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24 PICKMAN ST - BUILDING INSPECTION
' Commonwealh of V ssia'chus'efts 14�''' 'I Department of Public Safety Massachusetts State Building Code(780 CNIR) Building Permit Application for any Building other than a`One-or Two-Fam'IYP !Iin (This Section For Official Use 011 ) Building Permit Number — Date Applied: -1 3 Building Off' al. SECTION I:LU A I ION(Please indicate Block#and Lot#for locations for which Atreet add' tot available)"- 2--1 E L-r—M FatJ '-51 0 fxhT 0> No.and Street City/Town 6;0� Zip Code Name e ing(if applicable) SECTION 2:PROPOSED WORK Edition of NIA State Code used if New Construction check here 0 or check all that apply it, the two rows below p I ,Existing Building 0 'Re aji� IP I I 11: fill out an't1subinit Vjti`pelltlix I) Change ofUse` 13 Change of Occupancy. -.El i;,.%� Other El Specify:., Are building plans and/or construction documents being supplied as part of this permit application? Yes •0 No [San Independent Structural Engineering Peer Review required?red? Yes 0 No EY Brief Description of Proposed Work: Ro7 C)A 0 boAaO�Z ' hUy.4.4anAT4W 14TA7-KA 4 SECTION 3:COMPLETE THIS,SECTION IF EXISTING BUILDINGUNDERGOING RENOVATION,ADDITION,OR 1"* CHANCE IN USE OR OCCUPANCY < 1.1 o -- . —�, Check here if Existing Building n and Evaluation is enclosed(See 780 CNIR 34),13 Existing Use proposed U.qe Grotip(s): gar. Fpropo SECTION 4:BUILDING HEIGHT AND AREA Existing No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Proposed Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check licable) A: Assembly A-10 A-2 0 Nightclub 0 ,A-3 El A4 0 A-5 0 B: Business 0 E: Educational 0 F: Facto F-113 F2 0 H: High Hazard H-10 - H-.213 .fill [3 H-4 0 H-5 0 1: Institutional Ill 1-2 0 1-3 0 ..14 11 M: Mercantile 0 --F—R.- Residefitial R-10 R-2❑ R-3 11 R4 0 S: Storage S-10 S-1 ri Special Use 0 and Please describe below: Special Use: Fact o u As sembly'y F- I I'0 I Institutional'. Storage S_ Storage S_I E] _'pee' U, "I 'e SECTION 6:CONSTRUCTION TYPE(Check as lip li ble) IA 0 113 (3 IIA 0 IIB 0 IIIA E3 11111 0 IV,Cl VA 0 VB 13 SECTION ECTION 7;SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Suppi Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: i, Putil Check if outside Flood Zone Cl Indicate allillicipal A trench will not be Licensed Disposal Site Private 13 or 111LICIllify Zone. or fe(juiret.1 eor trench or specilfy:-!!�! AW16 "Ot-mit is 0 in site system 0 C-10 ed El Railroad right-of-way: Hazards to Air Navigation: MA CHANCE e, Existing Building Investigation and Ev aluation Check her 'an 'st u"" g Existing Use Gro�ps' No. of Floors/Stories "ILI", a 'IL �ut levels) &Are Fto (include basement Total Area ("I ft)a Total v,8 and If ht(ft 'age Disposal- L,L upp, flood Zone I :� :,-m- rs M"y Check L k I outside . ...... Ile C] -11 JoLlent, Z, Late, I�,Yt'Pat Private or in,site 6 lt-of_way \,r Navigation:a-lolad right NlAf hsi�1110 .. ..1, �,,ioll'o'w" Not Applicable wll�" Os Structure ivilh lairportappr acharea7 Is theirt ev'e, reyiewc( T A or consent to Build enclosed 0 or"o Y o I, "so Y11 0 Yes 0 No";�>" SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code:— Use Group(s): _ tYpe of Construction: Occupant Load per Floor Does the 111111ifing,contain an Sprinkler System?: -_—Slieci.ii Stipulations: 1") rD(--A q Pt C v,W)ra'n c. �Ps o-v SECTION 9: 1'ItOI'ER"rY OWNER AUTIIORIZA'FION M ee and r\ddress/Of Propery Owner tlek 4,6& T- Cav�Ofn�.iJu+.- Q gSouA-t iot) 2 e/ Pwwkw w sr !�A Nance(Print) No.and Street City/Town Zip Property Owner Contact Informations Tam ArkrNS 347_zZL — Tine Telephone No.(business) Telephone No. (cell) rnutil address If applicable, the property owner hereby authorizes lZ)A1AVA 0-fox 11y IoWivLD KA 009d, Name Street Address City/Town State Zip to act on the property owners behalf, in all matters relative to work authorized by this building permit ap2lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) if buildin is less than 35,000 cu.ft.of enclosed s ace and or not under Constmc[fon Control then check here❑and skip Section 111.1 10.1 Registered Professional Responsible for Construction Control J��I�t�1PoT rAK 97 s�sanP_ 'J- P�u`o� 1Z3bfD Nona(Ry�islrant) 'Telephone No. e-nmil address Registration Numbed f /s 3Z NtrtnlSe2:-nn1 l2A�ppsC.i�� NSA_ O�'i Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor„ 4 f L Company Name f IJ. V-4 1e1 . GS - obLD79 Name of Person Responsible for Construction License No. and Type if Applicable A / z R D 'moo � 0 4&3 Street Address City/Town State Zip M-_S2IZIq q* 828 IM0 dadA a a" A►,I -. 