43 ROSLYN ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
ssachusetts State Building Code, 780 C,1V[R SALEM
Ma
b Revised Mar 2011
JJ Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Divelling
This Section,For.Official Use Only
Building Permit Number: Daf Ap 'ed. 'r wv
-Building Official(Print Name) natureDate
SECTION 1:SITE INF
AMATION "
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
l.1 a 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 (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 Zone?
Public❑ Private ❑ Municipal if yeyes[:] unicipal❑ On site disposal system ❑
SECTION 2:,'PROPERTY OWNERSHH't.'
2.1+�Owner]ofRecordi_7�_ p jJ% V1 ij
C/r?r7 Gi -T) fit Jam716-/)7 /'%
Name(Print) z'-� re City,State,ZIP
y3 xa_gj�,2 St F7 9 `�77 S3Ja
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED W PRKz'(cbeck all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': 4 v ;D zd-4 r-zh
SECTION 4: ESTIMATED CONSTRUCTION COSTS::
Item Estimated Costs: Official Use Only,
Labor and L' faterials y'
I. Building S I Building Permit Fee. S Indicate how fee is determined:
❑ Standard City/`Cown,Application Fee
2. Electrical S ❑ Total Project Cose (Item 6)x multiplier. x
3. Plumbing S 2, Other Fees: $
4. Mechanical (HVAC) S List:S'/t/ A c i
5. Mechanical (Fire
Suppression) $ � Total All Fees:$ A t U0 e'
Check No. Check Amount: _Cash Amount', i/
6. '['otul Project Cost: S Paid in Full ❑ Outstanding
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Wration Date
Name of CSL [[older
List CSL Type(see below)
Type - Description
No. and Streit
U Unrestricted(Buildings up to 35,000 cu. ft.)
_ R Restricted 1&2 Family Dwelling
City/Town,State, `LIP r M Nlasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Felt hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State, 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 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 application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 1 d?A. Other important information on file MC Program can be found at
www.mass.,,ovroca Information on the Construction Supervisor License can be found at krww.nlass.^ov'do
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (sq. R.) Habitable room count
Number of tir,:places_ ___-- Number of bedrooms - _—_---
Number of bathrooitts Number of halG'buths
fype of heating system _-- Number of decks/porches----
1'ype of cooling sys nm__— ---- - Enclosed --- _ Pell
3. "I oral I'rojeCt Squnro Footage" may be sribstitutcd fol. :V'It.d Project Cost" ---
CITY OF S�1 EM, UxSSACHUSETTS
Bcii-mG DEPART1tE1NT
t 3 A+ 130 W.isHINGTON STREET,3iO'FLOOR. -
+� ` T'F-L. (978) 745-9595
F.ALX(978) 740-9846
KIN
iBERLEY DEtISCOt L
,1 LEY DR THO.%W ST.PIMM
DIRECTOR OF PLBLIC PROPERTY/BUMDNG COMMISSIONER
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 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
SJ
(name of facility))
(act'dress of facility)
signature of permit applicant
date
CITY OF S.ULE.bi
PUBLIC PROPERTY
DEPART1[ENT
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HOMEOWNER LICE,rSL EXE.I4PTIO,V
PltaN Ftiat
13
lob Loeadw H 3 k d 6 S f
Home Owner Addrew -
Home Owmar Telephone g 7 9 -9 `1 14 — 5 3 3 a
Ptsssst Mailing Address 4_3 R,j,se, J,,4 S-,
The current exempdon oC'Homeownere was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage m individual for
hire who daft not posun a license provided that the owner acts ft supervisor.
DEFINMON OF HCP"OWNMt
Person(s) who owns a parcel otland on which hdsbe resides or intends to reside, an
which then is, or is intended to be, a one or two f milt'dwelling, attached or detached
atn,ctsrm Accessory to such use and/or firm rtructurea 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 OQkial, on a form acceptable to the Building
OiNcial, that holshe be responsible for all such work performed under the Building
PermiL
The undersigned "homeowner'assumes responsibility for compliance with the State
Building Code and other applicable by-laws and reguladortL
The undersigned "homeowner'certifies that hNshe undentanda the City of Salem
Building Department minimum inspection procedure, and requirements and that hdshe
Will comply with said procedures and requirements.
HOMEOWNERS S[GYATL'RB
.APPROVAL Of BUILD/YG GNiSPECTOR
See other side far state coda