The URL can be used to link to this page

3 ROSEDALE AVE - BUILDING INSPECTION (4) 'S":55 c-K --7 - The Commonwealth of Massachusetts t Board of Building Regulations and Standards R CE I"by OF Massachusetts State Building Code, 780 CMR INSPECTI NALSNeS Revised Mar 2 1 Building Permit Application To Construct,Repair,Renovate Or Demoh One-or Two-Family Dwelling Ibis 3 A S �. ` This Section For Official Use Only �— Building Permit Number: Date Appiie : (� Building Official(Print Name) Signature Da e ( SECTION I:SITE INFORMATION n 1.1 Pr�ertyo Add ems• 1 I 1.2 Assessors Map&Parcel Numbers V J fC c� �,P 1.1 a Is this an accepted street?yes ✓�no Map Number Parcel Number I ^ 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 1.6 Water So ply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: fY/ Zone: _ Outside Flood Zone?. Public Private❑ Check if yeses Municipale disposal system ❑ SECTION 2: PROPERTY OWNERSIIIP' 2.1 Owner'of Record: Name rmt) City, State,ZIP 3 92,P ?;/4 No.and Street Telephone Email Address - SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building,S( Owner-Occupiedl,1I_ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : rfiiiate ( :i ne 0 u: Su as W l o s �r a caC C SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials Official Use Only 1.Building $ y70 �j 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ /7(IV ❑Paid in Full ❑ Outstanding Balance Due: SETAo Z �AD , � � s16 A SECTION 5: CONSTRUCTION SERVICES 5.1 onstruction Supervisor/Lipense(CSL) �l O - 32— / t License Number E piration Date Name of CSL Holder /f List CSL Type(see below) -Pou Ua /'jJ/'C No.and Street Type" - Descnpuon _ U Unrestricted(Buildings up to 35,000 cu.ft. QC? Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry - �� RC Roofing Covering WS Window and Siding /� SF Solid Fuel Burning Appliances 7 �G 771 ebWy�11 I I Insulation Telephone Email address D Demolition 5.2 Re ist,e//re99d Homf Impovem t Contractor(HIC) Z HIC Registration umber Expiration Date HIC omp3�nny Name or HIS Regisnant Name )almd No.�/Street Email address SCL,wf� � C211G F7V 72/6 7V Ci /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"CONTRACTORR APPLIES FOR BUILDING PERMIT" /1 eln I,as Owner of the subject property,hereby authorize , , 1114 G do a.-J to act on my behalf,in all matters relative to work authorized by building permit application. Print wner'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 inpis application is true and accurate to the best of my knowledge and understanding. (12111 Print wnel'i or Authorized'Agent's Name(Electronic Signature) Date k ,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 can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dns 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 SaU.FNl, TUNSSACHUSETTS BUILDING DEPARTMENT • 120 WASHINGTON STREET,ate FLOOR aj TEL. (978)745-9S95 FAX(978)740-9846 KINiBERLEY DRISCOLL MAYOR THOM&S ST.PMM DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / +,��I � Please Print Legibly dame(BusirxsslOrganizatio ndivi )): / 71 �'/lGd%!/(9 W 111 Address: /" r� City/State/Zip: S' uT �� ©jg(L Phone #: 22eL / 2/ c Z?-a- Are you an employer?Check the appropriate box: Type of project(required): l.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 employees(full and/or part-time). • have hired the sub-contractors 6. ❑New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet: 7Remodeling ship and have no employees These sub-contractors have 8. U Demolition working for mein any capacity, workers'comp.insurance. 9• ❑Building addition (No workers'comp.insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions myself.[No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' l3.❑Other comp. insurance required.) •Any applicant that chocks box#1 must also fill out the section below slowing their workers'compensation policy infuriation t I Inmeuwnm who submit this affidavit indicating they ate doing all work and then him outride contnterers must submit a new affidavit indicating such :Commcwn that check this box most anached an additional shoes showing the name of the sub.eontmctors and their workess'comp,policy infermation. !am an employer that is providing workers'compensation hisurance jar my employee Below Is the poNcy and Jab site information. Insurance Company dame: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Aftach a copy of the workers'compensation polity 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 imprisonment,as well as civil penalties in the form 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 or the DIA for insurance coverage verification. I do hereby certify a der the pains aannd pena les aj rJury that the information provided above Is true and correec Sign t ire' �/ (�°2 Date: C�?O) Phone#: -77t0 2W 6 -7 7 tE Official use only. Do not write in this area,to be completed by city or town official City or Town: PermiHl.icense# Issuing Authority(circle one): 1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: CITY OF SM.EM, iNLkSSACHUSETTS • Bull.DLNG DEPART 1&NT 120 WASHNGTON STREET,r FLOOR 450.0 TEL. (978) 745-9595 FA..c(978) 740-9846 KISIBERL.EY DRISCOLL MAYOR THows ST.NERRs DIRECTOR OF PUBLIC PROPERTY/B121I.DING CONMSSIONER 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 hau er) The debris will be disposed of in A" s110� (1�0 V-�, (name of facility) n�50J p.s (address of fa ility) Lsignature of pe 't applicant S_��2°75— date debri,alr.dm 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen isor t & 2 Famih License: CSFA-056432 4 I{EITT1 A MACDOIVALD . 6 Genoa Avenue. % Jul Saugus MA 0190b �� ,v.y_.nN Expiration commissioner 08131/2016 ✓lie t0o7runcaiuue¢�i uo,✓Z�aneac/u�aetla Office of Consumer Affairs&B mess Regulation t HOME IMPROVEMENT CONTRACTOR II Registration: . �111834 Type: Expiration V4/2017 DBA KE T MACDONALD CARPENTER/WOODWORK KEITH MacDONALD 6 GENOA AVE SAUGUS,MA 01906 = Undersecretary