50 FREEDOM HOLLOW - BUILDING INSPECTION (4) Commonwealth of N(assachusetts
Department of Public Safety
.\LP,,IC III wIis State Bu ihh IIg Code(7,40 C\IIll
I)uilding Permit Application for any Ruilding other than a One-or I'wo-Fantily Dwelling
((I's Svk tiun For(7tiiriel Use Onb•)
Ilu[idiot;I'cnnit Number. ._ _. _ I).rteApplied: Ilu ilding Offic ial:
SECTION I: LOCH I ION (I'I¢ase indicate Illuck 9 and Lot p fur I(catluns for which a street address is not available),
No. and io'.0 Cily /lowil /1rCode -lding
�," { Name ul lluildinl;(if applicable)
Sd r rc�d ailk SLCI'(ON 1: PROPOSED WUI(K
Pt uum nl \i:\Strtv C,nlr used -.. .. It;Nvty Construe tion IN.,it here❑ur check,III that a , +
{! 11' in Iho hyu rutvs below
F\isling Molding ❑ Rvpair❑ :\Iteration ❑ I Addilion❑ I Ut•ntuliIit'll ❑ (11Ivase till out and submit.\ppvndix l)
Ch,uq;v of Use ❑ C'11,11%v of Occul"ImLy O Other CIV S,ecit a
:\n'buildingplans,nnl/ur`1141r""t1ndtkunlcnlsbeingsuPillied.ispartoftItispmo,tapplW-11inn? 1'es ❑ 'Nil
Is an Indepondcnt Slructuad EngineerAin'g Peer Review royuired?
Thief Descri rtion of I'ru posed Work:_ tw p 1 Yes ❑ Nu
f F 1Y t-LI,L Tdcl('� W�1S (1J�)1)S 71• d•�lyi�l--NeW
iot Hn1 kv
SECTION J:CONII-LitrE ItilS SLCI-ION IF EXISTING BUILDING UNDERGOING RENOVATION,AUDITION,OI(
C{L\NGE IN USE OR OCCUPANCY
Check here if an Existing Ruilding Investigation ant] Evaluation is encluxd (Sve 7817 CMR 4) ❑
Existing use Gnaup(s): roaed Use
SECTION J: BUILDING 11FIGIIT AND AREA
Existing Proposed
Nu.ut Flours/Stories(include basenu•nt Icccls)h area Per flour(sy. ttJ _
Total Area(sq. ft),wil rutal Ileight(it') ,
SECI•ION 5: USE GROUP(Check as applicable)
A: Assembly:\-1 O' A-_'❑ Nightclub ❑ ,\.1 ❑ A.4 O A-i❑ B: Business ❑
F: Futu P•I ❑ F'_❑ F: Educational ❑
H: Ili h Hazard If"
❑ H-_'❑ 1 i,t ❑ I I-4❑ 11-3 O
I: Institutional 1.1 ❑ I-_'❑ 1-d O I-� ❑ ,,: , ercantllc O -
R I(esldent R-l0 R-_'❑ R-1❑ 11-4 O
S: Storage ,-1 ❑ S-'_❑ U: Utility❑ NFL! se O and' ,lease dcscrthv bcluw:
tiprcial Use
SECTION 6:CON:STI(UCrfON IYPF ((-heck as a t Iicable)
IA ❑ IB ❑ II,\ ❑ lid O IIIA ❑ [lilt ❑ IV ❑ \':\ ❑ \'B ❑
SF:(`r1ON 7: SI'I F I.NUMC IA HON(refer to 7,411('.\II( Ill fIR detJII9 Un e.lCh itcur)
Water Supply: I hold Lune 1 1:11ation: Sewage Uispusal: french 11crntit: Debris Rcuu,v Jl: __-_
ISabhc� Clink d out,ids I h•rd Gmv�. Inditaly nxmitip,al,$� \ It nt h\w,.ill oat bt• 1 Irrn,vJ I7a,ln ,ul tii R•,!
I'rit,uo❑ ormdvnlu( /iA .. ,`rim .nc,t Hrnt ❑ n•iplit nr berth or
parnnl a,fro Ie„vl ❑
It.li lrua,l ril;hbd-wJY IlaiJrJ.+tu .\ir .\,Icigaliun:
� nv•nr IludJ 11,�Iru,tore a nhua.urpon r.y•pn•a,h .ot,, Is l loaf 1,t it n �� niidr 1,d ' I i rt I,� rm ln.rd ❑ 1 I,,❑ q \,.
tiFCI (O.N,4: ( ONII.Vr(IF( FI(I IFI('.\Il?OP O( ( UI'.\.N'( Y
I ,Lhn I C, ,Ir 1- .r(,Ivl'I,I It r„I l �
I' u.Ii u,lii�n t`�� u1tw1l ��.nl l , rllrr
la,r� IhrluJdiu7;,. nLou.m `•lvm.(Ir r tit.Item` `•inr iA lylllmwli
1 • �(iLL(, � 1. � r"i���°
i
♦ r
--- tiCCIIUN t I'KUI'r 1r I UWNIAt AU I I IO iiw\IIUN
\ nna .utd \ddn ss of Irol ttv Usurer
Ph(�Il(S ?At-A- _ 506e oo l ll«.1 406
- I
Name (Pont) Nn, aml tilra ct city/ rown -
I'n,prrt• owner Gmlarl luhrcmatloo:
Et ___
�eW-� --- --- -� =_-._
---- �--- -- c-mail aahlress
I I'rlephona Nu, (business) relrphnne Nu. (cell)
II eppliiably, the prollefry owner hered+y aulhoriics Q1 yl•(-S
I 6,ko-N "(60S 5-C.- - _ __f.-�-----.._._N city/ f,r,vn 51ate Lip
_ --- N.une Street Address y/
lu act on the pro,crty owner's behalf, it, ell matters whitive to%cork authorized by this buildio ; p�application.
SECr10N IV:CONS 1 RUCI"ION CON"I'ItOL(Please fill Out Appendix 2)
If buildin•is Ivs+than Ii.UINI cu. ft.ul endoeed s mcv anJ or nor under Construction Control Ihvn check here O and ski ,Section In.l
lll.l Registered Professional Res onstble for Construction Control
I'ele hone No. e-ntaiL.nid«•s,y Regislraliun Number
NmOe(Itel:istrant) P - _.-- -
9uvct Address City/rows
State
Zip Discipline rxpiretiun Data
111.2 General Contractor
Ic�,A ?GcduS �-cl:Acf-r�Company Name /•�/' 14 c"7 -
-1llcanlA& 'R
License No. and rype if Applicable
Name of Person Responsible(or Construction
W.Q�
GS C1
Ciry/Town State Zip
Street Address
---
�TP�4_ (w•3`l' a-m.,il.,ddrass
relo ,hone No. business role,hone No. cdl
SECTION ll:rII aa.td:�r t I�au•t v.s t 0\ laa•t n;.\\y-r .(u a t•'.e a M.G.L.,a 152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidentsmust be iumpkled oral
submitted with this application. Failure h,provide this affidavit will result in the denial Of the issuance of the building permit.
Is.I si'ned Affidavit submitted with this a licetiun? Yes❑ No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor ) . -
0
heto and \laterials) rotal Construction Cost(frotu hem h 's_z�_---
'i 2 It r S('O- Ouilding Permit Fee 'Total Construction Cost x _(Insert here
I. 17uildin
'. lilrctrical S 3 SOc7 . .,pprupriaM municipal factor) S
1 Plumbing y $ o ocU . u ut.tit numici ,tlity)
Hole: \lininnnn
i. \Irrh.mit Other) 3 Enclose ebnek noble
t. I t,tl Gtsl ti '2.-8J440. (WoLlI t n U1110 valile) ,,Ill write cheek nundn•r tyre _... . -
SECrION L7:SIGNATURE OF BUILDING I'Elj,%wr Al'I'LICAN'F
By rn h•rin t; n,v n.uuv below. I hvrcbv attest tu,.lrr the pains.utd penalties of prrptry that Al of the n,lnnn,tnon conl,,incd in this
,thplicatiun is lrue.tn.l aa,uroty to the hvst of to, koor.lvd?;•,mil mtdcotanding. 16
'V
tale UWAR-r rleplu one \o Pot'.
I'Ir,rye pruu du.l at;n n.unc
C 111' for.tl �IJIe
. uri \Jd rr.c M�b A-
\look ipal lmpcetur to fill out this.eat' 111 It l'nn .Ippl•'.Iti Ia + a'•+h \.inu}.' I,.nr
r✓ns rrAfearsoe Bu a�C�Jl�rllcrc�rraeLtd
Office of Consumer Affair&Busifiess Regulation �j
OME IMPROVEMENT CONTRACTOR j
I r� egistration 116907
.� Type
xpiration F 8/2/ 64 , Individual 1'
THOMAS MARK JACOBSf�
' i
THOMAS JACOBSg
65 Garfield Street
MARBLEHEAD, MA Undersecretary
7 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isur I &1 Fumilr
License: CSFA-061957
`5e:rra v
THOMAS MJA�OBSz-\ Fni�
65 GARFIELD STD
MARBLEHFyAD MA. 0194
`f
tnc�a Expiration .
Commissioner 01/04/2014
Aug 9712012 15:11:00 910-303-0343 > 7B16391024 Hillary Davey Page 002
`sue av° CERTIFICATE_OF LIABILITY INSURANCE B„/2o12"YY'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOER NOT AFFIRMATIVELY OR NEGATIVELY AMENO, EXTEND OR ALTER THE COVERAGE AFFORDED B;Y THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS), AUTHORIZCD
REPREBEN'TA11VC OR PRODUCER,AND THE CERTIFICATE HOLDER.,
IMPORTANT: If fhe,Gertificats holder Is an ADDITIONAL INSURED, the po)icylleO must be endorsed. It SUBROOATION 19 WAIVED,subject to
the,terms anti conditions of the policy,cement Polities may require An endorsement. A statement nit this certificate does not onnfer tight$to the
eartificate holder In lieu of such endoisetnent(s).
PRODUC Hxy.F:. Shannon sperraesa
Risk Strategies Company rH{'N! Eul (761) 066-940U linlc.Fb, trnl)a -avu
15 paoella park Drive -�a—spesratzaL ri.ktratogic,_ e�.comy
suite 240 _.._ _..._...r...»...,.,._...�_
__ _. _ INSVRU;SI AIF RDIN6 CG\h,F 1GE 1 NAW
Randolph MA 02368
.__...._...— ... .. ..........__..._._.__..__. .._...........—. ....._..........._.. _.Ns�irsna AtnOuaxd......,....._...._ . ._ _ ..._._ A234-- ..
NsuaeG fNsuaERe Eas- Ou d .Xnsu--- ..'1.4702.,,.,,.,,_
Tom Jacobs Construction A Remodeling, Ina INSURERC
65 Garfield Street
iHsuNc•Ro _,,,
wsuaeRE'. I ,.
Marblehead MA 01945 NS RAF'
COVERAGES CERTIFfCATE NUM BERt:L12726511.1.0 RCVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NANIEU ABOVE fOR THE POLICY PERIOD
INDICATED NOWArl-iSI'ANOING ANY REQUIREMENT, TERM OR CONUI'PON OF ANY CONTRACT Olt OTHER DOCUMENT WITH RESPECT" TO WHICH THIS
CERTIFICATE MAY BE rSUED OR MAY PERTAIN, THE. INSUR44�E AFFORDED BY THE POLICIES CESCRIOEU HEREIN IS SUBJECT TO ALL THE
EXCLUSIONS ANDCONDIT-ONS OF SUCH FAOLICIF.S,LIMITS NHOWN MAY HAVF.SEEN REOUCF.G BY PFIO CLAIMS.
