8 GIFFORD CT - BUILDING INSPECTION The Commonwealth of Massachusetts
Q,y OF
Board of Building Regulations and Standards CITY
f��r Massachusetts State Building Code,780 CMR SALEM
Revised Mar 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: to Applied:
D
Building Official(Print Name) Signature z Date
SECTION 1:SITE INFORMATION
1.1 Propgy Ad </ressoa Ca: 1.2 Assessors Map&P Numbers
�i0 r W
Lla Is this an accepted street?yes >( no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required 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?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Po%iiN t7nt,/ Sii,r/W AA 't sak� h?A 01970
Name(Print) City,State,ZIP
JR 611clo2A clef 978' 7VS' 61-7S
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorkZ:
kernor�i l a.10.ysFu,vt
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ ,20 000 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ 2r0e0 ❑Standard City/Town Application Fee
❑Total Project Cosi3(Item 6)x multiplier x
3.Plumbing $ 3, 900 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 2 Sl 0 00 n n..:a:..s..0 n n......�..a:....o..i......o n..o-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) J 6, ,39.z7 10 313 1 e2"13
JA-I kul,le License Number Expiration?bate
Name of CSL Holder tl
List CSL Type(see below)
is (51i<oaq C/�7
No.and S t Type Description
ietwr M,4 of 970 U Unrestricted(Buddin2 up to 35,000 cu.ft.
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/ 1 SF Solid Fuel Burning Appliances
4/7-3$B'3L97 JD£1141eL6/q�.13JK 4WL0 I Insulation
Telephone Email address D Demolition
5.2 Regt/$I t reed Home Improvement Contractor(HIC) �b L L16 9
: S 6 /
t/d C ua, HIC Registration Number E uati n Date
` HIC CompanyN e HI Regis t Name
✓ �� gVT
An-4 o/goo G 3 3�/No.and S ee /7_ g L- 7 Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 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 ..........P, No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIESFOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 6
to act on my behalf,in all matters relative to w rk authorize y this building permit application.
Print Owner's Name(Electronic Signatt ) J —T�TDate
SECTION 7b: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 i, gp ication is true and accurate to the best of my knowledge and understanding.
10 y /
Print Owne 's r Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An O er 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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at 3nnL.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 Cost"
f CITY OF S�1I_E�I, N'L'f`SSACHUSE=
• BUILDING DEPARTSIENT
120 WASHINGTON STREET,San FLOOR
"ILL (978)745-9595
FAX(978) 7409846
KIJffiF1tI E D Y RISCOLL
THOMM ST.PtERRE
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSL.OSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information { /'/ / Please Print Legibly
ga Naine Rusinesw0rnization/Individual): Jill lt)l e (iDAS111y A1L) :Zt/e
Address: Y,7 L'i4cS�itu f Svi
City/State/Zip: /�,-,a to J M,4 Phone#:
Arre,you an employer'Cheek the appropriate box: Type of project(required):
I.ISI 1 am a employer with 3 4. ❑ 1 am a general contractor and 1 6. ❑New construction
/ employees(full and/or part-time).* have hired the sub-contractors
2-❑ I am a sole proprietor or partner- listed on the attached sheet: 7• remodeling
ship and have no employees These sub-contractors have V11,11 Demolition
working for me in any capacity. workers'comp.insumam 9. ❑Building addition
[No workers comp. insurance S. ❑ We are a corporation and its
10.El Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑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' 13.0 Other
comp.insurance required.)
•Any applicant that checks box 91 most also,fill out the section Ind"showing their woken'camp ..don policy information.
'I lone wnas who submit this affidavit indicating that are doing all work and than hoc mtaide controcems mug submit a new affidavit hxru ding suck
:Contractors that cheek this box must anached an a.Witiwol sheet showing the name of the subcontractors 2M their work=*comp,policy information.
l am an employer that it providing workers'compensation lnsarance for my employees. Below Is the pollay and job she
information.
Insurance Company dame: ,,
Policy#or Self-ins.Lie.#:A^^{ A ir$ 0 02 0l Z Expiration Date: ,R /C4 `2 tt/
Job Sire Address: 9 �r lFOK/ L 4 i City/State/Zip: S X,0r AnA 0/97d
Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fate
of up to S250.00 a day apinst the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify nil the pains and penaties of perjury that the information provided above true and correct
r ([A Dam: IO Y I Z
P o - G17- 3$$-3b67
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Departmeat 3.Cityffown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF S.U.ENl, 1�I.-kSS.kCHUSETTS
BUILDING DEPARTMENT
• 120 WASHNGTON STREET, Yo FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
lUN1BFiZT FY DRISCOLL
MAYOR THOMas ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/13UUMNG CONWISSIONER
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 111.5
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:
Joe M'l or � S7i✓e7�7ec/
(name of hauler)
The debris will be disposed of in :
/�/,J/ _dJ/ /.7,1 n,V I;
(name of facility)
of h Swa�Ps�f
^(dress of facility)
sign1fre of permit applicant
}� IZ
date
Jcbriwffdce
L
Joel White Construction LLC
Joel White Construction LLC _ _ __ Estimate
3 Bessom St Box 207 Date Estimate
Marblehead,MA 01945 F— ---
10/04/2012 1052
(617)388-3667
joelwhiteconstmetion@gmaii.com E
axpDDate
http://Joc]WhiteConstruction.com
Address
Robin ONeil
45Arley Walker
Gifford crt
• Salem,MA 01970
Date Activity Quantity Rate Amount
10/04/2012 Remodel First floor kitchen and bath
10/04/2012 Kitchen To include new cabinets,counter tops,appliances and lighting
,10/04/2012 Bathroom to include new tile floor and tile wainscoting with new fixtures
10/04/2012 Total material and labor including permit 25,000.00
j Total $25.000.
Labor is priced at $65/hour. Estimated costs are based on
- - - -- - --— -----
experience. Owner will be charged for actual hours devoted to the
project. When possible, owner will be advised if work is likely to