4C HART WAY - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
IJ 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)
5/ C 6AI ,)4 lt>r� Salem/ aw 0/9z0
No.and Street Lf City/Town 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 5 Repair& Alteration ❑ Addition ❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use . �❑ Change of Occupancy ❑ Other •❑ Specify: .' r __- _- ,
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No OC
Is an Independent Structural'Engincering Peer Review required? ,., - -;Yes ❑ Noy
i
Brief Descriptionof Proposed Work: & @ t t 3�/�Ir DO <J
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 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ I-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3 ❑ R4 ❑
S: Storage S-1 ❑ S-2❑ - - U:.Utility❑ Special Use.0-and please desu ibe below: -
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ 1 IV ❑ 1 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:
A trench will nut be Licensed Disposal Site❑
Public R Check if outside Flood Zone❑ Indicate municipal 4 A tre 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 i ices:
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 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 //
X, me_ S��oSS�uro 9c Arrl � S2(ew 04 /77-0
NaRie(Print) No.and Street n �� Zip
Property Owner Contact Information:
4t,.one(o,r«) 94-?10- ff,23 —
T,lFTelephone No.(Mxiatess) Telephone No. (cell) e-mailaddress
Ifupplicable, the property owner hereby authorizes 40'1 C
DA.Utd P-tmrola'l urel SA Sa/eArr *A
Name Street Address City/Town State Zip
to act on the property owner's 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❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
,!/a✓io� Ktorc�c,cy� __,�yld _DAW r-ro"Aco7ZIIP
On• . 6tb9 �2
Name(It�..gtstrant) Telephone No. e-mail addressRe "stration Number
� /.aurelS SakW4 10.4 e/9�b f ,�,L. a
Street Address City/Town StateDiscipline Expiration Date
10.2 General Contractor n
R�or�an CoaS co,
�Company N/a�me _..: ,
.WiA Kiot�„ CSC 0�2�1 Sr(o /3Juit( /S. Ro�,z
Name of Person Responsible for Construction License No. and Type if Applicable
a a FU a re�} �aiNe r3 I U�Q /�I•t���ef.+<! � O/ _
Street Address •` ' ' City/Town " ` - State .: Zip
Telephone No. , isi ness Telephone No. cell - e-mail address
SECTION 11: 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ DOD, — Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical - $ appropriate municipal factor)=$
i.
3. Plumbing $ -
4. Mechanical (HVAC) $ Note: Minhnum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ S QQ, (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 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 dame Title e one No Date
Street Address -City/Town State p
Municipal Inspector to fill out this section upon application approval: /
Nal e Da
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
i ur.11:1 Y:1nIN\91
/'\I 11t YI
12C %VAN#0,%.:If^i1aE'L•)' a $.ul•,A, M.tuar. 11 a I
1'cl. )7471S1i'1i • P Lr v711•71C•9t46
il.Yorkers' Curnpensatlon Insurance .%if lavit: Builders/Contractors ElectricignWPlumbers
� lcant In urtnrfio
/� A Ple• � int Le 'AI
V;It71t:Illuu:wSsit)rganvarinrvinJn„luall: /(�/�/�'Q L� �p� � -
- T �
city,st:lte.Zip- LM
l e dyl,g b/9�n Phone it:_ 1�� �yl as o--3
I .are/nu an engil+yer:l Check the uPprnprlole box:
I la( I am r employer with?_ 4, C] I ;'art r general cuWraetor and 1 I yPQ uPp''")uet(ruqulr+d):
T�L
u),VIM(cull untYur Paratime).• hove hired the sub-cuntraewrs (r' New construction
a tole proprientr or partner. listed on the anachcJ sheet : y ❑Remodeling
nd have no wnpluy".* These sub-contractors have
ing filr ma in any capacity. \rorken' comp. insurance
8- Demolition
orkers'cutup. iuturaltce J. 0 We are a col 9, ❑ Duildinr additiun
ed.) pantinn and itsot►lcers have cxenisvvl their 10.C]Electrical repairs or additions
homcu Juiny all workright ofeacmption per h(C)l. 11.0 Plumbing rupuirs or aWitinna
.(Ko wnrkcrs'comp• C. 1J2.§1(4),anj we hnve no
ce•required•1 t amPlalyecs. (No workers' 12. Roufrepairs
enmp, in.urancu rcquind.J 13. Out �✓oOr/ fir r irr
•%11)•.Pplw'ua It'd chucks bos Al mwl:llw till uW IM.cebml Ecllow cytio,
ur
'11um,n.rrrn who.ullnul this arlldsvie'"jog doing dt,wrh a11ne Ilive hiro"Side cunrr r°g muatl.u'hrre anA.r a1Rdilrit inJ(.aAine�wh.
