24 JAPONICA ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7 h edition OF SALEM
Revised January
�d1(f Building Permit Application Cons ct,Repair,Renovate Or Demolish a 1, 2008
J e- r Two-F mily Dwelling
is Section por OfficiAUse Only
Building Permit Number: Da Applied:
Signature: 4l • 1, I
Building CommissimiNkfmpec r Buil s Date
C :SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
s-r r- -2-
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 4 - 1.4 Property Dimensions:
IZZ 5rutitr FawltLy 71Zxi i n o
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(it)
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 Private❑ Check if yes6Y Municipal 18"On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
3Aco/ ,-,A sT. �n��rLi AV ai47()
Name Jr'nt) Address f Service:
q71.�'- J�i - a1R' 1
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building 91 Owner-Occupied 21 Repairs(s) Alteration(s) U1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': AVL/ 125
PNJ Ut a� L� 7�RZ�o A
lJI�Gi'�.Qjr T35GK�l�1� 1A)e-,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ S)090 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ DDd ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ is,pa0 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S Z�1 QBd 0 paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Rome 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. § 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.
Signature of Owner Date
,SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
I, 'rA IJ /r/{ GG UI.,t-.oUCzH ,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.
/1/lGG� oU H
Print Na
Signature of Owner or Authorized Agent Date r''
(Signed under the pains and penalties of 'u
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 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 I O.R6 and I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) .3 1-i7 D (including garage,finished basemenres,decks or porch)
Gross living area(Sq. Ft.) 33 0).(�_( Habitable room count��
Number of fireplaces D Number of bedrooms ra
Number of bathrooms 2 Number of half/baths /
Type of heating system 4,q" Number of decks/porches
Type of cooling system kJ Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Apri122, 2011
Mr. Tom McGrath
Assistant Building Inspector
City of Salem Inspectional Services
120 Washington St, 3rd Floor
Salem, MA 01970
Dear Mr. McGrath,
This letter is in regards to my request (as the owner) for a construction building permit
for the property at 24 Japonica Street, Salem MA 01970, parcel #26-0203. The scope of
the project will entail the renovation of the existing basement space and the installation of
a small kitchen and new full bathroom along with upgrades of the existing heating
system. The purpose of this renovation is to provide living space for the ease and comfort
of my elderly father-in-law in light of his numerous medical issues. I realize that the City
of Salem is concerned that these modifications to the home could allow for the potential
of a conversion to an illegal apartment as indicated by you on your site visit of 4/21/11.
This letter is intended as an affidavit to all concerned parties that we (Sean & Melissa
McCullough) will not use the modified space as a rental property and will legally
maintain the status as a single family home.
Thank you for your time and consideration in this matter,
Sincerely, /V
V""
Sean McCullough
24 Japonica Street
Salem, MA 01970
978-594-0181
The Commonwealth of aattsohuietli
on tip. ?S mr w
20 U
MC
appeared before me,and proved me L
9"actoy - of idenUacetidn,which were
to be 0e whose name ie signed on the Pr or
t in my preeerrce
attached _
MOWN
m ssan xpees -
DAISY FAMILIA
No Public
Up
Notary ommon tar of Massachusetts
My commission Expires
January 26,2012
CITY OF SMXL %vi
PUBLIC PROPERTY
DEPARTMENT
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HOMEOWNER LICLNSE EXEMPTION
P1ew Met
Data z r/
lob Location 2 .=EgmtG,4 t> , SALFM "A 61,I70
Home Owner Address ZY F,,ON -9r. G /UO&A /
Home Owner Telephone 7�s- RL! -tilts
preset Madding Address S g ZZ PQA1leA jTg(i <,44aM AIX aler70
The current exemption of"Homeowner"was extended to inchtds owners-occupied
dwellings of two Units or leas and to Aow such homeowner to engage an individual for
hire who dos not posses a lied=%provided that the owner acts as superAsor.
DEFINMON OF HOMEOWNER
Person(s) wbo owns a peed*find on wideh he/she resides or Intends to retldd6 on
which there is, or is intended to ba6 a one or two dtm ft dwellings attached or daubed
stnsctures accessory to such use and/or farm structures. A person who consttucta more
than one home in a two year period shall not be considered a homeowner. Such
"Imnoo*mw"shaft submit to the Building Ot®ciA on a forrm acceptable w the Building
OtllciaL 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 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
will comply with said procedure semen011,
HOMEOWNERS SiGNATL'RE y` S��dN .vI�Gc�yt�su�y
APPROVAL OF BUILDING INSPECTOR
See other side for state code
CITY OF S.0 E.NI, NLxSS.ACHUSETTS
• BUILDLNG DEPART%I&NT
120 WASHLNGTON STREET,P FLOOR
TEL (978) 745-959S
FAX(978) 740-9846
KISCBER FY DR.ISCOLL
T
MAYOR }touAs ST.PtERxB
DIRECTOR OF PUBLIC PROPERTY/BUnALNG CONWI55IONER
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 111.5
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:
F3P iZEMoV�LS
(name of hauler)
The debris will be disposed of in
N �ssAr0J
(name of facility)
Z q7 &904 9�AZ,4=;E t l yNN �,tq
(address of facility)
sign re of permit applicant
date
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