9 C RUSSELL DR - BUILDING INSPECTION (� -_. ,---- ----- I In: t ',inummwC.11th lit \lassarhusrlls
t lillurd lit iiullJing RCglllall0IIS ,nld .St.IndaidN t
%I.lssarImNc Os Stare Building Code. 'SO( MR. culmoii
Bill lJinu, I'Crinit :ApPlic.tlilm Tu ('linaruct. R Cnlii,JC l)r I)Cnll`li+lt a I !t, �,. .1
�- I his Sernlm K,r Otfi A I l'+e C nlY
Flu l IJIn" I'CI'III II Nu nl her _ — D11 1) led __- — t
SI_ILIIu;e V -N vu --- -
liw1d; CuR ni..umru 111111 I'll 01 13,111,1111
SECTION I: SH FORMA I ION
i.! Property \ddress: 1.2 \+sessurs \lap K Parcel Nuulbers
QQ
I !.I IS this .ill iLSCPICJ 111"0. \ll -._ _ ❑u__— x1..T, \unlhcf P.IL. .\unihil
1.-' :'.onina, Information: I 1.4 erupze?v Dimero-iiins:
--- - Irao�. d
.: I 3.1 •
1.5 Building Setbacks (R) T _
Front Yard Side Yards Rear 'laid 1
Reyuil APnnIJeJ ReyunrJ PnIVIJaJ R:you eJ po"I'lcd —
�1.6 Water Supply: 0.1 G L c. 40. §54i 1.7 Flood Zone Information: 1.8 Seleage Disposal Systenc
Zone: _ Outside Flood Zone!
PI uhlir ❑ Pmale ❑ Check it ye+❑ .\lunlclpal ❑ On ,Ile Jupo,al Ss,irin ❑
SECTION 2: PROPERTY OWNERSHIP'
1 2.1 Ow er of Re'orRL
I �-
\.ur: foolI Address for Sei 6,e: I1
Slgnrtorc Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
J
New Con.sti—L in ❑ Existing (3w)ding ❑ O\�ncr-Occupied ❑ Rcpwrsls) ❑ :\!teratlunl;l ❑ \JJlw n ❑
Drmohliun _. ❑ Acre..+aory BIJg. ❑ I Number u(Unns LOther ❑ Specify
1 Bn •t il���p >�d'Proposed W 14
i
— - —
i o
I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Esumoted Costs: Official Use Only
I Cahor.ind Materials, j
II3uIIJule 5 (� Cw I I. Building Penult Fee S—_ Indicate hllis lee I+ Jelel ml ICLI
IE
❑ Standard City%Town :\pphrauon Fee
�QQ ❑ Tow) Project Cunt' (Item 6) a mulliplicr x S Bv�O 2. Other feel: S -
� 4 \Ier hamral i lii, W) 7 —�
i \lexhamr.11 .FIle
ti feral :\II Fee+ 5 --
;it ,hint ---------
l, l'herl No _ ('hell \mnunl _ _('.Lh \nl,mm
h rotal Project Cost � ) S-ZS_QV 0Rod in Pall �_� ❑ fhiGLul.Ln,' li.11.ol.c Uue
HMO ¢x*--
SECTION 5: C'ONSTRUC'i-ION SER% ICES
--- ---- -
.1 Licensed Cn ostruction Supers isor IC'SL1 �G
5 p 5'
'
L / _ �/- �y„t'•r��- ____-_ Lt�ni.i \u;uhir I.yn;.;l i�:n U.tli (
A�ICG�IQ 11.. FLL~LLvs21L _ _— I .
� LiH I.�51. 1\ R' i•ii hi lout ._.__-.__._
1,IJ;i.• .I., n• Di,iti soon _._.______.___
R Re,Inaid I+c ' F.muh
filiph,:n \\S :: I un,tl 1A:.Kj"" ,Ird i_J,n i-
it K..iJ:uli.Il S,diJ I til Ii:u nu`\1+LL_in.: hnl.a i.il, •u
;2� i,-tere Ilurne mprurement Contractor UIIC') —
fill C'ongt.un Name errIII(, Re Imnl NJIIIC
Regl,tr.Wuu Nunlhir
' r`L� T S1553e630_ �expulij u Date _
sign r fc•Icphune
7alfidavit
N 6: WORKER" COMPENSATION INSURANCE AFFIDAVIT IM.G.L. c. 152. § 25CI611
nsation Insurance atfidavo must be completed and submitted with this application. 17.olure to pro,Ids
ll result in the denial of the Issuance ofthe budding permit.
t Attached? Yes ......._. f5r� No -... .. .. ❑WNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT
1 L as Owner of[he subject pniperty hercbv
authorize - to-act on my behalf. In :III m.lttels �.
relative to win k authorized by this building permit application.
I
1616E--------- —
Slgnatureol'Owner Date
SECTION 7b: OWNER! OR AUTHORIZED AGENT DECLARATION
1 �U/ / , as Owner err Authorized Agent hereby Jeclme
that the.statements and information on the f regoing application are true and accurate. to the best of my knowledge and
� behal�
Pant Vamc
I Ite of Owner or.Authonted :Agent Daw _
LSI med under the afro and enalties o' ru I
--�
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered .,)n! htl
I nut registered m the Home Impnnement Comraetor (ill
Pro"
will rrn! hacr secs„ to Inc .0 hitrauon j
program or guarimy fund under M.G L. c. 11_'A. Other Important infLumation on the III(' Program and
Construction Supervisor Licensing WSLI can he found In 780("NIR Regulations 1 10 R6 .Ind 110 145. rcepecooele
' When ,uhsiannal work Is planned, pro%ide the inhumation below:
-fetal lb,ors area ISy. Ft.I Imcluding garage. tim,hed hascnten Uuttics. Jeck, tic porih:
(iru,s living area I Sy. Ft.I Hahn.Ihle room count _-___ ..
