18 JAPONICA ST - BUILDING INSPECTION 33 cif 4lo � /
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
J Massachusetts State Building Code, 780 CMR, 7'"edition
020111111111
/:� Building Dept
/,(v, Building Permit Application To Construct, Repair, Renovate Or Demolish a it:vomwkvm
\ One- or Ato-Famd.v Duelling
^� This Section For Official Use Only
v y { Building Permit Number Date Applied:
• `�
Signature:
Building Commissioner/Inspeesof of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address. t 1.2 Assesson Map& Parcel Numbers
L I a Is this an acce led street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks(D)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
Name(Print) ,C.JP \ Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OAlelal Use Only
Labor and Materials
I. Buildingoc_
f L f-r I. Building Permit Fee: S Indicate how fee is determined:
2. Electricalf ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbingf 2. Other Fees: S
4. .Mechanical ( S Lisa:
S Mechanical ( S
Suppression) Total All Fees: f
Check No. _Check Amount: Cash Amount:_
A. Total Projecs : S ❑ Paid in Full ❑Outstanding Balance Due
33 / ,T;/ _f o eA, r,, r ),
x
v
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Superisor(CSL)/ 7;%4
16!!/ �Z.
t, �, r (� e QQNumb.r Ee ir uon Date
N;Ime of CSL- Helder L TYPe bee bauw)3� �` Descri non
Unrestricted u to 35,000 Cu. Ft.)
Restricted 1&2 Famil Dwellin Mason Only
RC Residential Rooting Covering
Telephone WS Residential Window and Siding
5F Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Reglstered Home rnprovemeggt Contr�tor(HIC) / 3 P/,S
Ci►ris��.. L. Wl / i
HIC Company Name or HIC Registrant Name Registration Number
Addmae, � -W— 21s-4�4 i Expiration Date
Signatu 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 .......... No...........
or I
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.
Signature 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
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
1. 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 M 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.R5, respectively.
2. When substantial work is planned, provide the information below:
Total (loon 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 halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage'may he.uhmitutcd for 'Total Project Cosy'
t
' CITY OF SALEM
PUBLIC: PROPRERTY
DEPARTMENT
Ili v's.•t:. i:.,: • I �� •r'.r V: ;a..
Construction Debris Disposal .at'liclacit
ociluircd lirr all d>:molitiun :u1J rcnut.lUon %Volk)
In accordance rt ith'the sixth edition of the State Building Code, 780 C•AIR section I 1 1.5
Debris, and tltc prot'isiuns of NIGL c 40, S 54;
Building Permit )t is 11JtICd with ttte condition that the dchris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The debris will he traniported by:
I name of hauler)
I he debris will be disposed ofin
al—nira%'
owinr of 13.Ja.0
I.idJrr.. of Ira lllyl
l�
L'IIdI OI I' 01 p:nnu .ipplic�nl
-7/ a3/a s
,I:
CITY OF S.1I_EM, A-liSSACHUSETTS
BL'IIDLNIG DEEAR711&NT.�-
1_0 WASHINGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
K]\BF_RIBY DRISCOLL
MAYOR Tll nuST.Muts DIRECTOR OF PL BLIC PROPERTY/BU ILCILNG CMMUSSION EIt
Workers' Compensation Insurance Aflldavit: guilders/Contractors/Electrfcfans/Pfumbers
annlicant Information �, Please PrintLesiblr
Naine (9usinev Orpnizationlndsv,dual): Arse," Al, &,esZ
Address:
cily/staldzip: L A- Df&Phone #: :k(
Are you an employer!Cheek the appropriate box: Type of projecl(required):
I V1 am a employer with 0 4. 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.0 1 am a sole proprietor ar partner- listed on the attached sheet : 7• ❑ Remodeling
:hip and have no employees These sub-contractors have a. 0 Demolition
workingfor me in an capacity. workers'comp.instuance
Y P tY• 9. C] building addition
[No workers' comp. insurance S. 0 We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152,41(4),and we have no 12.0 Roof repairs
insurance required-] t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any applicant the!drab Ito%el mtul alwt fill out the sstien below showing their wurken'compaistakn pulley infatmadoa
'I Iswmeuwrnen who submit this aflldrvin indicting they an doing all work and then him outride contrscmts nttta submit a row of den it indicating otelk
<•.nua,•to ,thin cheek this box mud anaehd an addisiwwd altst showing On name of the sub. i siare and their wodene'c mp.policy infwmati m,
I am an employer that&providing'workers'compensation Insuroace for my employees. Below Is the polley and Job 514*
injormution.
Insurance Company Name:
Policy #or Self-ins. Lic.#: Expiration Date-
job Site Address: City/State/Zip:
,%ttacb a copy of the workers'compensation policy declarstbm page(showing the policy number and explrsdam date).
Failure to sceure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to 51.500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a free
of up to 5230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of -
Inccangatiuntt ol'Ihe D►A for insurance coverage verification.
l do hereby certify under the pains and penalties ajpn/ury that the information provided above is true and carreea
�rennurc: Dune:
P wnc 4:
iOfrial use only. Do not write in this area, whir.umpleted by city or town rt/jlciaL
I
City or fuwa: eermidUcense
i
Lsuing Aulhonly (Circle unc): - -- - —_
I. Board of llrullh 2. Nuilding Department 1. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. 01 her _.
l,alucl Person: _ _ ._. ___ Phone#: