12A RUSSELL DR - BUILDING INSPECTION The Commonwealth of 1�V assach_ usetts
�} Department of PitIylrc Safety
J(7 Massachusetts State Buddgg Code(780 CMR)
Building Permit Application for any Building o er than a One-or Two-Fa ily welling
- (This Section For Official Use Ord
Building Permit Number: Date Applied: Building Offii — -'�
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is notavallable)-
No.and Street City/Town Zrp Code Name of Building(if applfi�le)
SECTION 2 PROPOSED WORK, �. Mow
Edition of MA State Code used [f New Construction check here O or check ail that apply in the two rows bExisting Building Repair 1Alteration ❑ Addition O Demolition Gl-(Please fill out and submit Appendi
Change of Use Cl Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No EB—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No B-'
Brief Description of Proposed Work: AiJtI V` �/U� ,2--�iLl� ( X/Z
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) 0
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 ❑ A=1❑ A-S❑ I B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ -H,3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ F3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2(3�11-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use 13 and please describe below:
Special Use:
SECTION 6.,CONSTRUCTION TYPE(Check as applicable) - -
IA ❑ 10 E3 HA 13 Hit 17 IIIA ❑ Hill 13 IV M- VA 13 VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Sfte
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:l silos
Private❑ or indentity Zone: or on site system❑ permit is enclosed❑ r'
MY
Railroad right-of-way: Hazards to Air Navigation: 1I_\Ilistnric_Cumn,fssiun Ityg:iu��_Pruce_s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
(`neo\L. - -D irk•O • - rnj::� 1 t_(5D ( Z n
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/TownZip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
fi/1110 OM5"fA- ) zj�/i
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2).
If budding is less than 35,000 cu.0: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 - - -
Name(Registrant) Telephone No. e-mad address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
- 10.2 General Contractor
Company Name
1� JAIQ
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
,t
Telephone No. business Telephone No. cell e-mailaddress
SECTION 11:a VORKERS'COMPENSA I10N INSURANCT AFFIDAVITM.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 E3 No ❑
SECTION 12.-.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ !ro 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 $ (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 conta ned in this
application is true and accurate to the best of my 1 wledge and understanding. /1� t�z 0�
Please print and sign name aIle Telephone No. Date
Street Address City/Town State Zip
F 44
Municipal Inspector to fill out this section upon application approval: `""
Name Date
+ The Commonweallh ofMassachusetl_s
' Depdrhnest ofladusnialAccidenis
1 Congress Sbeet,Suite 100
Boston,M-4 02114-2017
www.ma sgov/dip
Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleebicians/Plumbas.
TO BE FH"87TH T13E PERMTJNG AUTHORITY.
Applicant Information /1 Please Phot LedbN
Name(Business/Organization/Individuei): ��..//`JN� 7—YJ 4 A. /V
Address: )7 &Q?)AI cam•
City/State/Zip: 6j�i�L,4P% ZYi .Phone#: , );;'
Are you an employer?Cheek the appropriate box: 1Project red�pe of P J .f(rei►af :)
1.01 •Employer wtlb a igloyeea(full and/mpnut•tium)' 7. 0 New Conshuctlon
2. am asok isupaietorm parmeaship and have no engJoy soros)ling formero g: .®,BFmodelipg .
day capacity.[No mmken comp.innaarece requited] 9. El Denwlition'
3.01 not a homeow dabs all wodc myself.[No workeae'amp.insmaocerequired.)+
4.E]Iam a 6omEonwand m'H be huiug conuactms m andw aD wozk m myproputy. I wt71 10 0 Bal7diag 8ddition.
some that all conbactors eitrerhave workers'eumpemsmon insurance Miasmic 11.0 Electrical repairs or additions
pmpsietmswith no employees. 12.0 Plumbing repairs of additions
5.01®a general Counselor and l have hind the abcaosetors listed on the attached sheet 13.. . ROOF aha .
7bese mb-ambactum have employeas and have woAm,amp.namesee t �
6.0 Mean:a cosyoratibe and its officers have exercised 11aevright of ex®psionpq MGL c.
14.Q Other
752,§1(41 and we have no ayloyeea.(No workers'6oatp:insurance n.:gtmed.)
*Any a"Hoint&t-4 clu tion#1 must also fillour thecationkalowabowmgma wor]ras policy,kd0a*,.
t Homawms avho sabmif this amdava ihdiratmg shay sae doi g all work�d ditMe outside award must submit a new affidavit mdicaaug suck
tCouttamn Wet cbeek this baa mmretobed an additional skeet sbewmg the nome ofinesub-muzsmvs and sofa whederor lot those entities beve .
employes lftbe subcouaAues have emp)oyers,they must wavido Iles urmkasCcamp policy uuaim-. . . '
I am an employer matisproviang workers'Compensation insurance for my eaaplpyeea. Bf iy thepoticyandjob site -
Information.
Insurance Company /� - —
Policy d or Self-ins.Lie.M 00 f f g, 15— Expiration Date: Ip Z0 - ZO
Job Site Address: /af/- R'L/'. ) L)e &ICaI, GSty/State/Zip: SAP,!-, .�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGT,c. 152,§25A is a criminal violation punishable by a fine up to$1,500-00
and/or one-year impiisomnent,as well as civil penalties in the from da STOP WORK ORDER and a fine of up to$250.00 a
day against theviolator.A copy of this statement may be forwarded to the"Office of Investigations of the DIA fm ins rance
coverage verification.
I da hereby certify unndder �lepains and penalties ofperjuiy that the information provided abore is true and correeL
Siunareae• l� f� �dA Date:
one M
Ojjiciai use only. Do not write in this areq to be completed by ary or[own o,�refaL
City or Town' PermiNUcense#
Issuing Authority(circle one):
I.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(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a badness 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 nm 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-insuredcompanies should enter their
self-insurance license number on the appropriate lime.
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 wt71 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 starqued 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 dpg 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
07Y OF SALSA AWSAaR SEM
BEnDmDEPARTA&Nl
120 WAS MCTCNS9$EET,3xDADOR
TkL(978)745.9595.
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PAX(978)740-9846
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MAYOR NCAiASSTYMW
DIR rcRorPUBucPxamRw/BIIDDmOcm oj�=
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# 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:
,�Ugt2d, WA 4;F Of= Zk rl>/V
(name of facility)
RT /G, 1/ i�G
(address of facility)
Signature of applicant
Date
American Properties Team, Inc.
�
^41
TO: 12A Russell Drive
FROM: Jennifer Pappas, Property Manager
RE: Deck Replacement
DATE: December 7, 2015
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 for the
unit file as well.
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 at (781)932-9229.
w: Unit File
500 WEST CUMMINGS PARK-SUITE 6050 WOBURN -MA -01801.781-932-9229 -FAX 781-935-4289