Number of rueplaces Number ,d hedro,:m,
Numher of hmhtoom, _ - NUImhCt ttl h.�l lih.Ilhs _
I\1+e ,+t hr.Iling ,s,tcm _ _--__-_ Numhrr t:f dc.ks/ pt i,hcs _
I\pe ,,t .toling ,,,tam—
. �Tocd.Pr.yect Syu.lre Footage� may he ,uh,unueJ far '�fin.11 Proles Co,[ 'Co,t
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\lA,'t+R 12C.WAiIIINGI0NSr:cta:T 4 S,vt.Eaa,MA S%cla Sl:'r1S01'i7^�
l'vi.:978-.'45-9595 • I'sx:978-741-=1846
Workers' Compensation Insurance Affidavit:t Builders/Contractors/Electricians/Plumbers Pease rtnt Leillib v
ihcant Information
,✓l�l . �v S S�i
Vamt:(BusiocsslOr-.aniratinNindlviduull:
Address:
Cityisratei'z,. r 1 O f hone t?. � 3
36
:Ire you an employer? Check the appropriate box: "Type of project(required): .
i 4. ❑ 1 am a general contractor and! G New construction
1.❑ 1 am a employer with ❑
ny,loyces(lull and/or part-ume).` have hired the soh-contractors
2. 1 um a sole proprietor or partner- listed on the artuchcdr shave
7. y❑�Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
workers' comp. insurance. 9, ❑ Building addition
working far me in any capacity. 5. ❑ We are a corporation and its
[No workers' comp. insurance officers have exercised their 10.❑ Electrical repairs or additions
required.] I I. Plumbing rcPairs or additions
3.❑ I an, a homeowner doing all work right of exemption per MGL
myself. (No workers' ctnnp. C. 152,j 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LNo workers' 13.❑ Other
comp. insurance required.)
-An) :,,plicaut dmt clucks box#1 must also fill out the action below$bowing their wrorkers'cumpenwtiw,policy inlurmalion.
' I lomcuwm:n who submit this affidavit indicating Ihcy are doing all work and dten him outside contractors must$ubmit a new al'faavit indiw"ng such.
-C t ntu,,nett chuck this box must attached an additional.'h•et showing the"ante of ttm subcontractors and their workers'camp.policy information.
lit),, an enq)loyer that ix providing,vorkers'c•oinpen.snuan ussurttitce jar ray employees. Below is die pulicy and job vile
istfuivnation.
Insurance Company Name:
Expiration Date:
---�- - - CityrState/"Lip:
Job Site .Address: ----
Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Sectiun 25A of`IGL c. 152 can lead to the imposition of criminal penalties of a
tine up so S1.500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator. tic advised that a copy of this statement may be iorwarded to the Office of
Invcnli�aliuns ul'the DIA for insurance coverage verification.
l do hereby certify under Ilse pains i n teitallics of perjury that the information provided above is true and correct.
Date: 6�d
Official rise only. Do star write in dlis area, to be completed by city or town official.
City or'fow'n:_-.-- Permitil'icense X.__.--
Issuing:kuil,urily (circle one):
I. Board of livalth 2. Iluilding Department ]-Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Other
---
Contact Person: _- - Phone th
I •
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 written."
An emplayer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the toregoing 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, cunstruction 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, 525C(7)states"Neither the commonwealth nor any of its political 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 the 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 other than 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
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The al'f idavit should
be returned to the city or town that the application for the permit 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 till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 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
6.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
l'hc 001cc tit Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Reused 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
to CITY OF SALEM
` PUBLIC PROPRERTY
DEPARTMENT
12' A.\; III,t..,,N lritl:r r ♦ SAI r M. NLA,;
I'I:t; • Pis: 178 ''t J'13a6
Debi-is Disposal AffidavitConstruction Deb p
(rN(.1oircd lur all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CNIR section 1 1 L5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit it 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.
The debris will be transported by:
(name of h uler)
I Ile debris will be disposed of in
(name of�faci lav)
(address of tactav)
;1�Ilallll'e of lirlllit.1 alit
L
date .—. ...
AmericanmAmericanProperties Team, !no.TO: Andrea Liftman—9C Russell Drive
FROM: Jennifer Pappas, Property Manager
RE: Renovation Work
DATE: July 2, 2008
****•ssrm**�*rs�***ss*rs��*ss*sss****►s�***r*r*sssss*ss**s*r*s*ssr�r*a**
Please be advised that the Board of Trustees for Pickman Park are aware that you are completing
renovations to two of your bathrooms. This approval is contingent upon no exterior alterations
that would alter the appearance of the common area. If this is the case, you will need to send
another renovations request to the Board of Trustees for their review and decision.
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 MIMI MIMCS PARK.SUITE 8450 WOBURN .{yin .O1201 782-932-9229 FAX 781-93 ,289