6B NIMITZ WAY - BPA B-16-379 Cr-
rheCommonwealthofhlassachusetts TPRe
tN.SBoard of Building Regulations and StandardsCE
Massachusetts State Building Code, 780 CMR .L/ry 20/PBuilding Permit Application To Construct Repair, Renovate Or De 25
One-or Two-Family Dwelling
L This Section For.OfTciul Use Only
�Q Building Permit Number: Date.Ap. fed
DuilJiUS 0lricial(Print Name) Sig - Date
lYj SECTION 1"SITE INFORMATION"
I.1 Property Address: O 1.2 Assessors Map St Parcel Numbers
his 'r '15 i.l� i� Qn�PIY/ �al/7_0
I.1a Is this an acce ted street?ves no &lop Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot"Area(sy R) Frontage(R)
1.5 Building Setbacks(R)
. Sule Yarih' Rear Yard '
. From Yard
ReyuircJ Provided - Required -Provided. Required, Provided
1.6 Water Supply:(M.G.L c.40,§Sd) 1.7 Flood Zoae Information: 1.8 Sewage'Disposal System:
Public - Private O. Zone: _ Outside Flood Zone? Munieipel O l)tt site disposal system O
Cheek if est7
SECTION I: PROPERTY
.OWNERSHIP!
2.1 Ownert of RgFord: /e/st A44 dll170
--) City,Smte,ZIP
ne(Pnnl) � �-
6B Mr ;if W4v dgo /�at7ie/v�6o�{,afma:/.e��/
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)`
New Construction O Existing Building O Owner-Occupied O Repairs(s) O Alterotion(s) ❑ Addition O
Demolition . O Attxssory Bldg.O Number of Units_ Other O Specify:
Brief Description of Pro osed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Rem Estimated Costs: Official Use Only
Labor and Materials
I-Building - $ r✓-e 1. Building Permit Fee:S- Indicate how fee is determined:
O Standard Cityfrown Appllcation Fee
2.Electrical S O Total Project Costs(hem 6)s multiplier s
3. Plumbing $ 2V piker Fees: S
4.Mechanical (FIVAC) S List:
5.Mcchmtical (Fire $ Total All Fees:S
Su ression)
o Check No. CheckAmount Cash Amount:_
6.'rotul Project Cost: -S �fG00 G ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructioi Supeiv'istir License(CSL)
�� � fif License Number Expiration Date
-
NSnie df CSL410IJer " ` List CSL Type(see below)_ _
�7 grartc st- ;
No.:utd Stnxt Type, Description .
�,/ O J d Unrestricted(Buildings u to 35,000 cu.It.
4n/ e((.o R Restricted 1&2 Family Dwelling
Cityrrown,Stale,ZIP _ M Masonry
RC Rooting Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
�17 q 'L�ZdGy D)Wj:t ,,5171-4Ar 1 Insulation
Tele hone Email address D Demolition
5.2 Registered dome Improvement Contractor(HIC) 12 •72� _
F145 C0-M(l c���'h`ei� HIC Registration No Expiration Date
f I1C Cum .my Name or tllcc,RRegistrain Name
n� T�at?Sol'� J� �l hlo�SC-to9'ALC�'t7ao
Nu.rot �4e& DI0U Email address
City/Town. State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G.L F.I52.§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 Isi:uance of the building permit.
Signed Affidavit Attached? Yes ..........0 No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.WHEM :'..
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize FasC i a n, �2✓2/0 j/7 Py1
t9 act on my behalf,in all matters reI tiv to work auth rued by this building permit application.
Big gt t - 412%oi6
Print Owner's Ndme(Electronic Signature) _ - Date
SECTION 7b:OWNEW 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 this application is true and accurate to the best of any knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 figul have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Other important tnformn tt ono-n-lh—cH1C1'rogram can be-to—m-nd-
www.mass.cov'oaa Information on the Construction Supervisor License can be Found at www.nms� .
