37 ROSLYN ST - BUILDING INSPECTION (2) 1
1 +� All.
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The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts Stale Building Code, 780 CMR. 7"edition
r� Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a �
One- or Two-Fa!i • veffing
This Se n For O(Ticial Use Only
Building Permit umber 0 to Ap lied:
Signature: El 57 5o
Building Commission r/Inspect of Buwldm Date
SECTION I:SITE INFORMATION
I.1�.propert Address: 1.2 Assessors Map& Parcel Numbers
c5 7- gti&V1 -4
I.I a Is this an accep ed street'!yes no Map Number Parcel Number
1.3 Zoni n Information: 1.4 Property Dimensions:
17
Zoning District Proposed Use Lot Area(sq n) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard - Side Yards Rear Yard
Required Provided Required Provided Required7d.
1.6 Water Supply:(M.G.I.c.40,154) 1.7 Flood Zone Information: 1.3 Sewage DisPublic❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On Check i( esOSECTION 2: PROPERTY OWNERSHIP'
"t)
Ord:�ry n S}
_ Address for Service: J
Tel ne
ECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
Existing Building❑ Owner-Occupied ❑ Repairs(s) el Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units c9 Other ❑ Specify:
Brief Description of Proposed Work':
4 f Of L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of0cial Use Only 1
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. .Mechanical (HVAC) S List:
5 Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S50oe 7� 1(i�C06s ❑ paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
'' . - L,ccnse Numbcr Expiration Date
N4me of CSLL Helder List CSL Type bce below)
Ty Description
Address
U Unrestricted(up to 33,000 Cu. Ft.)
R Restricted 1&1 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
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.S 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 .......... O No........... O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
7th.estatements
Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
, as Owner or Authorized Agent hereby declare
and information on the foregoing application are true and accurate, to the best of my knowledge and
Y r
Signature of Owner or Auth6tized Agent Date
(Signed under the pains and penalties of perjury
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. 1 S2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I I OA5, 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 frrep)aces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of hearing system Number of decks/porches
Ty pe of cooling system Enclosed Open
1. "Total Project Square Footage"may he substituted for 'Total Project Cost"
Y
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I ','Y V: ',i L.
Construction Debris Disposal .at•lidavit
(required Ibr all dcnnolition :old Il:no%aIIon \vuIk)
In accordance wth tllc sixth edition ul'the State Building Code, 780 CNIR section I 11 5
Dcbris, and the provisions uf'.%IGL c 40, S 54;
Building Permit 0 is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The debris will be//transported by:
I name of hauler)
I he debris will be dispuscd uf'in
(name of facility)
Luhrc�� ii(laclit.v)
�we of pinnit .yq,0.ant
J6 a9 •
,lal.•
CITY OF SM.EIM
4D PUBLIC PROPERTY
DEPAR' MENT
K1fOkjL6Y N".vY L
Vwroa 1309rAsumcrew STum•SuFl4 NwStlOtistrrS 01910
TEL 9'8-715-9s" • FAX.976-740.9LN
HOMEOWNER LICENSE EXEM"ION
Plea" Print
Date o
Job Location 1 - 51 -L 5,4 �� N4 OI � �-b
Home Owner Address 3 1N� . Z# -;::w 2_ S41 o a 4 0 S 7 n
Home Owner Telephone (9 w) -2 z;y- -11 o
Present Mailing Address 3`4. s u 5 t- -r�-v S.+/ 44-,+ O/ 5 20
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who does not posseas a licenser provided that the owner acts as supervisor.
DEFINMON OF HOIZOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling. attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building OQicial, on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR ��
See other side for state code