5D STILLWELL DR - BUILDING INSPECTION (2) 7 -1 C I O 1 (6 g
z The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
^, Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
LIRoperty ddres : 1.2 Assessors Map&Parcel Numbers
1� 1.1 a Is this an accepted street?yes no Map Number Parcel Number
1,3_Zoning Information: 1.4 Property Dimensions:
t I
Lomng District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
L Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY O NERSHII''
2.1 ner of Re r :.
Name( int) City,St te,zrP
No.and-STreet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Q_ _
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify: /l94W'I'd >
Brie escription o Proposed Work':
LL
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ pC . Cyo 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
�— Check No. Check Amount: Cash Amount:
6. Total Project Cost: ❑Paid in Full ❑ Outstanding Balance Due:
SS1�tT (G 'Z S TL Cp IVT
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �J
& f�L�� 6 ', IkL-e License Number Expira onVDe
'Name of CSL Holder
List CSL Type(see below)
n ) D�a I�—,; A AL
No.and Street Type Description
/C/ U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 FamilyDwelling
C �_VL
,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
-s.a• -TY�- �/ / N I Insulation
Telephone Email address D Demolition
5.2 Registered Home Ir rprovement Con race (HIC) L 5
�� �_ t - C Registration Number xpir on Date
Company Name or IC Registrant me
No.and Street Ema�ddress
l t At,\ �\Nk b\q�S �\ Spa�l�C'r
CitV/Vown,State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the lssu2�2 of the building permit.
Signed Affidavit Attached? Yes ......... No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject pro erty,hereby authorize
to a cra
hal m all m ttem relative to work authorized by this building permit application.
mt m lectrmu Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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 the best of my knowledge and understanding.
A3 /
Print Wner's or Authorized Agent's Name(Electronic Si a e) )ate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dns
2. When substantial work is planned,provide the information below-
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i CITY OF S.�L.E�M XWSACHLSETTS
• BuUMLNG DEPARTMENT
' 130 WASHINGTON STREET,3�FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KINfBERLEY DRISCOLL
MAYOR THOL►L15 ST.PIF44R
DIRECTOR OF PUBLIC PROPERTY/BU U-DING COWWSSIONER
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 150A.
The debris will be transported by:
ga x Lu�t-�'z ,
(name of hauler)
The debris will be disposed of in :
(name of facility)
&l
(address of facility)
signature permnitr5in'
U C 2 /.S-
date
CITY OF S�3 Xm. NvLkSSACHUSE1TS
• BuUMINIG DEPART-Nf&XT
120 WASHINGTON STREET,Sao FLOOR
TEL (978)745-959S
FAX(978)740-9846
KINffiFRt EY DRISCOLL
MAYOR 'IXIosIAs ST.PtFltRli
DIRECTOR OF PUBLIC PROPERTY/BL'II.DLNlG CONMBSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaibiv
Name(BusinessiOrganiution/i)ndividmi):
Address:_sto lj/Ad .1� , l 2.0_"
City/State/zip: Phone #: �� S°I a .� -� K
Are you an employ eh Cheek the appropriate bast: Type of project(required):
/
l� 1 am a employer with 1/V 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7• ❑Remodeling
ship and have no employees These sub-contractors have a. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL ME]Plumbing repairs or additions
myself.[No workers'comp. C. 152.11(4),and we have no 12.❑Roof repairs 1
insurance required.]t, employees. (No workers' 13.ROther . '
comp. insurance required.]
Any applicant that checks box Of must also rill out the section bclow ahowiag their workers'compenadoo policy inf lmtadon.
t lfmrwuwrters who submit this affidavit indicating they am doing all work and that hire outside contractors oust submit a new af<davit indicating suck
:Commswrs that cheek this bat must anoched an additional sheet showing the more of rho sub.comractors and their workae'comp,policy inramation.
l am an employer that is providing workers'compensaden hrsuraneefar my employees. Below is the pall ondM site
information. / /W 4�Insurance Company Name: d_LJ( r ' ./,(,P/./ �vayl/�U/�
Policy#or SdFins.Li'c..#: W `t bo,J 0 '.rail I P 16 Expiration Date: 1411JL, `
Job Site Address: �U t 1 T( l.P)�.(X e�i 1te_— 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
fnvtstigations of the DIA for insurance coverage verification.
l do hereby ce, pder the pains and pe alder f perfa that the information provided above's true an correct
+ t tr • Date: ./,
Phonea
Ofclal asz only. Do not write in this area,to be completed by city or town oJJlciat
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Departmeat 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
American Properties Team, Inc.
TO: 5D Still fell Drive
FROM: Jennifer Pappas, Property Manager
f
RE: Window Replacement
i
DATE: May 21, 2015
Please be advised that thf Board of Trustees for Pickman Park'has approved replacement
windows for the above referenced unit. This approval is contingent upon them matching the
existing windows and that they fit in the existing opening. Installation of the windows must he
completed from the interior of the unit and they must be the same in appearance from the
exterior. Should the installation be completed from the exterior of the unit,you will be
responsible for any damage that your contractor might cause(this includes painting). The Board
will not allow windows with grids, crank outs, etc. Should you contractor find any rotor
damage during the windQQQ�w installation,please make sure that it is reported to my office
immediately.
We also require that pernvts be pulled in advance(regardless of what your contractor may tell
you),and then a copy of Ire final approved permit once completed must be sent to APT for the
unit file as well. We also recommend thatlowners obtain a certificate of insurance from the
licensed contractor.
I
You will need to bring a opy 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)569-2675.
cc: Unit File
f
t
I
' I
500 WEST CUMMIN S PARX•SUITE 5050• WOBURN •MA •01901.781•1 32-9229 •FAX 781-93 6 37 89
E.B. Window and Siding Co. Invoice
756 Western Ave
A-5
e
Rt 107 Date Invoice#
Lynn MA 01905 5/26/2015 51064
Bill To
Anne Wright
5 D Stillwell Drive
Salem MA 01970
P.O. No. Terms Project
Description City Rate Amount
Remove existing windows and prepare opening to accept new vinyl 0.00 O.00T
replacement windows
Furnish and install Mezzo replacement windows. 16 0.00 O.00T
Clima-techplus insulating glass including low e/Argon gas,double 0.00
strength glass
Seal Windows in and out using Tire bond lifetime sealant 0.00
Take away all job related debris 0.00
Any building permit required to complete project to be added at cost 0.00 0.00
to the final payment
Angies List Discount -30.00 per window 16 0.00 0.00
Note:All sizes on file ready to order 1/1
Total project 7,000.00 7,000.00
Thank you for your business.
Subtotal
Sales Tax
Total
Payments/Credits
Balance Due
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindowamsn.com www.ebwindow.com
gE.B. WindowandSidingCo. Invoice
756 Western Ave
Rt 107 Date Invoice#
Lynn MA 01905 5/26/2015 5to6a
Bill To
Anne Wright
5 D Stillwell Drive
Salem MA 01970
P.O. No. Terms Project
es iption Qty Rate Amount
0.00 O.00T
acceptance of pro*aIW
authorized signatu
Thank you for your business. Subtotal
$7,000.00
Sales Tax $0.00
Total $7,000.00
Payments/Credits -$2,300.00
Balance Due $4,700.00
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindow@msn.com www.ebwindow.com