2C ARNOLD DR - BPA-16-523 DECK REPAIR 28 C-l<, 136g
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
rry
Massachusetts State Building Code, 780 CMR Revlsed.Nar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
J(� This Section For.Of icial Use Only .
Building Permit Number. Date Applied. �'f
-�aew
Building 011icial(Print Ndme). Signature; Date —
Lj SECTION I.SITE7NFORLNATION M
lLJ 1.1 Property Address 1.2 Assessors IV lap dt Parcel Numbers �
- aQ
l I.la Is Ihis an acre ted street?yes ✓no Map Number Wueel Number w rn
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District P.ruposed Use. .. I.otAres(sq R) - Frontage(R) .. -
1.5 Building Setbacks(it) .
. From Yard'.. Side Yarib. _ .. . Rear Yard
- Required Provided - Required - Provided.. . aiequired Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.S Sewage Disposal System.
/ Zone: _ Outside Flood Zone? Munici a O On site d'u ilem O
Public 0-1 Private O. Cbedc if esO..:
SECTION is PROPE*W0%"EMff Pt " r .
2.1 Owner'of Record:
&eta pIKAn� KFxrUAA/ �-r
t ne(Print) Crty side,ZIP
aiz dLz� r u �f'l 31 z&13/
No.and Street Telephone -
SECTION 3:DESCRIPTION OF PROPOSED WORK'(cbeelr plLtbat apply)
New Construction O 6hiting Building O Otvner-0ccupied O Repairs(s) O Alteration(s) 0 Addition O
Demolition O Accessory Bldg.l7 . Number.ofUnits_ Other O Specify:
Brief Description of Proposed Work': !_ it v. r d L!
SECTION 4:ESTIAIATED CONSTRUCTION COSTS
hcm Estimated Costs: Official Use Only
Labor and Materials
I. Building S a e. I. Building Permit Fee:f indicate how fee is determined:
- S . 0Standard Cityfrown Application Fee
2. Electrical
❑Total Project Cost?(Item 6)x multiplier x
3. Plumbing S [C3
ther Fees: S
4.hlechanical (FiVAC) S :
5.Alechanical (Fire S l All Fees:S
Suppression)
k No. Check Amount: Cash Amount:
6.Total Project Cost: S `� o"o iid in Full O Outstanding Bah
nce Due:
511 q RP<t L.FD 'd) C11J1.1 i .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) J� 1 �— 29+'
•F/ J1111f b PECc,��G� License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
17C Type. Descriplion .
Nu_:md Street
U Unrestricted Bi ildings up to 35,000 cu. It.
�/0 R Restricted I&2 Family Dweilin
Cityfrown,State,ZIP M Masoary '
_ RC Rcofm Covering
_ WS Window and Siding
SF Solid Fuel Burning Appliances
r 1 Insalatton
Telephone Email address ' _r'ra„J D Demolition
5.2;Registered Home Improvement Contractor(HIC) JAZZ i 72 -
a.•�
,r�SG.AlJ/ 1�!/e/ HIC Registration Number Expiration Date
IIIC Company Name or HIF Registrant Name
No.and S Email address
�,e rr >e�io
Cityrrown,State ZIP Tel ono
SECTION 6:WORKERS'COMPENSATION I.NSURAIVCE AFFIDAVIT(M:G,L:C.Iq.4 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 Isfuance of the building permit.
Signed Affidavit Attached? Yes..........�--� No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPGETED.)VHEN
OWNER'S AGENT OR CONTlRACTOR APPLIES FOR BUILDING.PERMIT'
1,as Owner of the subject property,hereby authorize Aoq , �_7 *)t9 act on my behalf,in all matters rela've to w rk authorized by this building permit application.
Print Owner's Nance(Electronic Signature) ' Dos
S19CTION 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.
Print Owner's or Authorized Agent's Name(Elceunic Signature) Date
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 flll have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Otherimportont mforma ton on—the M-Program- can be f8tiat --
www.m:ss.eov.'oca Information on the Construction Supervisor License can be found at www•.mass._ov;dns .
