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31 ROSLYN ST - BUILDING INSPECTIONr � Tt3 -l`l— Zc� 1 -V ' 7S The Commonwealth of Massachusetts Board of Building Regulations and Standards -CITY OF Massachusetts State Building Code, 780 CMR - R yy`` 5E d Mar 2011 Building Permit Application To Construct,Repair,Renov EAVA h a One-or Two-Family Dwelling ;' ,0 This Section For Official Use Only Building Permit Number: Date Applie ICJ . Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address- 1.2 Assessors Map&Parcel Numbers 1.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information:2 -Yf-dM 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 Requred 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? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: Name(Print) City,State,ZIP 14 t"��12 5 ),7- v 0 o 1 No.and Street' Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Rep (s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work/2:: e nt at c k dJ r'S o Y 1 .S rA-rn i=C>C'7r 2 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ �j i3� 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: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ i� P Check No. Check Amount: Cash Amount: 6.Total Project Cost: U°`� 1?rb ❑Paid in Full ❑Outstanding Balance Due: IN P( P.kZ3,5 PEEP<C—S-C)tJ STr,rA� r�)E4T• �(� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor cease(CSL) Wilt , 1`, � License N6umber Ex�p{Irlattii Jn Date ate Name of CSL Holder l Litt b List CSL Type(see below) u F� �A IJVDMA-�� No.and Street Type Description (r_ r1 Unrestricted(Buildings u to 35,000 cu.ft. CityIT wn,State,ZIP R Restricted 1&2 FamilyDwelling M Masonry RC Roofing Covering WS Window and Siding d SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Hof/�e Improvement Contractor(HIC) & m-11 )� 1 Imo"',tMIJ '` rr HIC Registration Number Ex �(m"on(7Date HIC j�pany Npme or HIC ReTrant Name I IA mil No. $fret Email address , J I MA 6 9�f-7si Lq Ci /Town, tate,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..........01 No...........❑ SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize Z rmw ¢y/� to act on my behalf,in all matters relative to work authorized by this building permit application. Print O er's Name(Electrons ire) lTr) 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. ..� 4L-4z ro Print Owner'sAuthorized en Name(Electronic Signature) -l-Date NOTES: L M 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.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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" '�' I'Pc2 Nam- �� LNJrtot w Nome s Pt&©c. 4x _ loco Q Olt, -- =r C -_- __-- BU S :u 1-SS BuREau LAUGHLIN HOMES INC. � r�E�# Y554 925 - =`!0ER o= Co,u MERLE K;,;�n�,� r 9 Charles Street/P.O. Box 252 FED ID # 41-2365 Beverly Massac 15 WARREN PEA P.SOA CSL CS40995 (978) 922-5579 (978) 828-3979 cell Hie Lic. # 107999 J,{��0. PHONE /� �i �{,C✓G�/� -f �'lJ DATE .. JO AME JOB LOCA.� DATE OF P ANS JOB PHONE 23 Juy '-o �atione and esnmaies fF �� � -< SLS�—d �r % ...i�u✓' •�21..�1 .!. ... trS .Cc��!cC...S - � y."X.Y..'.�. .Y.��sf ..... � ✓ti� .<.C .i'c..�!... 4 !i./! G/'�/..CL/'�=.5. s,l.� ..:lL��/C.� �/ .-,j n � a �� '..C1 -,l�J` zrurt�c/ . .t � .... ... . ...... �:la:cQ..../e. /. ....c3 �-.Z� � ter.or _.. y. �s.�. . ..G ....=��/ ..�.�/�.�./.lr.✓r..Q.. t./L//GGIL:rJ.T� :� / CI':-/.%i�J''. (�l�/ f.7�21.e%✓f�../.T . �<•'..t.'....Ql�-.'.<..i�./.l�Gj .`jG."1.�C.�. .�LG.�{J�7 , r > ...Cn, � .... . . �."X s «l� �s .. /s!-t�W"?.�Z.. --/f�J:...V.6 I:..�7.4. .c�G./.�...�:t�?�yY<.. .� a ...... ......... 7C2..._4! Q 44.cif.... ....� CC�t/...5/G�....v/... ......... .................. // _2. .. -.lam i.0 S t. . .... .... .. ..... ... � a fc t 'rlc will begin: � Date work scheduled to be substantially c pletY e Trent Schedule: Initial Payment: illLTE `ez Payment 2: Payment 3, dueuponcompletionofcontract: GC.! Ii?! C-Q m6Ga�1¢ J - 'F lain rrr w"R that most hod,improvement contractors and subcontractors be registered with the Director of Home Improvement C ntractor Registration.Ynn mau t;cur_;,hmrf.a contractor registration by writing to the Director at One Ashburn Place,Room 1301.Boston,MA 02108 or by calling 61.7-727-3200 or 1-800-223-0033. rhr.