43 ROSLYN ST - BUILDING INSPECTION (6) C'u......ahh uPMwsachusells
/ Board of Building Regulations mid Standards CI'I'1' OF
Massachusetts State Building Code. 7SO C NIR SAL1:.\I
21)11
r,(�1 Building Permit Application To Construct. Repair, Renovate Or Demolish a
One- or Tsvo-filnnh Duvtfigiqr
vD rhis Section For Official Usc Only
Building Permit Number: Date Applied:
Ilwlding 0111cial(Print Nwne) Signature Date
SECTION 1: SITE INFORMATION
1.1 Propert Address: 1.2 Assessors,Hap III P «I Numbers
,
1.la Is this an acce led street?yes no Map Nunsh.r Purcul Numlxr
1.3 Zoning Information: 1.4 Property Dimenslons:
/Zoning District Proposed Use Lot Arco(sy 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yurd Side Yuma Rear Yard
Required Provided Required Provided Required Provided
RandStrcel
upply:(M.G.I.c. 40,154) 1.7 Flood Zone Information: tmlusn
wage Disposal System:
Zone: Outside Flood'Zone?
Private O — Check if cs0 pd❑ On site disposal system O
SECTION2: PROPERTY OWNERSHIP'
of Record/�:
ZQ rh if M aN ja SQ12JNL ��Mr4 C'ily. ' c.21P
�97 S . J - �"��3 a rulephune Fmuil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O I Repairs(s) Cl I Alteration(s) ❑ 1 Addition O
Demolition ❑ Accessory Bldg.❑ 1 N er of Units_ I Other ❑ Specify:
Brief Description of Proposed Wor tO
SECTION J: ESTIMATED CONSTRUCTION COSTS
liens Estimated Costs: Official Use Only
ILabur cmd .\laterialsl
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
'. 1l1ecuical S O Standard City!Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
I'hunMng S 1 Other Fees: S -
J, \Icclwaical ill\ \('1 i List:
5 Vcchjimal I) ire ------- ------- • - -" --- -
Cu pre sionl S Cord \11 Fees: S_'-----
pO� ('hed Vat. ( hak :\mount. C',t�h \w,nuu:
I. 1'utul i'rnject Cost: S v 0 Rid in Full 0 Outstanding B.d.ulce Due:
SEC I ION 5: CONS I'R(,(,rION SFRVI( FS
5.1 Cunit rue lion Sullen isur License(CSI-)
I
I i Nimibvr Viralwi
t er I ist L'Sl. 1'.%tic(,cc 110MO.—
l*)pt: 1%seriplion
No. ll I Inrestrivied I littilditt i u- to 15,000 01
R l(e"Irivted PL2 Famil D%%ellill
L*it%,To%%n.State./I I' %I Mason
RC K,%)Iiii Onerin
%S window.aid sidill
SF Solid Fuel Burning Appliances
1115111a Lion
I'l
I 1:11lail add .,i Demolition
5.2 Rtglstertd liurne Improvement Contractor(IIIC)
IIIC Registration Nianicr F%piralitln 0A
IIIC Ckillipall) Name or IIIC l(cgistrunt Njuna
No. and Street Email address
City/Town. State, ZIP relclihone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 25C(6))
Workers Compensation Insurance aMdavit must be completed and submitted with this application. Failure to provide
this atYidavit will result in the denial of the Issuance orthe building permit.
Signed Affidavit Attached? Yes .......... Cl No...........0
SECTION 7s. OWNER AUTHORIZATION TO WE—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.
Print Umicir's Nunic(Electrunic Signature) Data
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name
w. I hereby attest under the pains and penalties of perjury that all of the information
�0�
contained ill ' application is true and accurate to the best of my knowledge and understanding.
NOTES:
I. .\n Owner who obtains a building permit to do his her u\vn work,or an owner who hires an unregistered contractor
(out registered in the Hume Improvement Contractor(HIC) Fragraml,will no have have access to the arbitration
program or guaranly fund under M.G.L. v. 1421A. Other inipurtant inriarmalion on the HIC Program can be 11tusid at
,
I 111rorinaticin on the Construction Supervisor License can be round at �,\ •IP
lien substantial%lurk is planned•provide the information below:
rota) flour area 1 sy. 111 1 including garage. Imished basement attics, ducks or porch)
Cross li%inq area 1 S4. It I Habitable room count
Numher%it hcdrokwis
Ntili,incrol'bathrooms
I lie aiheating
I pcofcoohlig i.%imil 1:1%loicd .01wil
loial IlrolvI .Skluarc Fool,jcc- 111;1.% be whihlllled t1or ,I'otal Projed Cos[-
CITY OF S.uE.sv1
PUBLIC PROPERTY
-0 DEPARTMENT
u.o.,asr o�suai
`u`Ge 1 b wAwrmcnu stress•S�uaq Vwauoassrn Ot f-0
ML e-ars.sses•VAL r.tr?s.9sw
HOMEOWNER LICENSB EXE.MMON
Pfease Mat
DAN y G
Job Location 23 gov-1ga 6
Home Owner Address _ aSNd�1c'L/�ir rn i E.S'=f/2
Hors•Owner Telephone
Ptaeatt Mailing Addaxes
The current exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Unite or lean and to allow such homeowners to engage an individual for
hire who does not possess a lieeaae4 provided that the owner acts as supervisor.
DFYIN TION OF HOMEOWNER
Persons)who owns a parcel of land on which he/she resides or 112 to resider on
which there is, or is intended to bsl,a one or two family dwelling 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 usd other applicable bylaws and regulations.
The undenigned "homeowner'certifles that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
Mill comply with said procedures and requirements.
H041EOWNERS SIGNATUM
APPROVAL OF 9UILDIYG NSPECTOR
See other side for state code
CITY OF S.l Z%r, AUSACf- USE- TS
f ILLIZI NG OEP.1AT.%LLNT
120 W..U.4LNGTON 5rxw, 1'O 6tO0A
rEL 1978) 745-9599
KBWERF YOUWOLL F.kx(973) 1449844
MAYOR M<)..%W ST Pmxu
DIA=C&0/Pt SEIC PROPEILTY/9CQpt.VC Co.%c%jfsstON EA
Construction Debris Disposal Attidavit
(required for all demolition and renovation work)
rn uccrdance with the sixth edition of the Slat@ Building Code, 190 c,%fR section I 11,J
Debris, and the provisions of IWGL a 40, S 34;
Building Permit s is issued with the condition that the debris resulting rrom
this work shall be disposed of in 11 I, S I JOA. a properly licemed waste disposal racility as defined by Nlrt c
The debris
will be transported by:
////
(n.una ot'hautdr)
The debris will be disposed of in
(name o-llay)
(rddreo orr�rih�y)
4
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