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) N (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 ofcoolingsystem Enclosed Open
j. "Total Project Square Footage"may be substituted for"Total Project Cost"
PROPOSAL
FASCIANI DEVELOPMENT - Design/Build
17 Babson Street, Wakefield, MA 01880
61.7.953.6206
PROPOSAL SUBMITTED TO PHONE DATE/
STREET I
-(� JOB NAME [[
CITY,STATE,ZIP . JOB LOCATION
ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for.
cZLG I /�P2 -ruD
�-ws- fez
tLD2 r¢in6
We propOSe hereby to furnish material and r—complate in accordance with above sPec'rfications,for the Sit `h +✓u
Payment to be made as follows: dollars($ )
CG
NI�re[rYl Y 0®enbetl b Ce es erx11ie0.M wa%lo Ee mn dNed In a waMrrenYMe mervxr eaaU4g
to emmw p.cum.wY�eneremn o�e.wuon rrem mw..a.drceuma IwoM�p mme�mv VAII a Au[horizetl Signature
aaewba orb upon w on mdera end we loo—an coma dY,ve wer and drove trot menela.M _
ean.m«m<ware.muron eve«emanmer ooz,a baend aa-.1 owners c.rym.wwem Note:This proposal m&y be withdrawn by us'rf not accepted within tl
of--mo,Iwaive.ovwchae en NN aa'a^d by WUY+nenb Goaywaetlon Ireverrt.
Acoeptance of Proposal The above prices,specifications and
conditions are satisfactory and are hereby accepted.You are authorized
to do the work as specified.Payment will be made as outlined above.
Date of Acceptance Signature
i
Signature
t,
The Commonwealth ofAfasspchuseas
Departfi:ent oflndnsiridUcciden6
1 Congress Strce4 Suite 100
Boston,M9 02114-2017
www.mas%.gov/dia
WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbem-
TO BE F31"%TFH TBE P1FM3 TBNG AUTHORffl'-
Applicant o a o , Plena Print l4db
Name(Busn'?kin/Oigamrationandividual):- C✓T'Y .ljG(�. " _
Address:
City/state/Zip: / � Amp
Are you an employer?Cheek the ippropriere bor. - Typa of Or ailed(required):-
1.Qlemaemployerwvh eiop'IoYces(full end/orpart-t�e).r 7. ❑New construction
2. aeok pooprierormparmership end have no.empbyera wor]oog formem $; [�.atenlodeling
say capacity.[No viotkca'off.iouuance required] 9. ElDemolition-
3.E]I sat a homeownerdurog ell work myself.[No work= e—p•inS Dw!*gaued.)t -
4.1j I am a homeowner and will be hiring psmractms to condna all work en my property. I wrl 10 Q Bmltimg addition,
eoune that all convacton eitherhave workers'wmpeasrhon in a m are sole 11.0 Electrical repairs or additions
pmpietms wish mcesplq'eas. 12.0P1>®bing epsusofadditio s
5.Q l em a general tenancies,and l heve hired the subcmtwam listed on the aasehed sheet 13. Roof
31scm.subeamtracfo®have=VIOYees and have wotkgs'comp i^n^ * 0 repays _
6.Q We ue s corporation and its officers have exercised their right of exemption per MGL C. 14.❑Otbe7
15I,§I(4),end we have w employees.[No workers'Cou p immnnce regnhad) : -
•Any applinni Abet ehecloe 6o-s1mustsleo5uomtheeegimhelowshor'vmgtke"n wmkeie mpolicy nJaameOon. .. .
t Homeownms who submit titre nffidavitm&c;ding they are doing all wort®d hue outside eo ces moat submit a newa%devit mdimMg such
=Contractors that check this boa must incWted no•additional sheet slowing the rutuse of the sub-w ens and state wkettic er not those entities have .
employees. Iftbesebma Lage®p4oyees,tLey,mostpaovidethefr.wmkera'.camp.polieymmtier.law an axpfoyer that isproviding workers'compensation insuraaaeforosy eorplpyees. Behriv Ls ehepof ry andjob safe
to OMAN&&
Insurance Company Name: 7,aV 7/�CA9 /r - /
Policy#or Self-ins.LLiic.#: u//-> S ` Expiration Date: ,[r'1 /'_/-0""�(a
Job Site Address: (I'Q/ ,l�7TT� CityjState/Zip: C &q i
Attach a copy of the worriers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the team of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to ilia Office of Investigations of the DIA for ineiltance
.coverage verification.
I do hereby certify under th ains and,�w,/�-t7r�es /ury that the informaaan provided above is true and correct
Phone
F
1cial use only. Do not write in this area,to be eoarpleted by ciV or town offWaLy or Town• PersaWLicense#
ing Authority(circle one):
oard of Heakh 2-Building Department 3.Ckyfrown Clerk 4.Electrical Inspector 5.Plumbing Inspectorther
Contact Person: Phone#•
j
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or writtep."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,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,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work anti]acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)naru(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(I-I.P)with no employees other then 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
Aceideuts for confirmation of insurance coverage. Also be sore to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pemrit 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 Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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 for future permits or licenses. A new affidavit rust 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.a 4g license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/ilia
CITY OF SALEA MASSACHUSE M
BummmDErAjamw
120 WA9m4GAWdS7REET,3"FLooR
IkL(978)74549595.
