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44 RUSSELL RD - BUILDING INSPECTION r= i $ 105 RECEIVED The Commonwealth of assachusetts r�4n� Department of Public�R�( 8�tyrt� 3 A 5 Massachusetts State Building Co 1 ) � Building Permit Application for any Building other than a One-or Two-Family Dwelling �1 I (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: ( SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 4k R,/55E1.L ('2D 64L9k 61170 No.and Street City/Town Zip Code Name 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 Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No / Is an Independent Structural Engineering Peer Review required? Yes ❑ No C9� Brief Description of Pro used Work: g ep �Pr—"EN GA-i'3 f/UETS (�[ACE Tfi�5 /N 7 b r�TNS . 2EF�V4C.E Lll�r.�T y 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 enclowd(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Grou p(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❑ FL• Hi Hazard H-1 ❑ H-2❑ H-3 Cl1-14❑ H-5❑ 1: Institutional M ❑ 1-2❑ 1-3❑ 1-4 O NL• Merh cantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ I U: Utility❑ I Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) IA Ill ❑ HA ❑ 11110 111A13 11113 ❑ I IV ❑ 1 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: A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify: Private El indentify,Zune: or on site system❑ permit is enclosed❑ t' Railroad right-of-way: rds to Air Navigation: \I•\Ili,,t �i Not Applicable❑ T7-1-1a7a cture within airport approach arei? Is(heir review conrplchd? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ Nu ❑ SECTION 8:CONTENT 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: --- .r SECTION 9: PROPERTY OWNER AUTHORIZATION N to and Address f Pr perry Owner (,�r �nss '11r m rW& QQ769 Name(Print) No.and Street City/Town Zip Property Owner Contact Informations 77� 0 r m Title Telephone No. (business) Telephone No. (cell) a-mail address If applicable,the property owner hereby authorizes d gE &-<Crf"Z /, I.f zazr (C' l (- lu c22br fic &i 0 r R9(D Name Street Address City/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control / " /VC4-7A/N qlb3 _2e33 /327 / Name R �istra nt Telephone No. a-mail address Registration Numb r ��� Yf s iu ¢�r�crac 4 0/86o .9/Z7 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor kC&j-i(N Company Name ME C5042-11/7 vf)QEs-r2)c76D Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No. cell a-mail address SECTION 11:l%'0KK K.9'CORu'eNSA I ION INSURANCE AFFIDAVIT' M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the rvIA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the i,SSuance of the building permit. Is a signed Affidavit submitted with this application? Yes Ve No ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) 'Told Construction Cost(from Item 6)_$ C 1. Building $ 7000 Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical $ 800 appropriate municipal factor)_$ 3. Plumbing s 2 0 0 0 d. Mechanical (HVAC) S Note:Minimum fee=s (contact municipality) 5. blechanical Other $ Enclose check payable a tble to ° 6.Total Cost $ 1 (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 to tke best of my knows• ge and understanding. Please print and sign name Title Telephone No. Date Street Address City/Town State Zip ` [G"� ? Municipal Inspector to fill out this section upon application approval: � gl Name Date CAL jb �( clL - vP Details Page 1 of 1 the Offida weostle of 7e Execuii4a Of me of[��a;i,c Sa`aty and Secarifg(EOPSS) MamccvHome SMic'Acenaea ensee Details PmDetails c Informaf I`ulRame: `' ' M A L J MCGINN ender: bwner Name: Address: Address 2: City: Merrimac State: MA pcode: 01860 o nt : U 'ted fates icense No. S- 4 41 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 9/3/2014 Issue Date: Expiration Date: 6/9/2016 License Status: Active Today's Date: 3/11/2015 econdary License: Doing Business As: atus Change- Lic se Renew I -irere o rere uisite Information =entum No Discipline Information L.Close Window j ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license id=231548& 3/11/2015 V 1 ` The Commonwealth of Massachusetts (� Department of Industrial Accidents =+ I Congress Street, Suite 100 Boston, MA 0 017 www.mamass.govgovldi/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information p 'r Please Print Legibly Name (Business/Organization/Individual): M�?yA X (//��4 yS , Address: /z ait Altm-p2 S 7 City/State/Zip: M&2"o—// 6c AK O/e6ahone#: 91 �—, —3/'4 2953 Are you an employer?Check the appropriate box: Type of project(required): 1.I aemployer with employees(full and/or parr-time).* 7. ❑N constructt on 2. I am a sole proprietor or partnership and have no employees working for me in $, Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition 10❑Building addition 4.7 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet ]3.❑ROOF repairs These sub-contractors have employees and have workers'comp.insumnce.i - 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties fperjury that the information provided above is true and correct. Si ature� W4.44 " /' Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i J 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 employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing 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, construction 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,§25C(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 affidavit 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license 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 (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.rnass.gov/dia QTY OF SALEM, MASSACHUSEM Bun DING DEPARTMENT ' 120 WASHNGTON STREET,3' FLOOR TEL(978)745-9595 KIMBERLEYDRISOOLL FAX(978)740-9846 MAYOR THomAs ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUILDING ODlafiSSIONER 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: I-qELLO /,SPOS6L (name of facility) C-�aE2C� rawr�! (address of facility) `z& Signature of applicant -//—Is- Date O Massachusetts-Department of Public Safety r Board of Building Regulations and Standards Construction Supenlsor License: CS-042417 IS MICHAEL J MCG,tNN — I- a 12 WINTER ST ' 11 ' Merrimac MA 0 8601 r n >rrss`s Expiration Commissioner 06AN2016 ClLee �Panurrcanureall�z ayo Office of Consumer Affairs&Busid-3 Regulatl WME IMPROVEMENT CONTRACTOR R e,gist2tion: 132721 TYpiration: 3fd712m Individual MICHAEL J.MCGINN _ MICHAEL 'MCGINN - 12 WINTER ST. :y MERRIMAC,MA 01860 Undersecretary E American Properties Team, Inc. +m� TO: 4A Russell Drive FROM: Jennifer Pappas, Property Manager RE: Interior Renovations DATE: 03/13/15 Please be advised that the Board of Trustees for Pickman Park has approved interior renovations at the above referenced unit. This approval is contingent upon no exterior alterations to the unit. Should you need to make any new exterior alterations, you will have to submit a new request to the Board. All permits should be acquired 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. We also recommend that owners obtain a certificate of insurance from the licensed contractor. 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 the APT Service Team directly at(781)932-9229. cc: Unit File 500 WEST CUMMINGS PARK-SUITE 6050- WOBURN MA -01801 781-932-9229 -FAX 781-935-4289