7 FREEDOM HOLLOW - BUILDING INSPECTION 5 &' cam -7 q
The Commonwealth of Massachusetts
`~ Board of Building Regulations and Standards REC� �,F
Massachusetts State Building Code, 780 CMR iN$PE TL i �f� S
evtse N/m
r Building Permit Application To Construct,Repair,Renovate Or Demolish (CT
el
Otte-or Two-Family Dwelling [[JJ 23 A Q
Section For Official Use Only, � .
' n1 Building Permit Number: ..=a D e Applied:'
t Building Official(Print Name) �rs a e,Signature x " ,, t - ,, , *� Date ,
,.. 3e- SECTION 1 SITE INFORMATION . ?F
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
7 i
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards •- . Rear Yard
Required Provided Required Provided Required Provided
1.6 WaterrSSgpply:(M.G:L C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publics Private❑ - Zone: _ Outside Flood Zone? Municipal®'On site disposal system ❑
Check if yes[H�
r SECTION 2:f PROPERTY OWNERSHIP', `
2.1 QQw� n/eQ�rrofRec99���'d: 7
rF�G//L(l r4 CZd1/tea -t �evl )O� Olq��
Name(Print) - - City,State,ZIP
7reedlo.,� ,I�vw q� - iy-SZoI`/ �4
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED,WO Z,(check 11 all that apply) E„
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brie Description of Proposed Work : +- 2- Fia uw, --gAot e r aAa eu
m u ✓2—few ��>! c 7 c 2
SECTION 4:ESTIMATED CONSTRUCTION COSTSEstimated Costs:
Item Labor and Materials)
rOfficial Use Only
1.Building $02 U D ltr-� 1 Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ i ❑Standard'City/Town ApplicationFeea
2 GU ❑Total Project Cost'(Item 6)x multiplier x A, QA` ,,
3.Plumbing $ .355 of 2 'Other Fees $
4.Mechanical (HVAC) $ - List:k
5.Mechanical (FireA kf ffti ..
Suppression) $ / Total All Fees $
�7 Check No Check Amount Cash Amount
6.Total Project Cost: $ /
6 S D ❑Paid ih Full _ 11 Outstanding Balance Due:`- '
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 3�s Z 3
n c r/J r
Id,P i�A }�1 Q.E.J6"J '( License Number Expiration Date
Name of CSL Holder ,r
6 �1P/t List CSL Type(see below)
00. /T�
No.and Street ,,�( Type Description
Q "' Ut- S �'I U U Unrestricted(Buildings u to 35,000 cu.ft.
LL-5 tti3 Q D� R Restricted 1&2 Family Dwelling
City/Town, State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
7 7/ 7 / SF Solid Fuel Burning Appliances
3� I Insulation
Telephone Email address D Demolinon
5.2 Registered Hom"l Impr}yement C ntractor(HIC)
1'VIIJcsr�< Ic� // ygr7
HIC Registration Number Expiration Date
H- Zany Name or HIC Registrant Name
No d Street Email address
j Y 14A14 D7 acsto 9?P 77/ ?3�
City/Town, State ZIP Telephone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR"PLIES FOR BUILDING PERMIT `
��� ((1 n,(,( n
I,as Owner of the subject property,hereby authorize e '1 W� yV o,Ci'� 4L�(
to act on my behalf,in all matters relative to work authorized by this building permit application.
R( R-WA GAtiltst), &�, :g 0 0A3 /5
Print wner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 TUC Program can be found at
Mmn .mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.@ov/d s
2. When substantial work is planned,provide the information below: -
Total floor area(sq. ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost"
safetyinsurance BUSINESSOWNERS DECLARATIONS
PoheY: iate ................ is
AUTO HOME BUSINESS
..:;
Safety Insurance Company
B 6 07/24/2015 07/24/2016
MA000270
72-01 A.M.SmMwd Time e1 the dncribad to®non
3=i=:.ki'i-rciiiiiiirEiiii _.......
..._...._...._....._...._....._...__.._...._..._--
Renewal Declarations
_...
.... .n1u:`s :=...... �:;.... ..
Ir�am�d:�rtslirodartrxl'ISlfail�Etg'',Address
r99.
---- - TARPEY INS GROUP INC
KEITH MACDONALD 442 WATER ST PO BOX 567
6 GENOA AVE WAKEFIELD MA 01880
SAUGUS MA 01906
Telephone: 781-246-2677 33051
Form of Business: INDIVIDUAL
Type of Business: CARPENTRY - -
DESCRIBED PREMISES
AUTOMATIC INCREASE
:OC. gL-DG ADDRESS . .
