4 GIFFORD CT - BUILDING INSPECTION fp'] C)°'
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEI
�� Massachusetts State Building Code,780 CNIR Revised filar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
Building Official(Print Name). ignatine Date
SECTION 16 SITE INFORNIATION
1.1 Propert Address: 1.2 Assessors Mop&Parcel Numbers
yGi FD e C,�,
1.[a 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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check ifyes❑ Municipal❑ On site Disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
/11�. r�/rs. Y�fS SfI� //� /`i G/ 9 yo
bi'�me(Print) City,State,ZIP
02 G/ -4 CT 9Jel71/sy 9a UJAC910UD QUakLlow�
No.mid Street Telephone mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Lot Owner-Occupied 1 I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number ofUnits_d. Other ❑ Specify:
Brief Description of Proposed Work=: (//o(�A%> /�L///'>/�//✓� j,
spy d G
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building S Zrt 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical 5 ❑Standard City/Town Application Fee
0 ❑Total Project Costa(item 6)x multiplier x
3. Plumbing S2, 00 Q t� 2. Other Fees: S
4. Mechanical (HVAC) S 16 D of List: y
S. Mechanical (Fire S
Su ression) Total All Fees:S
�� 7�0 d Check No._Check Amount: Cash Amount
!. 'futul Project Cost: $ / d ❑ Paid in Full ❑Outstanding Balance Due:
J) 004-frG�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS t27�/£ y �
/ /`YU/J/'9 S' � �S�(/7TON _License Number E.epimtio Uate
Name of CSL Mulder
List CSL Type(see below)
8 7 HL�1 111,f_ Y
No.:urd Street 'type Description
U Unrestricted(Buildings Dwellto ing
cu. Il.)
R Restricted Ig2 Family Uwellin
Citylrown,State,Zip M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7,9/69/ 7,1a SAs A/ 6AI R//DL I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /IV91- yy Y
t.SL/7T 6/✓ r QA/S fjUGi l DN HIC Registration Number E.piraC n Dute
if IC C7 ��U/�I n: N:une or HIC Registrant Name
S' �e�//>ti S/jS�C Ca�v mac
No.and Street Email a mss
zoyz _/ /�/>i90 /7// !�-?/ 7,Z
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))r .
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Is§uance of the building permit.
Signed Affidavit Attached? Yes .......... 9' No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE CONIPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERDIIIT,'
I,as Owner of the subject property,hereby authorizeTC'+fl S\ \-� -A C-0
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
Inc,
!Tint Owner's Natuxylectrotiff Signature) Date
SECTION 7b:OWNER'OR UTHORIZED AGENT DECLARATION
By entering my name below,) 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 m knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
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 Florae 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 can be found at
www.mass.jniv:'oca Information on the Construction Supervisor License can be found at www.mass.rzov/dps
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) (including garage, finished baseutent/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number or 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`"road Project Cost"
L
CITY OF SAL E\t i�L1SSACHUSETTS �
Bt imD4G DEP.�R-nMNT
tr 120 W-ASHLNGTON STREET, 3" FLOOR
" TEL (978) 745-9595
F.uK(978) 7.10-9846
Kn BERLEY DRISCOLL
.NLAYOR THOSIAS ST.Prun
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CO%WISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
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 disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
y
y I SAD r N�T/l�Gi/o�✓
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
/,Z
date
CITY OF SM.E i, NLASSACHUSETTS
Buimi:NG DEP+RT%iF_NT
p a 120 1WASHLNGTON STREET, 3w FLOOR
\� b TEL (978)745-9595
FkX(978) 740-9846
KI\[BEftI LEYEY DRISCOLL
- THOhIASST.PMUS
MAYOR DR
DIRECTOR OF PCBLIC PROPERTY/BUMDL\G COSNISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (13usinessUrganiza�ion,'Inuivirlunl): s�l��!/✓fI� ��/y���rJ C ��N
Address: 507 IeIV
City/State/Zip:/4/X//�l/,�'//,e"/ W O/S4Y_Phone#: 7,Vl 7. >0'
Are you an employer?Check the appropriate box: 'Type of project(required):
1.❑ 1 am a employer with 4. [g I am a general contractor and 1 6. ❑New construction
J employees(full and/or part-time).' have hired the sub-contractor
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. QRemodeling
ship and have no employees These sub-contractor have S. ❑ Demolition
I working for me in any capacity. workers' comp. insurance. 0. ❑ Building addition
[No workers' comp, insurance 5. El We are a corporation mid its
i 10.0 Electrical repairs or additions
I required.) officer have exercised their
i� 3.❑ 1 am a homeowner doing all work right of exemption per MGL I t.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' I},❑ Other
comp. insurance required.)
-Any applicant tar checks box#1 must also GII out the section below showing their workcn'compensation policy infbnnation.
'I tomeowwas who suhmil this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
1111 :(:ommcwn shut chuck this box must attach d an additional shut showing flu name of the sub-conuaetors and their workcn'comp.policy infomution.
I ran an employer that is providing workers'compensation insurance for my euployees. Below is tale policy and fob site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic. fl: Expiration Date:
Job Site Address: A Gf.("FG�,D Gi' City/State/Zip: k5, 9, /:W/ M/9 g��7d'
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of AGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonmm as well as civil penalties in the form of a STOP WORK ORDER and a fine '
of up to S250-00a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ul'the MA for insurance coverage verification.
I do hereby certify rttrder the puinss and penalAes of perjury/fiat the infonnurion provided above is true and correct.
Siennure; r iriwr+ d Data:
Phone 1
Official use unly. Do not write its this area, to be completed by city or town officlut
City nr,ruwn: Permitfl.icense#
Issuing Authurity(circle one):
1. Board of health 2.Building Department },City(rown Clerk 4. Electrical Inspector 5. Plumbing Inspector -
6.Other
Contact Person: __-. Phone 4: