Loading...
8 ROSLYN ST - BUILDING INSPECTIONr 2S oo C4-Aa w The Commonwealth of Massachusetts RE&ff Board of Building Regulations and Standards ERV CE$ IMP CTII( A Massachusetts State Building Code,780 CMR Revised Mar 2077 Building Permit Application To Construct, Repair,Renovate Or Demolish 101 MAY IS A 3 0 9 One-or Two-Family Dwelling y.� This Section For Off ' l.Use Only Building Permit Number: Da[ Applied: 1 ^ Building Official(Print Name) Signature Date U ) SECTION 1:SITE INFORMATION I 1.1 rope70 A dress: 1.2 Assessors Map&Parcel Numbers r7S Vn 5'<- 1.1 a Is this an acc pted street?yes no Map Number Parcel Number h1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) 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 twnern of Record: 1 S � ®l y7 0 Name(Print) City,State,ZIP No.and Street I Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repans(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': b SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials 1.Buildingd tt1 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ a ❑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: $ ❑Paid in Full ❑Outstanding Balance Due: M �ILG70 3121 SECTION 5: CONSTRUCTION SERVICES =t 5.1 Construction Supervisor License(CSL) //;; '� .-- C5 1o.�6al f ,�. cyV o y u thl J -- License Number Expiration Date Name of CSL Holder V �� � List CSL Type(see below) No.and Street Tyae Description � U Unrestricted(Buildings u to 35,000 cu.ft.) G r/,' � r (S l 7 Restricted 1&2 Family Dwelling City/Town,S ate,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ISC r III,#-(WdW1W �"a1Ya taftsi' kl.if Registration stration Number x uahon Date vH�Col an dame y HIC Regis t Name �tt9d-'G it S'i'� �NpRl2® � /rl �cf'�✓tn��'y� off �O o7F 11 aG� Email address City/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 CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize Z'y zC/° 6000t>e<,i r"r to act on my behalf, ' all mat s relative to work authorized by this building permit application. c r r_Zf-- r t wner's Name(Electronic Signature Date SECTION 71:OWNER'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 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 ov/oca/oca Information on the Construction Supervisor License can be found at www.inass.gov/dps 2. When substantial work is planned,provide the information below: Total floor 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" 3/6/2015 3 : 55 : 35 PM 8618 11 02/02 I rrt ' CERTIFICATE OF LIABILITY INSURANCE °^o��15Y" CERTIFIICATE 0089 MOT AFFIRMATIVELMATTER OR OF INFORMATION AMENDYEXTEND NORRALfl3RTHTHE COVERAGEE APFPORDEOA BY THE POLICIES B9 BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A COORACT BETWEEN THE ISSUING I SURER(S), AUTHORIZED REPRESENTATIVE ORI PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the cortldoate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. NSUBROOAIIgNN 19 WAIVED eubJWA to the terms and conditions of the policy,co taln policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such andoreeme"s). PRODUCER 00303.001 CT CharlesA Sloe Agency Inc )• (7911631-oail fj Na. PO Box 0 1 Alec, Marblehead,MA 01945 IN.'e,pERlal AYFeRmaR COVPRenn . A.I.M.Mutual Insurance Company INSURED W H Goodwin Satesprisae P 0 Box 1396 VIRUSES Q Marblehead, L® 0194S INSURER F- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE,FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE y POUCYNUMBER M LIMITS GENERAL LIABILITY EACHOCCURRENCE $ T.0111ERCIALILITYGAL LIAB $ CLNMS.MADF OCCUR MEO ExP(AnV CAB pBreanl $ PERSONAL&ADVINJURY It GENERAL AGG REGA'rE I ENI-AGGREGATE LIMIT AFPUES PER PRODUCTS COMPIOPAGG