43 ROSLYN ST - BUILDING INSPECTION (3) lwl �
The Commonwealth of Massachusetts INSPECTIONAL SERVICES
� Board of Building Regulations and Standards SERVICES
OF
qJ(� ALENI
Massachusetts State Building Code, 780 CMR S10
�,. 2114 OCT - aJ�elt�MlA5nr1
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwellnrg
This Section For Official Use Only
Building Permit Number: Date plied:
112 is- Jy
nuild!ng Ot iciel(Print Name). Signature Date
SECTION 1:SITE INFORMATION`
1.1 ro erty dress: 1.2 Assessors Nlop&Parcel Numbers
Z�QSL `/,,,v s
!.!a Is this an acce ted street?yes_V no Map Number Parcel Number
1.3 'Zoning Information: IA Properly Dimensions:
"tuning District Proposed Use Lot Vrca(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rev 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? Municipal❑ On site disposal system ❑
Check if yesE3 -
SECTION2. PROPERTY OWNERSHIP,
jf) Owner:of Record: L
s1N me(Print) City,State,ZIP
t L /V s _ Telephone gig-9Z��5332
Nu.nnJ Street Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) JK Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
Aevr��is�n r�Ex si mg Z - sl v 1 DEck re eserv�
- �1:c.--YGrc�-• 2 0 . �'o+v si!`
T NArh aol rml ,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S (lam ° 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S Li father Fees: $
4.Mechanical (fIVAC) S List:
5.Mechanical (Fire S 'total All Fees:S
Su ression)
Check No. _Check Amount: Cash Amount:_
6. Totai Project Cost: -S 1),606 ❑Paid in Full ❑Outstanding Balance Due:
SEI, T 10� tS� I
c r . SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) p70Q )0 / '
-T� �^ 'l 09�7-� l4 f License Number Expiration Date
;me of CSL Holdery yP list CSL'f a(see below)
PC yU(oS- �Ty e � � - Description
No.and Street
U Unrestricted(Buildings u p to 35,000 cu. 11.
1nFAi3� k" 01� R Restricted 1&2 FamilyDwelling
Cityfrown,State,ZIP M Nfasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 4- � Z
l0 M 1' 4h a I lZ�l F[C Registration Number `spirutiun Date
IIIC Company Name or 111��g� me ant Na
o.and Street Email
City/Town,Sta ,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 Is4uance 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 ��o t7 A ry 4 PA S
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
&&1v1Q Tho��r�,X� � o it
Print Owner's Name(Electronic Signature) I Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this npplication is true and curate to the best of my_knowledge and understanding.
1 N7A �s o 2 I�
Print Owner's or Authorizcd Agent' ante(Electronic Signa re) Date
NOTES:
I. An Owner who obtains a building permit to do hislher 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.Royoca Information on the Construction Supervisor License can be found at www.mas.sov'dL .
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'fypeofcoolingsystem Enclosed Open_
i. 'Total Project Square Footage"may be substituted for Total Project Cost"
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43 Roslyv\f sl
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AC a
�- CERTIFICATE OF LIABILITY INSURANCE F DATE(MMfDO WY1
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEf/03/014
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTER CONTRACT BETWEEN THE ISSUING INSURERIS),AUTHORIZED
REPRESENTATIVE FI PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT;If the canlfIh holder Cy.Certain an A DI OIIC -IJAL INSURED,the pollcylies)must be endorsed.If SUBROGATION IS WAIVED,subject to the
terms a conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certifle to holder in Ileu of such endorsement s .
PRODUCER
EA Kelley CONTACT Brenda Ccezolino
450 Veterans Memorial Parkway nrc.N0' (401)709-8338
ADDRESS y FAX . (800)370-2924
Building 5 brendac eakelle .com
East Providence RI 02914 PRODUCER 216303
INSURED
INSURERA antic Casualty Ins Co D v
Atlantic John Pantapes -407 Lowell Street INSURER B. 42846
INSURER C:
Peabody MA 01960 INSURERD:
INSURER E:
COVERAGE CERTIFICATE NUMBER; INSURER F.
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED NUMBER.
MB ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM DR CONDITION OF ANY CONTRACTOR OTHER ENT WITH RESPECT 70
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PgID CLAIMS. WHICH THIS
INSR TYPE OFINSURANCE
AODL SURR POUCYNUMRER POLICY EFF GENERAL LIABILIT I, POLICY E%P
LIMITS COMMERCIAL 3EfJEPAL'_:<PILITY
EACIi GC0.VIRREFJCE g 1000,000
CLAIMS-MADE �OC_CUR Pp. c-1� '!
A °oavnenca) $ 50,000
L 118001204 LIED E>F;Any°n9 pason) $ 5,000
03262014 03262015 PEF;sCIiALe :/ul,>Jq.
