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10 GIFFORD CT - BUILDING INSPECTION (2) 1• e ' 1 9 The Commonwealth of Massachusetts Board of Building Regulations and Standards / Massachusetts State Building Code, 780 CMR, 7ih edition 10, �\ Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised One- or Two-Family Dwelling Aril 15, 2009 This Section For Official Use Only T+ Building Permit N er. A Date Applied: "cl Signature: Building Commissio nspector of Buildings Date. SECTION 1: SITE INFORMATION 1.1 Property Address _/O e d �T 1.2 Assessors Map& Parcel Numbers �r Ffo 1.1a Is this an accepted street?yes k no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 ter of Re d: el ^/ 1 Fr2✓ i Name P nt) Address for Service: S nature Telephone ACTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief De��jj prion of Prff posed Work-2: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ (0 QUO, 00 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee /0(70 00 ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ (a0o, ©o 2. Other Fees: $ 4.Mechanical (FIVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ /01 6 00, 00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES " 5..11 Licensed Construction Supervisor(CSL) 2\1 P 1'P r t" I U/1 a-tA License Number J Expi do Date Na e of CS -Holde List CSL Type(see below) r SeL� P�vi A ress Description _ Unrestricted(up to 35,000 Cu.Ft.) R Restricted 1&2 Family Dwelling St�g7natu a /l M Mason Only / 7 �7 —�`3�� RC Residential Roofing Coverin Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5. ' tered Hpgte I rovem¢nt Contractor(HIC) _ i� IVI I r d ti ,-) /J V HI om y Na or HIC gistrant Na `/ Registration Number r /Pvvi °7 A, M A ess `/7f p x i lion Date azure 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 pemmt. Signed Affidavit Attached? Yes .......... No ........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relativ to work auth ed this building permit application. Si ature of Owner I VDate - CTIO//N�1�71s ' OR AUTHORIZED AGENT DECLARATION I, Pp- p r I V I l'cl a.4A. r , as ea 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 der or Authorized Agent Date / (Signed under the pains and penalties of e h ) NOTES: 1. 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 110.R6 and 110.R5, 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"maybe substituted for"Total Project Cost" The Commonwealth of Massachusetts Department oflndustrialAccidents k vL;W�l t Office of Investigations 600 Washington Street Boston,m MAg02III www. ass. ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information c\ Please Print Le 'bl Name (Business/Orgmization/Individual): V V Address: _�2 rl City/State/Zip: d Phone 4 Are you an employer? Check the appropriate boa: Type of project(required): .El I am a em to er with 4. ❑ 1 am a general contractor and I 6 p y ❑New construction employees(full and/or part-time).* have hired the sub-contactors listed on the attached sheet. 7. ❑ Remodeling 2*1 am a sole proprietor or partner- ship and have no employees These sub-contractors have g. ❑Demolition workin for mein an capacity. employees and have workers' 9 g y p ty. ❑ Building addition o workers' com insurance comp. insurance.* P 10.❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ lam a homeowner doing all work. officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiation Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against 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 c tf of the ains a en es of perjury hat the information provided above is true and correct. Signature: Date: Phone# g 7� " �/ C-./— 9 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 Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Cylf d R S