2C RUSSELL DR - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Department of Public Safety
'i;• �;. � Nlassacuurlls SLuc fiuild inf;Cudc(7811CNI R)
Building Permit Application for any Building other than a One-or Two-Fancily Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION (I'lease indicate Block p and Lot k for locations for which a street address is not available)
No. and Street Cily /Town Zip Code Name of Building;(it appliC,1111C)
SECTION 2:PROPOSED WORK
Edition of NIA Stale Code used It New Construction check here❑or Check ell that apply in the two rows below"
Exislinj; IiuilJ ing❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ I Change of OCCuponcv ❑ 1 Other ❑ Specify:.__
Are building plans and/or construction daxuuicnts being supplied as part of this perncit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed%Pork:___
K I a e a -
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNiR 34) ❑
Existing Use Group(s): Proposed Use Grou p(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Fluor(sq. ft.)
Total Area(sq ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4 ❑ A-S❑ B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ 1 H: Hi h Ilazard H-1 ❑ H-2❑ H-3 ❑ H-�4❑ H-i❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-1 ❑
S: Storage S-1 ❑ S2❑ U: Utility❑ Special Use❑and please describe below:
Special Use -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 1130 IIIA ❑ IIIB ❑ 1 IV Cl I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Remo%al:
Public❑ Check if outside Hood Zone❑ Indic,uc numieipal ❑
A trench will nut be Licensed Disposal Site❑
Private❑ or indentifv Zone: or on site system ❑ required ❑or trench ar specify:__
permit is encosed ❑
Railroad right-of-way: Ilazards to Air Navigation: `•I ir.i• i r vni,... . .:,., i'...,, .;
Not Applieahle❑ Is Stniclure within airp„rt appmaCh area? Is their rev iehv conipleled"
or Consent to Build oneosed ❑ 1vs ❑ or Nu❑ Yes❑ No ❑
SFC'IION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
L'se C;roup(s): _ I vpv of Construction: occoponl Load per Flour.
toes the lniilJing;ion lain an Sprinkler System': Special St'pu tat inns:
SECTION 9: PROPIdi'IY OWNER AU'I 11ORIZA'I[ON
N,nur and :\ddntss of Prullrrll' Uwin•r __
L��t�1v_3vRN5----- aG Russell r�- - S 7, ---- -- -- 01 Q"?o-_
Name(Print) Nil,and Street City/Town Zip
Property Owner Contact Information:
L)Ile-- --- -__-___ .Telephone No. (business) Telephone No, (cell) e-mail address
It applicable, the property owner hereby authorizes
-- Name Street Address City/Town State "Lip
to act on the pro periv owner's behalf, in all matters relative to work authorized by This bilildiag permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,UtXl cu ft.of enclosed s pace and or not under Coumtruction Control then check here O and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
((/arreh PeccrSoh R?s�S 3 cps YO 99 U
Name(Registrant) Telephone No e-mail address Registration Number
titreit Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No and Type if Applicable
Street Address City/Town State Zip
Telephone No business Telephone No. cell e-mail address --
SECTION 11:lyl ( k wi,i_v,W(INS W-HRA.NCI Al F11 AVl t M.G.L.c.152. 25C 6 -
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be co mple(ed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) - Total Construction Cost(from Item 6)=S
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
? Electrical S appropriate municipal factor)=$
3. Plumbing S
Note: Minimum fee=S contact nu nuc liilc
a. \-Icch;mical (HVAC) $ (� )
3. Mechanical Other S Enclose check payable to �i7
h.Total Cost S a- (contact municipality)and write check minnber here _
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By enterinf; nw name below, 1 here[,%,attest,ynder the pains and penalties of perjury that all of the inf( i tion amLnineJ in This
application is true and accurate to the best of my know lydge and understanding,
R7s r6d�1 71L 1_-
Plcas• prii and sign�'}�n.ume - Title Tcleplunm No. Date
— L55���� !r' --------- -- - - -�a�en, — --- -- fig:__ 01970
tirret Add rosy Cih'i Tos+'n Slate Zip
Municipal Inspector to fill out this section upon application approval:._ '�'rrYp�- ` _ t
_-- Name Dale `
c
CITY OF S.U.&M, NL-kSS.ICHUSETTS
BLILDLNG DEPARTMENT
' 120 W.ksHLNGTON STREET, 3iD FLOOR
TFL (978) 745-9595
FAX(978) 740-9846
K1J®EnZY DUSCOLL
MAYOR T Hovm ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/Bt.'MO NG CMDUSSIONER
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
I 11, S 150A.
The debris will be transported by:
�Um,pskr S if C J S
a (name of auler)
The debris will be disposed of in
(name of facility)
(address of facility)
sigr6rurc of permit applicant
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.�w�.ntl Y:gIN III
\I NIM
I!:\Vnvrn.�t;1u.\iiBat:1- if i.vl•w. Mnth.p. 11 vl I INJ197.
I'r.i. t)Llii•f3nS • f Lx v)N•?tC•ISJA
livurkers' Cumptnsation Insurance %iflduvit: Hill lden/Cuntracturs/Electrldsns/PIumbars
1 )licant Information
PI •4x rI t le 'hl
V it I110 I ILnnlc.i I)raanl N1inN InJI v oleo)):
�tldr�.cx:
Cily,.5rarc.%ipr Phone fl:
IArt; $u11 all euq/loyer.1 Check the approprlato boar
I. 1 and a empluyur with 4. Q I;fin a ventral couuaetor and I I)Pe of project(required):
dnlpluydcs(toll and/or part•tinie).• have hired the.vuh•cumracwra h ❑New construction
1,fin a solo proprietor or partner• listed on the anachcd sheet. : �• ❑Remodeling
ship and have no umpluycua Theso sub•contracron have
Ivorking list mu in any capacity, worker'comp,insurance. d1' ❑Demolition
I Kn worker'comp, insurance J. Q we
a aolpontion and iu 9 ❑ DwWind addition
1.❑ nyuircd J ot)Tcen have e.xeroised their 10.Q Electrical repair or additions
I :fin a homanvner Juingell work right of axelnplIon per AfoL 1 L❑ Plumbing repuin ar additioru
myself.It\'o IYorken'comp. c. 137,¢Il4),and Ive hew ne
insurance required.)t Cmpluyced, Igo workers' 1�❑Ruul'mpuin
Coln; invurnnav nquinvJ,) 1�•❑Other.
• n>.,ylialN'a,d eld it:YiM.thM rl T .'%ud alw rill uw the wcnurs L Iuw de wine ithhe wwluti 4Ynlrrli w illfiu
'I I.nnw.wrwn.hu ualnul Ihie amdevtl indki,ine Iher a1r Juina dl work and Ih.w hhe ubaids eunlr W§MMI.,,hnN i nrw a1RJevi1 indfa,lina vlve.
.Cwlr f,l Thal llwva this has Tial J1fullad,N aadlliulYl nAgt ui'mins 1M nanlry/the,ee•vMlreelata and them wuA+n"41(7,@vil fn Infbrmanue.film do employrr'hut/r proud✓!nX Ivurkrra'evinprrtratlon barurnnee/br rn rrn /u
Bt
111 drinu'ia/n. y rra P J /utY Is the pulley y fin✓/u1.cile
Insuranta: C'unipany.Valet: .
1'ulicy a or Sulf•ina. Lic.to: - - - — _ _—•-
---- EAPiranon Dale:
)uls Situ . ddress;
Cltyr slate/Zip:
Attach it ow of the workers,cumpenxanun policy declaration page(showing the policy number and explratlun date).
Failure to sccun cuverulo as required under secliun?l.\ut'\IGL c. 152 wa lead to slit im
i fi I'll ni S O 00,rM y Ii one-year iniprisi le J4vi as well as Civil penuhla in the 1'unn of STOP WORK URGER and a rive
Waition of criminal Penalties of a
,,(fill ro i?Sp.gQ a Jay Iguinsr tilt vLsl:unr. Ile sdvl.rcd thus a Cupy of Ihls smtcmcnt may be Iurwarddj to the Utlice of
LiF;shyan�nu ul'Ulu I)IA Iqr insliaircu;,v.NJu Iei ifivatlun.
/Ile/a•rrey 1.:rti/y 14,14 r the p1/inr 11n9 penu/ficr ujper/ury thus the in/brindflon prvri✓e✓deuce is true on✓rorrerC
I'I,a: •:1
II 1)//lr%YI ll?I dilly. D,l 1m' wrifr ill Misfired, fd er rdlllp/Y'f✓ey wiry Yl fOwn a//JriuL
/ifY fir 151 wn: '
Ilvuing .\uthurity (tirclx nee); perininl.Ievn/e 0I. IL..arJ of Ilralrh 1. IhuLhuq ncp.utlncnl vr 1. ). �alvt Clerk J. Llucfric,il IutpC.•Wr i, prumbing htlyccrar
IG. t)th .
i l' ntaa I'tnun: �_
__ I'huae Y• -
I
information and Instructions
riot m the service of anoher under.uty cuntnct of hire,
�I't"'tcltusetirmY sue ral ta Laws
chapter 132
plikiied is define +s"Revelry pc lion n A the 6a workers co npensruon mix theircuty uYea.
