49 FREEDOM HOLLOW - BUILDING INSPECTION 5 �
The Commonwealth of Massachusetts
j� Department of Public Safety
' t Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Phis 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)
No.and Street City/Town Zip Code O19'9 U 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❑ 1 Repair I Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Changd of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ N01*1
Brief Description of Proposed Work:
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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIAO IIIB ❑ 1 IV ❑ 1 VAO VBO
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:
Public Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required El or trench or specify:
permit is enclosed❑
Railroad right-of-wa Hazards to Air Navigation: MA Historic Commission Review Process:
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:
I H
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of P operty Owner
IbLU(Z A,
ame(Print) No.and Street City/to" Zip
P;Qperty Owner ContV Information: A° S / tip Nc.�Q_N
( NA)7N:/!� /�9f ion �JU����// �O -2Y_ qua-2- L lit/f c� /tLJ
Title Telephone No. (business) Telephone No. (cell) e-mail address A
If plicable,the roperty owner hereby authorizes
Name Street Address City/Town State Zip
to act on the propertv owner's behalf,in all matters relative to work authorized by this building 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 O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Re Telep t e N e-mail addr ss R gistration Number /
eet Address City/Town State Zip Discipline Expiration bate
10.2 Gp-neraLContractor eq
Co p Name
Name of Per Responsible for Con u tion License No. and Type if licable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVrr 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
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6)
1.Building $ UO Building Permit Fee=Total Construction Cost x// (Insert here
2.Electrical $ appropriate municipal factor)
3.Plumbing $ V
4.Mechanical (HVAC) $ Note:Minimum fee=$ r5-(contact muunnnii/ci�pality) _w U
5.Mechanical Other $ Enclose check payable to 6/% g-l"
6.Total Cost $ L. (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name b w,I h reby attest under the pains and penalties of perjury that all of the information contained in this
ap do is true an accurate o the best of my knowledge and understanding.
Pleas t and sign n Title y *e1ephon No DatStreet Address City/Town ip
Municipal Inspector to fill out this section upon application approval:
Name Date
PlROPERTY
U 'MANAGEMENT
EASTEASTCOAS� a� Tom 'SECTION
�Y Ji PROPE R1jE 5, LLC NATIONAL ASSOCIATION OF REACTORS ®
November 25,2012
City of Salem
Building Department
120 Washington Street
Salem MA 01970
Re: 4-9 Freedom Hollow, Salem MA
Dear Sirs:
Enclosed please find the application for building permit for repairs to be done to the front steps of 4-9
Freedom Hollow, Salem, located in the Village at Vinnin Square Condominium Trust II. The Board of
Trustees has approved the repairs to the front steps to this building due to water related issues.
Also enclosed is check in the sum of$60 representing the cost for said building permit.
If you need anything further, please do not hesitate to call.
Very truly yours,
EAST C PROP TIES, LLC, Manager
BY:
Cyndy U elmo
Enclosures
REAL ESTATE AND PROPERTY MANAGEMENT
400 HIGHLAND AVENUE,SUITE 11 email: EastCoastProgaol.com Phone: (978) 741-2003
SALEM,MA 01970-1777 Fax: (978) 745-9684
CITY OF S.UE.M, Axss kCHLSETTS
BumDLNG DEP*.Rn NT
120 wnsHLNGTON STREET, r FLOOR
d TEL (978) 745-9595
Fnx(978) 740-9W
K1.\fBERLEY DRISCOLL
MAYOR THowts ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CMMUSSIONER
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
I11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature o mit applicant
date
JctrrivtZ:loc
09/17/2012 14:3ONorth Shore Travel&Ins (FAX)978 531 2228 P.001/001 } "
co TH CERTIFICATE OF LIABILITY INSURANCE 9 171aDATE("unocry )
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S)
'--,Re8ENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER , AE P ORIZEp
DIRTANT., ff the carlIftete holder Is an ADD 71 NAL INBUREO, the Po Cy(I W) must be endorsed. SUBROGATION 18 WAIVED,subject to
the temro mind conditions of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights to the
certi8 a s
eeto holder in Ilea of such sndoranen ,
FRODUCOR
North Shore Travel & Insurance
Ili Poster at PA (DTe) s31-24E2
s
Peabody, MA 01960 sae:
COVERAGE NAICN
INSURSRA:Libert Mu ual Yna. Cam an
INSURED
I PSU10 Correia D/B/A INSUREJ16.
INauRER e
P. Correia Construction I
i 33 Highland Park
Peabody, MA 01990 INSURER F.
COVERAGES CER71FIDATENUMBER; REVISION NUMBER:
THIS 16 TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE OEEN ISSUED TO THE INSLREO NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAN, THE INSURANCE AFFORDED BY THE POLICIES OESCRISED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OFSUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
VI I TYPE OF INSURANCE POULY MILAER1140 GENERALUADJUT LIMTB
HO'CURRENCE 6
COnTAERCIAL GENERALL14Bd.ITY p I
GLAIMSiAADE ❑OO:UR AND W W cm cram f
PERSONAL&ADVINJURY f
GENERALAO RELATE 6
OEN'LAOGREGA7E LMITAPPId!B PER PRODUCr6•00MPIOPAGO f
POLICY P LOC
AUTOMOBILE LIABILITY f
ANYAU70 samf Is $
�t WWO �EEDDULED BODILY INJURY(Per Canon) 6
NON-C ED BODILY INJURY(Pa,aealdani) ItNIREDAUTOE ,AUTOS Pa1e�RfY DAMq E e
d.
UMBRELLA LIAR OCCUR 6
EXCESSLIgB EACHOCCURRENCE 6
GLAIM$JYADE
CEO RETENTION I AGGREGATE a
AMRXFAS COMPENEA7i0N a
No FJAPLOYBRS'UABILITY rrNMNIA
A'C2-31S-373S99-012 7/11/%2 T/11/13
ANYPROPRIMBRAE CLUDEEYFCU'rMS S,L.E HACtlDeNY 100 000
DFFI�a%ryi aHN)EXCLIAE07
fa a dIdWtaOder E.L DI 100 000
O RIP OPEPATIONSWIaw
I eL.Dls I 6 100 000
I
ROMPTION OPOPERA'nONS I LOCATIONS/VEHICLES (ARaeh ACORD 101,Adadenal Ron"m SChedulo,IfrFan apes la rvgJnq)
I
RTIFICATE HOLDER CANCELLATION
I
SHOULD ANY OF 7H8 ABOVE D88CRlgED POUCIES BE CANCELLED BEFORE
Weatherly Drive Coneominium THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
iTrust ACCORDANCE WIYN THE POLICY PROVISIONS.
C/O East Coast Proportion, LLC AUTNORMED REPRESENTATIVE
400 Highland Ave.
70
)RD 28(2010/08) 88 010 ORD CORPORATION. All rights reserved,
Ths AC ORD name and logo are regletered me so RD
e: Fax:
E-Mail: