33 ROSLYN - BUILDING INSPECTION ( � The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7`"edition Wilbraham
� Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
` One- or Two-Family Dwelling Ext 118
This Section For Official Use Only
Building Permit Numbe . Date Applied: D { J 0
Signature: 1
Building mmissioner/Inspector of Buildings Dat� '��7
SECTION t: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepte street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Propos 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 Z ?
Public Private❑ Check ifyesf�l Municipal Eg On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
Owner'of Re ord:
t t n 3 os I .►� S- .Ca,G t
N e( int) Address for Service:
Igna r Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units-2— Other ❑ Specify:
Brief Description of Proposed Work': rN of ) t44 d-c,-,e_na[ * `7 ,CrFx&
T
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 7 3-0g--v 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $
❑Total Project Cost (Item 6)z multiplier x
3. Plumbing $ Other Fees:L
4. Mechanical (HVAC) $ ty List:_
5. Mechanical (Fire
Suppression) $ r.l A Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 5o,06.t> 13 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7S49S /
License Number Expiration ate
Name of C L-Hol er
� ��( � 1 List CSL Type(see below) d 0
Address T e Description
.�itw U Unrestricted u to 35,000 Cu.Ft.
/ R Restricted I&2 Family Dwelling
Signature M Masonry Only
�-151�2e 7`l-S- IT7< RC Residential Roofing Covert n
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 to act on my behalf, in all matters
relative to work authorized by this building permit wpplivation.
Signature of Owner _ Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
drl /22 o,,/,z '��4-C-r-ir, ,as Owner or Authorized Agent hereby declare
that the statements and information din the foregoing application are true and accurate,to the best of my knowledge and
behal
I— ®cc r1
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
l. 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"may be substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
D E P A R'I'v1 E N T
I I ')'$.'J 4.
construction Debris Disposal .affidavit
(Ivyuired For all demolition :ulJ renul:diun work)
In accordance l%till the sixth edition ofthe State Building Code, 780 ChIR section 111.5
Debris, and the provisions of'AGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by: _
I name ut Ilalil�r)
I he debris will be disposed of in
(name w taeJuy)
laddre.. ul I�cililvl -
agnalwe of perluit applicant
,late
CITY OF SALEM
w ,� , i,' ; PUBLIC PROPRERTY
DEPARTMENT A,. _
IMMIX 11"Jalll,-11
\Is:t,g IY WA,HI\l:lU� ClCliI' SAti VI.M.1lv.N.III it 11s0197C
lTa. 9711-713-95'15 • 1'ws 97x-.'4G'ISO,
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
t )Indnt Infurmalion Please Print Leeihlis
NnIne Ulu"I'c's I)r�am r:uinNlndn uluol l:
:'dill l'CSti:
c ily,Statc,zifo: Phone iJ:
Arc J ou an ratployer? Check the appropriate box: 'I'y Pc of project (required):
I.❑ I :tin a employer with 4. ❑ 1 am a gcncral coulractor and 1 6. ❑ new construction
e ntployces(full ansL'ur put-time).• have hired the sub-contractors 7. t+Relnudeling
?.❑ 1 alit a sole proprietor or partner- listed on the anachcd shut. :
ship and have proprietor
etor or pas These sub-contractors have S. 0 Demolition
working line n in any capacity workers' comp. insurance. 9. ❑ Building addition
In workers' comp. insurance 5. ❑ We area corporation and its officers have exercised their 10.® Electrical repairs or additions
� r quucd.]
ri ht of exemption per MGL I I.R Plumbing repairs or additions
3. 1911s a htnm owner doing all work g c. 152 12.R Ruuf repairs
myself. [No workers' cutup. , §l(4), and we have no
insurance required.) r ctnployces. LKo workers I J.❑ Ulher 9_! O UZ4 XRoe'
comp. insurance required.)
•4m.,;rphlanl Ibul checks boa AI mow a6u will wn the,ectmn I,uluw awwing thvrt wurkui cumpcn,a,I pulicy udirtrtutiun
' I lomwiwrwn who submit this affidavit indicting Ihcy are doing sell work aIW then hire sulfide carurmicon must submit a new aICdavil indiuliny such.
-f„mrxlur,that lbvck this box mswf anxhcrl an additional lheel.huvriov sew u:uno of tire sub•conlracton and their swurfion•crimp.roil cy tnfu afiun.
/inn an employer that is pruvidinr c•workers' urnpensadon insurance for cry emp/ayees. Be/oly is the po/icy and job ailr
injunoatiom
In,urancc Company Name:--
1'ulicv jot or Sclf-ins. Lie. i=: -�___ _. . _ ___ Expiration Date:
Job -Site Address: CttyrState/Zlp:
Attach It copy,of the workers'compensation pulicy declaration page(showing the policy number and expiration date).
I;ailurc to secure cuserage as required under Section '_5A ul.%IGL c. 152 can lead to the imposition of criminal penalties ofa
wine up to S1.5110.00 anJ.'ur one-year imprisonment, ar well as ,ivII penalties in the furm of a STOP WORK ORDER and a fine
Of up m S250.00 it day igailihi Ille violator. lie advl.icd that a copy of lhls iiatcnlemt nnay be turwarded to the Office of
Inw„n�J 1l Ulli ui IIiv DIA :or ln+urmcc cOwcragu wci ilicaUon.
Ida hereby iertijy suede♦ he pre nn unolliev ujperjary that the information provided above is true suer!correct.
:I "lablrr 7�� GL !/LN --_ Dttc_____ 9 ` /5"a)'
fJ/Ji,.iui live ugly. Do oat write in this area, to be cueupieted by city ur folvil ajjhidL
It itv or fawn: _.._ __ Pcrmitil.iccnse �.
h.uing.\uthurily (circle auc):
I. 11„urd of Ilc:dth 2. Iluildin" Mpuurtolcut .l. (:it):1'un11 Clerk 4. Electrical luipector i, Plumbing Inspector
6. Other . _
Ct,nlact l'cnuu: _.
Information and Instructions
%lansachusetts General Laws chapter I i2 requires all ewplo)ers to provide workers' compensation for their cmployces. _
Purmu.mt to this statute,in empluree is defined as "._every pcason in the service of another under any connact of hire,
express or Ilnplwd. oral or written."
An employer is defined as"an individual, partnership,association, corporation or other legal entity,or any two or more of the hrrecoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of .ul individual, pallnershlp, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling Ifouse of another who employs persons to do maintenance,can%truction or repair work on >uch dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be in employer."
.%IGL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant oho has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, bIGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance uf'public work until acceptable evidence ol'cutupliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants -
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not requiredto carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this alfidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. Tilt alfidavit should
he retuned to the city or town that the application for the permit or license is being requested, not the Department of
industrial Accidents. Should you have any questions regarding the law or If you ire required to obtain a workers'
compensation policy, please call the Department at the number listed below. Scif-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
I'lause be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple penniUlicense applications in any given year,need duly submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
Year. Where a home owner or citizen ispbtaining a license or permit not related to any business or commercial venture
(i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he I)like Ut Investigations w'uuld line to diank )'ou in advance for your cooperation and should you has'e any questions,
please do nut hesirate to give us a call.
fhe Ucparonent's address, telephone and fax number .
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia