5 ROSLYN ST - BUILDING INSPECTION O
r RECEIVED
%'rhe Commonwealth of MassaelA CITY OF
Board of Building Regulations and Standards P q SALEM
Massachusetts State Building Code, 78ggjbl)�{iN q Revised,Nar 2011
r
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
[n Building Perin Number: Date Applied;
t
BuilJin6011icial(PrintName). Stgnattrro. '. Date
SECTION I:SITE INFORhIAT10N
S
1.1 Pr,qperry Ad dressy: 1- LZ Assessors Mnp di Parcel Numbers
5 K vs Fyn S I rPQT
L la Is this an accepted street?yes X no Map Number ' Parcel Number
L3 'Zoning Information: I.J Property Dimensions:
Zoning District Proposed - Lot Troa is
R) Frontage(R) .-
1.5 Building Setbacks(R)
Front Yard - Side Yards - Rear Yard
Required Provided -Requbed 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 O.On site disposal system ❑
6heck if es0 ..
SECTIONZ: PROPEKTyOWNERSHIP;
2.1 Ownerr of Record:
' S4rvd QPc be r4 , MA. (J1,'_50
.INthme(Print) 1 City,State,ZIP
—7(, .5+44e SlrlQ } �j' 7T? OSa3 �JS•essoc;<l�s llc®y�c�,;tc
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ Existing Buildings Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWork2: Rei-NcCle( 1 i �ctirnS G c b�}h� lx+i:C
ptja_kp £le,
rc ✓rl t b,�c' nyelkcA .
SECTION a:ESTIMATED CONSTRUCTION COSTS
hcm - Estimated Costs: Official Use Only
Labor and Materials)
I. building S �, cry I: Building Permit Fee:S Indicate how fee is determined:
Standard City/Town Application Fee
2. Electrical S Pam` ❑Total Project Cost'(item 6)s multiplier s - \
J. Plumbing S '-J.C> :C.c;v 2?Qther Fees: S
4.Mechanical (FIVAC) S List: '
5.Mechanical (Fire S Total All Fees:S
Suppression)
Check No. Check rlmount: Cash Amount:
6. Total Project Cost: S 7 S, oC,o ❑Paid in Full ❑Outstanding Balance Due:
7 \
' i4r'(SELbT:ION5: CONSTRUCTION SERVICES
5.1 Construction•S apervisor License(CSL)
John CC,V,�, r-Q y vi"T License Number Expiration Date
None of CSL Holder List CSL'rype(see below) ( /
Cf Type. - - - Description
No.and Street
U I Unrestricted(Buildings tip to 35,000 cu. 11.
Sc,1 ✓V\GI (�17CU R I Restricted 1&2 Family Dwelling
Cityfruwn,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
975--S3'c-cel,74 TJCGone C nt�a, col 1 Insulation
Telephone Email uldress y, I,oc:. �wv D Demolition
5.2 Registered tiome Improvement Contractor(HIC) I Sr a i ,ZS ckj 117
J 6 h h C--,Yh Y - HIC Registration Number Expiration Date
HIC Comp:my Nnme or t11C Registira Name -
N and Street 7fl-S _cli� Email address
tilt 0iCl70 9 cf
City/Town, State ZIP Tele hone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.G.c.151.§25C(Q).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Istuance of the building permit
Signed Affidavit Attached? Yes .......... No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED.W HEN'
OWNER'S AGENTOR 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 permit application.
Prin Oxmcr's Nano(Electronic ngnmum) 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 in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or art owner who hires an unregistered contractor
-_-(not registered in the Home Improvement Contractor(HIC) Pro ram ;will ne have access to the arbitration
g ) LU
-- - - - -it-inForm -
program or guaranty Fund under M.G.L.c. 142A.-Ot-her tmP arrant a—noon f eli1C1'ro g ob
ram can berownd aT- —- -
w%vw niass.eav'oca Information on the Construction Supervisor License can be found at www.ntas�
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) 's (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/batlns
Type of heating system Number of decks/porches
'type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted t'or^Total Project Cost"
07YOF SALEA MASSAa-REEM
Bu mDmGDEPAimaw
120 TASfMCTCNS7REET,3EDFLOOR
UL(978)745.9593,
PAX(978)740-9846
KIblBERIEYDRISODI.L
MAYOR 7kCMASSTAEM
DmEcroRarPuBucrRoPmy/sujLDma mamomm
Construction Debris Dispose/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 d 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:
� r L z ��S�.f� 1 •
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
Wrkers'
wwwmass.gov/dia
Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Orgaruzation/Individual);_
Address: G S-�
City/State/Zip: Cg I1'r /'1c,. oi47cj Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
LE]II employer with employees(full and/or part-time).* 7. ❑N W construction
2. I am a sole proprietor or partnership and have no employees working for in $, ✓[]Remodeling
any capacity.[No workers'comp.insurance required.]
3.�I am a homeowner doing all work myself[No workers'comp.insurance required.]t Y. ❑Demolition
4.�1 am a homeowner and will be hiring contractors to conduct all work on mproperty. I will 10 Building addition
Y
ensure that all contractors either have workers'compensation insurance or are sole I LEJ Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
5.❑I am a general contractor and 1 have hired the subcontractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance) 13.❑Roof repairs
6.�We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
.Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
[Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. /�
Insurance Company Name: R'.10
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: R Cis I yt!'� S-4 , City/State/Zip: Sg l W"N
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Si mature �"J... Date
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
g g receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
house having not more than three apartment
s and who resides therein,or the occupant of the
owner of a dwelling another
g dwelling house
or repair work on such d g
Hance construction
dwelling house of another who employs persons to do maintenance, eP
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia