28 PICKMAN RD - BUILDING INSPECTION $ 13 � GK `i��b3to
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, Igo CMR ! Ia?b _II M 1 4SA 09
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
M One-or Two-Family Dwelling
W -- This Section For Official Use Only
C� Building Permit Number: Date Applied: _
'saw 411 J �A
Building Official(Print Name) _ Sigmnve D
SECTION 1:SITE INFORMATION
1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
t`(�d 28 PICKMAN ROAD SALEM,MA 01970 22 22-0184-0
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Rl ONE FAM
Zoning District Proposed Use Lot Area(sq ft) - Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requited 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 OWNERSHEP" -
2.1 Owner'of Record:
KEITH PHELAN SALEM,MA 01970
Name(Print) City,State,ZIP
28 PICKMAN ROAD 978-745-0212
No.and Street Telephow Email Addtcss
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building'9 Owner-Occupied V Repairs(s) Vf I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other af specify:Replacement
Brief Description of proposed Worle. REPLACE 13 WINDOWS
NO STRUCTURAL CHANGE
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Offtcial Use Only
(Labor and Materials
1.Building $ 18, 571 . 00 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard Cityfrown Application Fee
❑Total Project Costa(item 6)x multiplier x
3.Plumbing $ 2- Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No.. Check Amount: Cash Amount:
6.Total Project Cost: $ 18 , 571 . 00 ❑Paid in Fug ❑Outstanding Balance Due:
Mrt Lc ts-o t t's 5A-stz C� ( If6
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 90125 10-0 6-16
Jamie Moirn License Number Expiration Date
Name of CSL Holder U
86 Gardiner St Lis[CSL Type(see below)
No.and Street Type Description
Lynn, MA 01905 U Unrestricted(Buildings u to 35,000 on.ft.
R Restricted 1A2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
508-351-2214 I 1 Insulation
Telephone Email address D I Demolition
5.2 Registered Rome Improvement Contractor(HIC) 170810 12-2 3-17
Renewal by Andersen HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
30 Forbes Rd
No.and Sheet 508-351-2214 Email address
Northborough, MA 01532
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.
Sighted Affidavit Attached? Yes.......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Jamie Morin
to act on my behalf,in all matters relative to work authorized by this building permit application.
SEE CONTRACT
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I reby at trader the pains and penalties of perjury that all of the information
contained in this application ' true accurate to the best of my knowledge and understanding.
JAIME MORIN 6-10- t!�
Print Owner's or Author' Agors Name(Electronic Signature) Date
NOTES:
1. An Owner whdAKtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(INC)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.aov/oce Information on the Construction Supervisor License can be found at www.mass.eov/dos
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. fQ 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"
CITY OF S UJ&NI, INiASSACHUSETTS
BUMDLNG DEPAlI AffNT
130 W 1sHiNGTON STREET,3`a Mom
TEI-(978)745-9595
PAX(978)740-9846
tUNffiERLEY ARWOLL
MAYOR THOM"ST.PMUE
DIRECTOR OF PLOUC PROPEM/81:1LDING CONMUW40NER
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 150&
The debris will be transported by:
Renewal by Andersen
(name ofhauler)
The debris will be disposed of in :
Renewal by Andersen
(name of facility)
30 Forbes Rd, Northborough, MA 01532
(address of facility)
si of permit applicant
6 -/6 —1 L
data
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DP'051'7t1120'(GORIME THIRD MINIM DAYA17.1 1ftTHEDATEOFTHIS011biNSAC1"(ONt
VMICREVER DATE IS LATER.SEE Ti°!EATTACHED NOTICE OFGANCELLAITIONFORM 'FOILAN
RIGHT. Ca +l
mse:M��_�:'nM.znen q
sib)mute of Sales tlefsun IYR1lauene SIVIMtuc
Keith Oetchenesux Keith Phelan Both Phc#ant
lhnrt Wail IL o saes 1',or-to Print Nairatc Mile Noin e
05t19Y95 page 2 0 17
R ew l Ite�lzed Order Receipt
l'1sel JStra kmv- al by Amore&of Flvcsoe so"Ph am"104%Phillen
0. lratxwe:dsenewal hvAix"Jersen Let 23 h#rron Rae#
170810 5akrn.MA 01 A70.