... _._ ......___......."___....
iYVLUF aVSURANVE PULLYE F POL dYE%4
NSa ^nL cr VAteER MwlC10lY vY 'MMrSCNY1YY � 1.141i
GENE'AL LWSIUTY "
IAM, (t JPRCN F 1 000 000
XI„ �mfArNt IA rN- rL LiAtr. Y I^rAuac'rT rer.Nlfi
fr P " �nn� U, -, A 5v U00
A � 't4pR M\ f (X � Ad!R OB830440a h/22i2010 L/!2/:U 17 MCI fWl vc era,cl + 5 OOU
_. _ I 1143K N 13 Y! If dUh I S
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f I FNI AOGREGArCt A'APrL.11,5 Ill Ft _..I Fladr a.r u\wr O A.; L,006 0,DUO
II II1R+! �
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AUTOMOBILE LIABILITY i I ioNmn€9t"iF''f1ri17mr"
ANY AtNC to PLY IM1 ItY !•r Fertro r)
N OVYN'L ...� It CI
AUr05 1VTG� U IJJWeI IFm uclJrnf 4
HOFLt PROPERTY
t eM/HiF
RIREi,AV'OS 1UTOti,y I ,tl,C(a,{u<I,pla S
UM7R0LL0.LAG f I
L*%CESSLIAU L I AINV,'N9A0'
RFO0.1C
InWORKERS CGMPENSATIUATION I •`�pT•�"-'Y4
YAcw% to SJ+.l wiad I \A AtV t 11
4N0 @e LOYERe'UAOILI Y YIN Y LRC J.711a 1 YJL
ANY 1 Nv 111t IPAH NCRk%F Vtl. I •, It,, V vAVe F h A N A ('IJLNI b0U OUG
Y HFIC LRRA&L14fNFY ULt ! N NIA
(MAndatoty in NH K:RCSU Pl hI2 / 0, h/.:7/201 iCl rN+\ F IPt!4 --Lt _ VSUOI000
,,,_ >rychlrl l(N oprRA +b.'t(rJW i VI t.IT i !00 C?DD
I
DEKRIPTtON an OPEidem LOCATIONS AOORV 1I11,AdOrtlwxl N0111dYX,ScOeaV'e,IF met?Yp:ICO NYORnlrWl �-
iaoued an evldatue of insurance.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE 0I!3rW0!D POLICIES BE CANCELLED BEFORE
THE EXPIRA*ION DATE THEREOF, NOTICE WILL BE DELIVERED !N
Town Of Marblehead ACCORDANCE WITH THE POLICY PROVISIONS.
Building Department
7 Widger Road .tuiMJR!LEO AEINIEBENTATNF 4W—
Marblehead, MA 01945
Micbmel Chri,atian/814S l.v,; •,.-�;r t`-'wk:...,..��:...e?3�-,.
ACORD 28(201 0/08) S!i 888-.201888-.2010 ACORO CORPORATION, All rights reserved.
iNSB28:�nurcal m Th.Arr1Rn and Into.a n.rnni AlwM mnrlrc of ar-npn
HIC N00 -7 812�1�
CS 6LIqI.�-1 11L1 �Li
CITY OF S.-1LE1i, N ASSACHUSETI'S
BUILDING DEPARTMIE,�IT
� N 130 WASHINGTON STREET, 3?D FLOoR
TEL (978) 745-9595
FAx(978) 740-9846
KN{BERI RY DRISCOLL
NiAYOR THo.%w ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CMLIIISSIONER
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 It 1.5
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:
11
1M J(1 Cdt+.S C6 tAS j'C U c�Cd,�1
(name of hauler)
The debris will be disposed of in :
Tra, kr !�uv\ — Mwbk�4Lk
----_ (name of facility)- —�
WooafiVk - JFtfram— j yew6"O's-1
(address of facility)
S,
signature o�• t applicant
date
•lcbfisairdac
° CITY OF SLIt_Nl, N-L-kSSACHUSETTS
• MiLDLN,G DEPARTSIENT
Jr• 120 WASHINGTON STREET, 3so FLOOR
TM (978) 745-9595
F.A_X(978) 740-9846
i i.,115 R( EY DRISCOLL
MAYOR DIRECTOR
ST.PtFxRIs DIRECTOR OF PUBLIC PROPERTY/BUILDING CMI]MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4plilicant Information /- Please Print Legibly
Name(Busin�syorganizatioNlndividual): It TooA JG CC�aS �`Uit uCLltu-k Q. K-CIM CQ�OI/ 1 AC.
