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5C GRISWOLD DR - BUILDING INSPECTION (2) JJ =µ - hSPE' RECEIVf4 - , The Commonwealth of Massach�rysetts VICES Department of Public Safety `016 MAR Massachusetts State Building Code(780 CMR) 2$ A fa 6i Building Permit Application for any Building other than a One-or Two-Family Dwelling n l (This Section For Official Use Only) Building Permit Number: Date Applied: Budding Official: :..Q SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) j fG bRcrWACr7 Qft SAU� fCK/Y69N (21C �S No.and Street City/Town Zip Code Name of Building(if applicable) p SECTION 2:PROPOSED WORK. 1(I—` 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 ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Ur Is an Independent Structural Engineering PeeeeReview ireyl? Yes ❑ No 8� Brief Description of Proposed Work: ��-/��Nr" /W�9'GF��GS 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): I 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 Cl 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use. SECTION 6:CONSTRUCTION TYPE(Check as applicable) !A ❑ IB O IIA ❑ IIB ❑ ILIA ❑ 11111 ❑ IV ❑ 1 VA ❑ 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: Licensed Disposal Site❑ Public❑ ❑Check if outside Flood Zone❑ Indicate municipal A trench will not be P required❑or trench or specify: _ Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: i,�I li t,��<,�.=oinnu v n Rove v t r xcvs: 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 OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION - Nameand Addr'5"of Property Owner P Name(Print) No.and Street City/Town Zip r WZ ry ' Prope,rty-0wner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes( AK Name' Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this budding permit application. SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix.2) . f buddingis less than 33,000 cu.ft.of enclosed space and/or not under Construction Control then check here E3 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control -AA f4WV ), `7& - © 0 WFuTiAX 1582-67 Name(Registrant) Telephone o. e-mail address Registration Number Crm u cy19i�D. �' MA- Street Address City/Town State Zip Discipline Expi ,tion Date 10.2 General Contractor - Mr-PM e^AwFk ^s tcc 178 N k�ts�t F3t�r �p�itS Company Name 111MK- Pculetil k ors lay Name of Person Responsible for Construction License No. and Type if Applicable (p J l-oY`tIV��N��l' �, � GZ�N✓ /t'�H- 0�Q�fl Street Address City Town State Zip -�&- 2-4,Z 1 78—( _-V-QLb f Dail 01g 10ADL. ( &PA Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COKIPt NSAI'IONN INSURANCE Af.FIDAVI'I- M.G.L.c.152. 25C 6 A Workers'Compensation Insurance Affidavit from the NIA 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 $ 120-M Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3. Plumbing $ d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact tttmuniciippals 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ `30C c),jX> (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 a a on is true and accurate to the be f my knmvler and understanding. PaIE a rint an sign name Title Telephone No. Da e Street Address City Town State Zip f Municipal Inspector to fill out this section upon application approval: wL "O 3� name Date WOffice of Consumer Affairs and Business Regulation 3 Ea 10 Park Plaza --Suite 5 170 1 Boston, Massachusetts 02116 Home Improvement Co',tra Ta �;tor Registration Registration: 158287 Type: Private corporation F-yp4ratow iF-ir2ois 7rti 285W NORTH SHORE BUILDERS INC MARK FOURNIER P.O. BOX 8084 LYNN, MA 01904 te Address;and re-t card .rd.Mark reason for change. Address Rmeoral Employment Lost Card SCAI C� License or registration valid for individal use only olficc of Cansasocr Affairs P gfflzuGff before the expiration date. If found return to; ME IMPROVEMENT CONTRACTOR istrab" IM87 T"W. office of consumer Affairs and Business Regulation : ration - Vogt prm"comorabon to FAA Plaza-suite 5170 Boston,KA 02116 NORTH SHORE BUIi OERS iP MARKFOURMER y.... . W_� 63 COMMORNEALTH 1110., LYNN,MA 019a4 Not vatid without signature #V�J!izrd of S�Lq'5ng R� aBtaaxS Construction stqwrvhur-,- vnse:Lie 4 MARKNIFOURN V Lim AjL The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia rkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information n�aPlease Print Le ibly Name (Business/Orgaruzation/Individual): ,Mtn610 •/V�t Fit-A /L1-�'4S Address: P O B Q el V 16 V City/State/Zip: LY k"/J MA O $D - Phone#: j 6// ) c z— 2—RZ Are you an employer?Check the appropriate box: 7t , Type of roject(required): I.�m a employer withj/__employees(full and/or parr-time).' 'J, ]j r ject( equi construction 2.❑I am a sole proprietor or partnership and have no employees working f $, Remodel]non' 'rucuou any capacity.[No workers'comp.insurance required.) -3.�I am a homeowner doing al]work myself[No workers'comp.insuran9. qQ 1Jemolition 4.7 1 am a homeowner and will be hiring contractors to conduct all work on mproperty. I.will ] Building addition Y ensure that all contractors either have workers'compensation insurance or are sole ]1.�ElectrCal repairs or additions proprietors with no employees. ' '-- ' - 12.Q Plumbing repairs or additions 5.7 I am a general contractor and I have hired the subcontractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.,insumnce required.] °Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer•that is providing workers'compensation insurance for my employees. Below is the policy and job site information. c� Insurance Company Name: A S ) t9L/'�- � Cy Policy#or Self-ins.Lic.#:/ p'��C sw� / 5 /� Expiration Date::r / Job Site Address: 6_ a G - "'Walo Il�. City/State/Zip: : �/ , IvVA Attach a copy of the workers compensation policy declaration 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$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 do hereby c nder the patns and ties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: [60 cial use only. Do not write in this area,to be completed by city or town official or Town: Permit/License# ing Authority(circle one): oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector thertact 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 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 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-insured companies should enter their self-insurance license number on the appropriate line. 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 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 dog 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 I Congress Street, Suite 100 Boston, MA02114-2017 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 MASSAai[J@SE M Bu Dn9GDEPAx7MBNr 120 MMMOUN SUM,32D Fioox IkL(978)745.9595. $IMR PAX(978)740.9846 MAYOR THCMASSTAEM DntEcrcitcFpLmucpxcnmljluaDmamomom 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 W,S 54; Building Permit# I is issued with the condition that the debris resulting from this work shall be disposed of in a property licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: Anp sew R, (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signatu a of applicant ate American Properties Team, Inc. TO: 5C Griswold Drive FROM: Jennifer Pappas, Property Manager RE: Deck Replacement DATE: March 23, 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 60SO• WOBURN -MA •01801.781-932-9229 •FAX 781-935-4289