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2 ROSLYN ST - BUILDING INSPECTION Ck loS3 The Commonwealth of Massachusetts INSPECTI NALt^yE^Rq�E$ Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR ( 2 / sir 1 YJ 10,4 N�V i �'� Building Permit Application To Construct, Repair, Renovate Or Demo Ish One-or Two-Family Dwelling This Section For OttM se Only Building Permit Number. Date Applied Building Official(Print Name). Signature . . Dal )• SECTION 1:SITE INFORb1ATION' 1.1 Property Address: 1.2 Assessors dr: Parcel Numbers � �uL T rDU Sr�1��, � Ma Number Parcel Number I.1 a Is this an accepted street?yes no p 1.3 Zoning Information: IA Property Dimensions: Loning District Proposed Use Lot Area(sq ill Frontage(11) 1.5 Building Setbacks Front Yard Side Yards Rear Yard Require Provide) Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewagepfsposal System: f3� Private❑ Zone: _ Outside Flood ZoneT Municipal On site disposal system ❑ Public Check if es❑ SECTION 2: PROPERTY OWNERSHIP, 2.1 Owner•0,Record:, 2 1�� G '7eurt S/ 0/7 /'))e%m 4,f 121 Rime(Pri t) City,State,ZIP o�„� si- e, :ar -22 66dG&2 yn�-de lil>fy11��Cnl L (am Wo.and Street Telephone —� E�Addresg SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ 1 Existing Building 1>'1`-Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.O Number of Units Other ❑ Specify: Brit (Description of Proposed Work : l / L SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials - I. Building S 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee- 2. Electrical SU,000 ❑Total Project Cost"(Item 6)x multiplier x 3. Plumbing S OcJ 1%9ther Fees: S 4. Mechanical (11VAC) S 0a D List: 5. Mechanical (Fire S Suppression) "fatal All Fees:S Check No. Check Amount: Cash Amount: 6. TuCnl Project Cost: .S y7/J 1 W . ❑Paid in Full ❑Outstanding Balance Due: G4a'l.l.tco t.A '1_1 A^ z' ,i SECTION 5: CONSTRUCTION SERVICES 5.1 Constructioit Supervisor License(CSL) e 5 l o 016 •��N�,,,,t � l I ! License Number E.epimtiun ate Z 6 ! Mane of CSL Holder List CSL Type(see below) 'fy a Description No.and Street .. Unrestricted Buildin s Lip to 35,000 cu. Il. 243 R Restricted )&2 Family Dwelling Etyrfown,Stale,ZIP \ M Masonry Roofinx Covering 02-176 WS Window and Siding /� SF Solid Fuel Burning Appliances 7�/ ;7/e`y t Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) �Q 6 y y h� // cJog� e6�/y j�JGT/O _ HIC Registration Number Espirut n Date HIC Company Name or 111C Registrant Name No. mid Street Email address .c'iti�E�d R� 7R/ �l�'/96� City/Town,/Town,State ZIP C Telephone SECTION 6:WORKERS' CID IJ ENSA ION INSURANCE AFFIDAVIT(M.C.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 Is3uance 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 t9 act on my behalf,in all matters relative to work authorized by this building p mit application. Print Owne 's None(Electrons ignatum) Dale SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION r 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. 21 / c, Print Owner' or Authorized Agent's Name(Electronic Signature).ri C Date A 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(IIIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program can be found at ieww mass cov Information on the Construction Supervisor License can be round at www.mass.nw!dns _ { 2. When substantial work is planned,provide the information below: 'total floor area(sq. ftJ. ~ .