Address: VS G Af fi'2.A S'h/�tat_
City/State/Zip: hlcr6CCkLci, 1,, tAA 6194 S Phone #:_ 78 I— y`l Z—JZ3 C21
Arc you an employer?Check the appropriate box: .'Type of project(required): li
I.CW 1 am a employer with 6 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t Z Remodeling
ship and have no employees These sub-contractors have a. ❑ Demolition
workingfor mein an capacity. workers'comp. insurance.
Y P Y� 9. EJ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
officers have exercised their t0.�Electrical repairs or additions
required.)
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L.❑ Plumbing repairs or additions
(
my self. No workers'comp C. 152, g 1(4),and we have no 12.❑ Roof repairs
ns h employees. 'urance required.) P y ees. (No workers 13.�]O
comp. insurance required.) ther
-Any applicant out checks box 01 mutt alw fill out the seelion blow showing their workers'compensation policy inhumation,
'I lomeowners who submit this affidavit indicating they am doing all work and then hire outside contmcton most submit a new amdavit indicting such.
=Controctors that check this box most at aehed an additional chest showing the name of the sub ontracton and their workerd romp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below Is the polky and Job site
information.
Insurance CompanyName:_6UQfG4 T•sA�iAS,,rQ,%nUL
Policy 4 or Sclf-ins. Lie.H:Tgw c _ IZgZ 1 Expiration Date:— j
Job SiteAddress:S0 6-Cr_ lcln.l $1Ichnf � 4b6 City/State/Zip: S4I,94A tJ`-%A of476
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date)-
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
Fine up to S1,500.00 and/or one-year imprisonmem as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250A0 a day against the violator. Be advised that a copy of this statement may lief forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ida hereby certify under do ptLins and pemaltles of perjury lbut the hilormallon provided above is true and correct.
5ienanlrr; Date' (CIA) ZS r�Z
Phnne 1:
OfTcial use ualy. Do not write in this area,to be completed by city or/own official
City or 7rown: _..... Permit/LJcense#
Issuing Authority(circle one): ^-
1. Board of 11callh 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone a:
J
From:East Coast Properties LLC 978 745 9684 11 /08/2012 14:20 #324 P.001 /002
PROPERTY
® MANAGEMENT
E4 AST COAS� f SECTION
PROPERTIES, LLC NATI NATIONAL ASSOCIATION OF REACTORS I'
AUTHORIZATION TO DO REMODELLING WORK
DATE: NOVEMBER 8,2012
RE: UNIT#1601,15 OLDE VILLAGE DRIVE, SALEM,MA
OWNER: CAROLINE LENA
FAX TO: CIT OF SALEM,BULDING DEPARTMENT 978.740-9846
This.letter will confirm that Caroline Lena,who lives at the above unit at the Highland Condominium ac
Salem Trust,has approval from the Board of Trustees of the Highland Condominium at Salem Street,to
have a contractor renovate the half bathroom on the first floor of her townhouse located at 15 Olde
Village Drive,Salem.
East Coast Properties,LLC,Manager
BY:
Cyn$ly jnselmo
REAL ESTATE AND PROPERTY MANAGEMENT
400 HIGHLAND AVENUE,SUITE 11 email: EastCoastPro@aol.com Phone: (978) 741-2003
SALEM,MA 01970-1777 Fax: (978) 745-9684