'rele hone No. business Tele hone No, cell e-mail address SECTION 11:woRKHIL9 COnIPISNS,N LION M.G.L.c.152.5 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to yrovide this affidavit will result in the denial of the i ance of the building permit. Is a signed rffidavit submitted with this application? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item ,tad Materials) 'Fetal Construction Cost(from Item 6) 1. Building S '� Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical - $ appropriate municipal factor)-S 3. Plumbing $ al (HVA $ Note: i`linimum fee=S (contact municipality) L Mechanic C) 3 Mechanical Other $ Enclose check payable to 6.Total Cost 1 5 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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 a best oLmy o vledge-and understanding. . Please print and sign nam 'Title Telephone No, D. e 32 gr,,,rgm /Z1 o/ss Street Address City/Town State "Lip \lunicipal hispector to fill out this section upon application approval: Name Date 1 U \ Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supcn.isor License: CS-062079 DANIEL W PHILPOT ' 32 PEMBERTON-RDi TOPSFIELD MA%01983 7�; � s Expiration Commissioner 01/28/2015 - - —Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration 123610 Type: i Expiration:6 3/14/20'15' _ Private Corporatic D.W.Philpot Co INC , ti Daniel Philpot 32 Pemberton Rd Topsfield, MA 01983 Undersecretary y 1..,.�..�....�..,,...,a...;,,:....,..-..,:..�....,.,mom..,.--....,,...n....•.,,.e.R -.-.�___ CITY OF &U EM, NAXSSACHUSETTS BUILDING DEPAMIENT 120 W.iSHLNGTON STREET, 3so FLOOR TEL (978)745-9595 F&x(978) 740.9846 KINfBERLEY DRISCOLL MAYORTHObtAS ST.Pmuz DIRECTOR OF PL13LIC PROPERTY/11UHMU9G CONLTIISSIO.TER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Leaibly Nance(Busitx.&organizatiotvindividual): 1_ 1, Io 6(a�..fc 4 /IdtC Address: ilO 0. ,Boot: /77Y -1-4*' City/State/Zip: :]Zjjgg�;t1,0 '7NA 0s48'3 Phone#: Yz? 44*7 71✓� i Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 2_� 4. 0 I am a general contractor and 1 6. 0 New construction employees(full and/or part-time).' have hired the subcontractors ,r-ts�� 2.0 i am a sole proprietor or partner- listed on the attached sheet 1 ?• [iKemodeling ship and have no employees These sub-contractors have S. 0 Demolition working for me in any capacity. workers'camp.insurance. 9. 0 Building addition [No workers'comp.insurance S. 0 We are a corporation and its. required.) officers have exercised their 10.❑Electrical reports or additions 3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c.,152,§1(4),and we have no 12.O Roof repairs insurance required.)t employees.[No workers'. 13.0 Other comp,insurance required.) •Any applicam dtst checks box ill must also ftlt.u41 the Uclion blow showing chair workan'compenwton Policy inru motion, !I tnmeuwmw who submil this afltdsvis indleating they am doing all work and then hero outside cuntractoni man submit a now,attidavil indicating such �Contmctors that chuck thb box most a0whod an additional shoo showing tho name of thb sub+contnctom and their workers'comp.policy inf°munoo. I um an employer that is providing workers'compensaton bisurance for my employees: Below Is the pollcy and fob site inforarudom Insurance Company Name: CC-zT*4rrr2 Policy u or Self-its.Lic. 4: Expiration Date: n Job Site Address: Zaj /rGkpe AJ ST City/State/Zip: JQlAo fI 414 Attach a copy of the workers'compensation policy declaration page.