2. When substantial work is planned,provide the information below:
'rota) fluor area(sq. R.) `e (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 h:df/bmhs
'type of heating system Number of decks/porches
rype of cooling system Enclosed Open
]. 'Total Project Square Footage"may be substituted for"'total Project Cost"
CITY OF SALEA MASSA( HLBEM
BuaDINGDEPAR7MENP
120WASJ NSUEET,5"FLOOR
UL(978)745 9595,
PAX(978)740-9846
KIIABRLEYDRIStb1.L
MAYOR lli AST. IMM
DIREcroRoFPimucPRoYmm/BuaDmo o7-x
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 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 of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
The Commonwepbk ojMassachusetXs
Department gfhmWsYA dAeciden&
I Congress SAreer;Suite 100
Boston,M40211¢2017
www.maxegov/d&
Workers'Compensation Insurance Affidavit:Bnilders/Contractors/EleeMclansMiumbera.
TO BE FILED WITH THE PEItntirnNG AUT00111TY
Anolicant Iaformatlon Please Prlat I�bly
Name(Base,esdOWnization/Inmvidualj:
Address: l%�So Jf'
City/State/Zip: �L4, Al r1WO Phone#:
Are you an employer?Check the appropvloee Dos: - Type Of pro)ed(squired):
l.pI employer " riapbyees(fulleod/orpnt-time).% 7. ^Q�J`cw construction
2. amasokpmpsiceororparmepDryaadbavemempby¢eworlp'mg formem g, I�l�B -
aoy capaetty.(No wakais'wroA bbaoaae.re9abed.7
3.p l am a hemeownrrdoiog all wmkmyveY.fNo workers'oomP.iR9mancemqubed.I t 9: ❑Delnblinhm.'
. , 10 Q Bw7ding addition.
4.❑1amahomeov mdwr'abebkiogoonLactMmemdueteaworkonmypmpeny. Iwill
enure that all connactm adwhavc workers'=Tenzmm esuence er ae soh; 11.0 Electrical repairs or additions
12:p Phumbin oiadditivas
s.Q lamagenaal eoeudlbeveMad 9a suDybmraetdrd lisaA on Weene�3ed abet 13.. Roof g
7bpe.anbcoaceaomhave employee stud pave wodcaa?omip nuzee , p repe`rs.
6.QWe ae 14.0 Otlier ..
152,§I(4),and vve tiptieno employee:(No workeis'ec-----
. .eAnyaPPliuht cbeeb bwi#1 man also fill wtthe eeetim bebw dibd3ng tbea cow)rare pobey .
r Homeovimsvvbo submit the e�devitmduattmg they ere dobig oD wdAi®dlhedhoe outetde eotma ms mort bobaitt anewaffidavith&Mdng eurh:
tConttacmn the check this fin aWin•Led >edditioml shedzbewmg de nemft_afthe sub-wlitre and arse iek&ueimet ttime have .
employea_Htbe 4ubconRagpabereempinysas,t)x�'mustlnovide&eir-wmkms'-oomp policy'mmDei '.- : +.
I am an a wpky�that ispropm mgWrlters'conip®taattan msarmeca for my empltWeea Belaw t s thepoOry aadjob site-
brfbrniadon.
Insurance Company Name: T/��/7!� /r
policy#or Self-ins.Lic.#: /, �� 77a_� Eapbvbon Date:
Job Site Address: G �1 y( /l� G�"v /7r [fty�gtatr 4 : /
Attach a copy of the workers'compensation poft declaration page(showing the policy number and expiration date).
Foure to secure coverage as required under MGL c. 152,¢25A is a taimma]violation punishable by a fine up to$1,500.00
and/or one-year imprisoument,as well as civil penalties in the form of a STOP WORK ORDER and a Sne of up to$250.00 a
day against the violator.A copy of this stateirieat may be forwarded to the Office oflnvesdgutions of the DIA far ineiu nce
coverage verification.
I do hereby eertljy an er tbepaina and skies oj�the injormatioa provided above is true and aonsa
i
Phone M 61-7
�4 20
_
O,()Wal am only. Do not write in this area,to he completed by erry or town offleieL
City or Town: PermltaUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.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 of hire,
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 permk 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 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."
Applieants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)narne(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other then 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 Deparbnent at the number listed below. Self-insured'cornpanies should enter their
self-insurance license number on the appropriate lime.
City or Town Offidals
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 will be used as a reference number. In addition,an applicant
that emmat submit multiple pen ictobcrose 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 far future permits or licenses. A new affidavit rust 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 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. #617-727A900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15. www.mass.gov/dia
American Properties Team, Inc.
TO: 2C Arnold Drive
FROM: Jennifer Pappas, Property Manager
RE: Deck Replacement
DATE: May 16, 2016
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.
cc: Unit File
500 WEST CUMMINGS PARK-SUITE 6050• WOBURN -MA .01801.781-932-9229 -FAX 781-935-4289