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19 PICKMAN RD - BUILDING INSPECTION (2) ,. � c��S��. �� The Cq,�µ� �e�fl��Iassachusetts INSrc�Separtment of Public Safety �� Massachusetts Si�� te i11�ig�de(7S0 CMR) �/� Building Permit ApplicaN Ff��y�uild�g other than a One-or TwaFamily Dwelling � U I (This Section Fur Official Use Onl )� . � � Building Permit Number: Date Applied: ;Buildirig_Offici.�l: � SEC'CION 1:LOCATION(Please indicate Block#and Lot M for locations foi which a street address is nohavailable) � \� �\C��PN ��+�0 ��(�4 ` n No.and S[reet City/Town Zip Code Name of Building(if appiicable) �J � SECTION 2:PROPOSED WORK � Edition of MA Stn[e Code used� , If New Cuns[ruction check here�or check all tha[apply in the two rows below , � Existing 8uilding❑ Repair❑ Alterotiun ❑ Additiurt Demolition O (Please fill uut vid submit Appendix 1) \� Chmige uf Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or constmction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an fndependen[Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Des�criPtion of Proposed Work: �$�_�X 2-Cl ��DP iTl O I� �� iC`�-.E1-�sl� ��l_JC7 fL �-�RA D f"� , SECTION 3:COMPLETE TFIIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY � � � Check here if an ExisHng Building Investigation and EvaluaHon is endosed(See 780 CMR 3�k) O Existing Use Group(s): Proposed Use Croup(s): SECTiON 4:BUILDING HEIGHT AND AREA � � Existing Proposed No.of Floors/Stories(indude basement levels)&Area Per Flcwr(sy. ft.) '�j - 3 Total Area(sy.ft.)an1 Total Height(ft.) � �� - SECTION 5:USE GROUP(Check as a plica6le) . - � -� ` � A: Assembly A-1❑ A-2❑ Nightdub ❑ A-3 ❑ A-k❑ A-5❑ B: Business ❑ E: EduwNonal ❑ F: Facto F-I❑ F?❑ H: Hi h Hazud H-1❑ H-2❑ H-3 O H-9❑ H-5❑ L• Institutional I-I❑ F2❑ I-3❑ [�❑ M: MercanHle❑ R: Residential R-1❑ R- R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use�and please describe beluw: . Special Use: SEC'CION 6:CONSTRUCfION'CYPE(Check as a licable) ' IA ❑ I6 ❑ IIA ❑ ❑BO IIIA ❑ IIIB ❑ IV ❑ . VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 foc details an each item) Trench Permit: Debris Removal: Water Supp : .Flood Zone Informallon: Sewage Disposal: Licensed Dis os�l Site❑ Public� Check if outside Flood Zone❑ Indicate municipal �[rench will not be P �• required O ur trench or specify: . Private❑ or inden[ify Zone: or on site system❑ �ermi[is endosed❑ Railroad right-of-way: Huuds to Air Navigation: \I�\I I� � ri�.,<��nnu,si>n it,.._jc.� i r�„s: Not Applicable❑ Is Structure wilhin airport approach�rea? ls their review mmpleted? or Consent[o Build endosed❑ Ycs 0 or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERT[F[CATE OF OCCUPANCY [dition of Code: Use Croup(s): Type of Construction: Oaupnnt LoaJ per Flooc Dues Ihe builJuig contain�n Sprink�er System?: Special Stipulations: I�LG� UU ►�1C��'h��Gt,i�.0�� mg��-�..� 3�� IS SECTION 9: PROPERTY OWNER AUTHORIZATION ��Name a 1 ddmss of o erty Owner p ;e a � r� �� ic�m,�n c�(. ,��en1 , I�G v1927 - Name(Print) No.�nd Street City/Town Zip Property wner Contact Infonnation: : , - e�� • - - 9��'. 3�5_ �3�%a Title - Telephone No.(business) Telephone No. (cell) e-mail address [f applicable, the property owner hereby authorizes Nzvne Street Address City/Town State Zip to act on the ro er owner s behalf,in atl matters relative to work authorized b this buildin ermit a lication. � � . SECTION 10:CONSTRUCTION CONTROL(Please fili out Appendix 2j�.� . � � � � � If bu8din is less then 35,000 cu.ft:of encloseds ace and�or not under ConshvctlonControl�then check here O and ski��Section 301 10.1 Re istered�Professional Res on5ible for Construction Conhrol � � � � � �� fame(Registrant) Telephone No. e-mai(address Registration Numbcr Street Address City/Town Sta[e Zip Discipline Expiration Date 10.2 Generat Contractor � " � � � � � � - - - � � � � � � � G��I i 1- � Cov�s a- Comy.�ny Name� � l�k w� 1 � �ti.