The URL can be used to link to this page

25 JAPONICA ST - BUILDING INSPECTION 42— q The Commonwealth of Massachusetts jt►y Board of Building Regulations and Standards CITY OF �f 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 This Section For Official Use Only Building Permit Number: D to pplied: C f'! Building Official(Print Nagle)- - Si Date SECTION 1:SITE INFORMATION 1.1,Pronerty Address;, 1.2 Assessors Map&Parcel Numbers sS ,'Jr( On"c 0, S+ I.to Is this an acre ted street9 yes_G no Map Number Parcel Number 1.3 Zoning Information: 1A Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) 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: Public Er' Private❑ Zone: _ Outside Flood Zone? Municipal 0-15n site disposal system ❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Re Name(Print) City,State,ZIP o f JaPo n A C, S i- 36s3 No.and Street 0 1Telephone Email Address SECTION 3:DESCRH'TION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brie Descnption of Proposed Workt: 5 - fYP(ytC2 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ o �� 6 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ -01J. ,,j L Other Fees: $ /2J / 1 4.Mechanical (HVAC) $ Q 0 GlJ List: (�(s /� i Y 5.Mechanical (Fire $ Su ression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ a VL 05 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CY(0 d l ? Y _ < Ca 4- rRtJ�c.tJ t License Number Expi on Date Name of CSL Holder ) List CSL Type(see below) ll No and treet I Type Description U Unrestricted(Buildings up to 35,000 cu.ft. A �l J to R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding �l SF Solid Fuel Burning Appliances Cc6'J— 16�� ((a�.� Ssldu e° I Insulation Telephone Email address D Demolition 5.2 Registered Rome Improvement Contractor(HIC) a d ,5,�S— L L G0 4 lz A�4A - HIC Registration Number Expiration Date HIC Company Nam or HIC Registrant Name guy S�©arc® cov�, /� No. S 6 Email address �026 lLo�-2Gs�/.6� 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 1,as Owner of the subject property,hereby authorize S ES C6� AJAcJ4ey Z ) to act on my behalf,in all matters relative to work authorized by this building permit application. I rye, VykJo(vt4 (65 Print Owner's Name(Electronic Signature) ate SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information containedd''"this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hives 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 can be found at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF S.UFAI, NWSACHUSETTS BUILDING DEPART.%0NT r 120 WASHNGTON STREET, 3' FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KIJtBERLEY DRISCOLL MAYOR THoAuc ST.PwARB DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER 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: LLB S - w4 s� (name of hauler) The debris will be disposed of in : / (name of facility) CA"r 2 l'/ cSq (address of facility) signature of permit applicant date debriulTd(x i CITY OF S�U.&N4 2Nv'LkS&A CHLSETTS BUILDING DEPARTMENT ` 120 WASHINGTON STREET,3'a FLOOR TEL (978)745-9595 FAX(978)740-9846 KlmBFRIBY DRISCOLL MAYOR THONW ST.PMM DIRECTOR OF PUBLIC PROPERTY/BUILDING COM%MIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annilcant Information 1 Please Print Leeibly Name(Busime organintioN /rindividuw): S� t4<r+�Vl Address: `1 ��r400 4 City/State/Zip; P�� .a lil�f�JO 7G phone#: (p o 3 Are on an employer?Check the appropriate box: Type of project(required): 1.AI am a employer with '3 4. 0 I am a general contractor and 1 T New jestcons(required): employees(hill and/or part-time).* have hired the sub-contractors 6. 2.0 1 am a sole proprietor or partner- listed on the attached sheet: I. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition (No workers'comp.insurance 5. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself(No workers'comp. c. 152,§44),and we have no 12.21(foof repairs insurance required.]t employees.[No workers' 13.0 Other, COMP.insurance required.] Any applicam that checks box dl must nine,fin out the section below aborting their wotken'compensation policy inform"". •I Inmeownga who submit this affltYvh indicating they am doing all work and then hire outside comapm rs must introit a new anfdevit indicating web. :Commetom that check this box must attached an additional AM slowing the natn0 of the A&Mmraaen aM their wodxn'comp.policy inform on. lam as employer that is providing workers'compensation insurance for my employees; Below is the pocky and fob site information. Insurance Company Name: Policy#or Self--ins.Lie.#: c Expiration Date: a6 Job Site Address: � V G ,)A City/State/Zip:_ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of 1viGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the forth of a STOP WORK ORDER and a line of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under andpernarldes ofperfary that the informaBan provided above Is true and correct _ ion t rs' Dow Z/S phone 1: Ofcial use atdy. Do not write in this urea,to be completed by ctry or town n0kiat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person:____--- Phone#•