38 JAPONICA ST - BUILDING INSPECTION fhe Commonwealth of Massachusetts ECEIVTSERVICS
OF
WBoard of Building Regulations and �fkIDNALM
Massachusetts State Building Code, 2011
Building Permit Application To Construct, Repair, Regp rt &QQrt
One-or Two-Family Dwelling My u��
This Section For Official Use Only
v Building Permit Number: Date pplied
�GtD+r-i 1V/`i"
Building OlTicipl(Print Name). Signature . . Date
SECTION 1:SITE INFORMATIOW
L1 Property Address: �+ t.2 Assesson binp& Pnrcel Numbers
11V`1i` 3 53 Jet o v.
L l a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
_ "Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
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,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ClPublic❑ Private❑ — Check if es❑ P po y
SECTION2: PROPERTY OWNERSHIP,"
2.1 O vnert of Record:
T1r\Q VJ 5C::t .-\ V"\ 14 o k CI 10
NN me(Print) \ City,State,ZIP
38 )Qwe,, cca 5! c17fi -)H5'"31
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s)13 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work=:
Ijea4 i VIZo Sid �VAC'-c
a c
SECTION 4:ESTIDIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S ,O(�v 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier r
3. Plumbing $ �,Qther Fees: S
4.Mechanical (FIVAC) S List: 4
i.Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check Amount: Cash.\mount
6. Total Project Cost: S �p�O(.)0 0 Paid in Full ❑Oulstandhw Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL), 04:7") b
�y� ! ;.
t "),a 5 1✓-Z-�-.��S ✓ License Number Expiration Dale
Name of CSL Holder �� List CSL"type(see below) U
j l iev"" J Type - Description
No. and Street
W OidbD R Resuicted !&2 Family Dwelling
6tyfrown,Slate,"LIP M milsonry
RC Roofing Covering
WS Window andSidin
SF Solid Fuel Burning Appliances
r17 L4I Cluo 'low.V..-t ld leYtystete F'3; ,kt I I Insulation
Telephone nail address , c U I Demolition
5.2 Registered Home Improvement Contractor(HIC) 177-3 g63
_�$�eEQ B .) CL5 I VQ4. -,W l= 1 HIC Registration Number Expiration Date
III S�Comp;ay Name or HIC Registrar acne
Y U i3c>x 7_e) ii—
No.and SureQt Email address
.341 _� V"x to Oie'i7e� ci?8 '7 N.( I"70V
Cityfrown,State ZIP TAe hone
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 Ishuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... O
SECTION 7a:OWNER AUTHORIZATION:TO BE COIVIPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nome(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
Dy entering my na a below, 1 hereby atte nder the pains and penalties of perjury that all of the information
contained f this , lication is true and cc ra the best of my knowledge and understanding.
\a—
Print( s or Authorized Agent's Name(Glee nie 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 fro have access to the arbitration
program or guaranty fund under I.G.L.c. I42A. Other important information on the HIC Program can be found at
%vw.v mass eov'oca Information on the Construction Supervisor License can be Found at%vwvv.nms_i�wv!Jm .
2. When substantial work is planned, provide the information below:
'total floor area(sq. R.) `� .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/banns
Type of heating system - Number of decks/porches
Type of cooling system Enclose) Open_
1. "total Project Square Footage" may be;ubstituled tier"fora l Project Cost"
OTY OF SALEK MASSACHUSEM
BUIIAING DEPARTMENT
- - - 120_WASHINGTON STREET,YD FLOOR
_
TEL.(978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLICPROPERTy/BUILDING COMbIISSIONER
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# is 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:
M vv FfnSi c4 C (2av-+1,
(name of hauler)
The debris will be disposed of in:
JF
(name of facility)
(address of facility)
Signature of applicant
Date
` Q-I'Y OF SiULE.NI, ivL-1SSaCHUSETI-S
r BL•tt-Dwi;DEPARTJtEINT
120 NVASHLNGTON STREET, 3no FLOOR
—TEL (978) 745-9595 — -
F.,X(978) 7.10-98.36
)v.N(BFnI FY DRISCOL
`;Vf,1YOR TrlOnus ST.P1ERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatinu Please(Print Legibly
Name Inusitu.s Organiratio v'Intlivirlual): 1'�Ut( ,cam \5U i 1 G 1 yt C C 11CC�w�p cx� t r
Address: • C) �yX
City/State/Zip: S \e-- A 0At-4- o ag o Phoned: (2f ("700
Are you an employer?Check the appropriate box: 'rype of project(required):
I. 1 am a employer with 4. 0 I am a general contractor and i
6. New construction
- employees(full and/or part-time).* have hired the subcontractors
2.0 f am a sole proprietor or partner. listed on the attached sheet. t �• ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working tier me in any capacity. workers'comp. insurance. 9, 0 Building addition
INo 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, y 1(4),and we have no 12.❑ Roof repairs
insurance required.) f employees. (No workers' 13.�Other
cutup.insurance required.)
•Any applWarli that checks but el moat also rill out ore section belowshuwiag their waded campensadun policy information.
'I t omeuwnws who submit this atlldnvit indicating they are doing all work and Then him outcidecontnctms ,at submit a xv amdavit indicting such.
$wumcmn that check this butt must anwhai an additional sheet showing IN name orthe sub�vrttnclon and thelr widen,camp.policy information.
l unt an employer(hut is providing workers'cumpersadon Insurance for my employees. lrelow Is the pofley and fob site
injurnrurirn. 1-4
�.�A _
Insurance Company Nam 1
e: 1 '—L `! `J`V U`4
Policy 4 or Self-iris. Lie. 0: oy" Pm C_._ Expiration Data:. 3 —
Job Site Address: �' E .) atoo—dc4 a3t— City/Stau:/Zip: S(ed..., vtr A 0I5 `Io
Atlach a copy of the workers'compensation pulley declaration page(showing the policy number and explratloa data).
Failure to secure coverage as required under Suction 25A of SIGL e. 152 can lead to the imposition of criminal penalties of a
line up to SI.500.00 umVor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a find
Of up TO S250.00 a day against the violator. Ile advised that a copy of this statement may bo forwarded to the Office of
Invcstigmiunr ol'Ihd DIA for insurance coverage verilicaliun.
/do hereby certify under a pub, ud per rl.r of pe ry that the injuratwlats provided above is true and correct.
Phone,1: v I ou
a
Official use unly. Du not write in this area, robe cuurpleled by city or lawn n/f/elui
City Or Town: - -- _-- PermidlAcenseq__..-..__. ..----. . .---
lssulug Aulhurily (circle une):
I. Huard of Ileallh Z. Iluildlnq Ueparintem 1.Cilyfrutro clerk 4. Flectrical Inspector 5. Plumbing Lt.dpeewr I
b. Other
C°nlnct Verson:—