�s . Name of Person Responsible fur ConsWction License Na and 1'ype if Applicable Le,�q �v�a�� itila�/ S� �,' ��•v � cul��'Z. Street Address City/Torvn�- Sta[e Zip � 54�C L�ikln =Saw�P s(i.tr�n, - G�dr•� �.' ({��j,..,,.1 f Cu•�" Tele hone No. business Tele hone No. cell e-mvl addmss � SEC7'ION 11:VVOItKFRS'CObIPI:NSKI'ION WSUR:1NCki AfFIDAVff M.G.t.c.152 �25C 6 � A Workers'Compensation Insurance Affidavit from the MA Deparhnent of industri.il Accidents must be completed and submitted with this application. Failure to provide[his affidavit will resutt in the denial of[he issuance of[he building permit. Is a si ned Affidavi[submitted with this a HcaHon? - Yes 0 No O- � � � � SECTION 12.CONST2UCTION COSTS AND�PERMIT FEE��. . . � - � �� Item Estunated Costs:(Labor and Ma[erials) Tot�l Construction Cost(from Item 6)_$ � 1. 6uilding � .0 �A� BuilJing Permit Fee=Total ConsWction Cost x_([nsert here 2.Electrical $ pOq appropriate municipal factor)_$ , 3. Plumbing $ � 4.hlechanical (FIVAC) $ .� Note:Minunum fee=$ (contact municipality) 5. Mechanic:il Other � � Encfuse check payable to 6.Total Cost � `��_ (mntact municipality)and write check number here � SECTION 13:SIGNA'I'URE OF BUILDING PERhIIT APPLICANT. By entering my name below,f hereby attest under the pains and penalties of pe�jury th�t all of the infurmation contained in Hiis � application is true and acwra e ro the best of my vl 1 d under tanding. G�b 4�G�r ��2 !2/ �l9� �S _3�47� 3�`�/� Please print an � n ONw /� J � Title Telephone No. Date Strcet Address C, n � �� / ' /Town State Zip � r,C �� 5 �� Oj 4 7 h(unicipal Lispector to fill out this section upon application approvaL• � / ��+� -' L� ,�5 Name Date . � ` � C�TY OF SALEM, MASSAC�jUSETTS �� ; �; BUILL)INGDEPAR7METTT , �' 120WASI�iG7'pNS7REET,3RDF�,OpR � � TEL.(978)745-9595 g�E�yD�s�� Fax(978)7449846 IVInYOR 'h3oMns Sr.P�xxE DIRECI'OR OF Pi1BLICPROPERTI'/BUILDING�7�qH[�$IONER Construction Debris Disposa/Affidavit (required for all demolition and renovation work)� In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 D an . ebris d the provisions of MGL c40, S 54; Buildmg Permit# � is issued with the condition that the debris resulting from this work shail be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, 5150A. The debris will be transported by: _ � � dZ�pa.�'� � (name of hauler) The debris will be disposed of in: � � �vv� �s��l/ � ' (name of facility) f� PveY� �� I (address of facility) '�, Signature, of applicant Date . � Tlae Commo�xwealth of Massachusens � < DepartmentoflndustrialAccidents �� _ _� 1 Congress Street, Suite 100 A � Boston,MA 02114-2017 '-�� www mass.gov/dia �i'orkers'Compensation Insurance Atfidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITA THE PERMITTWG AUTHORITY. A licant Information Please Print Le ibl /I 9 J N8ID0 (Business/Organizalion/Iudividual): ey{� \ �l f l lr�uv� �� py (y-I-� ��/Iq�J J� �— AddreSS: �j L2..t 4 �vL R p f.✓L�/ City/State/Zip: ��' �9 v✓ p ZPhone#: �9 �7 � �� l'3 � � � Are you an employer?Check the appropriate box: Type of project(required�: - 1.�I am a employec with employees(full and/or part-time)." 'J, �]V cOnSfiucti0n 2.�am a sole propnetor or partnership and have no employees working for me in g, � emodeling any capacity.(No workers'comp.insurance required.J 9. molition 3.�f am a homeow�er doing all work myself.[No workers'comp.insurance required.]t 10 �lding addition 4.�I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all wntractors either have workers'compensation insurance or are sole I 1. E�BCtC1C31 i0p21iS OL 2dd7t10D5 proprietors with no employees. j2.n Plumbing repairs or additions 5.�I am a general contracmr and I have hired the sub-connacrors listed on the attached sheet Ryp These sub-wnhac[ors have employees and have workers'comp.insurance.= 13.�y�.00f repairs - 6.❑We are a coryoration and its offirers have exercised Iheir right of exemption per MGL c. �4.❑O[IIBi 152,§1(4),and we have no employees.[No workers'comp�.insurauce required.] � *Any applican[[hat checks box#1 must also fill out Ihe seclion below showing their workers'compensation policy infortnation. r Homeowners who submit[his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors[hat check this box must attached an additional sheet showing the name ofthe sub-contractors and state whether or no[[hose en[ities have � employees. If[he sub-contractors have employees,they must provide[heir workers'comp.policy number. I am an employer that is providing workers'compensatian i�xsurance for my emp[oyees. Below is the policy and jab site information. Insurance Company Name: Policy#or Self-ins.Lic.