43 ROSLYN ST - BUILDING INSPECTION (8) 7 - The Commonwealth of Massachusetts
y% - CFFY OF
y,} Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALEM
L,�..
Building Permit Application To Construct, Repair, Renovate Or D nolish a I(rrisrd llur?IJII
One-or Two-Funnit•DvellD{K
This Section For O tcial Use Onl
Building Permit Number: ate Applied:
3
Building Official tPrinl Mane) Signatu I
SECTION 1: SITE INFORIIIAT N
LI Property Address: 1.2 Assessor lap creel Numbers
Gf ;3 xA�y/T—2
1.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 It) Fronlage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards
Rear Yurd
Sewage Dispo
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.e.40,§54) 1.7 Flood Zone Information: 1.8 sal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposals stem ❑
Check if .r-t >
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Recoryd/ /p
/ /z Q i� ai/JPYJ1 ! 1
City, ZIP � 7
9Z8 979 �33�
Nu.and Street "relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':_ �-
SECTION a: ESTIMATED CONSTRUCTION COSTS
MEstimated Costs: Official Use Only
Labor and ..\laterials) Y
ing S I. Building Permit Fee: S Indicate how fee is determined:
ical g ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x ing S ? Other Fees: Sanical (IIV\CI S List:
ticaI 1 Fireionl S Total :\IlFces:SCheck No. CheckAmount: Cash.Anwunt:Project Cost: S ❑Paid in Full ❑Outstanding Balance Due: -
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Nunther---- - ' Ifxptralwn Date
--- — --------------------
N;una o(l'SI. I!older
List C:SI. I)PC(see below!
No. and Street ------- ------ - 1}pe Description
U l Inrestricted(Buildings uO to 35,000 cu. tl.)
R Restricted I 2 Family Duelling
Cit%ffour,.State,ZIP M Klasonry
RC Roolin,C'overin
-. - W'S W'indnw and Siding
SF Solid Fuel Burning Appliances
I Insulation -
I'cic hone [:mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Date
I IIC C'ontpan) Name or I IIC Registrant Name
No.and Street Email address
City/Town,State, ZIP 'rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 7n: 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 mer's Nmle(Electronic Signature) Date
SECTION 7b:OWNEW 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 Oaner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner tvho obtains a building permit to do his%her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will r o have access to the arbitration
program or guaranty fund under I.G.L.c. IJ_'A.Other important information on the HIC Program can be found at
tt w tt_niy�.. of oc.I Information on the Construction Supervisor License can be found at���„t_nia,
2. When substantial work is planned, provide the information below;
Total floor area(sq. ft.) 1 including garage, finished basement attics,decks or porch)
Gross living area Isq. tl.) Habitable room count
.\wnbcr of fireplaces Number of bedrooms
Number of bathrooms .Number of half baths
1)Ile of heating s)stem _ -- _-_-.- Number of decks, porches
I\pe of cooling iv"enl Enclosed Open
1 "T'olol I'rojcei Square Footage-may he substituted Ibr"Total Project Cost-
CITY OF S.U.&NI, �tiWSACHL'SETTS
OL DLNG DEPARTNtENT
110 WASHNGTON STRM, Y°FLOOR
Tips. (978) 74S.959S
FAX(978) 740-9846
KIJtBERLEY DBISCOLL
MAYOR T1io.+G3 ST.Pmx m n
DIRECTOR OF PLBLIC PROPERTY/HCIIDLYG CONNISSIONER
Construction Debris Disposal Affitdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section t 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N 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
1 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
CITY OF SIUYENI
PUBLIC PROPERTY
DEPARTMENT
w.u.a�ar�•- •�6
Vwroe 1]0 WMMN,Td star•ULM.WMAow'scrn 011'e
HOMEOWNER LICLNSE EXE.I4MON
Pfew Ftirat
Job Lecsdos
Home Owner Address
Home Ownar Telephone
Proemt Mailing Address
The current exemption of"Homeowners"was extended to include ownw-occupied
dwellings of two Units or few and to allow such homeowner to engage an individual for
hire who does not possess a license,provided that the owner sets as superviaw.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resider or intends to reside,on
which there is. or is intended to be.a one or two family dwelling. attached or detached
structures accessory to such use and/or farm shuctures. 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 and other applicable by-laws and reguladons.
The undersigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
.vill comply with said procedures and requirements.
HOMEOWNERS SIGNATLRS �07�
.APPROVAL OF BUILDING INSPECTOR lG�d
See other side For state code