(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 fior"Total Project Cost" T° CITY OF S:UEM, , L-15S:1CHC:SETTS s ASBL'1LD1.tG DEP.ART(I;VT 3 § r�1 120 WHDJGTON STREET, 3-FLOOR �� TEL (978) 745-9595 FA:c(978) 7404846 Kj\jBEpj FY DRISCOLL �;�{,AYOR Trlobvs Sr.PIFl1RR DIRECTOR OF PUBLIC PROPERTY/BCQ.DI\IG CO\LMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlcians/Plutnbers Apnlicant Informatinn Please Print Leeibly / V:Ilnclflwit ssOrganiratinNlndividualJ: / /G//� Qw/� ( ffN C zf AZ _ Address: City/State/Zip: % 6 /�jPhone H: Zd / �;Oo Are you an employer?Check the appropriate box: 'type of project(required): I.(] I am a employer with 4. ❑ turn a general contractor and 1 6. ❑Ne construction employees(full and/or pan-time).• have hired the sub-contractors 7. emodelin 2.❑ I am a sole proprietor or partner- IisI�J �she attached shut. t � g ship and have no employees T e sub-contractors have S. 0 Demolition working Misr me in any capacity. vikers'comp. insurance. 9. 0 Building addition INo worker•'comp. insurance 5. , We are a corporation and its reyuired.) officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself. (No workers'comp. C. 152, §1(4),and we have no 12.0 Roorrepairs insurance required.) t employees. [No workers' 13.0 Other cuntp. insurance required.I •Any appliv:un dud checks bw el mutt also foil out the section W-ow showing their workers'mmpentudon puti.y intormaeon. 'I h,muuwtwn who whntli this Whtavit indicating they am doing all work and then hire outside cantmetma Most.mbmil a new afildavit indicting such. Cnntaotun tAut chalk Ibis be%most anachal an aQuIunul shirr showing the nano of the sub•conlracton and their woken'cutup.policy infurmotion. I unr ua raFpluyer that is pruvid/ni;tvorhers's• m�i©r�insuruueejot my employers Below/s the pollry midJab site iujarmulian. Insurance Company Name: C /(/C Policy fl or Scif-its, Lie./h p Expiration Date: /rib Site Address: � CSI�'V ST C'000, T City/Slate/Zip: rg70 ,kitsch a copy of the ivarkers'compensatlon policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 und/or one-year imprisonment,as well us civil penalties in the form of a STOP WORK ORDER and a line of up to S230.00 a day against the violator. Ile advised that a copy of this statement may be furwarded to the Office of Invesligaiiuns os'lhc DIA for insurance coverage verification. /do/rereby certify Frieder lite puler stud r ad/es of perjury thal the frtjaratullon provided above is true and correct. i mi� t c' Date: Phoned: Of/fciul use mtly. Do not wrile he this area,to be completed by city or loran n/ffrM City or"l'uwn: Permit/1.1censeH__._"___. Issuing Authority(circle one): 1. Board ul'llealth 2. Building Bepartutcut .1.('itytfnwn Clerk J. Electrical 6tspectur 5. Plnntbing Inspector 6. Oilier Contact Person: _ _ Phnnc a: _ i Massachusetts -Department of Public Safety Board of Building Regulations and Standards ',Eotistruction Supervisor License: CS-074857 JOHNTKELLY - 'f 17 LINDEN ROAD s MELROSE MA 6217 y �..� �Gtgc. Expiration Commissioner . ' 10/26/2016 cfTF�g'o� .u�lch _ryo Officeo(Coasomer Affairs&Business Regulation t, OME IMPROVEMENT CONTRACTOR - eglstrallon 129654 type: `F1xplFabon:4 10/1'472015 DBA " KELLY HOME CONSTR OJION_?l;' _ i �,. T .. i �I JOHN KELLY 17%LINDEN RD ° MELROSE,'IiAPv03]Z6Y ` ' Undersecretary QTY OF SALEM, MASSACHUSEM BUILDING DEPARTAENT -�� 120WASFBNGTON STREET,3" FLooR TEL. (978)745-9595 F KIMBERLEY DRIS�LL FAX(978) 740-9846 MAYOR THomAS ST.PIERRE DIRE croR 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 c40, 5 54; Building Permit a# 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: (name of hauler The debris will be disposed of in: S�L n, - dr �� (name of facil ty) P\ c)e'T11 = C� M E4 (addr s of facility) 4Sigture of pp icant f D to