
Commercial est. cost x $11/$1,000 + $5.00=
COMMENTS _
The undersigned does hereby attest that all information: stated above is true to the best
of my knowledge under the penalties of perjur
Signe Date
��
CITY OF SALEM
�y
ri 1 PUBLIC PROPRERTY
a - ,' .
DEPARTMENT
III /'3 '4i I �x 1,78.'4:'1i4„
Construction Debris Disposal .affidavit
(reyuircd li,r all demolition and tvnovation work)
In accordance ith the sixth edition of the State Building Code, 7S0 Cb1R section I 11.5
Debris, and the provisions of MGL e 40, S 54;
Duiidins Permit At is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
(narne of hauler)
The debris will be disposed of in
(name ul facility) -
luddre�<uf I]cilily, -
is o(pcnnit .applicant
dale
CITY OF S.UEM
PUBLIC PROPERTY
DEPARTMENT
ENT
MAw. 130 VA"NUM"S7=n.UuK MAnAoas M 01970
nm.9'L745-95"•FAx 97a.74&9"
HOMEOWNER LICENSE EXE.MFnON
Pies""t
Date /�ex
Job Location .2 .oaw r'e v
Horne Owner Address
Home Owns Telephone l7 7�� 79Y
Present Mailing Address -"4"f'C
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or lea and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) 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 dwellin&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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATL
APPROVAL OF BUILDCYG Z40SOPECTOR /2m
See other side for state code