13B GRISWOLD DR - BUILDING INSPECTION (002) '6'4 L(
The Commonwealth of Massachusetts
W
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This.Section For Official Use Only):.
F Building Permit Number- Date Applied: Building Official:
SECTION 11:LOCATION(Please indicate Block#and Lot#for locations for which a street address is notavailable)
2 Q /
No.and Street f>ZCity/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORI(.
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building!L RepairW, r1ff,W-I Addition❑ Demolition Please fill out and submit Appendix 1) _
Change of Use ❑ 1 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 Peet Review required? Yes ❑ No
Brief Description of Proposed Work:
J7,0
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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: j!h Hazard H-1 13H-2❑. H-3 13H-4❑ H-5❑
I: Institutional I-1 E3I-2 C3 1-3❑ I-4❑ M: Mercantil ❑ R: Residential R-10 R-291,'-R-3[03 R4❑
S: Storage S-1 ❑ S-2 Cl U Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable -
IA ❑ 111 C3 IIA [3 IIB E3 IIIA ❑ 11113 C3 I IV 13 1 VA 13 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 I; Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site
required 13 or trench or specify: 496-E
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA I I istoric_Commission Reviug_Pr(wc,s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Ed ilion of Code: Use Group(s): Type 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 1
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
!
LX - o-�/W
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
.D/ryaLDK2l LSCa9rfG/ JW9-
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 Appendix2): -
Of budding is less than 35,000 cu.ft:of enclosed space and/or not under Constmction Control the,
check here El 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-
Company Name
Nene of Person Responsible for Construction License No. and Type if Applicable l�
Street Address City/Town State Zip
An 95��6z0 6 — J 1J/N1. ASG' Xi% U -G
Telephone No. business Telephone No. cell e-mailaddress
SECTION 11:WORKE16'COA,iPONSnI'R>N INSURANCE AFFIDAVIT 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 signed Affidavit submitted with this application? Yes 0 No O
SECTION I2.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 $ 7 (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 the best of my knowledgeand understanding.
Please tint and sign name Title Telephone No. Date
StrLe Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
NOO-20-2015 18: 15 FROM: - TO: 19787417666 F'.1/1
r American Properties Team, Inc.
TO: 1313 Griswold Drive
FROM: Jennifer Pappas, Property Manager
RE: Deck 12epk'tcement
DATE: November 20,2015
+ww+++++++w+++ww++w+++++++w+wwww+ww+++w++++w++++++w+rwwwwwwwwwwwwwwwwwww
Please be advised that the Board of Trustees for Pickman Park has approved the replacement of
the deck at the above referenced unit. This approval is contingent upon it matching the existing
deck(composite materials can be used)and following the Engineering Alliance Deck
Specifications. 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 far the
unit file as well.
You wili 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'feam at (781)932.9229.
cc: Unit File
600 WEST CUMMINGS PARK,SUITE 80$0. W08URN .MA �01801.781,932.9229 •FAK781-3984289
CITY OF SALEA MASSAML SE M
`i Bug DnaGDEPAmmLw
120 WAW4G7MS7REET,3IDR.00R
UL(978)745-9595.
PAX(978)740-9846
%7MBERLEYDRIS�I.L
MAYOR Yds ST.PmM
DntEcrcacorPUBucPAcPERTr/BuiLDmccmu SawR
Construction Debris Disposa/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 g 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
y:(name of hauler)
The debris will be disposed of in:
(name of facility)
9LI�a 40
(address of facility)
Signature of applicant
Date
' The Commonwealth ofUdwachuseto
Department oflndus'trialAcddents
I Congress Street,Suite 100
Boston,EI9 02114--2017
www.masxgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electrkiaas/Plumbers.
TO BE FILED WITH TBE MM17TING AMWORITY.
Aoollcannt Information Please Print IMblr
Name(Business/Olgmizatiodlndiv dual):_ fes/ './.�/!(// L /
Address:
City/State/Zip: Phone#E:
Are you an employer'Check the appropeEak hoz: - Type Of project
1.01 employer with .empkryees(fun aod/orpmt-time).4 7. 0 New construction
2. am a sok wopuickr or pmtwmhip apd have w emp"wo7kiog fasme in $; EV4906,g
avy .capacity.INa wmlkan'coacp iomumce reauueel 9. 0 Demolition'
3.p I am a homeow doins ell work myself.[No workers'mmp..inm..o�ragtmed.)t
4.01am a bomeowrkm end avll he hiring eonbectm m cmdM all work m my properly. I will 10 0 Building addition.
emcee that all oo>maetms eitherbave woskas'compemetion ioswanoc or are sole 11.0 Electrical repairs or additions
°""'�aO Oy0t8 12.oPlmnm glepairsoradditiims
5.07atnagewialcontractor and lbavehired the sob-idffiaamelistedanthe attached sheet. Roofr i�.
Ibm sob-conaactan have employees and hove workab'mmp.®sutaaxaS 0 ePa.
6.0 We are a corporate®sod its offices have exercised their risk of exemWtimper MGL c.
14.0Other
152,§1(4),and we bavean employes.IND Wa loMM'icmp ianamce tequaed.)
•Any epplieaattbet eheeka
hot#Imus[alsofill oto Poesecdenheloweho`wsug Poen workers comp lwkc3'imfo aa.
t Homeowms who submit Pols affidavit indicating they are doing all viork�d t6eilhhe of sside oontraGas tops[sob"a vewallidavitivdikaMg sack
iConuactosa thin check this koz must attached an additional sheet skowmg the nanae of the sub-rmtredm and state wtiuffi or not those entities have
employees. Ifthe subwahaciwa have employsea,they,mastpovide fi-:workas'.eomp.pnlicynomtim. -..:
I am an to e►[hot ra Wdin worbera'compensation insurance or m .
amp Y Pru 8 a+Pe f Y empiRpeea. Below is theppht y andfab uric
informadon. _
Insurance Company Name: 4474446 IA�
Polity#or Self-ins.Lic../M Expiration Date:
Job Site Address: (!54e/,qnC 5 FJ� City/State/Zip:��a�l I)G9
Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a aimiz a]violation punishable by a fine up to$1,500.00
and/or one-year impnsonwend,as well as civil penalties in the farm 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 t�hep/am'
'ss and penahia ofperJary that the inform adon provided abort is true and correct
Date;:
Phone#- l7 `0'ZD6
Offlefal use only. Do not write in this area,to be completed by city or town offwjaL
City or Town: Permft/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#:
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 ofhire,
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(�also star
es that"eve state or local lice agency shall withhold thhold the issuance or
licensing ger cY
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)slates"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-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LU)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-insired'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 permnittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple Pcmut/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 citi=is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg 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.mass.gov/dia