6B RUSSELL DR - BUILDING INSPECTION (2) i.
The Commonwealth of Massachusetts
(�3 Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
.(Phis Section For Official Use Only).
Building Permit Number: Date Applied: Building Official
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for w e di not a
t7
No.and Street City/Town Zip Code _ ame of Building if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used if New Construction check here❑or check all that apply in the two rows below
Existing Building q9 Repair A 1 Alteration ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use '❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering P Revi w required? �'` n Yes ❑ No ❑
Brief De.�c�tiSryogroposed Work: e � ��P \�(�,�� rY l�1 P�(-,+(
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 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ }L• Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ 1-3❑ 14 ClM: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
lA ❑ IS IIA ❑ IIB ❑ IIIA ❑ 111130 1 IV VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA I hh a nc Com�nhsi n R ,ic'.
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTIONS:CONPENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): 'I;Vpe of Construction: Occupant Load per Floor: -
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
_�cXStYIwe T `4Qma-�> 60�4s5Qll a1✓ I �'I'1 (� l r/
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: _
"L
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this buildnig permit a2plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendbc 2)
If building is less than 35,000 cu.ft.of enclosed s p ace and or not tinder Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
r 1eC� to
C up,ny Name t
10ksdo K era , 10-,z7
Name of Person Responsible for oast coon License No. end Type if lirible
��", f sP - k, d/9 �v
Street Address t6 City/Town State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:NORKERS'C:OMITNS,11'ION INSUIt:1NCli:1PFIUi\V'I'C M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a si&ned Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other) $ Enclose check payable to
6.Total Cost $ 01 cD I (contact mmiicipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest tinder 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.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
TO: 6B Russell Drive
FROM: Jennifer Pappas,Property Manager
RE: Deck Replacement
DATE: May 7,2014
#iii#Y3#3##iYi#####i#3333####ii333#Y#iYi###ii3Y##33YYYi##i##33##iiYYYYYY
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 in size/construction. Comosite materials can be used. The Board will not allow any other
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(281) 569-2675.
cc:. Unit File
500 WEST CUNNINGS PARK-SUrrE 6050. WOBURN -MA -01901 -781-937-9229 -FAX 781-935-4289
,� 5rr•
CITY OF S'U'E,tif; L%L1SSACHUSETTS
8L'ILDLNG DEP.1R-n[FNT
130 CV.I91ALYGTON STREET 1
TM (973) 745-9595
KIMBERLEY DRISCOLL FAA(973) 7.k)-994S
r-10.L Lu ST.PIEAR$
DIRECTOR OF PL;BLlC PROP ERTY/BCILDLYG COJLNnSSIO,NER
Construction Debris Disposal Aff7davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 Cp,IR section l l 1.5
Debris, and the provisions of tMGL c 40, S 54;
Building Permit hi is issued with the condition that the deb
this work shall be disposed of in a ro erl licensed waste disposal facili debris resulting from
1 11, S 150A. P P y P ty as defined by t�IGL c
The debris will be transported by:
W
(it�ntc et'It ut )
The debris will be disposed ufin
s4ewi -
(nanto of t:mility)
wdle"Ott
rigndtureut perrttif appfiarnt
__1 -Aw -as-V,y
CI"IY OF S,1q Em, NLA1SSACHL'SETTS
Ig?t� BUILDING DEPARTMF_NT
120 WASHINGTON STREET, 3w FLOOR
TEL (978) 745-9595
Rio(978) 740-9846
KlMBERLEY DRISCOLL
MAYOR THoms ST.PIE.KRE
DmEcrort OF PU BLIC PROPERTY/BU MD ING CO'%MISSIONER.
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electr)cians/Plumhers
A t llicant Information Please Print Le ihi
Name(11 usinessOrgdniraliom'Imliddual):
Address: S F70 pr� s p �/
City/State/Zip: �C$(e4 Phonelt: ��� U�J �/ /)"
Arc you un employer?Check the appropriate box: 'type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time)." have hired the sub-contractors -
2.�11 ran a sole proprietor or partner- listed on the attached sheet. : 7• ❑ Remodel'ng
ship and have no employees These sub-contractors have S. ❑ Demolition -
working for me in any capacity. work¢"'comp. insurance. y. ❑ pudding addition
lNo workers'comp. insurance 5. ❑ We are a corporation and its
required.) office"have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.[I Plumbing repairs or additions
myself. (No workers'comp. C. 152, §1(4),and we have no 12.❑ Root,re airs
insurance required.] t employees. (No workers' 13. theF
comp. insurance required.)
Any applicarn dui checks but 41 most alsu rill out arc secaon below showing thcir workers'compensation policy ijoi rmaaun.
;An
I bwncowrwn who whmit this affidavit indicating ihcy am doing all work and then hire Outside contractors most suhmii a new afndxvii indicating such.
('n im. iurs that chtvk this box muit attached an additiuwl A-1 showing aw mmne of the subrontrxton and their wnrkoW camp,policy infummtion.
l ant can eniplayer that is providing workers'conipensadon inturuuce for my employees. Lfelow Is the policy and Job she
information.
Insurance Company Vmne:
Policy g or Self-ins. Lic, d: Expiration Date:
lob Site Address: City/State/Zip:
Attach at copy of the svorhers'compensation policy declargtlon page(showing the policy number and expiration date).
Fuiluru to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500,00 and/or one-year imprisonment,as%veil as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigmiuns ol'the DIA for insurance coverage verification.
/do hereby certify under the pains mod penah/es of per/ury that the hifurmuthin provided abuve is true and correct.
Phone d'
UQ7u3eou..L',"y,,y. Do not ivrite in this area, robe completed by city ur town nfficiaL .
CitPermit/f.lcenseissuily (circle uric):l. Hlth 2. Building Departuteut 3.Cilylfnwn Clerk 4..F,lectrical luspector 5. Plumbing Ispector
6. OCon : Phone It:
.ill