2 GIFFORD CT - BUILDING INSPECTION The Commonwealth of Massachusetts
s� Board of Building Regulations and Standards CITY
` r Massachusetts State Building Code. 790 CMR, 74,edition OF SALEM
Rrvr)wr Junuory
:(NAY
Building Permit App ' anon To Constrltct, Re i% Renovate Ur Demolish a :(NAY
)nr-or Twu-Fumi! rllinR
is Sectio a Official se Onl
Building Permit Num r: Date Applied:
Signature: �JZ2if j
Huilding Commissioner or of Buildings Date
SECTION 1:SITE INFORMATION
1.1 P_ro"rrty lydress: 1.2 Assessors Map A Parcel Numbers
Cr I-M h
I.la Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(rt)
Front Yard Side Y216 Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewnge Disposal System:
Public Private❑ Zone: _ Outside Flood Zone? Munici
�
Check if es❑ palOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Rec rd:
` a l�s CrrrtD Gh
\i Name rint) 1p Address fa Service:
A
Signature Telephone
ION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Unit_ Other ❑ Specify: -
Brief Description of Proposed Work':
OyN
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 0111c1a1 Use Only
Labor and Materials
I. Building S Is— t5v� 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
J. Plumbing s 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. _Check Amount: Cash Amount:
6. Total Protect Cost: S� (] v ❑Paid in Full ❑Outstanding Balance Due:
97&
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) C' S �Q�3� 12g (
SP s (��IC"nd1U� I.icense Number fsphratiu OWC
i ist CSL rype(sce below) - v
in A.1 A. lr Descriction
� U Unrestricted to)5,000 Cu.FI.
�j R Restricted Id2 Family Uwcllin
M M 11111
(i RC Residential Raulin C'ovcrin
relcphwhe WS Residential Window and Sidin
SF Residential Solid Fuel Burning Amsliancc Installation
D Residential Demolition
S.2 R�gytcredHomelmprovemeat Contractor(HIC) /,t7 3+L/r7
L < utra inn Number
I IIC Company Name r)IIC Registrant Name
R gall
I 7 jj 21!� Expiration Date
Si one "rclaphune
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2.f 23C(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 ..........0 No...........O
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 A as Owner�f thh subject property hereby
authorize Cr <Q ) �h y� �°YV Q S �0to aci on my behalf,in all matters
relative to work authorized by this building permit application. '
Si ore of Owner Date
T SECT([[ 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
A1Ct x n/-)() ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc We and accurate,to the best of my knowledge and
behalf,
Pri Name d
Signa u of Owner or Authorized Agent
Si under the sins 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)Progrom).will ad 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 790 CMR Regulations 1 I O.R6 and 110.RJ.respectively.
1. When substantial work is planned,provide the information below:
Total tloors 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
). "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
s. "\
' PUBLIC PROPRERTY
DEPARTMENT
X'W, till
�I'.,"1' 110 IX�.untvt,rc?v 5n+err � S.il r�i, S1a+;n,.l a sr r,;,11r'.;
frl: 978-74 9595 . rAx: 978-74C19846
Construction Debris Disposal Affidavit
(required lour all demolition and renovation work)
In accord;uice with the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Debris, and.thc provisions-of MGL.c.40,_S 54;_..__
Building Permit # __ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
&(Z.lQhv, VJAste
I name ot•hauler)
The debris will be disposed of in
J�l l l t cJ W%o,34-
---_ ._.
(name of,(aci ity)
(address of tacility)
signature of permit applicant
01/2-01 ,
! date
dcFi isafl'u,K
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.1\I11:a:I:Y:)xlia:\111.
