40-42 ROSLYN ST - BUILDING INSPECTION Commercial and Other than One or Two Family
The Commonwealth of Massachusetts b,
U1 Board of Building Regulations and Sit ards
Massachusetts State Budding-Code, 780 R 7i' Edition �
Application to change use construct,alter, ren�r, ate repair or demolish� Yz Sa. � eh°x. tkr,.t�a 'ghIS�CC. flo or_,.4 c n^4+ .`@
Building Permit Number.: ate of application
Signature:i
Buil m COdluritsswne ns ec[ r ,'. Date . --•�
$}F„r'h.
SF
1. Proper d ss; 1.2 Assessors Map &Parcel Numbers
6- y �e
� sly, � � �-
L Ia Is this an accepted street. Yes ❑ 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(feet)
Front Yard Side Yard
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?
Check if yes ❑ Municipal❑ On site disposal system ❑
1.9 ZBA Special Permit 1.10 Old&Historic Commission 1.11 Conservation Commission
Date filed N/A ❑ Date filed N/A❑ Number 40- N/A❑
v f n•4
1�4 1iffx
2.1 Owner of Reco
Name(Print) Address for Servi/c�e/xQ�.���
Signature of Owner Tele hone
New Construction❑ Existing Building❑ Alteration(s) Addition ❑ Repairs(s) ❑ Demolition❑
Change of Use ❑ ❑ Change of Occupancy❑ Other ❑ Specify:
Description of Proposed Work: It yZ:-,gp A /9/IrrfE7,/-
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IN t xs N n rf W aJ
Item Estimated Costs
labor and materials) This Section For 0Ocial Use Only
1. Building $ v
3aoP Building: $10/$1000
2. Electrical $ Building+_Plumbing-$12/$1000' Building°+Electrical: $1.3/$1000'
Building+Electrical+'Plumbing combined:$15/$1000
3. Plumbing $
Total project cost(labor and materials)$ r
4. Mechanical (HVAC) $
5. Fire Suppression $
Fee multiplier from above$ $I000
6. Total Project Cost $ ��� Permit Fee$ Receipt Number
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r.,i ' � Y:, . '.3r. ...�r*., ,af ; _-i i�^ ,."Ti f 5t
5.1 Construction Su ervisor License(CSL)
License /0�7.J 3 Expiration Date
Name of CSL Registrant / Description.
/G fJyZ s7,✓•nC Avg L/LiTE �-d U Unrestricted(up to 35,000 Cu.Ft.
Address R Restricted 1&2 FamilyDwelling
+ - M Masonry Only
Signature RC Residential Roofing Covering
WS Residential Window and Siding
elephone FJ SF Residential Solid Fuel Burning Appliance
D Residential Demolition
5,24ome Improvement Contractor Registration(HIC)
Registration Expiration Date �/"�
HIC Company Name or HIC Registrant Name
/O
Address
Sig a are
7,f-/— Zoo/—J i
Telephone
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affidavit may result in the denial of a building permit.
Signed affidavit attached? Yes ❑ y No ❑
ey ki lP .G_6
as Owner of the subject property, hereby authorize
to act on my behalf in all matters relevant to work
authorized by thi uil 'ug permit application.
Signat re of Wrier Date
as Owner or Authorized Agent, hereby declare that
the statements atid4tif4altuatton on the fore oin a lieation are,true and accurate,to test of m knowleedge and belief.
_� l4
Si r Authori ed Agent Date
(Signed under the pains and penalties of perjury)
� Uti a,
AMR
r._ �t�`i: i. es'ta.,.,'
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 110.R5.
When substantial work is planned,provide the following information;
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Number enclosed of decks/porches
Habitable room count Number open of decks/porches
Number of bedrooms Number of fireplaces
Number of bathrooms Type of heating system
Number of half/baths Type of cooling system
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
,kttt�,l Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/1 lectricians/Plumbers
AV12licant Information
Please Print Legibly
Noma(Business/Organization/Individual): �'/S/�/!✓ T�jt�e,�/��,
Address: �� <l�i7C %v — -4 d -
City/State/Zip: phone #:
[2.[E-9'rialinployseese
e you an employer?Check the appropriate box:
) I am a employer with 4. 0 I am a general contractor andTF9. 0
of project(required):
(full and or part-t me).* have hired the sub-contractorNew construction proprietor or partner- listed on the attached sheet. Remodeling
slip and have no employees These sub-contractors have
working for me in any capacity. employees and have workers' Demolition
working
[No workers'comp,insurance camp.insurance.t Building addition
3.❑ required.] 5. Q We are a corporation and its 10.❑Electrical repairs or additions
I am a homeowner doing all work officers have exercised their
myself 1 L❑Plumb ng repairs or additions y [No workers'comp. right of exemption per MGL
insurance required.]t C. 152, §1(4),and we have no 12•Q Roof repairs
employees. [No workers' 13.❑Other
comp. insurance required.]
Ho*An applicant that checks box#I must also fill out the section
t below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 4
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
information.
Insmarice Company Narne:
Policy#or Self-ins. Lic. #:
Expiration Date:
Job Site Address:
City/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
pf criminal penalties of a
fine up to$1,500.00 and/or.one-year imprisonment,as well as civil penalties in the form of 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.
I do Hereby certify under t inZ,a ..
fperjury that the information provided above is true and correct
Si nature.Phone#; 7d
[Official only. Do not write in thiv area,to be completed by city or town official.n: Permit/License#
hority(circle one):Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son:
Phone#:
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees,
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as "an individual, partnership,association, corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,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 house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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 who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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 are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-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.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only 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 is obtaining a license or permit not related to any business or commercial venture
( g
i.e. a do license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department'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
Revised 4-24-07
www.tnass.gov/dia
i
CITY OF S.0 F-,NNi, N'LuSACHUSETTS
i BUMDL\G DEPARTJIENT
1 1 N r 120 WASHLNGTON STREET, 3i°FLOom
TF.L (978) 745-9595
Fnx(978) 740.9846
KI.Nff3ERi E.Y DRISCOLL
AVL;YOR THO�L15 ST.P1FRitR
DIRECTOR OF PUBLIC PROPERTY/BUILDLYG CO\L,IISSIONER
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 1 l 1.5
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
I11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
// (name of facility)
(address of Facility)
signature of permit apg 'cap
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