38 Ea!bxs=,oxl9 Woathho(Ou9h,MAjpj!p32 E2073)145-02r2
'MORE-' C-$97'"52-551U
101 Bih(l'1 Window:, Dauhlt-1,11w wg, Equal, Slope Sill InUrl, Tradlllonal
Chetkl@ill, E;kTER.IO R Whge�, IWERIFrR'4VhLtey GIo+!#: Sa510 All:
High PerinrmanLe SmarSun Glass, No Pattern. Hardware.
'Whitt-, Screen:: Fiberglass, Ful I Screen, Grill, Style; No Grilles,
(Mien: Non
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High Pertowiance SmartUn GIm No P,it a.Hardware,
Whtile, 'Sfrreem,, Fibe4ass, full Screen, GRI:lle St;'y1e=.Alo Grilles,
IMisc- Non
102 Mostorl aeth Window-. Douhle? kHung•, Equal, 510pr) SIII In.lart, Traditional
Cbeck roll, EXTER10It White, I"I'ER OR Whlto„ Glaw, Sa,% All:
High Performance SmartSun Glass, No Pattern,. Ha:rdwarsYa
While, Screen: Fiberglass Full Screen, Grille 51yle !No Grilles,
Mint: Non
103 d+>4 ver WIMawt boullI&-Hung•, Equal, S100L Sill Inserq, tradifiorral
CJtetkfLill, EItTERIOR.VVlwo, 114 Rlt}R Whi to, Glast; 'bsh All:
High Periormance Smalisun Glass No Pattern. Hardwhife
While, 5graen: Fiberglass, Full 5aten, Grille Style.No Grilles,
Misc. Non
103 KI1Ch Wlndowu Picture,, Eut4tame, EXTERIOR While. MTiERIOR.
While, Grlihim Sash AM-Hollh hiforroanro 5mari5on Cslw,i. No
Pattern, Gelinb Style-.tie Gnill z, Mlii Wo
104 'Living rril Window., Picture, lm o5 Frame, EXTERIOR White gHTERIOR
While. Glass, Sash AR;High Performance SmarsSrm 'Glass. Ou
(Pattern, Grille StVJ'e,No Grilles. Mlsct Nun
4D?,rl^.rAb 'pa•Re 4 r 87
R al Itemized order Receipt
(pl. ea1sen nlbaa Rsnraaj 1,Anns alF Roffma : . l omb and aoth 1411,440n
knit 14rme:itienewal by ljp*rsen at 23'"ANn A:nai
170810 5a'hm.Fd h 01970
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106 Liwing tin Wlndawt Picture, Futl-Frame, EXTERIOR Whitey INTIERIOR
'While, Glass-, Sash AN.High I'edGrn)iance 5rowtlSom GIttss, Mop
Pattern, GrI110 Stylor No Guiles, Mile, Nuys
201 'C1Crihwalm Window, Double-Hung, (Equal, Slope Sill Insen,'Traditional
Checkrall, EXTERIOR White, INTERIUR Whitt, Glass: 5aSh all:
High Performance SmarlSun Glass, No Pattern, Hardware:
While, SUairnr Fibv;g1a4s. Full Screeer, Grille Style, 'No Grilles,
Mist: Windom 20 t and ZW art/ M1.11106 tQ43elhe
202 Downstairs Window, Double-Hung; Equal. Slope Sill Insert„Traditional
Chetkrall, EXTERIOR Whae, IMTERIUR Whlte, Glass:Sash All:
High Performance SmartSun Glass, No Patterns,FBardware,
While, Scraon: Fiberglass, Full sofeen, Grille Style. No Grille„
11&411 tt Non
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high Performance SmanSun Glass,: No Pattem, Plardware.
