5D FILLMORE RD - BUILDING INSPECTION �'a ao
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The'COinmonwealtfto{ MassachiiSettS` r•`%^ ''
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Buildingµother than a Qne-or Two- mil Dwe g
(This Section For Official Use Only) - _
Building Permit Number: Date Applied: Building OfficiaF•• \4
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for w skeet a ress is not available) J
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City 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 Buildin Repair❑ ❑ (Pie'ase"fill out and subriiAt Appendix 1) -'- .
Change of Use ❑ Change of Occupancy ❑ Other)XSpecify: 44✓977
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Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ Now
Brief Description of Proposed Work: AAl/] 445&1k�
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 Fluor(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❑ FI: Hi h Hazud H-1 ❑ H-2❑ H-3 ClH-4❑ H-5❑
L' Institutional I.1 ❑ 1-2❑ 1-3❑ 14❑ bL• Mercantile❑ R: Residential R40 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 plicable)
IA ❑ IB ❑ IL\ ❑ I113 ❑ 1 IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site❑
Public El Check if outside Flood Zone El Indicate municipal Elos
A trench will not be p •
required❑or trench or specify:
Priv ue❑ or mdentify Zone: or on site system❑ permit is enclosed❑
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- Railroad rr ht of-wa Hazards to Air Navigation: i snn No,4w Pr,.,
Not Applicablc•P •::xe„,Is Structure within airpo[tappronch area? Is their review completed? r
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:
j Does the building contain in Sprinkler System?: Special St ipulatiuns:
11 `dEJJt� I�Ft_-nl-717 TO 01-JNG-7�
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Na re and Address of Property Owner
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Name(Print) No.Ad Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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 33,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Nurse(Registrant) Telephone No. e-mail address y�b'N� Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor k . : .a..
Cot�y Name
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
Telephone No. business Tele hone No. cell e-mail address
SECTION 11:FV01ZKF S'c0[dl'IiNSA'I10N INSURAN(T AH 10AVIT 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.
Ise signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor D!l v
and Materials) Total Construction Cost(from Rem 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 S 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 contained in this
application is true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Atm ��it1�ldZL rtA. �/a Ge�3✓) fI O/9 O
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
4 CITY OF S:U Em) NW&kCHUSE 1
SumDL\,G DEPAR-MENT
130 WASHNGTON STREET,3AO ROOR
TF-L. (978) 745-9595
KIMBERI.EY DRISCOLL Fla(978) 7 t4 9844
,bL-1YOlt THObLAS ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/HCII.104\G CO%NISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixdt edition of the State Building Code, 780 CMR section I 11.5
Debris, and die provisions of MGL c 40, S 54;
Building Permit I# 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
I 11, S 150A.
The debris will be transported by:
ti
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of futility)
signa re ofpermit applicant
Z
ate
American Properties Team, Inc. /\
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TO: Kevin St.Claire—5D Fillmore Road
FROM: Jennifer Pappas,Property Manager
RE: Pellet Stove Installation
DATE: December 12,2013
Please be advised that the Board of Trustees for Pickman Park has approved a pellet stove installation with the
understanding that the current flue can be used. We do 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(781)569-2675.
cc: Unit File
500 WEST CUMMINGS PARK•SUITE 6050. W0BURN -MA .01801-781-932-9229 -FAX 781-935-4289