15 ROSLYN ST - BUILDING INSPECTION /clo ? �
The Commonwealth of Massachusetts
/ Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7" edition Rev ed�anuary
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. Date Applied: O
Signature:
Building Co hMoner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
15 Roslyn S+ 5alern MA 01g7o
L l a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: IA Property Dimensions,
Zoning District Proposed Use Lot Area(sq tt) 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;R(On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.7 woe'' f Recor I
Nam ' Address for Service:
( ts)c1)
Sign Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:5 and T CiRWO
Brief Description of ProposedWurkZ: Install new replacement windows, 9ofhroQrn repair work
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:
❑Standard City/Town Application Fee
2.Electrical $ ❑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: $ 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
2i9oL 9 -3n- 11
David F. Tohnst6n License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below) LL
0" T Description
Address U Unrestricted to 35,000 Cu.Ft.
r� R Restricted]&2 Family Dwelling
Signature M Masonry Only
918 5 3 5 - 3128 RC Residential Routing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
-' D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
Tohnsfan fonsfruct-inn on Tnr 12 3 r Zy
HIC Company Name or HIC Regisham Name Registration Number
2 Rea Road Peabody MA o19Lo
Address i t - i t- i a
4111 686 -3 ZZ8 Expiration Date
Si elephone
SECTION 6:W RKERS'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, a, �t
�1 I )a um as Owner of the subject property hereby
autho ' to act on my behalf, in all matters
relati e o authorized y this building permit application.
(� lilln
Si weer _- Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of )
NOTES:
I. 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 I IO.R6 and I IO.RS,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"maybe substituted for"Total Project Cost"
Niassachusetts - Department of Public Safetc
A Board of Building Regulations and Standards -
' Construction Supervisor License -
License: CS 21906
Restricted to: 00
DAVID E JOHNSTON
2 REO RD
PEABODY, MA 01960
i
—� -� Expiration: 9/W/2011 -
(Lnunissim,cr Tr#: 3095
Board A.011n`g deg""ula"iio°,(S an'd tt.—'A':d�a License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 123124 Board of Building Regulations and Standards
WO
Expuatiom�-_1.2112/2010 Tr# 278545 One Ashburton Place Rm 1301
Boston,Mo.02108
Type: Private Corporation
JOHNSTON CONST CO,INC_.
DAVID JOHNSTON
2 REO RD r,
PEABODY,MA 01960 Administrator Not valid withou9si nature _
05/30/2002 14: 51 FAX 17815935412 CANON - fm 002/002
I', �'111'�I' -;�!•RR F ;� ,(IV� ^ jp +. ,'�t+ DATE(bwooK1
Th
The Douglas insurance Agency ON13 CERTIFICATE IS ISSUED AS A LY MATTEROF INFORMATION
AND CONFERS NO R1011T9 UPON THE CERTIFICATE
Lynnfield Woods Office Park HOLDER. THIS CERTIFICATE DOES NOT AMEND, EMNO OR
220 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Lynnfield, MA 07940 Broadway Suite #301 COMPANIES AFFORDING COVERAGE
iel M coSIVANY -"
- A Commerce Insurance Co.
Johnston Construction Co. COMPANY
B Travelers_Insurance Co_
2 REao Road I coMPANr—
Peabody, MA 01960 1 C
• I— •-- -�---
I cpNPrwr
D
ICOVERAGES '�,.:,.;,i,x' , , ,1' •: '. �'J. r. I .,. .. ,•i.;: -' ... ._.....
IF ..r.IR' L.• ', .
I :THIS IS TO CEP i IFV THAT THE POLICIES OF INSURANCE USTEOW BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWfTHSTANOINO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOOVMENT WITH RESRECI TO WHICH tHIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
E%CLNSION_S AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDVCEC BY PAID OLAIMS.
TYPE OF INSURANCE ROUCY C"FM FOUCY SEPARATSEPARATION ._. ... .. .1 ,rn � POIICT NUMFER WFE
_ DAY[(1164 I DATE IF11t'vDI UMI
GENE RAL'_IAB4Rr I GENERA.A03REOAT6 I l
__...1,OQO,000
�,COuu ERCgL OENEML LU8ILIT, - FROOUCTSH:GA•Fgv AGG 1 L QOD,DOD
A .__T CLA+uSMADE ❑ OCCUR JN9125 8120/09 8/20110 PERSOMII- AACVIr URY I L.000,000
_ Ow-E q'S E CONi Pg01 &ACHOCCVRRENCE 1 1.DOD,DOO
.. ._._._ FIRE OAAFABF IMF u�N.I I. 5D,DOO
M60 EAF IMY F'+PNRFA) l I
. AIRo.aelLf L:AwLm � ,
AN,Avto COMBINED 81NOLE LIu1 i
X ALL ONNEO AVTCS
000RY IWURY
A X stHEDvIeeAUros OOMMT16128 I 1 /1/09 11/1 /11 v.IP.wII `250,000
NONdWNFP WTO$ - 8OOILY INJURY
Ipr ROEJII 500,000
PROPERTY DAMAGE Y 100,000
cARACE IJAEIIJi,' AUTO DOILY Fw AOCIOENY
ANT AUTO --• -- .______.
'OTHER THAN AUTO CW/v _.
.. .._. .--. EACH ACCIDENT 1
AOOREaATE 1
E%C6 L6181f�TY -"
EACH OCCURREHOF I
wBpf LLA-FORM ' � i _pORFOATE- - {
OTNfR THAN UMBRELLA FORM .rtI
NORREO COMP6HAAT*"µO STATUTORY LIMR$
EAF%OYLAS UAFILT I ..._ y••..... .
THEPAWRIETOry NaI XHUB-3307T03-4-09 9/20/091 9120110 CCH EASAccIOER 1500,000
B FAgtNfAyE%ECU➢vE DISE_----- wR 1500,000
OFFICERS A E-` _-� E%CL I D15EASE EACH EMPLOYEE I �Q49__
O WEEP
I
�ESCRIFMriM 0OF OPERI itON(1pCATgNWE MCLLIDBFECJAL nLW -
Construction work at various locations
CERYIFICATE HOLDER CANCELLATION
City of Salem I SHDULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED 1161 THE
Salem, MA 01970 I FARRATION DATE THEREOF, THE 1141 COURANT MLL ENOFw VOA TO MA,
I PAYS Y% R HOME TO THE CERTIFICATE HOLDER FUMED TO THE LEPI
Iy BUT FAILURE TO IAL WCH WnCE SMALL MAOCI E W OGSp TN]N OR LIABILJ
. . ... . ....._.., ._- ..._... I ALftlNF E)!i4 OR REPRESEMTA1Ni5
.. . ... _. I RQ
BY A� Ili _.0 ACORD COR _.
A. ..,•, „ , A` TION 199D
ACpRD 25.5 (9193) I.... ._........_ . .... F cowAIRr.
JOHNSTON CONSTRUCTION CO., INC.
Two Reo Road
W. Peabody, Massachusetts 01960
(978) 535-3228
www.iohnstonconstructioninc.com
June 1, 2010
Cheri Gagnon
15 Roslyn Street
Salem, MA 01970
Description of Work: Install New Window and Bathroom Repair Work
Install thirteen new replacement windows.
Material: ...............................................................................$2,200.00
Labor: ..................................................................................$1,300.00
Repair bathroom floor, re-install new toilet.
Re-tile tube area.
Labor: ..................................................................................$1,100.00
Install new 6' kitchen cabinets, countertop and sink.
Labor: ..................................................................................$1,400.00
Rubbish Fees; (Allowance $250.00)
Total: ...................................................................................$6,000.00
I