10 GIFFORD COURT - BUILDING INSPECTION (2) Y 1 ' The Commonwealth of Massachusetts
JZ), Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a !
Ono- or Taro-Furnih,D 1 /ling
This Section f Oflicial se Only
Building Permit N be'r � � Dat A fit d:
//�7,
Signature: i l�"'^'
Building Commissioner/ pector of Builds s Date
SECTION 1: TE INFORMATION
1.1 Property Addre `; �--s y 1.2 Assessors Map& Parcel Numbers
j h �, S°T Jrk V,vN
Ma Number Parcel Number
I.I a Is this an accepted street?yes_ no
P
1.3 Zoning information: 1.4 Property Dimensions:
Zoning Distnct Proposed Use Lot Area(sq fl) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Etired 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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check it yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Name(Prim) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other 10 Specify:
Lr---
Brief
Dese nption of Proposed Work': l
1 <WI Ctre C� p� SS CSO) rP A/'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building sO 6c, 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing E 2. Other Fees: E
4. Mechanical (HVAC) 5 List:
5. Mechanical (Fire 5 Total All Fees: S
S,.pp,sqiqq I cob
Check No. _Check Amount: Cash Amount:_
6.Total Project Cost: S �;t GS`� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES r
5.1 Licensed Construction Supjervisor(CSL) (ts %( ll,
r-I&�r1 1 tr _ � / 1 h License Number Expiration Date
N4fLme oCSHpId r { ,3� 1 f List CSL Type(see below)--D
v 1p
Address [ Type Description
U Unrestricted up to 35,000 Cu. Ft.)
' R Restricted 1&2 FamilyDwellin
ignature p M ,Mason Onl
97� /G�•n9 �� RC Rc,, ential Roofing Coverin
Telephone WS Rridrnual Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Re istered {i�'ome Improv ment Contractor(HIC) l 9
�AA 2r�1 W fin r.s' ou it !;(
HIC CompanNam or HIC Registrant N Registration Number
^ A
Address 'Tr -.2 y • 2 009
t ?]GG Ue12C� Expiration Date
gnature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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
1, MIAU, CA v`. .J A.c:o 6y as Owner of the subject property hereby
authorize s- d k, A,,u 111 A. 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
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 1 I O.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,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 Cosi'
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.i VCM I \ +Ilhl „11
12- W'k't .l'^SI,LL l' s ).111'\I, bl.%.%%' III IInal'17:
I r.l. vtt '1i93-05 • 1 at v711'4J laab
Workers' Cumpensalion Insurunce litftdoxiC iluilders/Cuntracturs/Electricians/Plumbers
11,I1 d]Lant Information Please Print Leeihly
VII ITIc Ilhl.uwas.l)r;pnl nlnnNlnJla'dui l 1'
moo'
Clly.Srare.%ip Thune '!: bc�aq
.\rw y ou in vinployer:r Check the appropriate bus: l'ype of project(rwquired):
I.E31 .un a employer with 4 ❑ 1 :un a general anumetor and 1 6. ❑ new construction
� u- npluyccs(furl anaL'ur part-time).• hate hired the suh-contractors 7. E] Reinodelins
2.ICJ ' .uu a sore proprietor or partner- listed un :le
the ached sheet. t
, These subcontractors have V. C] Demolition
flip:uhal have no aanpluywes
working formw In any capacity. workers' comp. Insurance, g. ❑ Building addition
No workers*cum . insurance 5. C]
We are a corporation and its
( p otfice"have exely ised their 10.❑ Electrical repairs or additions
1 I :on acJ.] I L Plumhin repairs or additions
3.❑ r am a homwuwner doing all work right of exemption per hICL ❑ g P'
myself. LKo workers' comp. C. 152.Q 1(4),and we have no 12.❑ Ruuf repar�irs (
insurance required.) cmployees. (Ko workers' U.Q Unlet I`)PrIC
comp. insurance required.]
• m .,plLc+u1 Iter tF.ceka Om AI moat+tau lilt Yat the vemm,I Iwluw awwmy Iheu wurkni cumpanaW iwa Iwhcy udium+aiwc
' I IumeO..ion xhY w.armil IAia a111Javir imliuuna Ihcy ae damfo ell work aw Own him uuialda wmuxlun mull.uhmil+new+Irda.i1 mJiW lay mch.
-r,.nlrau.n
that akcck Ihla box MUM+omhud.ln addlliurwl•tw11 ahuwmy Ilw nauw of thou oao wenlrxwn and their uurkwa•comppllhcy mfurmanun
/,,,or un emplayer rhuf Is prariding worAers'rutnprnsirdals i0i'varlrnce for lily enrp/uyees. Below is the policy mild/tib life
lrr`arirlmlinit.
in,urancc Cumpauy Name
Pnlicv is or Scl Gins. Lic. M: __.. . . .. ___ Ewpiratwn Date:
)ab Site Address: _—' Clty,staicizlp.
