43 ROSLYN ST - BUILDING INSPECTION (7) `
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� � I he Commonwealth of Massachusetts
�i^n Doard of Building Regulations and Standards CI"fY OF
�� � � Massachusetts State Buildin Code, 780 CMR SAL6M
� �\41 ; g Rerised:tlnr701/
�� y6 Building Permit Application To Construct, Repair, Renovare Or Demolish a
� ^ One-or Ttivu-Fnnrrly D}velliirg
��( j This Section For Ofticial Use Only
t/ /
;`f Building Permit Number: Date Applied:
i�� '
uilding Of �cial(Print N�une) . Signature Date
SECTION 1:SITE INFORMATION '
I.I Property AJ ress: 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes no Map Number Purccl Number
1.3 Zoning Information: 1.S Property Dimensions:
Zuning Dis[ric[ PropuseJ Use Lot Arca(sy R) I'runtage(It)
1.5 Building Setbacks(R)
Front Yurd Side Yards Rear Y;vd
Reyuired Provided Required Provided Reyuired Provided
1.6 Water Supply: (M.G.L c.40.§54) IJ Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zune: _ Outside Flood Zone? Municipal O On sice dispas�l system ❑
Check if ycs0
SECTION 2: PROPERTY OWNERSHIP�
2.1 wner�of ecord•
C� ��-��4 �'harna�� -�� �n� a1 g 7 �
N;une(Priny City.Statc.%IP
�i` � �Zo�/u�v .s� 97 S�` 9 7 9 �"� 3� ,
Nu. and Street �� "felephune Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that npply)
New Construction❑ Existing Building❑ OwnerOccupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Deinolition ❑ Accessory Bldg. ❑ Number of Uni[s Other ❑ Specily:
Brief Description of Proposed Work':
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SECTION i: ESTIMATED CONSTRUCTION COSTS
� e Estimared Costs: Ofticial Use Only
Labor nnd �-laterials)
I. Building $ �� Ud �• Building Permit Fee: $ Indica[e how fee is detennined:
❑Standard Ciry/Town Application Fee
'. Elec[rical $ �
- ❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
�1. M1iechnnical (HVAC) 5 Lisl: ��_�� I �.(
S. iVechanical IFire �
Su �ression) Total All Fees: $
O�� 0O, Check No. Check Amuunt: Cash AmounC
/ 6. To[al Project Cust S �. ❑p�id in Full ❑Outstanding 6alance Due:___
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SECTION 5: CONS'PRUCPION SF.RVICES
SJ Construction Supervisor License(CSL)
I.icensc Numbcr P.xpiratinn Datc
Nmnc uf CSL. I luldcr
List CSL'fype(sec belo�v)
Nu. ;md titrcet Type Uescription
U Unrestrictcd Buildin�s u' to 35,000 cu. �l.) �
R Rcstricted 1&? Pamil Dwcllin
C LLyllown.SW[e.%IP M Moson
RC Rou�in�Coverin
WS Window;mdSidin
SF Solid Fuel 13uming Applimices
I hisulatiun
7�cic hone L'mail adJmss D Demolitiun
5.2 Registcred Home Improvement Contractor(HIC)
f IIC Registraliun Number 1?spiration Uute
I-IIC Company Name ur HIC Registranl Name
Nu.and Streel Hmail addrcss
Ci /Town,State,ZIP Telc hone
SECTIOIV 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.§ 25C(6))
Workers Compensation Insurance at�idavit must be completed and submitted with this application. Failure to provide
this affidavit wi�l result in the denial of the Issuance of[he building permit.
Signed Aftidavit 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.
