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3C HALSEY WAY - BUILDING INSPECTION ~NSJWUST�W fk.-E 1D APPROVED BY T+IE 1111Sp=jDA pWR TD.AI PERMIT 1 WN0 GRANTED CITY OF_SALEM is Properly Located in / Location of s // t the Historic District? Ye No!/ Building 3 C fY P cr.�c Is Property Located in Ow Conservation Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) R stall Siding, Construct Deck, Shed, Pool, epair/Replac�er: PLEASE FILL OUT LE BLY&COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: l . Owner's Name a c i / V t 1 i ntr Address & Phone c/� Xce s4_ a a (M -7 L' /L. Architect's Name Address & Phone 1 Mechanics Name R - u Address & Phone I A1W 1m.L � � Whet Is uw purpose of w,laWr Pu l Es l 6`0 Matedal of bulldim? If a dwell g,for how many families? � I WO buftV conform to law? Asbestos? Eoftated cost _ q��Gty Licenser layIa t ;Signature of Applicant SIGNED UNDER THE PENALTY OF PERJURY _ DESCRIPTION OF WORK TO BE DONE MAIL PERMIT TO: r ._ APPLICATION FOR PERMIT TO �L�[�i��.wr— G✓iN 1�oc.l� LOCATION: PERMIT GRANTED �3 o , 7.0© ,.�- AP RO'VfD �t 6��ECTOR OF B ILDINGS i FROM QUESTUS PHONE NO. 7816391905 Mar. 24 2005 07:05PM Pi American Properties Team, Inc. /\ TO: Pat Vigliotta, 3C Halsey Way FROM: Jill Fama, Property Manag RE: Window Replacement DATE: March 2, 2005 Please be advised,that the Board of Trustees for Pickman Park has approved replacements windows for the above referenced unit,providing they match the existing windows, and can fit in the existing opening. They must be the same in appearance from the exterior. The Board will not allow windows with grids, crank outs, etc. Obviously, we also require the permits be pulled in advance, and then a copy of the final approved permit once completed. Should you have any questions or require additional information, please feel free to call me directly at(781)932-9229. cc: Tom St. Pierre - Salem Building Department 500 WEST CUMMINGS PARK • SUITE 6050 • WOBURN • MA • 01501 • 781-935-4200 • FAX 781-935-4289 .` � CEWIM1aAlN5cppf�R � , ' ' �F11KIN PERFDRMAN NEqual Sigh WO V►nYl D66010 Hung ARGON till,00 for 1p S u "' r � eclful�Mr b �M afion cell fie` arvidt Y ... 'n�[x \�ryixl'1Cx'YFwy1 . _ T. yly. 'Clil.]fN�py.•�� 'Ir•JRqy4u..•-r * M' - _ , ' ,31 §ZN AEI&aUfEml�iag8 - CO G(OR - . HOTABIMPROVEM— -. 6pn Reg! 72D455 ... ' cjdyr�yyp06 � �tRPlartieCard y s - - 01LRAYA�WM'StlOPti PAUL SOON 4D FJ MQi R� phi10T ►N 11DDs 0 . o • o w I+4 h - p•1 PR OCT-19-04 TUE D18 PH BILL RAC` Fg No., EIBB164032 Pa 0170 .. S; CC1firt�N kr �# �b! A qr Illti' �d4 �j��L A Rr�NC1; L"613 a5� WATFfMMfADllhj nx p`TAuH aRs AIR 24 DA TCty �t�t>tLDral�. A ii ��iiT� 1�>�ITI aS5UPASAINAifi AFiNR411R61iATp il,pr �D RD $A Nl h1p,1"I�NFSf3�.MDRi6HT5pFAM �C�NtT18iA>�T{ f1SDl�� ,4 Ifi1iV�MPAnPOUMPTA-MN91>ai tJAt9R oi��i#A 4;BA ,IDA"CfR H�%h��"Ia�ArH>;,(AF'FCRDDP9�'THI:pi��:ISS113S;A)�4DW. ThAimu: D,GRIdBG-60TT HAaI,S�f��7b*Sii 7 �f�pt1� R5ArFPRkINAFrpNNFbA g, TRIM nVNyRkRi Am@i l Hcm� Aaaaa�DhcP Tyra, '• fl �lyrpW�itlLkr :�t"1F"e , >7;?} DM�IDi�, atiili #��'��+iPdS'� 7N8MR2Rdl " '� *xAwtesita�Yn Sha•y��hmr•, S»'m:, . ..: ._ : 41f 005 TMI.RDup�F6mAFINr�N14ANpb�p"'�''f�Pa,PW�#Aue@� 1 i7K?TN ��`kNAMkPfi4PYl13�lDTyaHP�1'A61R1'89RIpA7NGI�AT1.-'o:NDNJIrNarANA�MP - ' ! dNPRNRVIIEMGIlY CNM�R� PIi1wM�iNANYakpNl�iERIP`!hp&yN1�1TINITHR� f{5wyM1aH.TNIh�f�TIPIDATFMnvaels9u€AaR a�AY+pp�1,1 y pI, y Ate iL pfiHy�8De17yD1�'41? 9 I�yPn�RgY�R@lI IJIpIFiIHRyP�' ila66SRHfx9RMA Hen JGIeNDnND con DIrIDNa Da suDN RRTNH rN I�p M11{A N �� iF MR111 q ilT T lip, 1 L TYpf Pf INAPJIM17fio`' PpFI Y NNM4�i x, • -{. DATE N -0A -, I,IMiiD. R uLyFN,APLPq��.�MH� DANANALUl,aILTM � .;;.' .•, - eAAMmacuRAENCE 37 DDp,DAA , - ,t,, � FRMAICACl6l(.SE1iR+,I.I.I+�IPINPIY �R7ri,S'$$ATAnG� . Aua/�sJDA PBIy}?.JDb PtRE➢AMAgCtMIYIMLLRd t "SAD Sh>yD , GWM9 MADEAID 'ACDUR MSD.LKP IAnran4Prri 4Al `f g,Q'Afl �. -.._- +..,.