GENT AGGREGATE LIId IT Fppi c.r 3 100Q000
Imo_ cF
X PO CENER-LACSPEc ATE $ 2000,000
AUTOMOBILE
,TY,A _Cr PF1FJCTS
E LIABILITY I,CMP/OPAEG 5 1000,000
IWYALITO fpM31NED SRJ6LE EMIT
ALL OWNED AIJTCS {Ea@Iv-, nti $
6CHEOULEDAUI'06 EDD;L,w.»Rv ayr Dersgnl 4
HIREDAIJTOj ECD,LY Is!,AJPyfpora^gtlbnO
NON-O"WEDAUTOS FPO?EP'Y DAIM GE
(Faracciu4n11 $
UMBRELLA LIAS $
OCCUR
EXCESS LUE
DEDUCT ISLE CLAIM: MADE EACH C'C.LIp RENr_E $
AGGR=GALE
RETENTiCN g $
WORKERS COMPENSATION AND EMPLOYERS'LIABILITY
WqM�YpP�ROPRIETOR/ARTNER /ECUTIVE YIN
IMaritlatory in N��EXrLUpES, N NIA T!'''A:IL C
II y5 Jearnbe�ntlar E L EACH SCCIDENT $
�r'R IPT IN hp -RAT'CNS urnv EL 05EAec`-EAE M'LQfFF $
EL DISEASE-FOLI-_Y LPIIT $
DESCRIPTION OF OPERATIONS/LOCATIONS'VEHICLES(Attach ACORD 101.Atltllti°nal Remarps ScheCUlq If mare space is requlrctl)
Carpentry Contractor.
CERTIFICATE HOLDER
CANCELLATION
Brenda Thoman
SHOULDANY OF THE ABOVE DESCRIBED POLICIES B CANCEL
43 Roslyn Street THE EXPIRATION DATE THEREOF,NOTICE WILL SE DELIVERED INED BEFORE
ACCORDANCE WITH THE POLICY PROVISIONS.
Salem MA 01970 AUTHORIZED REPRESENTATIVE
Katherine M. Kelley, AAI, CIC
ACORD 25(2009/09)
The ACORD name and logo are registered mark(D 1 gCORD9 ACORD CORPORATION.All rights reserved
CITY OF SALEM, MASSAMUSEM
BUILDING DEPARTMENT
120 WASHINGTONSTREET,31DFLOOR
TEL. (978)745-9595
KIMBERL.EYDRISCOLL FAX(978)740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING Cob affSSIONER
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 c40, 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 deposit facility as defined by MGL c 111, 5150A.
The debris will be transported by:
1 � r \l ,
(name of hauler)
The debris will be disposed of in:
(name off cility)
(address o facility)
4Siature of applicant
ate
CI-I'Y OF S:\LEM, K�SSACHUSETTS
I' BUILDING DEPARTN1F_NT
�r I 120 WASH44GTON STREET, 3w FLOOR
C °"mod TEL (978) 745-9595
F.kx(978) 740-9846
1CI%LBERI FFY DRISCOLL.
s,q-%YOR T HCltW ST.PIEAlM
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLMISSIONER
Workers' Compensation Insurance AlMdavit: Builders/Contractors/Electricians/Plumbers
Applicant Infnrmrtinn Please Print Legibly
rA� L' nl7 14 (�/d i
V;It11C(HminessOrganieation.'Individual): _l1CJ I�l f�P � A
Address: QG • C1 UI- LiQ&L
City/State/Zip: ?=A 6�7 fl'\6 6 150 Phone hf: (-?29--
Arc you on employer'.'Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4• ❑ 1 am a general contractor and 1 6. ❑New construction
npioyees(full and/or pan-time).• have hired the sub•contractorx M�y
2 lama sole proprietor or partner. listed on the attached sheet.
t y �• lop Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity,
workers'comp.insurance. 9• Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.) officers have exercised their 11
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself. (No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurancerequired,lt employecs. [No workers' j3.DOther
comp. insurance required.)
•Any uppliewl Our ehvcka but al must also fill out arc section below,showing their wotkew'eompemadun pulicy inru mailon.
'I fumwswnvn wha suhmit this atfldnvit indicating Ihry art doing all work and then hire outside contractors mica suhmit a new affidavit indicating such.
$mumcwrs shut ch vk this box most anachal an additiunal.hrwl shuwing dw none of the subrentrsctors and their workon'comp.policy inr°rmalian.
I ant can employer that is providing workers'rompensadon insurance for my employees. Lfdlow ix the policy and Job slid
fufvnmtion.
Insurance Company Name:
Policy it or Sclf-ins. Lie, d: Expiration Date:
Job Site Address: City/Stulldzip:
attach a copy of(he workers'compensatloo pulley declaration page(showing the policy number and expiration data).
Failuru to secure coverage as required under Section 25A of bIGL e. 152 can lead to the imposition oferiminal penalties of a
fine up to S1,500.00 and/or one-year imprisanmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a tine
Of up to S250.00 a day against the violator. Ile advised that a copy of this.statement may be furwardcd to the Office of
Invrstigatiuns ul'Ihc DIA fur insurance coverage verification.
1 du hereby c•rnffy rut •r Nos poi s rd pe allies of perjury that the infuriation provided abuve is true and correct
Si •n t rc' Cy Q" �,/ �/ Dare: /a�'�/��
Phone 1:
Official use only. Do not write in lids area, tube completed by city up town o1pauf.
Ciry nr fawn: PermiulAccnse N
—
-----
Issuing Aullo rity (circle one): _-- —_
1. Board of llealth 2. Building I]cparuucot .i.cilylfnwn Clerk J. Flectrical bupcctur 5. Plnnibing Impecmr
6. Office
Phone.I: