0003B FLETCHER WAY - PICKMAN PARK - BPAr-
The Commonwealth of Massachusetts
v 1 pBoard of Building Regulations and Standards Town of
)Y Massachusetts State Building Code, 780 CMR, 7'"edition '
amw
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a !rte
One-or Two-Fmnily Dwelling
This Section For Official Use Only
Building Permit N ber. Date- Applied://
Signature: "� � Yl! A&2
Building Commissioner/Inspector of Buildings Date —'
SECTION 1:SITE INFORMATION
1.1 Property qddress�„ / !� � 1.2 Assessors Map& Parcel Numbers
361c/��hcr5i 10,04MA110#1- t
1.1 a Is this an accepted street?yes t' no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(0)
1.5 Building Setbacks(ft)
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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) ' Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied e Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed WorkZ: L421 q
n v
c _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 04 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:$ ,l�o
Check No._Check Amount: Cash Amount: iz
6.Total Project Cost: $ 0 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervtso (CSL) 9 F
License Number Expti n Date
Name of CSL-HQlder �� ' D List CSL Type(see below)
Type Description
Ad ss�j� yyr n `r U Unrestricted u to 35,000 Cu.Ft.)
*- �� „/'✓ ��``'� R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
// ��/_- `/Jo 1�� SDF Residential Solid Fuel Burning Appliance Installation
6 Residential Demolition
5.2 Registered Honlie Improve3trent Contractor(HI ,3,3 9'3
HIC Company Name or HI Registr t Nam Registration Number
dow
Address
' /Expirlition Date
Signature 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 Issuance 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
1 as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
I. 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
CITY OF SALEM
PUBLIC PROPRERTY
a ` ` DEPARTMENT
n,n'.xI S ,xht ,-1 l
12: W,,H IU,:IUB SCt LLT * SAIPU,MANS\I III ill I,�I97:
1LA. 'PI.71y'ti'ti • 1:\,X 979.74".'1x46
Workers' Compensation Insurunce llfftda�it: IJuilders/Contractors/ElectricianslPlumbers
I klicant Information Please Print Letzibiv
V 111T7C IBu•nwsl)r�anv.ninNlndn�duall: ��/// �r/ �_l o
�Jdross: , Q t� />
City,St: re zip lAfrp C �0 ( e r�s I'hunr r': /7! ?— S2' 70 :Z _
.tire you al employer'!Check the appropriale box: 'Type of project(required):
I :un a general contractor and 1
1. ❑ 1 :uo u employer with 4 ❑ fi. E] New construction
employees(full antL'ur port-time).• hate hired the :tall-cuntracturs
?.X I ant a sole proprietor or partner-
listed on rhe attached sheet. 7. ❑ Remodeling
ship and have no employees These subcontractors have 9. ❑ Demolition
working for me in any capacity, workers' comp. Insurance. g, ❑ Building addition
I No workers' comp. insurance 5. ❑ We are a corporation and its
Irequired.) officers have exercised their 10.C] Electrical repairs or additions
7. ❑ 1 am it homeowner doing all work right of exemption per MCL I I.❑ Plumbing repair or additions
myself. [No workers'comp. c. 152, j 1(3),and we have no 12.❑ Ruuf repairs
in.urancl:required.) t .rnpluyccs. [No workers' I).❑ Utlter
comp. insurance required.]
•,... .q+pLcaul low checks boa nl marl abo till u,a Ill¢¢coma Iluw,Lowing Ihea wu(kai cunnpenrtaiws Iwlncy mlurnuliun.
' I lumcuwmn..hu,nbmil this at71davil indicating Ill.)am doing all work and Own hire"lode caumcton meal.uhmo a new arrdavil indi"..g elcA.
C,mtrxlury that chock this box mutt aowhnd..n uddnlional.died,hewing Ilw n:mw of the sub-cotnracoors and their wurken'co np.policy mfurtnalion
f tun un employer that i.s pruviding workers'c•unrpenvadoin insurance jar ary employees. Befall,is dile puffcy and job sifir
iafortnuthas.
Ir.>urancc Company Name:__,_. . -- _ ------_.—_—
1'oli:.v 4 or Self-ins. Lic. n: __. . . .. ___ Expiration Date:
lob Site Address: _._. Ctty.SlatetZlp:
.\hath is copy of the workers' cumpeniation policy declaration page(showing file policy number and expiration date).
Ioailure to,ccury coserage as required under Section 25:\til'.%ICaL c. 151 can lead to the imposition of criminal penalties of a
rine op en i 1.5110.110 andlor une-pear imprisonment, as well is cis d pcnalhcs in the farm of a STOP WORK ORDER and a fine
nl up ns i'_50 00 it clay .Igainst the violator. He adv l.a:d that a copy of this,latcincnt may be [or%urdcd to the 011ice ut
In%..,i amply ul :hc DIA :or io,marce ,uificaUon.
f du hereby t,rtifr under dile pains nand peauhiev of perjury thus the infurmallon provided above is true and correct.
�I•::LiIUI_ — -- .—._ Daly;------
FAuiliurily
rdy. Do not write in this arra,to he rmup/eird by airy•or All ,Ilhio2 I
or : _ Per mitil.iccnie 0
urity (circle nae):
le.dth 2. Ilulldia; Mparoocnt 1. Cit,.-foon Clerk 1, Uci:lmal lu;pccror i, Plumbing hi,peclor
Coulucl Vvriun: .. __ Phone y:
Intormation and Instructions
1 sero Gcneral Laws chapter 152 requires All cnymloycrs to provide workers' compensation for their ennployces.
[Ita�sasl u
th r under.m �untrust of hire,
. . • , � th• scree of Anu e Y
I'ur+u.urt w itis +lawte, an rmpluler a Jetined as" .el cry psi,on m �
.press or implied. ural or written."
\n ,,npfu)-,•r is delined as"an individual, partnership, .issociatwu, corporation or tither legal cntity, or Any two or more
,r the tumguu,g engaged in ajoint cnicrpnse, and including the Icgal representatives of a deceased employer,or the
r eccis er or trusice of All individual,pumnenhip. Association or other legal cnnty,employing employees. However the
owner of a dwelling house having not more than three Apartments and who resides therein, or the occupant of the
Jwclhng huu.:e of another who employs persons to do maintenance,construction or rcpuir work on such dwelling house
or,til rhe grountis or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.N,IGL 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."
%Jditiunally, sIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhiic work until acceptable evidence ui cumpliance with the insurance
requirements of this chapter have been presented w 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
Inswunce. 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
.\cc idents for confirmation of insurance coverage. Also be sure to sign and date The affidavit. The affidavit should
be lemoned 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
elf-insurance license number on the appropriate line.
City or Town Officials
please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
111zase be sure to till in the pennit/license number which will be used as a reference numher. In addition,an applicant
that must submit multiple permit licence 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 perTnits 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
a dug license or permit to burn leaves ctc.)said person is NOT required to complete this affidavit.
I h. ,)trice UI 111vesrhation) would live to thank )'ou ill adv;loco for your cooperation and should you have :my questions,
please Ju not hesitate to give us A call
fhe Dep.unncnl's address,telephone and fax number'
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfAce of Invesdgadons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
d ; tai www.mass.gov/die
CITY OF SALEM
~j rj Via. PUBLIC PROPRERTY
DEPAR'T'MENT
�•I I: _
I', U \II II\I..ONS Itl.ti # SAI I \I. \I.\,i\i
I i i s )'s 'as: 978 '4:.194,E
Construction Debris Disposal Affidavit
(re(luired lur all demolition and renovation work)
In accordance \pith the sixth edition ofthe 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:
?s �AyI UAB
(name of hauler)
The debris will be disposed of in
(natnr of l� ility)
puldresxul'1'acili -
\ignuturc i>f prnnit upplicant
a� o
:C�41•il IJ.�
X
PROPOSAL N . 4..
3
SHEET NO.
SCOTT BLOMERTH CONSTRUCTION DATE /
"BUILDING & RENOVATIONS ,
260 East Border Rd., Medford, MA 02155 • 617-571-7047 • 'Fax: 781=629-1060 • Licensed & Insured
PROPOSAL-SUBMITTED TO: - _ _WORK TO BE PERFORMED AT '
ADDRESS,'
ADDRESS
i
- - DATE OF PLANS
Ing
PHONE NO. ARCNITEOT
r-
r v X ' r %
! ! 700 42a , 10 C, pup
za-0, r , ^ ss,
a . '- .•.e w..N .a.Rw nm; .eo
}
All material is guaranteed to be as specified and the above work to be performed in accordance vufth the drawings • .- '
and specifications submitted for above work and completed in a substantial workmanlike manner for the some of" _
Dollars($ ? SOD: �� )with payments to be made as ollows.'=
Any alteration or deviation from the above specifications, involving.extra costs wil be Respectfully subnor
executed only upon written order,and will become an extra charge over and above the
estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. - Per '
Note-Thet proposal may withdrawn by us it not accepted within days
•
ACCEPTANCE OF PROPOSAL
The above prices,specifications and conditions are satisfactory and are hereby accepted-Youfare authorized'to dothework as s ecdled.'
Payments will be made as outlined above - - ,
JJ
Signature "' „yrid h�� • -
:.Date Signature
:,
RPR-23-2009 03:07 FROM:PICKMRN 978 741 7666 TO:19787409846 P.1/1
• y41;eWLLiU71 LG:4F7 1tJUJ1:eW4 91EFFFIELD HE F*iT5 PAGE 02
Amedcen Properdies Tamm, Inc.
10
PC)M e c) wher
TO: 3B Pletcher Way
FROM: lenaifer Pappas,Property Manager
RE! Deck:Replecement
DATE;' April 22,2009
♦wwarMr.Fwrf+rrrrrsrf«.as•rwwr,rrrrrrrMrsrrrrrtrtfwearrrs.�rrrtrrrsrrrwrrrrr
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 conthigent upon it matching the existing
deck. The Board will not allow any design alterations;
We also require that pennits be pulled in advance(regardless of what your contractor may tell
ym),and then a copy of the final approved per mt once completed must be sent to APT for the
unit file as well.
You will ne3d to bring a copy of this letter to the Salem Building Department in order to receive
Your permit.
Should you Lave any questions or require additional information,.please feel ftce to call me
directly at(781)932-9229.
cc: Unit Pile
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