10 GIFFORD CT - BUILDING INSPECTION S
1
Q The Commonwealth of Massachuscits
Board of Building Regulations and Standards **ddW6*A&
�l Massachusetts State Building Code, 780 CMR, T"edition
�t{ Building Permit Application To Construct, Repair, Renovate Or Demolish a
IJ1 One. or rito-FairtilY Duelling
This Section For Official Use Only
Building Permit Nu r: le App ed:
Signature: ' � 9
Building Commission 'Inspector of Bu ldtn Date
SECTION I:IS4U INFORMATION
1.1 P? y/Add s: 1.2 Assessors Map& Parcel Numbers
1.l a Is this an accepted street'!yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning'Disinct Proposed Use Lot Area(sq B) Frontage 00
1.5 Building Setbacks(R)
Front Yard I Side Yards Rear Yud
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al❑ On site disposal s stem ❑
Public❑ Private O Check if esO P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /
L CWYLL
Pr' ) Ad#cn for Service:
Signature Telephone '
ECTION l: DESCRIPTION OF PROPOSED WORK'(cheek all thee apply)
New Construction❑ Existing Building❑ Owner-Occupied O 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify!
Bri'ewf Desert 'ion of Ikaposed Work7'
A✓ _ /n 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical f ❑Total Project Cosl'(Item 6)x multiplier x
) Plumbing f 2. Other Fees: S
J. Mechanical (HVAC) S List:-
5 Mechanical (Fire S Total Ali Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:
v 6 Total Project Cost: ,fJV 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Licence Number Espiration Date
Nypr ut CSL Hylder List CSL Type lace ttclow)
Address Ti, Description
U Unrestricted u Ft to)5,000 Cu. Fl.
R Restricted Ih2 Family Dwelling
Signature M Masonry Only
RC Rcsidentral Ron Co
vering
Telephone WS Revdenual ofi
Window and Siding
SF Residential Solid Fuel Eluming Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 2SC(6))
Work 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 AIM, vit Attached? es. .. ..... O No........... O
SECTI 7 :OWNER UTH TION TO BE COMPLETED WHEN
OWN ' AGEN R OR APPLIES FOR BUILDING PERMIT
ILEv t` as Owner of the subject property hereby
authonze to act on my behalf, in all matters
relative to work authorized by this building permit application.
Si nature 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
(Si tined under the psins and penalties ofperjury)
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 so have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110 RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, Finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
.'umber of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Type of heating system Number of decks/ porches
Typeof cooling system Enclosed Open
3 "Total Project Square Footage" may he substituted for 'Total Project Cost'
CITY OF SM.E.M
PUBLIC PROPERTY
DEPARTMENT
w,
MAYOR 130 WAUGA TCH SITE=•SALEK%L%SSACHLSKM 01910
TFL 9'5.7354S95• FA)-976740.964
HOMEOWNER LICENSE EXE.MMON
Please Pria
Date q / a
Job Location 10 &rj Uk6�t
Home Owner Address Q.vu-e—
Home Owner Telephone eD-11
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she arse/ ds the City of Salem
Building Department minimum i n procedur an requirements and that he/she
will comply with said procedures an uiremen
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDNG NSPECTOR
See other side for state code
CITY OF SALLM
PUBLIC: PROPRERTY
,.,_.,. DEPARTMENT
Construction Debris Disposal Aflidm it
(rerluited air AI demolition .uld I'vI10%-IIIIll work)
In accunlance \\Ith the sixth edition of the State Building Code, 750 CTIR sccton I I 1 5
Debris, and the provisions of MGL a 40, S 54;
Building Permit H Is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
11I. S 150A.
The debris will be transported by:
61hi
I namc tit hauled
I he debris will be disposed ol'in
�W1 �
(Mint ul Utility)
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