�izo�,� / h�vr,� � G �a� r i
Pnnt Owner's Name(Ele tromc Signamrc) Date
SECTION 76: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 O�cncr's nr r\uthori'r.eJ Agcnt's Nmnc(131cctronic SignaWrc) . p���
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 nnt have access to the arbitration
program or guaranty fund under M.G.L. c. 14'_A.Other important information on the HIC Program can be found at
1t�5��'.m:iqs.}u�_'nca Infomiation on the Construc[ion Supervisor License can be found at�a�����_in;u;.�yoo��1�
2. 1Vhen substantial work is planned, provide the infonnation below:
Tutal Floor area(sq. ft.) (including garage, finished basement/attics,decks or porch�
Gross living area(sq. R.) Flabitable room count
Number of fireplaces Number of bedroums
Number uf bathrooms vumbcr uf half;'baths
Type of heating system Number of decks/porches
Type of eouling system _ Enclosed Open
3. "foLil Project Square Pootage"may be substiW�ed for"1'otal Project CosC'
�
CITY OF S.�I.E.tit
PUBLIC PROPERTY
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HONEOWYEA LICE.YSS EXE.�[PTIO�1
plew hi.t
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Job Laeatlo� 11� �os�L y, � �
Hom�O�vnt.4d�er �o.�,�
Hom�OwnrrTelephoe� 97� 974 �� � �..
Prcaant Mailio�Addrer S'�n, �
T6�cumnt a�pttao ot"Homeowne�s"wa�eat�ded to ineltd�owrnar-aecupied
dweWnp ot hw Unib ar far md to�Ibw�6 homeo�vnan to en�s�m ied{viduaJ tor
hict who doa not po�es a Ife�piovidad tAat th�ow�n�aeb a�auparvisor.
DEFIIVIITON OF HOi�OWNEA
Panonp) rbs ow�nr�p�ed otLad oa wMeh hd�cedda ar tntwd�to raid� on
whicb thet�i� or ir intaaded Eo Mi.a oa�or twro 'Aimily dwdW�` athehed or detached
nwetiu� aeceswry w�ue6 u�and/ar f5rm atruature�. A panos who eomtruct�mors
chaa on�hom� ia a nvo yar periad ahaU not b�eonadaed s homeowruir 9ueb
"homeownd'ahall �ubmit w th�Buildin�OQleial,on a fono aeeeptabb to t!u Buildin;
Of!leial, that hdah� b�rcaporoibl�fa all �ueD work pacformed uader c!u Buildin�
Pamit
Th�undasi�ed "homeownd'wuma re�pon�ibiliry for compliane�with th�Stat�
Buildin�Cod�and other oppiicabl�by�laavf oad rc�utationa
Ths undeni�ed "homeownd'ceroAa that hd�ht wdmtand� th�City o(Sslem
Bwidin� Dryartrnrnt minimum irupectioa proceduns and requircmrnts and that hdshe
�viU comply witl� said procadura and raquiremmt�.
HONEOWYER$ SIGYATL'RE� �
.�PPROVAL OF BUILD(NG L�iSPECTOR -
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� � CITY OF S�-1I.E.�1, I�L�SS.-1CHL'SETTS
� B�[IDING DEP.1R'I�IED:T
� 130 W.�.iHL�IGTON STREET, ]iO F200R
` 'It�L (97� 7iS-959S
Fnx(97� 7449846
Ki3BERI.EY DRLSCOLL
,�UYOR �I�iO.uAs ST.P[ERltB
D11lECTOR OP PI:BLlG PROPEA'!Y/HI:II.DL�IG CO\L�IISSIOVEA
Construction Debris Disposal At'fidavit
(required for all demolition and renovation work)
� in accordan
ce with the sixth edition of the State Building Code, 780 CMR section t I I.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 disposcd of in a properly licensed wusta disposal facility as defincd by MGL c
11 l, S I SOA.
The debris wiil be transported by:
�/r/fz. �,�n, �c�q/ �'/o ���s.-�� � rnA
(nartte of haulrr)
The debris will be disposed of in :
(name of Facility)
, (addmss of facility)
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/ signa�ure of permit applican[ �
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l�:IIC
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