5D HALSEY WAY - BUILDING INSPECTION (2) t � 7
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
(This Section For Official Use Only)
Building Permit Number. Date Applied: Building Official
(• SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
ti l W�sFt/�o W Y70
No.and Street City/Twnt 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 Building❑ Repair❑ Alteration ❑ Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other Ff Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No-$—
Is an Independent Structural Engineerin Peer Review required? Yes ❑ No$—
Brief Description of Proposed Work: G
i
!/G
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 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 ❑
R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ 1-3❑ 1-4❑ 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 S:CONSTRUCTION TYPE(Check as applicable) --
IA ❑ IB ❑ IIA ❑ IIB ❑ IHA ❑ IIIB O 1 IV ❑ 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:
Disposal Site
Public❑ Check if outside Flood Zone Indicate municipal A trench will not be P
Prwate8$ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: FMjK:H:hs::t:oo:�rj:c:,Commission Review Process:
NotApplicable42- Is Structure within airport approach area? Is ir review completed?
or Consent to Build enclosed❑ Yes❑ or No$ Yes❑ No-9—
SECTION S.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:
i
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Ps/k- h—Akccs ow L-- 3D s)Ov �L- -t A ai97o
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
,-/
NTForG� keC . cam
itle 0 Telephone No.(business) Telephone No. (cell) e-mail address
If Applicable,the property owner hereby authorizes
/0& Z4�jf O� 6V-_ ;5 ylK- wnity /40C 70
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 application-
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
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
D ` �� yJ�z Ly9g 5Lew nr��s - -.:-
e-mailIT
address�/A�_400J Registration Number
c5s l.E� 1/170 Z
Street Address City/Town State Zip Discipline Expira 'on Date
102 General Contractor
5'u�:/roo�s P/V.s
Compan Name
Name of Person Responsible for Construction License No. and Type if Applicable
!�?4 04 r;;Z�(J [S S � M 0/g7�
Street Address �j�� City/Town State Zip
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Telephone No. usiness Telephone No. cell 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 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 17 No$'
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1.Building $ 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 $ 41 2-67- — (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 Telepho a No. Date
lP �� doG y 5s� S.��i� lew o
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name ate
CITY OF S.u.Fm. TN'LxSSACHUSETTS
• BUII.DLNG DEPARTMENT
• 120 WASHIINGTON STREET,Yo FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
Kl�{BERLEY DRISCOI.L
TMAYOR TT-ows ST.PmRRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMUSSIONER
Construction Debris Disposal 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 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 :
(name of facility')
27 LC4e&y' -s7- ��o,,4r
(address of facility)
signature of permit applicant
LO�7�2oG!
date
dcbrivffduo
a
CITY OF S �1 ZINI, ��1.�1SSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET, 3m FLOOR
T EL. (978) 745-9595
FAX(978) 740-9846
KI.N BFRi FY DRISCOII
VjAYOR T HOdtAS ST.PIERttli
DIRECTOR OF PUBLIC PROPERTY/BCILDING COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BusitxssOrganizatiorvindividual):&�h��yl/k: a,
Address:1"g& a&Aa c54
City/State/Zip: 5.5�i AM e=7e9 - Phone #:_97B 7Y/ 1-K&'
Are you an employer?Check the appropriate box: Type or project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.6a I am a sole proprietor or partner- listed on the attached sheet.: ?• WLRemodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for mein any capacity, workers'comp. insurance. 9• Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
COMP. insurance required.]
•Any applicant that checks box#I most also fill out the section below showing their worker'compensation policy infunnation.
t I lomeowners who submit this affidavit indicating they am doing all work and then him outside contractor most submit a new,affidavit indicating suck
=Contmior that check this box most attached an additional shed showing the name of the sub-contractors and thew worker'comp.policy information.
I am an employer that Is providing workers'compensadon/nsarance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the worker'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 S 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 S250.00 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.
I do hereby cerrl&under the pains and penahles of perjury that the information provided above is true and correct.
Siltnature: i�� �- Date• O
- 7
P on X- e
Ojfrcial use only. Do not write in this area,to be completed by city or town offrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone#:
-+� Massachusetts - Department of Public Safet'
Board of Building Regulations and Standards
J Construction Supervisor License
-
License: CS 13083
Restricted to 00
PET` R A OBRIEN m
66 DEARBORN STREET e
SALEM, MA 01970
Expiration: 5/10/2012
(l anm icrioner Te�,23760
�.nor..Sri/.e.P`+i'x."'T•awrAnn.,m.M�wTyP^?+'�.ee...s.:.o.r.-e�-+.,^
Office ofco9me�. -wrA i ess egua ron„
--- HOME IMPROVEMENT CONTRACTOR"''
Registration ,106808 Type:
Expiration: 7/27{2012 DBA
SUC WMS PLUS t '.
1 � hr�
:f
Peter O'Brien
66 Dearborn St. �.-
Salem, MA 01970 Undersecretary
American Properties Team, Inc.
TO: 5D Halsey Way
FROM: Jennifer Pappas,Property Manager
RE: Window Replacement
DATE: September 22, 2011
**xx*xxxxxxx*x*xxxxxxxxxxx*xxxx***xxxxxxxxxx****xxx*x**xxxxxxxx*x*xxxxxx
Please be advised that the Board of Trustees for Pickman Park has approved replacement
windows for the above referenced unit. This approval is contingent upon them matching the
existing windows and that they fit in the existing opening. Installation must be completed from
the interior of the unit and they must be the same in appearance from the.exterior. Should the
installation be completed from the exterior of the unit,you will be responsible for any damage
that your contractor might cause (this includes painting). The Board will not allow windows
with grids, crank outs, etc. Should you contractor find any rot or damage during the window
installation, please make sure that it is reported to my office immediately.
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. 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- WOBURN - MA - 01801 • 781-932-9229 - FAX 781-935-4289