4 ROSLYN ST - BUILDING INSPECTION .,
-r - � -7 �P
�
The Commonwealth of Massachusetts- RECEIVED
Board of Building Regulations and Sta CTIMAL $mR I% &CIO ALITY
Massachusetts State Building Code, 780 CMRedition USE
' - Building Permit Application To Construct,Repair, Reno(0c Ji lis0a 3bdsed January
r One- or Two-Family Dwelling 1, 2008
•. This Section For Official Use Only
�.. Building Permit Number• Date Applied �f
< Signature: /ImLl
Building Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Addr 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes_Lo�ono Map Number 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
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑- Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' '
2.1 Owvr'of Recp rd: 0
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': ! i, tln . —e
il/Llei �YOGF
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑:Total Project Cost'(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: $ �S/ fX�G• ❑Paid in Full ❑ Outstanding Balance Due:
WS V 1 l 118 Cok t-tan L, V -U .
o/ � - sit,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed ConstructiotiZSupe'rvisor(CSL) �/�
t '��Ir) l�tl�1� ` �3 Y
t/ L,(� �
� License Number Expiration Date
Name of CSL-Holder r;trsbf List CSL Type(see below)
Address ���-J�— Type � Description
/�� !'/��5� U Unrestricted(u to 35,000 Cu.Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
, C— / SF Residential Solid Fuel BurningAppliance Installation
J D Residential Demolition
5.2 Registered Hoilre Im rove/Wlgent Contractor($ICLL `
,1 /
HIC Company N ame snan�amen l7 Registration Number
Ad ress OK
Expiration Date
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 of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TOBE COMPLETED WHEN
: -
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT "
I, ' U C! (L G as Owner of the subject property'hereby
authorize to act on my behalf, in;all matters
relative to work authorized by this building permit cation.
Signature of Owner Date
SECTION 7bt` WNE '.OR AUTHORIZED AGENT DECLARATION'
.__.. `
I, G 6s-, ,as Owner or Authorized Agent hereby declare
that the statements and informati n on the foregoing application are true and accurate,to the best of my knowledge and
behalf. /Print Name
/ o
Signature of Owner o Authorize t Date
(Signed under the pains and penalties ofperjury)
NOTES. s
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 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"