43 ROSLYN ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a !
One. or rsro-Fomi/ Dwelling
This Section For Official Use Onl
^ — Building Permit Number: Date Applied: ' V
Signature: 'L
\ Bwlding Commissioner/Inspects of Buildings Date
SECTION 1: SITE INFORMATION
1 Propert Add r ss: 1.2 Assessors Map dt Parcel Numbers
Ma Number Parcel Number
I.I a is this an accepted street''yes_ no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage III)
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.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnert
�=-�"—Name mt) �� Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building f I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing f 2. Other Fees: f —�
4. Mechanical (HVAC) S List:
5 Mechanical (Fire S Total All Fees: f
Su ression
A Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S SW- z ' ❑ Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construcilon Supervisor(CSL)
License Number Expiration Date
N.4me of CSL- 1191der Lmt CSL Type ype(,cc below)
Address T' Desert tion
U Unrestricted u to 35.000 Cu. Ft.)
Signature R Restricted I&2 Family Dw'11.
M Mason Only
RC Residential Roofin Covering
Telephone WS Reside nu al Window and Siding
SF Residential Solid Fuel Buming 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. 152.1 2SC(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 ...........O
SECTION 7a: 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.
Si nature of Owner Date
/SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
1. /✓'�/✓��'� ��� ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Dale
(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 g&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 offireplaces Number ofbedrooms
,Number of bathrooms Number of halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may he substituted for 'Total Project Cost"
' CITY OF SALLM
PUBLIC: PROPRERTY
DEP. I MENT
Construction Debris Disposal Aflidanit
(required lire all demolition :old renowauun work)
In accurdance %\ith the sixth edition oft I ic State Building Code, 750 CTIR section I 1 15
Dcbris, and the provisions ot"vIGL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I11. S 1511A.
The debris will be transported by:
I name ul hauler)
I he debris will be disposed of in
t wme u( LeeI IIY1
1•IJdres. ,.r l]ulm vl
'IC11.1fure Ot panut .y+pha ant
life
CITY OF &UEM
PUBLIC PROPERTY
DEPARTMENT
KI101FJIJaY rvw•ry
KAYO! 130 WASONGTON STW4T•SALE MAMAONI.'StM 01970 ..
Tn.978•74S-9S9S*FAx 976740.9&u
HOMEOWNER LICENSE EXEMM'ION
Please Print
Date Y - // - D 9 .
Job Location e4l:
Home Owner Address
Home Owner Telephone
Present Mailing Address
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
him who,does not possess a license,provided that the owner acts as supervisor.
DEFINMON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which time is, or is intended to be, a one or two family dwellin&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 Official,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