0027A MARION ROAD - BPA-16-549 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM dMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
n This Section For Official Use Only
Building Permit Number: Date Applied:
f Building Official(Print Name) Signature ate
1f\�' SECTION 1: SITE INFORMATION c m
1.1 prro�eW �'IGr Ad press: �\ 1.2 Assessors Map&Parcel Numbers b
/(�� I/M ICtJ T-J
l.l As'this an cepted street?yens,_ no Map Number Parcel Number rn t;
rn
1.3 Zoning Information: 1.4 Property Dimensions: r co
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft) O'
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
�./ Zone: _ Outside Flood Zone? 1
Public�P Private❑ Check if yes❑ Municipal:In On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
, l / —C � < 1G /�^ `��
Name(Print) City,State,ZIP u 1
l7 �4rimn �� Gch
N .a Street Telephone Email Ad&dss
SECTION 3: DESCRIPTION OF PROPOSED WORW (check all that apply)
New Construction❑ Existing Building e I Owner-Occupied ❑ 1 Repairs(s) W I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Beef Descr pho of Pro osed WorkZ: !' o
n U CL el M Az
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1 :— 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑ Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (FfVAC) $ List:
5. Mechanical (Fire $
r6.up
ression Total All Fees: $
Check No. Check Amount: Cash Amount:
Total Project Cost: $/D ❑Paid in Full ❑ Outstanding Balance Due:
rut�t�ro Qa C .C. 5 (2,-'1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS 116 2[�r d
�_ License Number) 1 l c ira on Date
J+rr�P�S t��ctrillQ P
Name of CSL Holder
�� ` C` ,��� List CSL Type(see below)
Noo and Street rJ T 4. Description
9 K �^ I tf )t^ q- 6kq 1/ Unrestricted(Buildings u to 35,000 cu.ft.
J u 1, l R Restricted 1&2 Family Dwelling
Crown,StAte,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/ /h \ SF Solid Fuel Binning Appliances
/tY�(' Yi��j/(.1Se//rta •C I Insulation
Telephone IEmail address D Demolition
5.2 Regist red Hom .57
(Improveme l Contractor(HIC) L C'
IC IIt1.(,1,� J IVnp'.d� SI1 C egistratin Number ExpvatiDon Date
HIC o pan Naynegr HIC Regis t Nam \
ls %►x �c ' tad�rjlG�ta9 ,C
an JStree�t , ^� avu VD "0360 L /r Email address
Ci /Town,(S ate,`ZIP Telephone VV
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issruptce of the building permit.
Signed Affidavit Attached? Yes ..........Ii No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize __Mame�, 'ttir 121 u
to act on my behalf, in all matters relative to work authorized by this building permit application.
L �U�
Print wner's N e(Electronic Signature) D to
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
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 understand'n
on es e/ rL I q
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass. og v/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
aCITY OF &U.ENk 1, 2ANSSACHUSETTS
Bi:IIDLNG DEPARTSO NT
120 W 1SHINGTON STREET, 3w FLOOR TE1_ (978) 745-9595
Fax(978) 740-9846
K-,tBERt EY DRISCOLL
T
j41AYOR �iObUS ST.PD?RR&
DIRECTOR OF PUBLIC PROPERTY/BCII-DING CO\MIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I Please Print Le ibl
Name (Business:OrganizatioNlndividual): l
Address: ('
City/State/Zip: � Lk 4 61 Phone #: (p (S
Are you an employer?Cheek the appropriate box: Type of project(required):
l.❑ t am a employer with 4. ❑ I am a general contractor and 1
4employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction
1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑ modeling
ship and have no employees These subcontractors have S. molition
working for me in 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.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. e. 152,§1(4),and we have no 12.❑'Roof repa'
insurance required.]t employees. [No workers' 1312� Other �Gjc
comp. insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their workua'compensation policy information.
t I f ownwa who submit this affidavit indicating they ate doing all work and then hire omside contracrots must submit a new afridavil indicting such
;Contractor that cheek this box must attached an additional sheet showing the name of the subcontractors and their workers'comp,policy information.
i am an employer that is pro70LL
orkers'compensmion i+rsm nce jar my employees. Below is the pollcy and Jab site
injormatian.Insurance Company Name:
Policy N or Self-ins. Lic. '#11:_�M Expiration Date: p _t�
Job Site Address:X� 'tT 1' lW SE I01A Imo!) Ciry/State/Zip;�jAA ��__M /q
?j
Attach a copy of the workers'compensation polity 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$250.00 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 i ante coverage verification.
l do hereby •erdfy and r the pa nd penaltles ofperjary that the information provided a ve is tr a and correeL
Si enat re' Doty.
Phone 4: �l —
O dal z only. Do not write in this area,to be completed by city or town official
City or Town: Permit/I.feense#
Issuing Authority(circle one):
L Board of Ifealth 2. Building Department 3.Cilyrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: ___. Phone#:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement C� ctor Registration
Registration: 178307
Type: LLC
z Expiration: 412/2018. Tr# 419291
LIGHTHOUSE HOMES AND DESI TV L=-LG. LL
JAMES CLARIZIA a
13 JORDAN ST w
BEVERLY, MA 01915
y�S Update Address and return card.Mark reason for change.
El Address ElRenewal Employment Lost Card
SCA 1 @ 2(IM-05/11
(92. t(Jirrnrivo WV'1-4 a�V6Zad.�ac�itu4eU.b
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
VOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: ��78307 Type: Office of Consumer Affairs and Business Regulation
1, 10 Park Plaza-Suite 5170
xpiration:__47212018_. LLC -
,-, Boston,MA 02116
LIGHTHOUSE HOM A_ND,D-SI-�NyLLC. -
JAMES CLARIZIA A p/
13 JORDAN ST
BEVERLY,MA 01915
Undersecretary Not valid without signature
RF
s
y 'Massachusetts - Departrileni of o�biic Seety
°�y' Board o: `dwldiRg Reguistigns a_ncr Sta,.ai ds
Congtruction Supemsi'r
License: CS-107459
JAMES CLARI7,IA•` ';,
LQ
13JORDANSTREETJ 1zk
Beverly MA.01915
F
Gr nn.ss ier 1 012 6/20 1 7
14pnrestricted-Buildings of any use group which
contain less than 35,1)00 cubic feet(991M )of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Builcling Code is cause for revocation of this license. ,
For DPS licensing information visit: w ,.Mass.Gov/DPS
American Properties Team, Inc.
TO: 27A Marion Road
FROM: Jennifer Pappas, Property Manager
RE: Deck Replacement
DATE: May 12, 2016
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