001 6 GEATOA AVE SAUGUS MA 01906 _....... a :::;:;;':;;;:»::r::;a;;s
-PROP
VALUATION DEDUCTIBLE LIMIT OF
LOC BLDG COVERAGE INSURANCE
Replacement Cost $
SOG $ 3, 347
001 001 Personal Property
Deductible shown above applies per any one occurrence
BUSINESS INCOME: Actual Loss Sustained Not Exceeding 12 Consecutive Months
LIABILITY AND MEDICAL EXPENSES
Except for Fire Legal Liability, each paid claim for the coverages listed reduces the amount of insurance ra provide
Liability Covera
during the applicable annual period. Please refer to Paragraph D.4. of the Businessowners provide
Form.
LIMITS OF INSURANCE
BUSINESS LIABILITY COVERAGE
f
Liability $ 1,000,000 Per Occurrence
$ 10,00o Per Person
Medical Expenses
Fire Legal Liability $ 10o,0o0 Any one Fire/Explosion
ADDITIONAL COVERAGES
Some property coverages are subject to deductibles specified in the policy forms. Limits of Insurance
Optional Property Coverage Description
LOC -BLDG ` DESCRIBED COVERAGES- $ 5,000
001 001 Contractors Tools - Blanket Basis
Optional Liability Coverage Description Limits of Insurance
Contractors-payroll $28,600
CHANGE IN PREMIUM: $ TOTAL PREMIUM: $
MORTGAGEES/LOSS PAYEES/ADDITIONAL INSUREDS
LOC BLDG TYPE POLICY INTERESTS
001 001 Al Owners, Lessees or 'Contract -
BPDEC2011 INSURED
.' ice^^ � Pc l' :.` i If cu• _
gu:'d,re Peg � a
�nnstruclion supen isn _ 2 i'anvlti
ucense. CSFA-056432
i
KEITH A MACDONAID
6 Genoa Avenue.
Saugus MA 01906
Commissioner •
- Office of Consumer A[fairs&Bu mess Rcguiaaon
} HOME IMPROVEMENT CONTRACTOR Type:
" '`"Re istration: .,,q 17834
9
";�tt�r Expiration: 214/2017 DBA
KEITH MACDONALD CARPENTERNVOODWORK
KEITH MacDONALD -,
e GENOA AVE
SAUGUS,MA 07906 - Uodersecretary
CITY OF SMXINI, NIASSACHUSETTS
• Bt:HMING DEPARTMENT
• 120 WASHINGTON STREET, 3m FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
KI\tBERI-EY DRISCOLL
T
MAYOR �[OMAS ST.P[ERRS
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information A Please Print Legibly
Name(Busincssiftanizatio vi 1): Q
Address: b �_em oa I (fie. �7
City/State/Zip: �u-S M4 U706 Phone#: %?,t�- '27l (e,73JC-
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a illoyer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
e oyees(full and/or part-time).* have hired the subcontractors
2. 1 am a sole proprietor or partner- listed on the attached sheteL t 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
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 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' I3 ❑Other
comp. insurance required.)
Any aitpliVint that cher:ks box 91 most also fill out the section below showing their workers'compensation policy inforta doo.
t I lameownen who submit this affidavit indicating dtcy ate doing all work and than hire outside contractor,must submit a now affidavit indicating such.
=Cunumwn that cheek this box must attached an additional shoal showing the name of the aub•eontracton and their woduan,comp.policy inionsadon.
I am an employer that Is providing workers'compensadon hisurance for my employees. Below is the policy and Job site
informarion.
Insurance Company Name:
Policy#or Self-ins.Lic. M Expiration Date:
Job Site Address: City/State/Zip:
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 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations urthc DIA for insurance coverage verification.
l do hereby certify U er�the wins and penahleess of ry at the information provided above Is awe and correcL
Signature: / ' L/mil/( Date /0/L3
Phone#: 97e771& 73p-
OJjcial use only. Do not write in this area,to be completed by city or town ofciaL
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#:
p
CITY OF Smym, INIASSACHUSETTS
• BUILDING DEPARTNIENT
• 120 W 1SHINGTON STREET,Yo FLOOR
T EL- (978) 745-9595
FAX(978) 740-9M
1Q519FRt FY DRISCOLL
MAYOR THoetAs ST.PmRRa
DIRECTOR OF PUBLIC PROPERTY/BUII.DING COMMSSIONER
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 :
Ae/l0 7Yr441---
(name of facility)
ngc4„Le �!? c ��
(address of facility)
signature of permit applicant
date
debri„irdm
r
Marcia Kirkpatrick
From: Cyndy Anselmo <cyndy@ecpllc.net>
Sent: Friday, October 23, 2015 9:26 AM
To: Marcia Kirkpatrick
Subject: Unit#7, 7 Freedom Hollow,Salem - bathroom renovation
Hi Marcia
Please be advised that the Board of Trustees of the Village at Vinnin Square Condominium Trust II have approved the
repairs to be made in the bathroom of 7 Freedom Hollow, Salem, Mass., which work is being done by Keith McDonald.
Cyndy
Cyndy Anselmo
East Coast Properties, LLC
Real Estate and Property Management
400 Highland Avenue Suite 11
Salem, MA 01970
P: 978-741-2003
E: 978-745-9684
cyndv(i7ecpllc.net
1