1C NIMITZ WAY - BUILDING INSPECTION (002) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 1011
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 Da e
l
SECTION 1: SITE INFORMATION"
1.1 PGrloperty Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted stree . yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: p
1/64191�eo Lem 1066vo-uy L lLc7i `e, '57,/� /4+
'N a(Print)��- I I Ci State,ZIP
/ C MI-4,d2- Li f!/ �7� 99Y713?y
No.and Street Telephone - Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : 1 ts'w jt— ,a// >gt ,4 v aK,- s<
Lj y PG A<aiLnarc rivwt f !k a/ iN
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑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:
}�Gll( Ta Co CSE—'loft /'o/L' 15AI-)G)US
1��12
co 0—A, P �� • B asp
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 65 a,j& Y-f �/ 20
AaVIr License Number Expirati n Date Q
Name of CSL Holder
6 i_Qn / I List CSL Type(see below)
No.and Street /�j�' / Type Description
C2f' Z`/Y- Cj/gOY U Unrestricted(Buildings u to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
City/Tow ,State,ZIP M Masonry
RC Roofing Coverin
WS Window and Siding
77� / SF Solid Fuel Burning Appliances
3� X �� 97� e7m(ypy ,H4 I' Insulation
Telephone Email address D Demolition
5.2JJRe-'giipstered Home Ina HI
ovement Contractor(HIC) 2 �/�7
, P'T113G�ls�a�! /IP'3
7 C Registra ion Number Expiration Date
HI Co a (Ne orYC Registrant Name
ZMf
No.and Street � Email address
� gt(p rytyt�¢ 6/s� 9 / & �
Ct / own,'State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c1152.§ 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 building permit.
Signed Affidavit Attached? Yes .......... No...:.......❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR
/ /eAPPLIES FOR BBUILDING PERMIT
/'
I,as Owner of the subject property,hereby authorize /! el '" "` /ne-A iV-1
to act on my behalf,in all matters relative to work authorized by this building permit application.
`. N e Olio P o G 42,-)/,L
int Offer's Name(ElectrIhie Signa ) Date
SECTION 7b:OWNEW ORAUTHORIZED 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 applliicaa ion is a and accurate to the best of my knowledge and understanding
Print Owner's or A orized nt's Name(Electronic Signature) �— Dater
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(IIIC)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. o�Information on the Construction Supervisor License can be found at www.mass. ov/dn§
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"maybe substituted for"Total Project Cost"
American Properties Team, Inc.
TO: 1C Nimitz Way
FROM: Jennifer Pappas, Property Manager
RE: Renovation Work Approval
DATE: October 5,2016
•r****arrarrr►*■�**r*a*rxrnr*>t*x►xs�rssrrsxrs«s:►:sxaxsxa*M�>k*�x*�***s*a
Please be advised that the Board of Trustees for Pickman Park has approved renovation work at
the above referenced unit. This work includes but is not limited to plumbing,plastering and tile
installation
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. 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 me
directly at (7811569-2675.
cc: Unit File
500 WEST CUMMINGS PARK-SUITE 6050 WOBURN MA 01801 781-932-9229 FAX 781-935-4289
1 '
� Office of Consumer Affairs&B mess Regulation t{p
KEE19HOME IMPROVEMENT CONTRACTOR
f Registration: . ,111834 Type:
Expiration: 2J4/20,17 DBA {{k
MACDONALD cARPENTERMOODWORK - t
�1
KEITH MacDONALD ` k
6 GENOA AVE.
SAUGUS,MA 01906 _., Undersecretary
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CSFA-056432 .
Construction Supervisor 1 & 2
Family
KEITH A MACDONALD
6 GENOA AVENUE
SAUGUS MA 01806
Expiration:
Commissioner 0813112018
W, Safefy Insurance BUSINESSOWNERS DECLARATIONS
AUTO - HOME • BUSINESSPo11CY Pet�bd
Safety Insurance Company Policy Number From
To
BMAD002706 07/24/2016 - 07/24/2017
12:01 A.M.Standard Time at the described location
Transaction ':
Renewal Declarations
Named Insured and Mailing Address Agent
KEITH MACDONALD TARPEY INS GROUP INC
6 GENOA AVE 442 WATER ST PO BOX 567
SAUGUS MA 01906 WAKEFIELD MA 01880
Telephone: 781-246-2677 33051
Form of Business: INDIVIDUAL Type of Business: CARPENTRY-INTERIOR
DESCRIBED PREMISES
LOC BLDG ADDRESS AUTOMATIC INCREASE
001 6 GENOA AVE SAUGUS MA 01906 4%
PROPERTY
LOC BLDG COVERAGE VALUATION DEDUCTIBLE LIMIT OF
INSURANCE
001 001 Personal Property Replacement Cost $ 500 $ 4, 104
Deductible shown above applies per any one occurrence
BUSINESS INCOME: Actual Loss Sustained Not Exceeding 12 Consecutive Months
LIABILITY AND MEDICAL EXPENSES
Except for Fire Legal Liability, each paid claim for the coverages listed reduces the amount of insurance we provide
during the applicable annual period. Please refer to Paragraph D.4. of the Businessowners Liability Coverage Form.
BUSINESS LIABILITY COVERAGE LIMITS OF INSURANCE
Liability $ 1, 000,000 Per Occurrence
Medical Expenses $ lo, oo0 Per Person
Fire Legal Liability $ loo, 000 Any one Fire/Explosion
ADDITIONAL COVERAGES
Some property coverages are subject to deductibles specified in the policy forms.