-r'.mtrwhAn Ihsr.heck thin Ems rnW arravhwl nn addiriuyl\Poet.haring Itl,r nanN dltY leg.eenlf achrs Intl their wuresn'cony.prlNy mlMrnsnua ./tun an employer tAer,/t pruuid/gr evarkert',re/nprnradon bltarnnce for Imy efnp/uyrrx. Brlury/x fAe pu//sy und�ol xile
Illfur/111fNI/L
InNurancc Company Vame:g�� ----
Policy a or sclr-ins. Lic.w: o
Ewpirutlon Date:
O
Jub Site .\ddress:
.Attach it Cullyw ---^r C'ny,$lataLlp: O 9
of the 'Yorkers'eumpunsatl Is pulley Jeclarullun page(showlnq the policy number and expiratlus dote).
I allure to xcura wseruge as required uuJcr Scdiun?JA ul'JIGC c. 152 call lead to nu imposition or'criminal yenaItiea oPa
tine ufi m.l'LSIIOJM y Illur uueIyear iroprisotlmcnt, .l.v \veil aA civil Penult,"in the ruin ora STOP WORK GIRDER and a find
��Pup ra i?SQ.AO n Jay.ILuival th+vLN.nor. Ilc adviscJ that a copy of Ihih.Statement inay be IurwardcJ lot the pllicu VI'
Inr,suganuns of :l1v I)L\ for 111""u'ce a»craw \crilicapon.
/du/avrAy a.nify If :lr�r,li itold p rn/ et ufprr/ary/but die infurinerlo/r prupid7d ebuve is uue and correct
rl,:,l:e , � 1iJl N. f`CI'arG�avt
It)j/lciuf cur un/y. Dd rtnl:trig in lhLt urru, ru Aa runty/ereJby airy ur ronn a//IriuL
( itv ur Town:
-- - Permit/Lleeme I
IS.aina .\uthorily (circle one):
I. IL�arJ of lIV41811 1. Ihulditl". Ucpannlcul I. l;ill.'fo\vt Clerk J. Electrical lulpccfur i. Pfuutpin
6. ILIIvr
It Inspector
I l' wl.rcl I'1 null:
�—'-_ 11hunc 1:
Information and Instructions
v et ion m the service of another under .lily contract of hire,
\Lc1>,ti hUseux(J.:nCf al Laws chayfel I32 reyulres all Cl,lg)Ie)er1 to provide workers' cmnpensabun for their untp ogees.
i'ursu.utc to ties ,utule, in reeplurra is defined as"_.e cry p'
,.press or unplicJ, oral Or written." of lilytwo or more
�n crnpfuprr ti defined as"an mdiviJual, purtnenhip.as,00311oa-corporation or Other Icg,al entiry,
,t the (arC�e,ngl eny'agCJ In a joint Cnitfpflxe, and IINladlllgthe legal fCpfC3C111an empell loying
ang :nipI)Yes•1 However he
l cce,vet or truatea ul'.set indindual, plumenillp,assoewuoo or other legal andty,temp Y g
ant of the
owner of a dwelling house having snot more than three apartments and who resides therein or then i
appurtenant thereto shall not because of such employment be deemed to be m rmpluyer."
owner o house of another who em to a rsons w Jo maintdnunce• cunstructipn of repuir work Tried such dwelling haute
r on ,he grounds or building aPP
\IGL chapter 152. ti35C(6) also states that"ever)'state or local licensingbuildings
dings I shall withheld the Issuance as or
ulred•'
renewal of a license or permit to operate a bualneu or to eoestruet bwith the uildings le to;its political subdivisions shall
,ypllcone »ho has not producedacceptable t, eevidence of er the commoner lIce rlth n t any ranee coverage bdi
Additionally, %IGL chapter 1 S_. S- I _ .