#: � `� E�cpiration Date: 7ob Site Address: �� i'/��(LY/y v� /�� City/State/Zip: Jq��/�/J , Attach a copy of the workers' compensation policy eclaration page(showing the policy number aud 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 form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of tUis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. , I do hereby certify under thepains and penalties ofperjury that the informntion provided above is riue and correct. Sienature: C/`'��"��%��'+�-r�%f'..�.�....� Date: 2�7 1,.� /Z ^ v J Phone#: � Officia!use only. Do not write in tbis area,to be co�np[eted by city or town officia[. 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#: Information and Instructions Massachusetts Genera]Laws chapter 152 requires all employers to provide workers' compensation for their employees. ' Pursuant to this statute,an eneployee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written" 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 �eceiver 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 apartmen[s and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,conshuction or repair work on such dwelling house or on the gounds 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 sta[e or local licensiog agency shall wiffihold 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 compiiance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of ifs politica]subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out tt�e workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees othei than the members or pariners,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 Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or tovm that the application for the permit or license is being requested, uot the Deparhnent of Industria]Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the D.eparhnent 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 appiicant. P]ease be sure to fil]in the permiUlicense number which will be used as a reference number. In addition,an applicant � that must submit multiple pernutQicense applications in any given year,need only s�bmiY 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 must 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The DeparhnenYs address,telephone and fas number. � The Commonwealth of Massachusetts Deparhnent 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/dia Details Page 1 of 1 �';e O�Cri s ru,si^.o o( h�E„ecu�:i�ro 6 icc cf-ub'�c a`'aty aqc Se ,��tr:=0PS5j . i t,1as=.GovHcme SIEYoAasndes ensee Details ull ame: ' Mark E Williams �Gender: er Name: ddress: ddress 2: City: Salisbury State: MA ipcode: 01950 o nt : U 'ted tates icense No: -0 4 71 License Type: Construction Supervisor 1 &2 Family Profession: Building Licenses Date of Last Renewal: 4/18/2014 Issue Date: Expiration Date: 4/16/2016 License Status: Active Today's Date: 3/30/2015 econdary License: Doing Business As: atus Chan e: Lic nse Renewal o rere uisite Information No Disci line Information ocumen um � Close Window I � OO 2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=253325& 3/30/2015 l ' � �^ I N � � � � �ao �ao .r� 0 0 0 � � � � , �� , , , � , � , � , � , � � , � � , � � , � � I � � Z , - I � � � F , � � � N ' � i ' � i � a i ' o i � F i 1 , y '^ - � I v/ � I I I � � I I � , � I I I � I _ m � oo ; � N ' � � � � � � �� \ � a i 0 i i ii m � �1 ` ; \ � ; � , - � � � � � , �oo� � � o �, -- -— , � _ �.,: � � � , - o , , � , � � , R � ' I I fD3 �+Z � i ��"�� Z i � �o� � °-�� i � � �.�d -_. � i ry a =.n i � �3 m' i � o � � I =� I � � _ _ � I N S I • 1 � I I � � I I � � I � I � I � I I � 1 � 1 � I � I � 1 Interior reposition master bedroom second floor addrtion M�,�a,2015 G\StERED � Mataragas Residence HH Design GroupArch�ects e�o6`''S . 19 Pickman Road 1 Ticehurst Lane � � � Salem, MA 01945 Marblehead, MA 01945 � eO Mp'" ,z�, ' 781639 3493 `�9� '` r"_,��'°":' David M. 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