009C FILLMORE ROAD - B-16-825 RPR FRONT DECK SN- The Commonwealth of Massachusetts
Department of Public Saf ��j� 25
Massachusetts State Building Code(ety, NRr
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Om )- ar
Building Permit Number: Date Applied: _Building Official: 1(e
SECT ON 1:LOCATION(Please indicate Block ff and Lot p for locations for which a street addre not available)
GT
I
vkAe- c I AQ
n No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK.
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes O No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
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.)
SECTIONS:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 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 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use.
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ 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:os Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municiped❑ A trench will not be P s
required❑or trench or specify:
Private❑ or indenti[y Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA I li,t-�.icC im i,,ion.Ile.i, v_)
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
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
`� Z M Get LEI�D ib CO IS r
SECTION 9: PROPERTY OWNER AUTHORIZATION
N�urre�nd Add f Property Owner
Name(Print).f tl .i, No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Nmne 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 fillout Appendix 2)(If budding buddin is less than 35,000 cu.R:of enclosed space and/or or not under Construction Control thencheck here O 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 /
�,O/L t�hUi �elLc ®d��rHy 2- 25 -2-c) 1 ''7
Company Name
vt J1/lmnru2 Ooa23 � �o�LS7` JJ_.�otyisaits
Name of Person Responsible for Construction License No. and Type if Applicable
l� E-Lt� 5� �eLw+it�s O/ 92
Street Address Q City/Town State Zip
-$ �37� S`431a 3i 6- ?- n t o� e w at�G/s,.�q
Telephone No. business Telephone No. cell e-mail address
SECTION 11:W0RKE1Z.9'C_0MPFNSA'I10N INSURANCE AFF'IDAVI'r M.G.L.c.152.9 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❑ No ❑
SECTION 12: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 $
d.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cos[ $ v` (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 knowledge and understanding.
Please 6 print anndsi r naie Title Telephone No. Dat
si wt S /�a n ✓ems DK D 22 3
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: "' "G✓
Name Date
J The Commonwealth ofMassachnse&s
Deparltitrent oflndustridAccddents
I Congress Street,Suite I00
Boston,AM 02114-2017
www massgov/dies
Workers,Compensation Insurance Affidavit:Builders/Contractora/Etectricians/Piumbers.
TO BE FIX"WITH THE PERMrrnNG AUTHORITY.
Anolicant Information Please Print Letdbly
Name(Blames/Orgamration/fndividual): M e)/_,t c%
r �
.. Address:_
City/State/ZiP: /92�-zA-5 L14A D612 3 Phone#: 9 9-'y —9/ 4 —
Are you an empbyerr Cbeck the appropriate box:
l.❑I am a employer with LKL]Other
project(required):
eagrbyees(twl and/nrpart-Cate).•
ew construction
2.glamaaolelsel etormparmetrbW and have eo—Ployees working form in g
my caPacity.(No workas'comp.m mane mgtmed) Remodeling
i.❑1 am a homeowev doing all conic myself.[No workers• emolition
eoW.inaamMe requhedj t
4.❑I am a homeownm and will be hiring cone cans,m conduct all wort m ilding addition .
emrne that all contractors either have workers' �'a sole I wig
corePem+tion insmmce or are sole ctrical repairs or additions
Proprietors;with an antonyms. -
s.❑,am a general contractor sea,have hired the umbing repairs or additions
subcontractor listed on the attached sheet.
7bese sib-contractor have employees and have workers,comp.msmarmt ofrepairs
6.❑We are a corporation and its offrcers have exercised thearight of exemption per MGL C. er
I52,§I(4),and we Lave no employees.[No workm'comp.MSS required]
'Arty applic®t that checks box Al must also fill out the section below showing Wen wosker'compravaticn policy mfmnration. .
Honrcownva who submit this affidavit indicating they are doing all work and then bire ommle coffiactms must submit a new,agidavit indicating such
tContracton that check this box must anwjw an additional shed showing the name ofthe sub-toucans and site whetherm meet
thane. as leave
employees Iftbe aub�imams have employees,they munpmvide tins workess'CMW pohcynwnber.
I am an employer that is providing workers'compensation insurance for ray employees Below is thepolicy andjob site
information.
Insurance Company Name:_
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address: q a /slat _ t
oo
Attach a copy of the workers'con ensation oil dJ ar tion ow tt e/Zy r t
P p ry page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S 1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$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 de h=evy cartrjy order the pains and penaMes ojperjury tkar the information provided above is trae mid correct
Signature, Date
Phone#:
O,/jaew!are only. Do not write in this area,to be mail"a d by city or town ofjrcutL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.C,ty/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,am 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 then three apartrnents 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 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)'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."
Applicants 01
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)namme(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-insured companies should enter their
self-insurance license number on the appromiate]me.
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 will 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 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 nun 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 dog license or pernit to bin leaves etc.)said pet-son is NOT required to complete this affidavit
The Department's address,telephone and fax nurnber:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02 1 14-201 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEA MASSACHLEETt±
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Construction Debris Disposa/Affidavit
(required for•all demolition and,.renovation wonky
In accordance with the shah edition of the State Building Code, 780 CMR, Section 111.s Debris,
and the provisions of MGL cW,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 15M.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Vi;nature of applicant
Date
American Properties Team, Inc.
TO: 9D Fillmore Road
FROM: Jenni rer Pappas, Property Manager
RE: Deck.Replacement
DATE: July 11, 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'f le 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•5UITE 6050, W09URN •MA -01E01.781.932-9229 •FAX 78]r935.4289