enter into any contract for the performaMd of public work until acceptable evidence of cuntyliattce with the insurance
requiramcne of this chapter
have been presented to that contracting authorit
Applicants p 1 to our situation and,if
tee and hone number(])&long with'ht no employees u her than the
Please lilt out the workers' Compensation alndavit completely,by checking the boxes that a it p Y
necessary,supply sub-contraetor(s)n4mcfs),address( to P
insurance. Limited Liability Companies(LLC)01worken'cco pamatioe ituurance,(if an)LLC or LLP does have
members or partners, are not required to Carry ge submitted to the Department of Industrial
employees,a policy is requited. 13e advised that this of idavit'nay lL the O,;partreteat of
\ccidents for confirmation of insurance coverage- Also be sure to sit and Jute the ufltdavlt Tle otliilavit should
ha Eder eJ to the city or town that the rpplicauan for the pcnnit or lieen3e is being{requested,
you have any catio otu regarding the low or if you are required to obtain u workers'
Industrial .\ccidanss. Should Y uttnent at the number listed below. Self-insured companies should enter their
e
compensation policy,ylease call the D p
elf-insurance license number on the a ro fiats line.
(-ley orrown omelets Irintcri the applicant
rP the affidavit that
you to 1�11 cut in the event the complete and O lice ot�lnvestigrt Investigations h:ts to CU�Ct yUU regtafding provided U space at the bottom
applications in any given year, need only submit Ono affidavit indicating current
of III'e be sure to lilt in the pl out in
a number which will be used as a reference number. In Addition,an app Leant
lhcu most submit multiple yennio'licettse ..
policy informuii.in it necessary) and under"lob SititAddreas" the applicant shoOW write:
locutions o (city or
••,\copy,sf the uffidavit that has been officially stem elm is uTQj or r licensee ked by`I A now lt city �alflJavi r town �um bey be llled out each
town) for fotutt commercial venture
as roof that a valid uffiJuvit is an file p permit net related to any business or affidavit.
appheant r
year. \0'here a hwna uwnar or cieizcn is ebmining a license or
t i e, t dug license or permit to burn leaves cte.) +aid person is NOT required to complete this affidavit. umllons,
lnvcnc)llicc Ot igatiuns wuuld like to thank you in ad
vance for your cooperation and should you
I he t hake.InY 4
+lease du not hesitate to give US +call.
f he Ucpanlncnt s address, 'tclephune and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Otflee of[avesdaadons
600 WW&Ston Street
Batton, MA 02111
'rel. pe617.727.4900 ext 406 or I-877-MASSAFE
Fax M 617-727-7749
www.mass.ilov/die
CITY OF S.U.&Ni, ,NL1SS.ICHL'SETTS
BULLDLYG DEPARTMENT
120 W.tsHLNGTON STAEST, Ya FLOOR
TM (978) 745-9595
FAX(978) 740-9846
KIJBEPjEY DRLSCOLL
,MAYOR THoms ST.PtElttta
DIRECTOR OP PLeLtc PROPERTY/SLADLNG CONNISSIONER
Construction Debris Disposal Afriidavit
(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 a 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 :
�CJ1fL151�e fct _
(name of fac/tlit))lity)
s low
i' (address of facili y)
r
e
3iynwure of permit applicant
du
Lnnvif.l.w ..
American Properties Team, Inc.
bett/�d, ,L7Oxk&x cell ,
1?8 1 Z Z 3 Z
TO: 4C Hart Way y23
FROM: Jennifer Pappas, Property Manager
RE: Slider Replacement
DATE: April 20, 2011
Please be advised that the Board of Trustees for Pickman Park has approved a replacement slider
for the above referenced unit. This approval is contingent upon it matching the existing slider,
fitting in the existing opening and being the same in appearance from the exterior. The Board will
not allow grids, etc. unless they are removable. You should also be aware that your contractor is
responsible for painting any new trim/clapboards as a result of the installation. Should your
contractor find any rot or damage during the slider installation, it should be 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. In addition, we 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
I
�;•500 WEST CUMMINGS PARK-SUITE 6050- WOBURN -MA -01801.781-932-9229 -FAX 781-9354289
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