50 PICKMAN RD - BUILDING INSPECTION It ,
The Commonwealth of Massachu
f1ii'F�CTIONAL SERVI ES CITY OF
Board of Building Regulations and Stan ar s SALE I
Massachusetts State Building Code, 780 CMR vrsed Mar 2011
UI4 S�P�O A II 4 i
Building Permit Application To Construct, Repair, Renovate eemohsh a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print N.une). Signatpre" '. - Date
SECTION l:SITE INFORMATION'
L 1 Pro er((yy Address: 1.2 Assessors Map&Parcel Numbers
So �lc%m4n /rJ
1.1 a Is this an accepted street?yes_ no M1lap Nwnber Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(1t)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§5d) 1.7 Flood Zone Information: Lg Sewage Disposal System:
Public t?� Private❑ Zone: _ Outside Flood Zone? Municipal If On site disposal system ❑
Check if yes13
SECTION2. PROPERTY OWNERSHIP".'
2.1 Owner of Record:
locc;,4s< Valk AZ gSaS3
I�trne(Print) City,State,ZIP
SIN 97t,,239'o1807 Chi/j 17hr6n 13�Gmo;�rarn
No. and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
Existing Building lii ❑ if ❑
Owner-Occupied Repairs(s) Altemtion(s) . Addition ❑
New Construction C,
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-:
l7imen //n f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S o1�75,0. 00 I. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cityfro,wn Application Fee
2. Electrical $ ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing S 1%9ther Fees: S
a.Mechanical (IIVAC) S List:
i.Mechanical (Fire Total All Fees:S
Su «ssion)
Check No.__Check Amount: Cash Amount:_
6.Total Project Cost: S a 7-�76, 06 ❑Paid in Full ❑Outstanding Balance Due:
"0 P�U — SE�v T- 0 0T 1 012C\
OME 68 a�y463-2
i
y
SECTION 5: CONSTRUCTION SERVICES
5.1jjJJCunstructio/nSupeerrvviii License(CSL) C5_071S5`1 gh7lanLS—
/SO h er T /' rA/ITOU K License Number Expiration Date
Name ofCSL Holder
G(/ J List CSL'fype(see below)
O l TGUIGM "type - Description
No.and Strec
n //Cy Unrest ricled(Buildings u �l0 35,000 cu. It.
�n f (%a �h 43 A R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
�03-y3 l-4}63Fr I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
111C Registration Number Expiration Date -
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.$ 2SC(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.
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED W HEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize 1?J1,1 /Qe0
t9 act on my behalf,in all matters relative to work authorized by this building iWirmit application.
Print Owner's Name(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 my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
wwvv.nnass.�oL � Information on the Construction Supervisor License can be found at www.ma;s.gov:'dus .
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.). (including garage,finished basemenNattics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Typcofcoolingsystem Enclosed Open_
]. "total Project Square Footage"may be substituted finr"'rot:d Project Cost"
r
QTY OF SALEM, MASSAC HUSEM
BUILDING DEPARTMENT
120 WASHINGTON STREET,3" FLOOR
\\ +� TEL. (978)745-9595
KIMBERLEY DRISOOLL FAX(978)740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONIMISSIONER
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 # 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:
�70��S r4 ,�•�r ��o Tiuw
(name of facility) B
/D Wac key l wa 4,2"C
(address of facility)
Signature of applicant
M;79/ly
Date
American Properties Team, Inc. 0/ro®
i
TO: 50C Pickman Road
FROM: Jennifer Pappas,Property Manager
RE: Deck Replacement
DATE: September 26, 2014
**:��r�ars•r*►tr«:rr�a�:*sr�r*sa:r«s**�*a*�r*w*�rrr�******rw��*ors*�s*:ss*
Please be advised that the Board of Trustees for Pickman Park has approved the replacement of
your deck at the above referenced unit. This approval is contingent upon it matching the existing
deck(composite materials can be used). 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 me
directly at(781)932-9229.
cc: Unit File
500 WEST CUMMINGS PARK SUITE 6050. WOBURN MA O180i 781.932-9229 •FAX 781.935-4289
° CITY OF SALEM, N-WSACHLSETTS
BUILDING DEPART>IENT
120 %VASHLNGTON STREET, 3w FLOOR
TEL (978) 745-9595
F.ce(979) 740-9846
Kl.Np)ERLEY DRISCOLL
�:tifAYOR TrlontAs ST.PIIFARB
DIRECTOR OF PU13LIC PROPERTY/BUQ.DNG CO\LMISSIONER
%Vorkers' Ctnnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlfcant Information /� /� Please Print Legibly
Name(BusincssOrganiran�tinm'Individu:dl 22i(5 Jf0ft—rc- f _— aeedG �Y/Yia41l
Address: Pi la Mlle ��1 00V
City/state/Zip: Adkf I& oMY4 ' Phone M 4010'e,?Gel 9D33
Are you an employer.'Check the appropriate box. Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and I
- 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors.
2.Ellain a sole proprietor or partner- listed on the attached sheet,t 7• Remodeling
,hip and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. y. Q Building addition
INo workers'comp. insurance 3. We are a corporation and its
required.) officers have exercised their 10.❑Electrical repair or additions
3.Q I ant a homeowner doing all work right of exemption per MOL I I C] Plumbing repairs or additions
myself.(No workers'comp. c. 152. §](4),and we have no 12.❑ Roof repairs
insurance required.l t employees. (No workers' 13.❑Other
curnp..insurance required.)
•Any oppliututl dual checks but f 1 most also fill out the section bclowshowing their weaken'compensation policy infummtion.
'I lomuowm"o'ha whmil this amAnvii indicating they are doing ell work and then hire nuclide comraetnn most submit s new al3ldavit indicating such.
:Cnmtuium shut check this box mini onaehd an addoiurad shoul,hawing the name ofihc subM1vmracten and theta woken'camp.pulley fnfurmalion.
l ant can earpluyer!liar Is providing Ivorkers'compeasadun itisuruaeejor my erttployees. Uelolia is tha pollcy and job rile
iajurinalian.
Insurance Company Name: `._'---
Policy it or Scif-ins. Lie. 0:n �J Expiration Date: /
yob Site Address: �d C N/G/ man do/_ City/Stall/Zip: ,�*/PM IW OM 7Q
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure covdmge as required under Section 23A of MGL c. 152 can lead to The imposition of criminal penalties of a
line up to SI.500.00 and/or one-year imprisonment,as well as civil penalties in(he form of it STOP WORK ORDER and a fine
oFup m S230.00 a day against the violnior. De advised that a copy of this statement may be forwarded to dle 007ce of
In vesligotions of the DIA for insurance coverage verification. -
l In hereby certify under the pohis and penaltes ujperjury that the b furittatlon provided above is true and correct.
Sinn unre' /p Z r ' -- O a I 'l_hune • (/013' 43
R
OJ/ichil use only. Do not write in this area,to be cumpleted by city tar town o ichrL
City nr Town;
Issuing Aut hurily (circle one): -__ - _—_ ---
I. lfoard cal'Ileakh 2. Building Dep:rrintcm .1.('ityffnwn Clerk J. Electrical luspectur 5. Phunbing luspeerur
b. Other
(lutist I'erum: -._._._._ Phone a: ,
� , .
1;
r
. _ ����
__---