28-30 ROSLYN ST - BUILDING INSPECTION t
The Commonwealth of Massachusetts
Ulfvtse Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7°edition ReO ALEMry
V 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 qum5erDate Applied: !
q
Signature: k G�
But mg Com issi Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: V 1.2 Assessors Map& Parcel Numbers
A0tA0.4l�v 6-15
L la Is this an accepted street?yeses no 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.
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record:
EsiseJA 5;!�- kNrA
N i t) / Address for Service:
JR) 3.34/d
Signature Telephone
S TION 3:DES ION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other a?Specify:TW-z;..;A rYi�.✓
Brief Description of Proposed Work 2:�N/Svl 4:1c if-
M
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ �0 U 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: $ /A\/
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 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
104tI7�I /
F AA 4yozM License Number Expiration Date
Name o� f CSL- �T��
List CSL Type(see below) (J
nZA 19Qb et<.S 1�:Gr k}wC Si7wJ
AwS -
N//-/ T Descri tion
U Unrestricted u to 35,000 Cu.Ft.R Restricted 1&2 Famil DwellinM Maso Onl RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Applianw Installation
D Residential Demolition
5.2 a iststered Home Improvement Contractor(MC)
' (/ AA Yarn-P Ia
HIC Com y ame or Hl egistrant Name Registration Number
ddries
Addres 10 "'Z 1 ZO/f
?C)O Expiration Date
S' Telephone
ECTION 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 .......... R'0' No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 45MIC, Cru!r e l2lc^, ip7 as Owner of the subject property hereby
authorize F to act on my behalf, in all matters
rel ' wcAk autho 'ze y is buildm permit application.
Si azure of wner Date
S CT ON 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
1, _S)r as Owner or Authorized Agent hereby declare
that the statements on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature rAu on dAgent Date
(Si ed under th airs and nalties
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 1 10.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"
' The Commonwealth ofMassaehusetts
Department of lndustrtal Accidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizadon/Individual):J`�J f(![J/
SecaSosa;si 411e9. --i
Address:_ ?o (Q6>o 8 q
City/State/Zip: Lavw w MA ®/ 1f0 41 Phone #: _7r% —Pi Yt(-4'G )O
F[No
mployer)Check the appropriate box: Type of project(required):
mployer with 7 4. ❑ I am a general contractor and I 6. El construction
es (full and/or part-time).* have hired the sub-contractors
le proprietor or partner- listed on the attached sheet.> 7. ❑Remodeling
have no employees These sub-contractors have 8. ❑Demolition
for me inany capacity. workers' comp. insurance. 9. ❑Building addition
kers' comp. insurance 5. ❑ We.are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per bfGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no
12.❑Roof repairs
insurance required.] t employees. workers' ,U j4
comp. insurance required.]
[�]
red.] 13. "lfthe r�
Any applicant that checks box XI most 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 anew affidavit indicating such.
iContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'camp.policy information.
I am an employer that is providing workers'co mpensadon insurance for my employees. Below is the policv and job site
information. �j M
Insurance Company Name: A 1 / 1 i� mou 1
Policy# or Self-ins. Lic. #: VWr 60Qg5_V Jl,7Q6/0 Expiration Date:
Job Site Address: ,$�3�—__,w31YE-4 I;;—' City/State/Zip:54A¢.," ✓+?:.¢ O! ')0
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereby eerti under the pains and penalties of perjury that the information provided above is true and correct
Si nature: Date: e7
Phone#:
F
l use only. Do not write in this area, to be completed by cig'or town official
r Town; PermitfLicense #
g Authority (circle one);
rd of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspectorer
ct Person: Phone #;
'S•cat � sah7-;wArG;a;e;g
Office oG Cnasumer nfPRets<m?iw¢va Ret,mPodon 1•ioemse Or registration validfor indivddul ase only
HOLE IMPROVEMENT CONTRACTOR before the expiration date. if found return tu: '
Regi9tr Son: 184564 OfBcc of Consumer Atfnirs end Business Rege�tati,in
Expiry dim IN211201,I "Pro 289821 10 Park P@sae-Suite 5170
iyp indiv'rJaoi Eiostun, MIA 02114
,,ErF:REY BRAY OT7E
_ JLrFRE'Y MAYOTTE
29 ANDREWS LN. __-
CAST KINC55"FCIN,fdM09827
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R.-shicI,i lu: 00 s, ,
JEFFREY MAYOTTE - a,
29 ANDREWS LN
EAST KINGSTON, NH 03827 �'
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09/20/201,022.10 17815955820 AMBROSE INSURANCE PAGE 02/02
ArX=TM CERTIFICATE OF LIABILITY INSURANCE � DATE( 1/201
?ODUC2R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
,i09E; InffiuranCEe Aganoy, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENO OR
56 Central Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
I,}R:TL, MA 01901 j !
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Lynn, MA 01904 I INSURER D ------ �e�
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ANY REQUIREMENT, SUR C CONDITION Of ANY CONTRACTOR ISED pCCUMESU SUBJECT
RESPECT TO WHICH THIS CF_RTI AND C MAY BE 13 OF S OR
' MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCR16ED HEREIN Ei SRBJECT TO ALL THE TP.RNIS, EXCLUSIONS AND CONDITh2N5 OF SUCH
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_
City DE Salem 814OULD ANY Or,THE ABOVE OSSCRIBEO PULICIES BG CANCELLED EEFORE T4E EAPIRATION
DkM THEREOF, THE ISsUINC INSURER WI.L ENDEAVOR TO MAIL 20 GAYS WRITTEN
City 8a11 t . : HuilClincT Dept. NOTICE 10 T{B CERTIFICA?E HOLDER NAMCD TO THE LEFT.PJT FAILURE TO OO SO SHALL
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Salem, MA 01470 I^y
REPRESENTATIVES, J p_
AUTHORRED P.EPRESENTAT,VG +-ry ::I� ,
COR025(2001/481 QACORD CORPORATION 1980