5C HALSEY WAY - BUILDING INSPECTION (2) 02
The Commonwealth of Massachusetts
® Department of Public.Safety
Massachusetts State Building )
Building Permit Application for any Buildfl o Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: 63u 'ng 'c'
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a stteetil"Mrdress is not available)
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No.and Street City own Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here Vor the all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition (Please fill out and submit Appendix 1)
l Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
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 ❑ No
Brief Description of Proposed Work:
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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) 13
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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ 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)
IA ❑ IB ❑ IIA O IIB ❑ ILIA ❑ IIIB ❑ I 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,
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site
or
Private❑ or indentify Zone: or on site system Elrequired❑permit is enccll trench or specify:
osed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? i
I Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ i 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and 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
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Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit applica ' n.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 m.ft.of enclosed space and/or not under Construction Control then check here Vaod skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Nam ( �tr+anIraTr,� Teghon NoS e-mail address tra
Number
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Street Address City/Town State Discipline Expua on Date
10.2 General Contractor
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Company 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
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Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents ust be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the' ance 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 OecV_- $ u d� Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ �! U�� (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.
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Ple�vrmt d name Title Telephone No. Date
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Street Address T City/Town tate Zip
Municipal Inspector to fill out this section upon application approval: �01"�" -7 5
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block# and Lot# for locations for which a street address is not
available)
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No. and Street City/ own Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No 02/ Provider notified and Release obtained? Yes ❑ No
Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No
Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No 9?0'"
Yes ❑ No Provider notified and Release obtained? Yes ❑ No ay"
Other (if applicable)
Yes ❑ No Ml***' Provider notified and Release obtained? Yes ❑ No
Other (if applicable)
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The Commonwealth of Massachusetts
' Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application to Construct,Repair, Renovate or Demolish any
Building other than a One-or Two-Family Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application, that no outstanding property taxes, water fees;
etc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the Building Permit fee. The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application. The check is to be made payable to the
local city or town where the work will be done.
- American Properties Team, Inc.
TO: 5C Halsey Way
FROM: Jennifer Pappas,Property Manager
RE: Deck Replacement
DATE: June 30, 2016
******xxx*xx*************xxxx*********xx*xx**********x****xxx*xx********
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 CUNRYIENGS PARK SUITE 6050 WOBURN MA 01801 781-932-9229 FAX 781-935-4289
Pickman Park Condominium
Deck Inspection
June-August,2015
Saugus,MA 01906 Portsmouth,NH 03801
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Offiet of Cousu me r Affairs&Business Regulation
LLB` 1..HOME IMPROVEMENT CONTRACTOR
'Registration- 164701 Type:
Expiration: 1013012017 DBA
WEBSTER CONTRACTING
MICHAEL WEBSTER
7 FRANKLIN ST#3
DANVERS,MA 01923 Undersecretary
Missac;husetis Deparmle,� ot P,;Az-
Ruftk-g
Construction Super,isor
sense CS-097289
NUCHAEL D WEI)STER-,-
7 FRANKLIN ST#3
DANVERS MA 011923
08/22/2016
i CITY OF S.U.E�1I, NLNSSACHUSETTS
• Bu DING DEPARTJIENT
130 WASHINGTON STREET, 310 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KINBERMY DRLSCOLL
T
MAYOR �tOMAs ST.PffRR6
DIRECTOR OF PUBLIC PROPERTY/BL'IIDLNG CO%06HSSIONER
Workers' Compensation Insurance Affidavit: BuildersiContractors/Electricians/Plumbers
Aaplicant Information T ( Please Print Legibly
Name (Busit OrganimtioNtndividual): fit^`,
Address: -2 i�v�-�C?t� 54. ' 2
City/State/Zip:Wit, /L&L• Phone #: -761 `l7s~332ff
Are Y.94sn employer?Cheek the appropriate box: Type or�ttuject(required):
A2 I am a employer with 3 4. ❑ 1 am a general contractor and 1 6. New construction
employees(full and/or' have hired the sub-contractors
2.Q 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑ Belhodeling
ship and have no employees These sub-contractors have 8. eDemolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its
required.] officers have exercised they 10.❑Electrical repays or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers'
13,Q Other,
comp. insurance required.]
•Any appbgm that checks box 91 must also fill out the section below showing their worker'comprnaation polity information.
t I Fe xm sees who submit this affidavit indicting they ar doing all work and then hire outside contractwa must submit a new affidavit indicting such.
Conuaturs that Lhmk this box most attached an additional sheet showing the name of the subeonteeetess and their workors'comp.poliey information.
I am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and job sire
information. ^ C_Insurance Company Name: /YG Alhtri CC' .t-�r-
►'t C- CO
Policy#or Self-ins. Lie.#: /�.S 0-to 606 3 a�s5 b [.� Expiration Date: 17 ` 17
Job Site Address: g6�i� WG'/ City/State/Zip: erlun , A Ule�7U
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to SI,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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
1 do hereby certify under/fie /an/d�jnahles of perjury that the information provided above Is/true and correct
Sienattire: �����l � /' —�-7� Date:
Phone g:
okrd use only. Do not write in this area,to be completed by city or town officiat
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
1. Board of Ifealth 2.Building Department 3.Cilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone M
i —
CITY OF S.-II.E:N1, 2NvLkS&A6CHUSETTS
BUILDLNG DEPARTMENT
120 WASHNGTON STREET, 3"FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
Kl\LBERLEY DRISCOLL
MAYOR THo.%As ST.PtERm
DIRECTOR OF PI:BLIC PROPERTY/BUTEMIING COJ[NaSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
1n accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
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(name of facility)
nn
KcWG-->/ 11GC ,
(address of facility)
signature of permit applicant
date
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