19 JAPONICA ST - BUILDING INSPECTION (2) e y
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a,
One or Two Family Dwelling
°J 11 This$echon Foi Official Use Only %
Building Permit Number:,., Date plied", f
Building Official(Print Name) Date:
SECTION 1: SITE'INFORMA ON
1.1 Pro er Address: � 1.2 Assessors arcel Numbers
%y
1.la Is this an accepted street?yes ✓ no Ivfap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION;., PROPERTY OWNERSHIP''
2.1 Ownert of ReV
Name(Print) City,State,ZIP
=3 /078 7 ys q�,2
No. and Street / y J oCh g- Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK"(cbeck all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Cl Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': /ZEPt ACF T[ rca✓t d I'/ m o N . /z o .vT
1,0a C 1� '-,�f'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only„ ,
Labor and Materials
1. Building $ 1 Building Permit.Fee $ Indicate how fee is determined:
2. Electrical $ ❑.Standard City/Town Application Fee'
❑TotaP;Pro�ect CosY,(Item.6)xmulttphei. x
3. Plumbing $ 2 Other Fees. $
4. Mechanical (HVAC) S List x
5, \Mechanical (Fire
Su ression Total rill Fees: $
Check No. Check Amount Cash Amount'
6. Total Project Cost: S 5,0o, 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES ,
5.1 Construction Supervisor License (CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/Town, State, ZIP NI Nlasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Hone Improvement Contractor(HIC)
IIIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 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 ........... ❑
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERt 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.
--_Rrrat er's or Authorized Agent' ame(Electronic Signature) Date
NOTES:
I. 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 not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www.mass.,=ov%oca Information on the Construction Supervisor License can be found at www.mass.,ov cIps
2. When substantial work is planned, provide the information below:
Total floor 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 haWbaths
Type of heating system Number of decks/porches
Type of cooling system_ Enclosed Open
J, "Total Project ScImue Footage" may be substituted for"Total Project Cost"
CITY OF Sm.E.0
PUBLIC PROPERTY
DEPARTNIENT
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HOMEOWNER LICLNSL EXEJtI MON
Plow !Nett
Date /'/ ,-
job Loesdols / JA ' 0 A]% C L1i g 7 Ell A 1-t /yl
Home Owum Addrew
Home Owner Telepboee _ 979 7 V 5 Z
P vss tt Mailing Address /S _I A pn /,i I y A s-r
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of me Units or fees and to allow such homeowners to engage ao individual for
him who does not poems a license 4 provided that the owner acts w supesvfaw:
DEF124MON O/HOMEOWNER
Pawn(a) wbo owns a parcel o[faad on which hetshe resides or intends to resid@6 on
which there is, or is intended to bo, a one or two family dwef ,6 attached or detached
structarea accessory to such use and/or farm structures. A pawn who constructs more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"sW submit to the Building OQlci4 on a form acceptable to the Building
O�al. that he/she be responsible for all such work performed under the Building
t.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable bylaws 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
.viIf comply with said procedures and requirements.
HOMEOWNERS STGNAILRI
.APPROVAL OF SUILD NG LNSPECTOR
See other side for state code
• II
CITY OF Sa1I.E1\I, AxsSACHUSETTS
BL:imL\,G DEP1R—MENT
!�• 120 WASHINGTON STREET, 3' Rom
TEL (978) 745-9595
1-'Ar(978) 740-9846
KI5{BERLEY DRISCOLL
MAYORTHONtAS ST.PIFFpR DIRECTOR OF PUBLIC PROPERTY/BCILDLJG COJLMISSIONER
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 It 1.5
Debris, and the provisions of MGL c 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
111, S 150A.
The debris will be transported by:
(name of hauler) �—
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
dcbnsm CJ.x