43 ROSLYN ST - BUILDING INSPECTION (5) <C
e- f
(J/7 0 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
( O Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
'w Revised Jurnr<rw
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 'DON
One-or Two-Family Dwelling
This Sepdbtl For Official Use Only
Building Permit mbbcr: V,94te Applied:
Signature: v G 10
Building Cummissi /Inspector of Builds Date
SECTION 1:SITE INFORMATION
.1 Property Addres : 1.2 Assessors Map& Parcel Numbers
J-
I.la 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 Il) Frontage(0)
1.5 Building Setbacks(it)
From 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
L;:ng
��/E'!�r Q ,ram
Address fo ice:
� � Z Telephone
3: DESCRIPTION OF PROPOSED WORK°(check all that apply)
New Constructiing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building S 1 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical s ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S -
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number lixpiration Date
Name ol'CSL-Ilulder List CSL Type(see below)
T pe Dcwri Lion
Address U 1.1mrstricledAup to 35,000 Cu.Ft.
R Restricted IR2 Family Dwelling
Signature M Masonry Only
RC Residential Roulfing Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or f IIC Registrant Name
Registration Number
Address Expiration Date
Signature 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 .......... O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
W-Ael2 ii ,as Owner or Authorized Agent hereby declare
that the stat ments and information on the foregoing application are we and accurate,to the best of my knowledge and
behalf
Print N
. 1gnature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, respectively.
? When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenVanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY O .� Y. M r FS
PUBLIC PROPERTY
DEPARTMENT
Wra I30WAoun[.MSne8r05ALZKMAMACMLSW l019.6
rai 975.74S-9ass • r..z r.t.7+asw
HOMEOWNER LICENSE EXEMPTION
Please
Dam s 93 Z
Job location Qss' l h f
Home Owner Address
Home Owner?elepbond o
Presses 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
hire who.does not possess a license.provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of lard on which he/she resides or intends to reside, on
which there 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 "homeownee"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 proc es and requirements and that he/she
will comply with said procedures and requir ents.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING INSPECTOR
See other side for state code
I .
` 1 CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
r.u: pit,
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\I . •'w fFl:v:t.71}9}v3 P�'t:'llt•NS'IM�A
Construction Debris Disposal AlVdavit
(required lur all demolition and renovation work)
In accurduncc with the sixth edition of the Slate Building Code. 780 CMR section 11 I.S
Debris, and the provisions of MGL c 4U, S 54; MGL e
is issued with the condition that the debris resulting from
Building Permit N rp r1 licensed waste disposal facility as defined by
this work shall he disposed of in a property Y .
111. S 130A.
The deb ' will be transported by.
ptoma of hauler)
The debris will be disposed of in
tnarne w aci tly
taddr"s of I'acdityl
atnaturt of permit,pyticant
Jate
I.bu.al s.