<nnfraclor's obligation to obtain any and all necessa,contruction-related permits,should the owner secure their own contruction-related permits or deal with !:_Ftered cm tractors the nwner shall be excluded from access to the guaranbte fund. lnless nthenvise noted in this document.the contract shall not imply that any lien or other security interest has been placed on the residence. ptance ;:f Cor:tract DO NOT SIGN THIS CONTRACT IF THERF,ARE BLANK,S CES ca s and conditions are satisfactory 1 c r ce.Ye arc auth..... tQ de the worA Signior .Ii e nade as cudin abode./ / c -Ace. ncc71 Q ��'� ��� �._� _ Signature ;cav;anal this a;reement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main office or branch thereof,provided ilic 50ner in ruin_at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business dao Followimp _---t� ���� �,,'��� � � 4S�_-- � . _---� , �7 '--�, )� ��-� ,. ��``1 d� �1� �-` �� ,� ,r f � ♦i!. 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'1tM, ` .. ..'tit. :�t i a CITY OF siuy 1, NLXSSACHUSETTS BUILDING DEPAR-MENT 120 WASHINGTON STREET,3'FLOOR T EL- (978) 745-9595 FAX(978)740-98U KINiBERLEY DRISCOLL MAYOR THoMAs ST.P[ERRB DIRECTOR OF PUBLIC PROPERTY/BI'ILDING COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,,11 ���y��) Please Print Legibly Name(BusilxssOrganizatioNlndividual): 1 I Arrtrl Fe0b Address: I Sp �flfl �1 Na �rC o City/State/Zip: 01Yz ��4 „(A nlgO Phone +'/: g-7�r-7SQ � Are you an employer?Check the appropriate box: 1.® 1 am a employer with� 6. ❑4. ❑ I am a general contractor and 1 Type Nprojectew construction required): employees(full and/or part-time).' have hired the sub-contractors b 2.0 1 am a sole proprietor or partner- listed on the attached sheet 2 7. ❑Remodeling ship and have no employees' These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑ Building addition [No workers'comp. insurance S. El We are a corporation and its 10 Electrical re required.] officers have exercised their ❑ pairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees. [No workers' comp. insurance required.] 13.®0ther I1 . rah rCpe�r •Any applicant that chocks box#1 most also Gal Out the section below showing their workers'compensation policy infom+atioa ?I lnmeowaen who submit this affidavit indicating they ate doing all work and then hire outside contractors most submit a new affidavit indicting such :Conuaxors that check this box must anached an additional shed showing the name of this sub-contractors and their workers'comp,policy information. I am an employer that Is providing workers'compensadon insurance for my employees. Below Is the policy and job site information. Insurance Company dame: -Id+rel u Policy#or Self-ins.Lic.#:-- A, maul Expiration Date: 3I�b l s Job Site Address: 3] .nl�7Ta Ciry/State/Zip: 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. I do hereby certify under the pains and penalties of perjury that the informatlon provided above/is true and correct. Sirnitu Date' 16 ZII J Phone#: 4-v,-7it-M5 Official use only. Do not write in this urea,to be completed by city or town ofciaL 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#• i• w CITY OF S.0 ENI, 1 NSSACHUSETTS Bt1LDLNG DEPARTMENT �r 120 WASHNGTON STREET,Yo FLOOR TtL (978) 745-9595 FAX(978) 740-9846 Kls,IBERLEY DRISCOLL MAYOR T1 omm ST.PiERRs DIRECTOR OF PUBLIC PROPERTY/BCIIDING CONMRSSIONER Construction Debris Disposal 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 c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: V � (name of hauler) The debris will be disposed of in (name offacility) i P)� 5'iam (address of facility) signature�of�permit applicant Idai JcbriulrJuc