1'anu.rrtt o
:.press or implied. oral or wnnen", two or more
artnenhip,,tssocianon,corporation or tither legal emery,or attY t.r or the
,in c/nplopar to dctincJ as"an mdiviJtctl,p andem to in vas loyees. However the
t the I, ,egomg engaged ,n a joint enterprise
rslsoetau a or other r legal entity tveDof a ce PeJ amp uY '
,ccmver or trustee ul'.m individual, p n.or the
uwnet of a dwelling{house having not ,/ore ons to o nainaparyiennun e,cothan th"dnstr resides uction ion tit reDoefei ir work unsu h dwelling ncI cupant of the
haute
Jwelhng huusa of another who employ. De
or tin the grounJa or building appurtenant thereto shill not because of sucA employment be deemed to be an employer.'
censing allesey
ad
d the Issuance
mGL chapter 152. 125C(6) also states that"every bu peas or to consttruct buildings lathe otmmotnwealth for any
r
aired."
renewal j n"lie
or permit to operateol•its political subdivisions shall
typlleant alto has not produced cC P;,brte�r'Neither the ommonw alth nor any ranee coverage
Additionally. SIGL chuptcr IS_, a-S
corer into any contract for the perfomtance ul'public work until acceptable wiJena ufcuntyli;mcs with the insurance
requirements of this chapter have been pfewnteJ to the contracting authority."
J
Applicantsing the boxes p to our situation and,if
compensation atlldavit completely,
and phone number($)&long with howl artificute(s)of
Please gill twl the workers' comp with no em loyees other than IAe
necessary,supply sub-contractors)nama(s). •address( )' P
workers' compensation insurance. It at LLC or LLP Jost have
�nsurance, Limited Liability Companies(LLC)or Limited Liability PaMerships(LLP)
memban or paMers,are not required to carry be yubtnim d to the Department of Industrial
employees,a policy is required 9e advised that this affidavit be
mayTlle t nt of
Also be sure to sign aed data tAtfmvno/he lkDaAmt.xhou
ld
Accidents for contirrnation of insurance coverageI cation for the permit or license is being requested.
he rctumed tO dio_city or,town that the aDD t-OM regarding the taw ur if you are umd co to obtain hould enter their
Industrial AceiJents. Should you have Any lines
compensation policy,Please call the Deportment at the number listed below. Self-insured companies
self•insurance license number on the a ro riots lino.
City or Town Officials intcd
y. The
Please
the affidavit ejur �ur you to fill nutsin the event the Officetot�lnlvestigat�DOn$has to contact you regarding the epartment has provided a space of tapplicanL
hiber which
in any given year,need only submit une affidavit indicating current
Oflil Ile sari to till in the 11 out in the a number which will be toad as a reference numbor, In addition,an App team or
that must submit multiple pen","icenss app ' provided to tMt
policy intimation of necessary) and under"Job Site Address" or marked mbys he city orei own l mnay be Pin l' Y
tuwnl•" \copy of the ufTlJuvit that has been offlciAlly sump'
applicant us proof that a Will affidavit citizen
iis on file for Mut Permit"or licenses. Anew affidavit trust be filled out each
to any
t Car.m\tlug I�a home owner 0 perms to burn loaves ate.)wiJ p is license is NOTirequired o not �complete business
4 atfldav tmmereia venture
eme
hv
slice kitIuve,tigations rwuld like to think you in advance fur your cooperation and should you have Arty yuesuits,
I )
lca.e du nut hesitate to give us call.
p
fhc U.parnnent's address, toicphuna and fax number.
The Commonwealth of Mnssachusetta
Department of Industrial Accidents
Office of favesdgadons
600 Vlleshington Street
Boston, MA 02111
fag. M 617-727-4900 ext 406 or 1-977-MASSAFE
Fax N 617-727.7749
www,maw.glov/dis.
i
" American Properties Team, Inc.
TO: 2C Russell Drive
FROM: Jennifer Pappas, Property Manager
RE: Deck Replacement/Repairs
DATE: June 8, 2011
*********►a***►*****m******a*s**r**■*+�***s*►*****s�*x***�*m**s*m**s*rsx
Please be advised that the Board of Trustees for Pickman Park has approved the replacement and
or repairs of your deck at the above referenced unit. This approval is contingent upon ii
matching the existing deck. 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•SURE 6050• WOBURN •MA -01801.78t932-9229 -FAX 781-9354289