Optional Property Coverage Description Limits of Insurance
LOC BLDG DESCRIBED COVERAGES
001 001 Contractors Tools - Blanket Basis $ 5, 000
Optional Liability Coverage Description Limits of Insurance
Contractors-payroll $28, 600
CHANGE IN PREMIUM: $ TOTAL PREMIUM: $ 943
MORTGAGEES/LOSS PAYEES/ADDITIONAL INSUREDS
LOC BLDG TYPE POLICY INTERESTS
001 001 AI Owners, Lessees or Contract BP0450
LARRY GROIPEN
13 CUTTING RD
SWAMPSCOTT MA 01907
BPDEC2011
INSURED
d i
MEMO Safety Insurance BUSINESSOWNERS DECLARATIONS
AUTO • HOME • BUSINESS P0114Y Period
Wo Safety Insurance Company Rolrcy Number From To
BRA0002706 07/24/2016 07/24/2017
12:01 A.M.Standard Time at the described location
Transaction ....
Renewal Declarations
Named Insured and`Mailing Address Agent
_.
KEITH MACDONALD TARPEY INS GROUP INC
6 GENOA AVE 442 WATER ST PO BOX 567
SAUGUS MA 01906 WAKEFIELD MA 01880
Telephone: 781-246-2677 33051
FORMS AND ENDORSEMENTS SCHEDULE
Coverage line Form Number Ed. Date Description
Businessowners BP0417 (01/96) Employment Related Practices Exc usion
Businessowners BPOIOS (03/98) Massachusetts Changes
Businessowners BP0439 (01/96) Abuse or Molestation Exclusion
Businessowners BP0009 (01/97) Businessowners Common Policy Conditions
Businessowners BP0450 (01/97) Add. Insured - Owners, Lessees or Contr.
Businessowners SB0002 (11/99) Businessowners Special Prop. Cov. Form
Businessowners SB0006 (11/99) Businessowners Liability coverage Form
Businessowners SBO518 (04/07) Asbestos or Other Respirable Dust EXCI .
Businessowners IL0003 (04/98) Calculation of Premium
Businessowners SB0517 (04/07) Silica or Silica-Related Dust Excl.
Businessowners BP1004 (04/98) Excl of Certain Computer-Related Losses
Businessowners SBC542 (02/16) Excl Pun Damage Related to Act of Terror
Businessowners BP1005 (04/98) Excl-Year 2000 Computer Related Losses
Businessowners SBO514 (05/04) War Liability Exclusion
Businessowners BPN110 (12/15) Snow Removal Advisory
Businessowners SBOS76 (06/07) Limited Fungi or Bacteria Cov. (Property)
Businessowners SBM001 (06/01) Equipment Breakdown Endorsement
Businessowners SBOS77 (11/02) Fungi or Bacteria Exclusion
Businessowners SBOS44 (04/07) Roofing Operations Exclusion
Businessowners SB0701 (04/16) Safety Contractors Property Endorsement
Businessowners STN110 (02/16) Notice of Terrorism Insurance Coverage
Businessowners BP0703 (01/97) Property Damage Liab. Ded (Per Claim)
$250 Deductible
Businessowners SBOS38 (02/16) Excl Acts of Terrorism Outside the US
Premium has been waived for this coverage.
Businessowners SB0706 (01/97) Contractors Tools and Equipment Coverage
Blanket Limit $5, 000
Businessowners BP0419 (06/89) Amend-Liquor Liab. Exclusion (Exception)
Countersigned By:
BPDEC2011
INSURED
CITY OF SM.&M. %iAsskciiusETrs
• BUELDLNIG DEPARTJL.NIT
130 WASHINGTON STREET,r FLOOR
TEL (9713)745-9595
FAX(978)740-9846
KI\IBERLEY DRISCOLL
MAYOR DIRECTOR
ST.PtERRH
DIRECTOR OF Punic PROPERTY/BL'tfDLNG C01MCISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information _9 Please Print Le bl
Name(Business/iOrranizatio clivi ): Il- e T"aryl l !�" �"`�b/(✓4 l
Address:
City/State/Zip: s�U�i�.L� �/`/b �o Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4. 0 I am a general contractor and 1 6. 0 New construction
mployees(full and/or part-time),* have hired the subcontractors
21 am a sole proprietor or partner- listed on the attached sheet: 7. 0 Remodeling
ship and have no employees These subcontractors have S. 0 Demolition
working for me in any capacity, workers'comp.insurance. 9, 0 Building addition
(No workers'comp. insurance S. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,¢1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.0 Other
comp.insurance required.)
•Any applicant that chocks box el must also fill out the section below showing their workers'wmpema ion policy infunnatitm
t I lameowrcn who submit this affidavit indicating they are doing all work and thin hire outside eonnoesors must submit a new,atrtdavil indicating such.
;Commmn that cheek this hon must anachcd an additional sheer showing the nano of this subamntmetons and thelr workers'comp,policy inronamm,.
I am an employer that&providing workers'compensation Insurance jar my employees. Below Is the pollay and fab silo
information. .
Insurance Company dame:
Policy#or Self-ins.Lie. #: 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 Section 25A of MGC c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
!do hereby certify nn r the pains one o rJury that the information provided above is true and correct
Signature 1 O ���J(/
Date:
Phone#: q 7j 77/ w 73r—
Official
3FOfficial use only. Do not write in this area,to be completed by city or town offlaYaL
City or Town: Permit/I.Iceuse#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cilyfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other,
Contact Person• Phone#'
CITY OF S.U.E,,\1, UNSSACHUSETTS
• BUILDING DEP iRTJCEVT
130 WASHINGTON STREET, 3m FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
(vL%,{gFRi F.Y DRISCOLL
MAYOR THODtAs ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUU-DING CONL%aSSIONER
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:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
/(o
date
dcbriufT.dm