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2C HALSEY WAY - BUILDING INSPECTION (2) 1 I f 1-5 H fz z Z) 7-�,59 Ll� } The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling .(I1ils Section For Official Use Only) Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block If and Lot ff for locations for which a street address is not available) 2c- Hlcil�y � �0L4--V ® 70 No.and Street City/Town Zip Code Name of Budding(if applicable) SECTION 2.PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or cheek all that apply in the two rows below Existing Building❑ Repair❑ I Alteration ❑ 1 Addit kin❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occin, ❑ Other ❑ Specify: Are building plans and/or construction documents being supplictl as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Or! Descjiption c,� Propus Work: eJ ` n ^ A^tr4— s s ^2 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 S.USE GROUP(Check ae a I- lit A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑ F. Facto F-i❑ F2❑ 1 1 High Huard H-1❑. H-2❑ H-3 ❑ H4❑ H-S❑ 1: Institutional W❑ 1-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ - S-2❑ I U. Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) - IA ❑ ISO HA13 1180 IIIA ❑ IIIB ❑ 1 IV 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CIVIR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ ' Private❑ or indentity required❑or trench or specify:Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA I L11 is C...mni,c_nt lto,w..; Not Applicable❑ Is Structure within airport approach area? Is their review completed? nr Consent to Budd enclosed❑ 1 Yes[] or No❑ 1 Yes❑ No ❑ I SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction:. OLcupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: M A-I L_EO q 110, 11 L l SECTION 9: PROPERTY OWNER AUTHORIZATION , XI Name and A dress of Prope ty Owner 1 VV f� . G. /� © �� 14 K /D r 2 ��}isrY � Y11 0 R r Name(Print) No.and Street - City/Town Zip Property Owner Contact Information: ,{ q-)5 '�o2 ©Wo -- vrY�`-�lorzo-0�00c195 ' Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes '7P CvnAh 1t{ M' 11 `i�.d wi��l 1ti1Yk a(43� 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) If building Is less than 35,000 cu.ft.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 © y C"J\ #h 9A.'�W. tqz �ec3� 'av�l rya F} le (s�o18 Mu (Reg�retn,n�)1 n I;fi n�q,C/ c mail address 1 C1.�r Registration Num / !` j rf (Mid JD b Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Coame rn � � ` 9 ZV oo y �'>� Name o Person Respons�¢le fur Construction License No. and Type if Applicable ---- 1 f-} IM I ll � e�T'C4 ol it 01 ci 36 Street Address City/Town State Zip . 9'2f -q1X- 13Z v-Hoolc t co vN- Tele hone No. business Telephone No. cell a-mail address SECTION 11:4VORREIS'CObIPENSAIION INSURANC1i AFFIDAVIT 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. Is a signed Affidavit submitted with this application? - Yes 0 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE' Item Estimated Costs:(Labor and Materials) TotalConstruction Cost(from Item 6)_$ 1. Building 5 Building Permit Fee-Total Construction Cost x_(Insert here 2.Electrical $ - appropriate municipal(actor)_$ 3. Plumbing $ J.Mechanical (HVAC) $ Note:Minimum fee a$ (contact municipality) 5. Mechanical Other $ Enclose check payable to �1,n� Pr fi.Tr tat Cost $ "00 1 CO (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,1 hereby attest under the pains anti penalties of perjury that all of the information contained in this application is true.md-"rate to the b of my knowledge and understanding. 6 Cu�c <�7q 998- 1`32 9 fa Ple:ue grin nq sign name �/� Title Telephone No. Date rLl ZMr [l �k A?22�2 /,.�l t ( E3f - Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Cn Y OF SALSA M4SSAalL SEM BL wiwDEPAYjAw4r 120WA9MCXNS7REET,3RDRDOR hL(978)745-9395, %IMBERLEYDRISQ7LL FAX(978)740-9846 MAYOR 7)ICKU STYLME DmEcrca cFPmucPRomw/BumDma mg=cm Construction Debris Disposa/Afdavit (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 00, 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. �5� �T lq- yl • (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Sig ature of applicant Date The Commonwealth of Massachusetts 't Department oflndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass govldia workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print 1*sjblv Name(Business/Organization/Individuua��l): 6 (P/,r Address: y IM 1� q ppry City/State/Zi Phone#: Are you an employer?Chec=bo appropriate box: Type of project(required): 1 7 am a employer with employees(full and/or part-time).• 7. ❑New construction 2.❑I am a sole proprietor orership and have no employees working for me in MI (No workemp.insurance nquvedl 8. ❑Remodeling 3.❑I am a homeowner doingork myself[No workers'comp.insuranea required.]t 9. ❑Demolition 4.❑1 am a homeowner and whiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractorr have workers'wmpensation insurance or are sole 11. Electricaltampnetors with no empl . ❑ Iepeirs Or edditionS12.❑Plumbing repairs or additions5.❑Ism a general contractor have hired the subcormactors listed on the attached sheet.These sub-contractors havloyees and have workers'wrap,insuranw,f 13.❑Roof ails 777eee�ppp r�6.❑Weare a corporation and icers have exemaed their right of exemption per MGL c. 14.❑Other "eCA- 4090. R- 152,§1(4),and we have nloyees.[No workers'comp.insmamw requved.] 'Any applicant that checks box#1 must also fill out the section below show ing their workers'compensation policy information. t Homwwners who submit this affidavit indicating they am 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 suite whether or not Nose entities have employees. If the sub=contractors have employees,they must provide they worker•comp,policy number. I am an employer,that is providing workers'compensation insurancefor my employees. Below is the policy and job site btformation. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 under pains pen es ofperjury that the information provided above is true and correct Si ature• .,f c - ate: I J p Phone#: QBicial use only. Do not write in this area,to be completed by city or town ofcbtl City or Town: Perm]t/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Iuspector 5.Plumbing Inspector 6.Other Contact Person- Phone#' i 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 bur 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 02 1 1 4-20 1 7 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Massachusetts Department of Public Safety ' ® Board of Building Regulations and Standards 2_ 5t License: CS-101924 Construction Supervisor ROY E CURRAN III - 8 GOVE AVENUE= BEVERLY MA 01916 Expiration: f Commissioner 02/16/2017 ^E5E5` - - c. . C71ze +�turea�o�(�amac%uaetta ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR 1 Registration'. f8018 " Type: Expirab & .Individual, ' ROY E,CURRAN ROY-CURRAN 14 MILL RD. IPSWICH, MA 01938 �� Uudersecretary c }� =' American Properties Team, Inc. TO: 2C Halsey Way FROM: Jennifer Pappas, Property Manager RE: Deck Replacement and/or Major Repairs DATE: April 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(or major repairs). 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 781-9354289