S OLICY RO' OC AUTOMOBILE LIABILITY T ANY AUTO _ BODILYINAIRY(Pw pomm)' $ ALL OWNED SCHEDULED AUTOS AUTOS BOpLY INJURY(Per ntddnt) E HIRED AUTOS pU COV D $ LIMERELLA LIAa OCCUR EACH OCCURRENCE $ axe a LIgB CLAIMSMADE AGGREGATE I DED RETENrIC1N I.J. $ &*MVW X A CUTVE MM NIA AWC•d00-7g23969.2g15A 111/2018 111/2019 E'L'EACHACODENT $ 1,000,0g0,00 I(MAndMory InggNCHCd) E.L.DISEASE.EA EMP,.OYEE I 1,000,000.00 OE r1 VF9SPERATIO S Mow E1.1ISEASE.POUCYLIMIT $ 1,D00000.00 DESCRIPTION OP OPERA TIONSILOCATIONsV V611CLE11(ANSCHACCRO 101.AddidanBIRM4110 Saheduls,Irma.am.Irir Ifnd) ProoT of Coverage CERTIFICATE HOLDER CANCELLATION W H GOOdWn Enterprises PO 139E Marbleblo SHOULD ANY OF THE AGMCVSCM=POLICIES CANCELLED BEFORE head,MA 01945 THE EXPIRATION DATE THEREOF ED, WILL BB DUPAM D IN ACCORDANCE WITH THE POLMY PROVRWONS. AUTHORGIED REPR WTATNa �- ACORD25 (MOMS C fills+sBeNe � ) The ACORD name and logo are registered nlarss of ACORD 1601 CERTIFICATE OF LIABILITY INSURANCE DATE 03/05/201 MS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THE Ef1TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(ft AUTHORIZED EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. N SUBROGATION IS WANED, subject to e terms and condillons of the policy,certain policies may require an endorsement. A statement on this certificate doeslnot confer rights to the stlllmte folder In Neu of such endorsements. )UCER tp CA ACT D-JOHNSON INSURANCE AGENCY INC. PRONE 978 887-8304 FA -978-887-5517 DALE E.JOHNSON,AGENT E IL XUDREW;DALE-JOHNSONCcDFARM-FAMILY.CC-)M 7 GROVE ST.,SUITE 201 INSURER 8 AFFOROMO COVERAGE NAICA TOPSFIELD, MA 01983 MEURER A:FARM FAMILY CASUALTY INSURANCE RED INSURER Bt WH GOODWIN ENTERPRISES INSURERC: 8 ROSLYN STREET SALEM,MA 01970 INSURER O: INSURER E: INSURER F: VERAGES CERTIFICATE NUMBER: REVIMON NUMB R. 41S IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE Flon THE POLICY PERIOD DICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS 'RTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. TYPEOFINSU ANCE ADM SUM POLICY NUMBER POLICY FF POLICY EXP LIMITS X COMMERCIAL GENERAL LIABILITY 2001L6485 01/01/201501101/2016 EACH OCCURRENCE $ 1 000000 _ CLAIMS-MADE aOCCUR REMISES Meoxurtenc $ 100000 _ MED EXP(Any one person) $ 5000 PERSONAL A ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY❑JEOT ❑LOG PRODUCTS-COMWOP AGG $ 2,000,000 OTHER: $ Auro MOBILE LIABILITY 20D1052566A 01/05/201501/05/2016GOMBINEDEINGUE M $ ANY AUTO BODILY INJURY(Per person) $ 1000000 ALL OWNED SCHEDULED BODILY INJURY 1,000,000 AUTOS X SAUTOSCHEDULED (Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ 250,000 X UMBRELLA LIAB X I OCCUR 2001EI138 01/01/201501/01/2016 EACH OCCURRENCE $ 1000000 EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1 000000 DED RETENTION $ YVORKE119 COMP ENS Al N p O ANO E'MPI.OYERS•LUIBILITY Y/N Eq oFF1 BR/MREM�BOER EXo NU"ECUrNE ❑ N/A E.LEACHACGR)ENT $ It ca alory hr NH1 E.L.DISEASE-EA EMPLOYE tl Ye9 d"Raft under O S4IRIPTION OF OPERATIONS balm E.L DISEASE-POLICY LI IT $ '!RIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,ACdIUenMAeR,erya SchedUlP,may be attached If mare apace le"Iced) 3RIS REMOVAL, LANDSCAPE GARDENING, HERBICIDE/PESTICIDE APPLICATION, PAINTING-EXTERIOR, CARPENTRY, TREE 1NING, STREET CLEANING, RESIDENTIAL ROOFING TIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BEICANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FOR INSURANCE VERIFICATION PURPOSES ACCORDANCE WITH THE:POLICY PROVISION& AUTHORIZED REPRESENTATIVE �s tp ®1980-2014 ACORD CORPORATION. All rights reserved. RD 25(2014/01) The ACORD name and 1000 are reciatered marks of ACORD