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R wa1 Itemized Order Receipt
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f eab3t ehur e:1 enen a16v Arskirsen Lit 2a r Silr In Road
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MNDOWS 13 PATIO DOOK0 $PECIM .,0 MIStt4 $18,,1571
UPDATED: OVISIM
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= DelreoAmis3ofla'drsbW laidenss
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Boston.MA 02111
wt wnsamgm•rdia
Wonders' C omimniintion lid uraece AtMit]a wit-3tti]ders/Contractors/Electric@a>fis/Ptntttbelr8
Anplkant 3nfor- adon PreitsQ P17;m.i1gP°bly
IVettltl tliusiness/iN{a"+ ationAndiri dire i RENEWAL BY ANDERSEN
Addre+gq: 30 FORBES ROAD
City/State'7ap- NORTHBORO,MA 01532 _ __ Pholle#: 508-351-2200 --
Are os as emphlyt:r"Caeek the appropriate boa
3 '1}Pc of Pt+ojw't I:required):
1.l—I 1 am a employer with 30 4. Q 1 am a Swercl.3uuractot and I 6. Q New cmretrtwtion
cmploydes MIN andorpat-time)." have hired theotbcontradors �,/
2.0 1 am a sole pmprittor or patmer- li'st--d on the attached Nhert< I 7. 3/Remodoling
ship and have ne,vmployea Illicit sub-:ontrei*)rs have S. Q Sh rnolition
working for me m ate capacity. workers'camp.iosuran'r. o, Q Building addition
[Nu workes'tiomp.mstinewc 5• Q We are a corporation and it-
required.] offices have exercised choir ME]ElecNrical repairs w atdditiarrs
S.0 1 am a homeowner doing all work right of ax::nptiun per\dial. 11.0 Phunbing repairs or additions
myself:INo workers'comp, C. 152,91(41,and we have,no 110, Roof repairs
insmance rdquu%.]° employees.No workers' 13_0 Other
,mmp.resilience require3.1 --- '-----
!asv'.Wwmt that jr&�drka:nmei a w:fill ae the v.4 m bduw iliaujo p ion P:rtic37 mwnn&
'Itamcisowmi who k6btait thk affl"vit iadicatat&they s::domit ail work tins dwn uac ivpt&,;,maU.n nlam wbmit u new a16dNvi1.uxlfiate>!t s%wh.
\:aAIU'NAUni r!pea'M:j:ih9f htYa/AISt lalalt,ea da ddd!t'ndlBi VaeM�1'dw9W flee n&1'd(R ta[�Ytlh:Yl4atlef.:.aml than wOrKbr:Y LUfaP.PNlap flltlwTlrI1J4
t am an eaptoyer Bxa is prorMV wantera'conWasaa'on hisrtrmrcejor ag•employees. Belot,iv eke poky aid jab she
/njbrmution.
lamirance Cumpary Name. OLD REPUBLIC INS. CO.
pirlicy^!lop Sel%im Lic. ;_...p r��30�43744 _.— I:xpi!at on Hato: 10-01-16
iob8iteA4dress:28 PICKMAN ROAD— —__-- CityCStata'Lip: SALEM,MA 01970
Attach a copy of the workers'compensation pnlie) deciamdon pW(shovidng the polky^number and esplratbe dese). i
Failure to secure wvetagt as required tm&—SWi:m'_5A of MG1,c: 152 can dead to th i; skion of%riminai pcnahi•-of a
fine up to$1,5G0.00 and/or one-year iaiprisonmen4 as well as c.vil penWtie in tht form of a STOP WORK OME;R and a fins
of up to S12-50.00 a day agairw the violator. He advisee that a copy of this swoment may he fm wardad to the Office of
Investigators of the DIA for insurance coverage veiif icahiwt.
t do hereb xmier ekepam andpenai irs 00erlwq'rkat dw iyoiruiun pit»*kd aboiv it rent and cormt
1'hcmey_ 508-351-2200
0#khd ate oxly. Do not write in this urea,to be rompkied by r;&or town v074-lei
City or Town: �PerwWLieense ill
issuing Authority(sarek one):
I. Board of IlealtY L Building Departrueat 3.City!Towo Clerk 4.Elee43eal Inspector.5 Plumbing inspector
6.Other
Contact Permu. _ -- Phone
Ma nochucetts-Department of Pubic Saiety
Board of Building Regulation.-and Standards
Conztmrtion Sapen-isor
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ME IMPROVEMENT CONTRACTOR
Reglstrallon..-.479$t0 - Type:
Ezplydticpf 4YT Supplement Card
RENEWAL BY AND {LtC--- ,.
JAIME MORIN
30 FORBES RD •�=--
NORTHBOROUGH,MA 01532 Undersecretary
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