FAX(978)740.9846
KIIvlSERLEYDRISOOLL
MAYOR TEAS ST.FMM
DntEcrcotcFpuujcpxomw/BunLDmccmm=OMR
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 c40,S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility) ,
(address of facility)
Signature of applicant
Date
A CERTIFICATE OF LIABILITY INSURANCE DATE IMMIOD"YY)
06/10/2015
THIS CERTIFICATE IS ISSUED AS A MATTER N INFOFhATIVEL1 AM ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the POlicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the Policy, certain Policies may require an endorsement. A statement On this certificate does not confer rights to the
certificate holder in lieu of such endomement(s).
PRODUCER
NAMNTE�ul Derek Cataldo
R.M. CATALDO INSURANCE AGENCY INC. PHONE FA% ._
230 SQUIRE RD. (Ma ,EMI: (781) 289 - 5286 lac,Nof(781) 289 _526
PDDRESS_
REVERE, MA 02151
INSURERIS)AFFORDING COVERAGE NAIC y
-------- ---------___ INSURER A:GREEN MOUNTAIN 23850
DINO PERSIA DEA FASCIANI DEVELOPMENT INSURER B:
:17 RA SON ST INSURER C --- _
INSURER D:
WAKEFIELD, MA 01880
INSURER E: —�
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
TH,b IS TO C�I p: THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM .OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS
WHICH THIS
HIS I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR _
LTR TYPE OF INSURANCE POLC EFF POLICY EX
INSR WVO POLICY NUMBER (MMIDDrIYY) (MMIDDM'YY) LIMITS
A GENE COMMERCIAL IY Y 20004835 06/10/15 06/10/16 EACH OCCURRENCE s 2,000,000
R- COMMERCIAL LIABILITY PREMISES(Ea occurrence) S 500,000
CLAIMS-MADE L ]OCCUR MEO EXP(My one person) 5 10,000
PERSONAL B AW INJURY s 2,0001000
—'— GENERAL AGGREGATE s 4,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
-�POLICY PRO PRODUCTS-COMPICP AGG S 4,000,000
JECT LOC
AUTOMOBILE LIABILITY
$
ANYAUTO I (Enaccident) $
ALL OWNED SCHEDULED BODILY INJURY(Per person) S -- —
AUTOS AUTOS
NON-0WNED BODILY INJURY(Perac[itlenp S
_-..I HIRED AUTOS _ AUTOS , -- --- -
P RTY A-6MAGE_--- S(Peemitlenp
$
_J UMBRELLA LIAR J OCCUR
_ EXCESS L1A6 EACH OCCURRENCE S --
_1 CLAIMS-MADE _
S
DED RETENTION s AGGREGATE
WORKERS COMPENSATION s
AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN TORV LIMITS ER _
OFFICERIMEMeER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT S
(Mandatory in NH)
If yes.describe under E.L.DISEASE-EA EMPLOYEE s
DESCRIPTION OF OPERATIONS below _-
E.L.DISEASE-POLICY LIMIT 5
IESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional RemaAs Schedule,a Mort space Is required)
2ESIDENTIAL CARPENTRY
:ERTIFICATE HOLDER
:ITY OF SALEM _ CANCELLATION
'UBLIC PROPERTY DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION TE THEREOF, NOTICE WILL BE DELIVERED IN
20 WASHINGTON ST. ACCORDANCE NTH' OLICVPROVISIONS.
'ALEM, MA 01970
.TTN: MICHAEL E. LUTRZYEOWSEI AUTHOR REPRESE TATIVE
CORD 25(2010/05) 1 -2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
American Propefties`Team, Inc. /6 7 �\
r
TO: 6B Nimitz Way
FROM: Jennifer Pappas, Property Manager
RE: Deck Replacement
DATE: April 20, 2016
Please be advised that the Board of Trustees for Pickman Park has approved the replacement of
the deck at the above referenced unit. This approval is contingent upon it matching the existing
deck(composite materials can be used) and following the Engineering Alliance Deck
Specifications. The Board will not allow any design alterations.
We also require that permits be pulled in advance (regardless of what your contractor may tell
you), and then a copy of the final approved permit once completed must be sent to APT for the
unit file as well.
You will need to bring a copy of this letter to the Salem Building Department in order to receive
your permit.
Should you have any questions or require additional information, please feel free to call the APT
Service Team at (781)932-9229.
cc: Unit File
500 WEST CUMMINGS PARK-SUITE 6050- WOBURN •MA •01801.781-932-9229 •FAX 781-9354289