38 JAPONICA ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
WJ Massachusetts State Building Code, 780 CMR, 7 h edition OF SALEM
'l Revised January
nQ Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For OT&Cjil Use Only
Building Permit Numb I PraleApplied:
rSignature: �L} pry ��
• Building Commissioner/to ector of Buildings Date
SECTION 1: INFORMATION
IJ Prgperty Address: 1 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted street?yes no Map Ndinber 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
/57 '71" o '�
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 SewageDisposal System:
Public 5k Private❑ Zone: _ Outside Flood Zone? Municipal H/On site disposal system ❑
Check if yesul`_�_
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: � 3� J t cik �z_-t
�jCl[V� K iM i " C CaG'r
Name(Print) Address for Service:
CC978) - W5- wia3(
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : 073"f6" e ' S'' A-cfc(,-HcP% tU -WV kw4G IL Lt F-l-
5i 1� U4= horn�� Gn (Hr� L..�irhts� �n oncf Fk-IcF (34 ift<m-n �
e/ (9 eu
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ Mo, c. 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ W ❑ Standard City/Town Application Fee
9 coo ' ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ UUv• e" 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 41 a(JQ 1 a 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
7�-7 �3
5 2 ���,,,.��,¢.� Lci enseNumber Exp' tion ate
Name of CSL-Holder
� dZo x QCt9 '0P,%:4 e(kYW. List CSL Type(see below)
Address �- TyDe Description
Unrestricted(up to 35,000 Cu. Ft.
R Restricted 1&2 Family Dwelling
Si nature rR
Mason Only
(NO may- `f`1j Residential Roofin CoverinTelephone Residential Window and Sidin Residential Solid Fuel Burnin A liance Installation
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
WIC Company Name or HIC Regisifant Name Registration Number
(J
Addr(5ss
Vz" .)'/)y—�(�1� Expiration Dat&
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 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, 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.
Signature of Owner Date
SECTION 7b:OWNERS Oft AUTHORIZED AGENT DECLARATION
I, 77T, 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.
--Ca. L 7�, ---b�4 S
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of a '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 I0.R6 and I I O.RS,respectively.
2. When substantial work is planned provide the information below:
Total floors 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 haWbaths
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 &U EN19 �L�SS.ICHLSETTS
• BUl1.DI,2iG DEPART%CLNT
N 120 WASHINGTON STREET, Sao FLOOR
o�
� "I EL (9713) 745-9595
FAx 978 740-9846
KIxIBERLEY DRISCOLL
MAYOR THOMAS ST.PiERR&
DIAEC['OR OF PUBLIC PROPERTY/BUILDLNG COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print1Leeibly(�
Name (Busim-ss Organization/Individual): e / Ith 1—�C-t
Address: S `atio�aSS �g� WVF �U 7 Y0rAt
City/State/Zip: Phone d: C�
Are yo employer?Check the appropriate box: Type of project(required):
1.EY1 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.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. LNo workers' 13.❑Other
comp. insurance required.]
Any applicant that checks box 01 most also rill rut the section below slowing their workers'mmpensadon policy information.
*I lomeowners who submit this affidavit indicating they ate doing all work and that hire outside contactors must submit a new affidavit indicating such
:C'ontmlon that check this box most attached an additional ahem showing the name of the sub.eontractoa and their workea'comp.policy infomatios.
I am an employer that is providing workers'e'ompensadon hrsurance for my employees. Below Is the policy and job site
information. .
Insurance Company Name: r/
Policy#or Self-ins.Liic.`#: �lI"'�'/�O�Expiration Date:
Job Site Address: 3V 7U07/ CA .45y±22.& City/State/Zip: S4t"� ;4,4 06,2e3
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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonmem as well as civil penalties in the fort of a STOP WORK ORDER and a fine
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 cent! die pains and penalties of perjury that the information provided above is t e and correct
Sit,n.t ire• Date: S L3 IU
Phoned:
Oficial use only. Do not write in this area,to be completed by city or town ajrciat
City or Town: Permit/I.icense#
Issuing Authority (circle one):
I. Board of Health 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF S.- LEM. 1%LkSS.A.CHUSETTS
• BUILDLNG DEPARTMENT
• p 130 WASHLNGTON STREET, 3" FLOOR
'�'• T L (978) 745-9595
FAX(978) 740-9846
KINfBERLEY DRISCOLL
MAYOR THowS ST.PiERRH
DIRECTOR OF PUBLIC PROPERTY/BUMDQQG COJLUiSSIONER
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:
&)
(name of hauler)
The debris will be disposed of in :
/VIS�V� Q1S�o� G
(name of
facility)
(address of facility)
signature of Jpermit applicant
�f�3/ lU
date
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