9 FREEDOM HOLW - BUILDING INSPECTION The Commonwealth of Massachusetts f3EC£IV D CITY OF
Board of Building Regulations and Standards' '?E'T10HAL ERV
<,y Massachusetts State Building Code, 780 CMR
hJ � _ 1,, Revised M Marar 2011
Building Permit Application To Construct,Repair,Renovate(9t"8eifclilh L( 20
One-or Two-Family Dwelling
Y This Section For Official Use Only .
1
Building Permit Number. Date Ap 'ed:
Building Official(Print Name) _ -- 'Signature = - ,,=Date
` SECTION l:SITE INFORMATION "
r 1.1 Prop rtyrddress: 1.2 Assessors Map&Parcel Numbers
9���< d �4
Lla 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 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disisposal System:
Public Gk Private❑ Zone: _ Outside Flood Zone? Municipal&On site disposal system ❑
Check if yes❑
pwn 13 �p SECTION 2: 'PROPERTY OWNERSHIP'
/ 2JKe'oflf7>'C�ccfS Sa/��vl f�� 6/� 70
Name(Print) e City,State,ZIP 0
J�✓ Pz°cY�y, 6/low 617 S%7- 5 (N� i F-LG wlarf COWN e�-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)X I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : e o< /e_ O" a
1 s c e
r w a 3 L kyCr < C5Y a ,c
N-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier = x'
3.Plumbing $ ,-00,Ul) 2. Other Fees: $ / x
4.Mechanical (HVAC) $ List: tJ
5.Mechanical (Fire S ssion es:$ Total All Fe $
u re
6.Total Project Cost: $ 3 i Check No. Check Amount: Cash Amount:
S ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTIONS SERVICES
5.1 Co struct' n Supervisor icensee(�qSL) C 5 Or6 t f3 7 3/ l
�/jT?j '�' ��C{C/ Np(G/// License Number Expvation ate
Name of CSL Holder /
6i n�Ua List CSL Type(see below)
No. U et -Type 1. Description. A
�� �,1,� A �, / U Unrestricted(Buildings u to 35,000 cu.ft.
it Is So R Restricted 1&2 Family Dwelling
City/Town,Sta e,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/ r7 y
r/ SF Solid Fuel Burning Appliances
97k �7
/ 7/ &71 �6� / 7Q �C C°iT//U I Insulation
Telephone Email address D Demolition
5.2 Regsteed Hgipee rovemenhContactor( C)
1 II3
-el \ Y /
HIC Registration Number xpirationDate
-ITC Cop pany Name or C Re �strant Name (,
1 D l 12nQ-CJA 'l/"� IJ�VIA Q C q I' �GlNtCa-l' m/(Q
No. d Street Email address
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 Issuanc the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
' SECTION.7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
"k:... ' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PE/RNM
( I,as Owner of the subject property,hereby authorize // e ! // /QC �6Z/R/�
7to a on my b half,in a afters relative to work authorized by this building permit application.
V
��/JJJIII _
a
owner' ame lec onic at Signure) Date
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 understanding.
1�el'A Aa cjn=ruAy 9
Print Owner's or Auth zed A ent's a(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 HIC Program can be found at
www.mass oov/oca Information on the Construction Supervisor License can be found at www.mass. o� v/dns
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"maybe substituted for"Total Project Cost"
CITY OF SM.&M. IMASSACHLSEM
BUMDLNG DEPARTsm-4T
120 WASHINGTON STREET,3"FLOOR
TEL (978) 745-9595
FAX(978)740-9846
KIMBERT RY DRISCOLI
MAYOR THOMAS ST.PtF1tRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Legibly
Name tBusinssiOrpni:atio/ ndividuat '
Address: LO -/7
City/State/Zip: i C 4 � 0 io6 Phone #: C( 7rT 7 / 6 Z3P-
Are you to employer?Check the appropriate box: Type of project pro1 (required):
red):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
1 am a sole proprietor or partner-
listed on the attached sheet.: 7•✓�Remc deling
b
ship and have no employees These sub-contractors have 8. ❑ emolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its 10 El Electrical airs or additions
required.) officers have exercised then
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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.❑Other
comp. insurance required.)
•Any applicant that chocks box N I must also fill uul the motion below showing their worker'compenestion policy inturtnuion.
t I lomeowneta who submit this affidavit indicating they am doing all work and then him outside ewntractae most submit a new,affidavit indicating such.
=Contra son that cheek this box mug attached an additional sheel showing the name of ft aubeonuacton and their woken'conop.policy information.
l am an employer that Is providing workers'compensation Insurance jar my employees. Below is the Polley and fob site
information.
Insurance Company Name:
Policy#or Self--ins.Lie.M Expiration Date:
Job Site Address: City/State./Zip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration hate).
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 certify under th ins an pens ler of a Jury that the information provided above is true and correct.
i
Sienature: r' Dare•
Phone#: 9 7 d ?-7
Offclol use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: _ Phone#'
Massachusetts -Department of- Public Safely
gu'ations and Standards
Board of Building Re
Construction Supen-isor 1 2 Famils .t -
License: CSFA-056432 -
;r
ICEITH A MACDONALD
6 Genoa Avenue. ; c
Saugus MA 0190&
w`� Expiration
Commissioner 08/3112016
✓�n ���a� .
Office of Consumer Affairs&B m��ess Regula[ioo
HOME IMPROVEMENT CONTRACTOR
Registration s 111834 Type:
Expiration 274/2017 DBA
KEIT MACDONALD CARPENTER/WOODWORK
KEITH MacDONALD
6 GENOA AVE ------------
SAUGUS,MA 01906•':.;,,tom,_ -% Undersecretary
PIMERNIA Safety insurance
BUSINESSOwNERS DECLARATIONS
AUTO o HOME 8USMESS Pdliclr NurttbeC -- frotnp
Safety Insurance Company
EXA0002706 ,07 A.M.2 /2015lmeec07/24c e2016
Renewal Declarations .
::::;;s`;ii ;;:iAd.-
..........-
::fearneslfinsured:a�t� as�Bg::3ddress ;.. e
EY
KEITS MACDONALD 442TAR WA INS GROUP INC
6 GENOA AVE 42 WATER ST PO 80% 567
SAUGUS MA 01906 wAKEFIELD MA 01880
Telephone: 781-246-2677 33051
Form of Business: INDIVIDUAL Type of Business: CARPENTRY
DESCRIBED PREMISES
SE
.ADDRESS_
AUTOh1ATiC INCn^^EA
SAU MA 01906
4%
GUS
001 6 GENOA AVE ........................... Tion .:::: : :: ::.:::::: ::::::::::::.-:::::::::::::::.:::::::::::::.:-::::::.�:::::.-::::::::::::::::::�-::
_........ .....
IT
LOC BLDG COVERAGE VALUATION DEDUCTIBLE IN URANCE
Replacement Cost $ 500 $ 3, 9a7
Re
001 001 Personal Property P
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 we provide
during the applicable annual period. Please refer to Paragraph D.4. of the Businessowners Liability Coverage Form.
BUSINESS LIABILITY COVERAGE LIMITS OF INSURANCE
Liability $ 1,o00,000 Per Occurrence
Medical Expenses $ lo,000 Per Person
Fire Legal Liability $ 1o0,000 Any one Fire/Explosion
ADDITIONAL COVERAGES
Some property coverages are subject to deductibles specified in the policy forms.
Optional Property Coverage Description Limits of Insurance
LOC BLDG " DESCRIBED-COVERAGES"
001 001 Contractors Tools - Blanket Basis $ 5,000
Optional Liability Coverage Description Limits of Insurance
Contractors-payroll $28,600
CHANGE IN PREMIUM: $ TOTAL PREMIUM: $
MORTGAGEES/LOSS PAYEESIADDITIONAL INSUREDS
LC BLDG TYPE POLICY INTERESTS
O
001 001 AT Owners, Lessees or Contract
BPDEC2011 INSURED
y
CITY OF S.U.ENI, TNL�SSACHUSETTS
• BUILDING DEPAR'nm%T
130 WASHINGTON STREET, 3"FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KIMBERf FY DRISCOLL
MAYOR THomAs ST.PtERR6
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSIONER
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: \ n
(name of hauler)
The debris will be disposed of in :
e l�o Tn7�cs4-,- F
(name of facility)
/1 qw; / 'St
(address of faci ity)
signature of permit applican
date
debrimirdm
Marcia Kirkpatrick
From: Cyndy Anselmo <cyndy@ecpllc.net>
Sent: Tuesday, April 19, 2016 10:34 AM
To: Marcia Kirkpatrick
Subject: 9 Freedom Hollow,Salem
Hi Marcia
Michael Strauss, the owner of 9 Freedom Hollow, has received permission from the Board of Trustees of the Village at
Vinnin Square Condominium Trust to do bathroom repairs and replacement in his bathroom. We have the appropriate
certificates of insurance from his contractor, Keith McDonald.
Thank you.
Cyndy
Cyndy Anselmo
East Coast Properties, LLC
Real Estate and Property Management
400 Highland Avenue Suite 11
Salem, MA 01970
P: 978-741-2003
F: 978-745-9684
cyndy(u,ecnllc.net
1