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