\L\1't Nt I2C WAtrtING ION 5'1'SELT • )At L'.M.MANSACI It ib.l I\0197^�
978.745.9595 is F.\x. 97N-74C•7846
Workers' Compensation Insurance :ILtl7davit: Builders/Contrac tors/EIectricians/Flu mbers
%onlicant Information Please Print Legibly
Naine(noitne gr;;anintinlvindlv�duull: , " 1 C�„ I ��-t/w\ 5�/l U L71nr�
:4tltifoss:
lF� L= A
City,S[a[c:Zip:
j Phone 0:
al Arc you an employer:' Check the appropriate box: 'Type of project(required):
4. Q 1 wn a general contractor and 1
I.(�I :can a employer with G. Q New construction
employees(full andfur part-time).• have hired the suh-contracturs 7. Q Remodeling
2.❑ 1 mn a sole proprietor or partner- listed on the attached sheet. *-
ship and have no cinpluyucs These sub-contractors have S. ❑ Demolirion
working for me in any capacity. workers' comp. insurance. 9, Q Building addition
No workers'comp. insurance 5. Q We are a corporation and its required.] of 10.❑ Electrical repairs or additions
officers have exercised their
3.❑ 1 ant a homeowner doing all work right ofexcntption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §t(3),and we have no ,12.[X Roof repairs
insurance required.] t cinployces. LNo workers' 13.Q Other
comp. insurance required.]
•Any:,p phcanl that chucks box el must:dxu till out the senimt buluw showing their aurkuri cumgtenvaiw,pull y inliurmliiun
' I lomcuwners whu mdmul this of 1davit indicating they are doing atl work and then hire outside culnraeton must submit a new affidavit indicting wch.
-Commctur thol shuck this box Intut atlachad an addiiiunal.,heat shu-ing the umno of the sub-contractors and their workers'comp.policy information.
f gar un employer tbar Lr providing,vorkers'corapensalinn in.rar(utee fur ray employees. Belaly is the pu/iay and job site
%ofarraatio4 t\ _ T�u v1 !A q ce
Insurance Company Vame: H C` p . f7 rn"�'(/'v`-'4�—.-_---.--
11olicy a car Sclf-ins. Lic. N:`_ t�VW Cr—C r YJ..,../ /-2 k3 Expiration Date: G_
Job SiteAddress: 9 Gf t1U f 7f _ CityislatdZlp:J IBA 0) 7--b
Attach Is copy of the workers'compensation policy declaration page (showing;the policy number and expiration date).
Failure If)accuru coverage as required under Section 25A of'bIGL c. 152 can lead to the imposition of criminal penalties of a
tine up In S1.5110.00 and/or cue-year imprisomncnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up rr,S250.00 it day against the violator. lie advised that a copy of this statement may be forwarded to the Office of'
In\ran-ao.nis ufthu DIA for iniurar.ce a\veragc \ciitwaliun.
l do hereby crriif seder the pains and penalties ufperjury that the information provided ubuvq is true and correct.
Official ti.ce ugly. Do nal write itt this area, tube cuuipleted by city or lawn ti icial.
C'ily or l'own: ._ Permit/l.icense g___ ._._.
Issuing;Aulhurily (circle one): i
1. Board of Ilcalih 2. Building Departiocot 3. Cityi 1'a\vo Clerk 4. L•'Iectrical Inspector 5. Plumbing; Inspector
b. Other __.
Cnnlact l'cnon: __ _ Phmfe 7:
Information and Instructions
\iasiachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emplgvee is defined as "...every person in the service of another under any contract of hire,
etpress or implied, oral or written."
An employer is defined as"an individual,partnership,associafiou,corporation or other legal entity,or any two or more
or the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of :ul individual,parmership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
• t t contract for the erfomwnce of public work until acceptable evidence ofcompliance with the insurance
enter p
Y
requirements of this chapter have been resented to the contracting authority."
q P P
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(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does 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 dale the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department 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 Omehitls
Please he sure that the affidavit is complete and printed legibly. The Department has provided uspace at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitAicetue applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address" the applicant should write"all locations in (city or
town)."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 ter future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I'hc Off cc of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do nut hesirate to give us a call.
The Deparnnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgadons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Rt -.i,ed i-26-05
www.mass.gov/din
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Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT. 311 FAX (978) 740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property:
Name of Record Owner: Philip& Donna Yates
Description of Work Proposed:
Replacement of roof to replicate existing (black or charcoal grey 3-tab, NOT architectural). No changes in
color, material, design or outward appearance. Non-applicable due to being in kind maintenance/replacement.
Dated: September 13 2010 SALE IC MMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.