(showing the policy number and expiration date). Failure to secure coverage as required under Section 21A of yIGL c. 152 can lead to the imposition of criminal penalties of a line up to S1,500.00 and/or one-year imprisonmem,as well as civil penalties in the form of STOP WORK ODDER and a line of up to S230.00 a day against the violator. Be advised that a copy of this statement may be'forwardcd to the Office of Investigations ufthe DIA for insurance coverage verification.. - I do hereby certify wader rbe pabts and/ten !es ojperfury t/tu(!he iajormullon propldad above is.irwe mrd correct Si t Dail: le)-na Ph one Official use only. Do not write in this area,to be completed by city or town offlciuL City nr•Town: Permft/i.leense# _ Issuing Authority(circle one): 1. Board of Ilcalih 2. Building Department 3.Cityffown Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Persons ------- Phone#: ° CITY OF S. .E.Nl, NLLSSACHUSETTS BUILDLNG DEPARTMENT 130%V.�sHLNGTON STREET, 3' FLOOR " T EL (978) 745-9595 Rux(978) 740-9M KIN{BFRT RY DRISCOLL NAAYOR THo.%w ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONER 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 I50A. "fhe debris will be transported by: (name of hauler) 'fhe debris will be disposed of in : j (name of facility) (address of facility) �J Lsignature of permit applicant zes` date — • / ® DATE(MMIDDIYYYY) .4CORD CERTIFICATE OF LIABILITY INSURANCE 1 10/07/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 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 endorsement(s). PRODUCER CONTACT NAME: DALE JOHNSON UGONE-JOHNSON INSURANCE AGENCY, INC. PN"C"N E t.978-887-8304 uc Na: 978 887-5517 DALE JOHNSON-AGENT EMAIL ADDRESS:DALE_JOHNSON FARM-FAMILY.COM 7 GROVE STREET, SUITE 201 INSURER(S)AFFORDING COVERAGE NAIC# TOPSFIELD, MA 01983 INSURERA:FARM FAMILY CASUALTY INSURANCE INSURED INSURER B: DW PHILPOT & COMPANY, INC. INSURERC: P.O. SOX 174 INSURERD: _ TOPSFIELD, MA 01983 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY 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 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IXP �TR TYPE OF INSURANCE INSR Mi ADDL�SUBR POLICY NUMBER MMLDD/YYn MM/DD/YPOLICY EYYY LIMITS A GENERAL LIABILITY 2005XO998 07/10/2013 07/10/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES E.pop urt.rce $ 50,000 CLAIMS-MADE aOCCUR VIED EXP(Any one person) $ 5000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1,000,000 X POLICY PRO LOC $ A AUTOMOBILE LIABILITY POLICY#2001050063A 12/11/201212/11/2013 COMBINED SINGLE LIMIT Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ 100,000 ALL AUTOS OWNED CHED�( SCHEDULED BODILY INJURY(Per accitlenl) $ 300,000 NON-OWNED PROPERTY DAMAGE $ 100,000 HIRED AUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ E%CE33 LIAR CLAIMS MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION POLICY#2001 W7151 08/06/2013 08/06/2014 TWOS LIMIT X OTH AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMSER EXCLUDED? Y� NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS DeIoW E.L.DISEASE-POLICY LIMIT $ 500,000 DAN PHILPOT IS NOT COVERED UNDER WORKERS COMPENSATION DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Addltlonal Remarks Schedule,if more space Is required) LIABILITY POLICY INCLUDES CARPENTRY - RESIDENTIAL PROPERTY NOT EXCEEDING THREE STORIES CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LSALEWMO SALEM BUILDING INSPECTOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HINGTON STREET ACCORDANCE WITH THE POLICY PROVISIONS. I 01990AUTHORIZED REPRESENTATIVE DALE E JOHNSON ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(20101051 The ACORD name and Joao are registered marks of ACORD Pickman Street Condominium Association 24 Pickman Street Salem, MA 01970 23 October 2013 Mr. Thomas J. St. Pierre Inspectional Services Director 120 Washington Street, 3`d Floor Salem, MA 01970 Dear Mr. St. Pierre: This letter is to let you know that we are fully supportive of the work to be done to our two-unit condominium home in accordance with the building permit filed by Daniel W. Philpot, Contractor. This work includes discovery of water damage, including some wood rot,replacement of damaged areas, wrapping, re-siding, and trimming part of the house. Please let one of us know if you have any questions. Sincerely, *JI . Smi ` — 'I ,L airb ynda Fanks Atkins t2 $ ickinan Street l onda Aubin-Smith 24A Pickman Street