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29 JAPONICA ST - BUILDING INSPECTION (6) The Commonwealth of Massachusetts ° OF A 1 Board of Building Regulations and Standards CITY M n Massachusetts State Building Code, 780 CMR SdMar 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: Date Applied: �ID 4,wK C� - lam' t� Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 29 Japonica St 1.1 a Is this an accepted street?yes X no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage III) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided r i 1.6 Water Supply: (M.G.L c.4Q, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public❑ _Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Christian & Sarah Murphy Salem, MA 01970 Name(Print) City,State,ZIP 29 Japonica St 978-335-2446 ehristian@apentee.com No.and Street Telephone Email Address - SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction ❑lgiing Building 0 Owner-Occupied Repairs(s) ❑ I Alteration(s) EI I Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work':Demolish bathroom down to studs and install now bathroom. Replace; rafter ties above bathroom which require replacing partial ceiling in adjacent bedroom. SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $2000 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $500 ❑Total Project Costa(Item 6)x nutiltiplier x 3. Plumbing $2500 2. Other Fees: $ 4. Mechanical (I VAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $5000 0 Paid in Full ❑ Outstanding Balance Due: SECTION 5: 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 M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) H HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date 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 1,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: OWNEW 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. Christian Murphy 6/1 6120 1 5 Print Owner's or Authorized Agent's Name(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. 142A. Other important information on the HIC Program can be found at www.mass.eoy/oca Information on the Construction Supervisor License can be found at www.mass.1=o- v., /dos 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 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 SM EM, 1+'WSACHLSETTS BU'II.DLNG DEPARTNtENT • + 120 WASHINGTON STREET,3"FLOOR \ TEL (978)745-9595 FAX(978)740-9W KI\fBF1tI EY DRISCOLL MAYOR T1iOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BU'II.DING COyLvnsSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leldbly Name(Business:Organaaziowlmtividmi): Christian Murphy Address: ?9 Japonica St City/State/Zip: Salem, MA 01970 Phone#: 978-335-244(3 Are you an employer?Check the appropriate box: Type or project(required): l.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.: 7. Q Remodeling �. ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp..insurance. Y P tY� 9. Q Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its !0.❑ Electrical repairs or additions required.] officers have exercised their 3.© 1 am a homeowner doing all work right of exemption per MGL I t.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.LNo workers' comp.insurance required.] (3.❑Other Any applicaint that checks box al] must also till Out the section below showing their twxken'oxxnpenaatwn polity information. 'I k rpm wnas who submit this affidavit indicating they ace doing all work and than hire outside contractors must submit a new affidavit indicating such. -COmmetmv that check this box must attached an additioml sheet showing the name of the sub-cm uactom and their workM'a»np.policy informotioa. I am an employer that is providing workers'compensado s insurance for my employees. Below is the policy and Job site information. Insurance Company Name: Policy B or Self-ins.Lie.#: Expiration Date: Job Site Address: City/Staw/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration hate). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonmcnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I de hereby Gerd under the pains aandd�penaJl ies of perjury that the information provided above is true and correct. Sienature: �d!/✓�iDt—�/ Date: Phone#: '17$— 3 3 S-241,i6 OJJ:cial use only. Do not write in this area,to be cotapleted by city or town oftiriaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person• Phone#: CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT` 120 WASFIINGTON STREET,3R FLOOR T-�L. (978) 745-9595 FAX(978)740-9846 KIMBERL.EY DRISCOLL MAYOR TrTOMAS ST.PIERRE DIRECTOR OF PUBTdC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date G1. JobLocation� Sable, *�4' /�070 Home Owner Address �-5 J�Oaw Ya S� Ste% nih o/92d Present Mailing Address Sam The current exemption of"Homeowners" was extended to"include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire that does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)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 dwelling, 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 understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING INSPECTOR �rw G1 TY OF SALEM, MASSAa iUSE M BUILDING DEPARTb1ENT 120 WASEENGTONSTREET,3'DFLOOR TkL.(978)745-9595 KRaERLEYDRISCOLL FAX(978)740-9846 MAYOR THOMnS ST.PIERRE DIRECTOROPPUBmcPROPERTY/Bu[ DINGomms$IONER 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 c40, S 54; Building Permit IY iis issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: W�S7� �G�n.tcey-� (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) 4 Signature of applicant Date l