� • . :.. ti6R9DNAL tdDv7NJURY GENERAL AGGRLGATP r 3.flDfl,DYIi a aEN'LADGAEDATE�Ior11PPLIE4iPEI4 PRODUCTS•COMP1DRdGC 32 AD.D,DDp POUCY ]F1T LOC ANYAVYD IF--sjdMNIMGI.CNMA' s¢�DDD,ODD - fl,3.S7:6D,51S3�T4.9 D�/D��Ah. . OAJ0+1/Ds - ALLDk`NPDf+UTOB - hO➢1LY IN]URY S ELllp➢W.CDAUrCS _ {hArpyGpn)_- : $. MAGOJ:JiOQ - DDN]URY S '}�'{ NON,Dl4NFpAVr00 - (nPvac)JLYIdnAD . i -• .- .. (Paapc6itl➢AAIACC S' I AANADD UAWLfM • AUTO.ONLV-BA ACGDN 3, -'• . ANYAUTD ALMO D AGG .WCC&UAI]UIY��3 .. - CCURNEI(CE 4 l DCaJA i... CUU AGGREGATt Lip _ A[pDrneLC s :. femmloN . wplilnRB ][ TORY I kMPLt]Y+u19'LUtn1UT! 9PC7,7 J.�1 >' A9/Z4J0+1 D'J��!i�f➢5 tl',GALNACCIDP.N7 t5C)0 9DD ELwsEese•rrnaWYEE55DO DAD DINA EL.atz;mB(•PDLIDY L]Mrr Y$DD,noo n naDabiytiy tsasr�it x75Ai'rA�@:UDC, �.9fA�%D-0 ,1D/01�'ns DDnty:AuDna YlEfivraPnoN nr gPFf+A�ltlns(.ocnnoNsr✓cmc �er.DEDBIDNSA➢t1W PY�NDc+ti&MGNfl9PED1ALI'NPv(sIONG' atFlT1ncwrE}10LCIER N AD11ONAL.INSuRnowurm I.MNrm 04m;G UATlON f �'^ ` �L '. hN071LBWNYAFTNCAhOVQ P[40RIPPo.,roymi®BE CANCELLtP BEFT)ftETyCL%piP.tTDN 444f • . . hAT�'lNeR[Or TNA1`yujNO INR:W F.cA'iYILL CNPFAVMYA ML ,�-_pn}ayfNTfJ�, NoTtAgTDTNE CkRTI1�CAKNOLO�RNAMEO TD 4nt LLtT our RnILUN%TD OD SO SNALL ' • IMPDAL'NO DRLIDATJON f4 L1411TTDrANY$IND UPON TNFINSURE♦Z,1r5 AGENTA OR . huR`ZoNTAT1vR9.' d-v - ' 'fNFNO PR EMr. ALCO1tD SLS(//(17) o ¢jACoR➢coRNAWTION Ian The Commonwealth of Massachusetts Department of Industrial Accidents t - ofceoflmesugamons F 600 Washington Street, 7`h Floor Boston,Mass. 02111 Workers' Compensation Insurance Affidavit: Bulldin Plumbin /Electrical Contractors 'Alicaot r name: i address' city state: J zip: / phone# work site location(full address): �/%/«c.1 / Q-N ❑ I am a homeowner performing all work myself. Project T pe: ❑New Construction❑Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition m an emplo er providi workers' compensation for my employees working on this job com an nam : '" ' -- n r address: - - - - am r a x insu nce co. olie # s ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: - + city: phone#: insurance co. noliev# x company name: t p r address: CItV: phone#:5e ;�,`* �ea 6#R ex'iz ba5dfi''t insurance co. a - 14:,� olic' # EfB£151h34rE' ' Failure to secure coverage m required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a time up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. l do heerre/e err s-er enables of perjury that the information provided above is true and correct. // n Signa / � Date "�l✓ v`1 Print name Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license q Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phoned; []Other 4—sed Sc,10113) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the`law",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 ajoint 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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,?°Floor Boston, Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 o CITY OF SALEM� MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR 1 SALEM, MA 01970 TEL. (978)745-9595 EXT. 380 FAX (978) 740-9846 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition of Building Permit# , all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility, as defined by MGL c III, S150A. The debris will be disposed of at: Location of Facility/ Signature of Permit Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant Firm Name, if any it P Address, City & State The above statute requires that debris from the demolition, renovation, rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S 150A, and the building permits or licenses are to indicate the location of the facility.