Uta h n copy of the workers'cumpensatlun policy declaration page(shit log the policy number and expiration date).
padurc .r vccwrw cusemge as required under Section 25A ul'>1GL c. 152 can lead to file imposition of criminal penalties of a
rine op to S 1.500.00 anlb'ut one-year impris imcnt•as well as cia d penalties in the furor of a STOP WORK ORDER and a fine
.,i up til i250 rA i day .Igauut file violator. Re adv Led that a copy of this iialvineal may be lore irded to the 011ice ul'
Iq�:.n 1u'nH ul :lie DIA Jor n1vul.Incc lliaaLun.
/du hereby a.rlifr it ler Ibe Dolt%u idlr alliew u/yoiury that the tn/uneaflon provided above is true mud correct.
t/(/It IaI nye U//Iy. I)a Iu1l .'rife ill dlir area. to be rumpleted by.iry ur town aJJh ia1 1 _
f ihv lir fnvn[ ._ parmiul.iccnoc s
laauing \uthurlty (ciralc file):
I. IL"arJ of Ilvahh '. IlndJiny Ilep.ulnla tit L (.A,.'fuuu Clctk 4. Electriear lnwpector i. Pluulbinq Inspector
L. Other
('„nlawl I'cnull: .. .. Phone o:
Information and Instructions
%U».is huseus Gcncral Laws chapter I Q rt•quircs all anployers to protide workers' wmpensalion Err their employees.'
Pu r.u.uit to Ims .%%toIt, all eenpluree is avimcd is ' c%cry Pelson in the iervi%e if inuther un.ler .lily cOn U 3 of hire,
%press Or I InpII,& Oral or %%I it ten
%n :rnpluyer is detincd ai "in individual, partnership, associattou, corporation or other legal entity, or any two or inure
..t ate Llregolr.g engaged In a pr ant enicrpr,se. and meludmg the legal represewilives of a deceased emplu.%cr, or the
re%n%cr or trustee Of .w Individual, pa+tnctshlp, association or other legal clingy,employing employed. However the
owner of'a dwelling house having not more than three apartments and who resides thereto. or the occupant Of the
.h.;Ilulg huuse of another who employ%persons to do maintenance,construction or repair work on such dwelling house
Of lit: the.round%or budding appurtenant thereto shall not because of such employment be dccmeJ to be an employer "
NIGL chapter 152. 425C(6)also states that "every state or local licensing ageney shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings ii the commonwealth for any
:applicant w hti bas not produced acceptable evidence of compliance with the insurance coverage required."
Udiuonally, SILL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions ,hall
enter into any :untract for the perfomlance of puhlie work until acecperble c%idence of cumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(cis)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employ es other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP docs have
employees.a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the aftidavis. The aff irlavit should
be returned to the city or town that the application for the permit or license is being requested, not the Ihpartment of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete;and printed legibly. The Department has provided a space at the buttons
of dle affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pl:asc be sure to fill in the penni✓license nuniWr which will be used as a reference nuinber. In addition,in applicant
th:u must submit multiple pennitilicetlse applications in any given year,need only subtmt one affidavit indicating current
Policy intormation(if necessary)and under"Job Site Address"the applicant should write "all locations in (city or
townf- A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
rear. where a hums owner or citizen is obtaining a license or permit not related to any business or commercial venture
(t.e, it dug license or permit to burn leaves cte.)said person is NOT required to complete this affidavit.
I h; 1)bice In Itl%e.ngatiuns %%Oulu hi.e to thank you in id%:ulec tor your cuoperation and shuuld yuu Ila%. ,arty gtac Dlloni,
Please du nut hesfratc to give us a call
fhe DJ parnncnt's address. telephone and fax number'
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfAce of lovesdradons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
d 'n.ui
www.mass.gov/die
i
s CITY OF SALEM
l ( 5 PUBLIC PROPRERTY
:,.4
DEPARTMENT
I I I '/-8 -4; ';-,; • I \' 'i'Y V_ 1141,
Construction Debris Disposal .-affidavit
(required I'm all demolition and rcnuv:nion work)
In accordance \\ith the sixth edition of the State Building Code, 780 CNIR section 11 1.5
Dcbris, and the provisions ut MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this wvork shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
111. S 150A.
The debris will be transported by:
1 name of balder)
I he debris will be disposed uf•in
Inamr of facility) .
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NLIIJIUIC nt p.•nna.yy,hcant
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