50 FREEDOM HOLLOW - BUILDING INSPECTION (7) 2S GK 01
The Commonwealth of Massachusetts
Ulf
OF
Board of Building Regulations and Standards CITY M
Massachusetts State Building Code, 780 CMR S
Revisedd Mar Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied: rn
o
` n Building Official(Print Name) Signature `Date --'
J—/ SECTION 1: SITE INFORMATION s rr--
1.1 Pro �ty�A�dr s: ` a/ 1.2 Assessors Map&Parcel Numbers m
c� CkEn 14b1l
1.1 a Is this an accepted street4 yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: o `"
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 Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 - ner'of ecord: 2,114
Na e(rmt) /� City,State,ZIP D 1 I-
L'I ( �7Y LLytr- Z. )9&r&
o.and SVeet Telephone Email Addressftla4sk, _
SECTION 3:DESCRIPTION OF PROPOSED WORIO (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other V Specify: (76d-AO
Brief Description of Pr osedWork':
Pr 7Ye
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ y9(U O, UCH 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 (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due:
rn zA -3p-ro -1 1 1 0
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su ervisor License(CSL) eS_0/0 8-�n '� S
License Number Ex ratio Date
Name of CSL Holder
List CSL Type(see below)
*adeet T eDescription
�/ �%!, U Unrestricted(Buildin s u to 35,000 cu.ft.V Restricted 1&2 Famil Dwellin State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
' SF Solid Fuel Burning Appliances
l.Sq,)q y7 C 1 Insulation
Tele hone Email address D Demolition
5.2 Regist�ercdMome Improvement C tractor(HIC) S (�
�fz (�� �L� C HIC Registratiioon Number E irati nDate
HIC Company Name or-HIC Registrant Nam
No.and Street _ ^�c� --y Email address
CityYTown, State,ZIP Tele one
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 Issuapee of the building permit.
Signed Affidavit Attached? Yes .......... 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 U ICJ f�
to act on my behalf, iki matterrrss',reelative to work authorized by this building permit applicati n.
Prin Owner's Name(Electronic Signature
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATI N
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 )U owledge and understanding.
o r
Pont Owner's or Authorized Agent's Name Ztlectronic gna re) D to
NOTES:
I. 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. a 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dps
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"
i CITY OF SM ENI, 2AXSSACHUSETTS
• BUILDING DEPARI'ntENT
120 WASHINGTON STREET,Yo FLOOR
'ILL (978) 745-9595
FAX(978) 740-9846
1IMBERL.EY DRISCOLL
MAYORTHOMAS ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMaSSIONER
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 :
(name of facility)
�4 AL
(tiddrds of facility)
signature pe i ppf t
U
to
dcbrivird«
CITY OF &U.&N1, DI.J.SSACHUS=S
• BUII.DIING DEPART S1ENr
120 WASHINGTON STREET,3'n FLOOR
\ 'ILL (978)745-9595
FAX(978)740-9846
KI\fBERI.EY DRISCOLL
MAYOR Tt�IOANS ST.PtFItRH
DIRECTOR OF PUBLIC PROPERTY/110E DING CO%L%USSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aptilicant Information Please Print Leflibly
Name(BusinessiOrgani:ati'on/IInd�ividual):
1.2 /J
Address: ��o IT-4 �� 4( 1e_ C �A
City/State/Zip: �J Phone#: C7 L
Arroe you an employe . Check/the appropriate box: Type of project(required):
Pemployer
pra.tthi I am a era to with.�1� 4. El am a general contractor and t
I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workets'comp.insurance. 9• ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL IL.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152.§1(4),and we have no 12. Roof re
insurance required.)t employees.[No workers' ❑ �/
comp. insurance required.] 13.�/ Otter
Any applicant that chess box at must also fill out the section below stowing thew workea'cwnpensaflon policy i,inffumutioo_
t llomcownera who submit this affidavit indicating arcy am doing all wmk and thm him outside ewarsio ors roust submit a new affidavit indicating such.
'Comracusts that cheek this tax mtret aaachad an additional sheet showing the name of the sultieouttactora and their warfas'annp.policy information,
l am an employer that is providing workers'compensation lnsuratncefor my employees. Below Is the policy and Job site
information. _
Insurance Company Name: AAAPolicy korSelf-ins.Lic.#:/ L2(Lqb()__)6aAIOG- AAA Expiration Date: /. I `
Job Site Address:,5-o T✓Lz(»G(�n G3!CO 1(� 17 City/State/Zi�
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 imprisonmenl,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 cagy Of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certJfy under the pains and penaties ofperfary that the lnformush m provided above is true and cor►ec4
Sienatnre: Date•
Phone#:
Official use only. Do not write in this area,to be completed by city or town oJf7cial,
City or Town: Permitil.kense#
Issuing Authority(circle one):
1.Board of Heallh 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01SM-0970
(800) 876-2765 NCCI NO 26158
POLICY NO. .'AWC-4047022109-2014A
PRIOR NO: AWC-400.702210972013A!
ITEM
1. The Insured: Edmund Byme
DBA: Ed Byrne Window Company
Mailing address: 756 Western Ave FEIN: "--9236
Lynn,MA 01905-2456
Legal Entity Type: Sole Proprietor
Other workplaces not shown above: Sea Location
2. The policy period is from 12/13/2014 to _12 I312015 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liabiltty Insurance:Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident
Bodily Injury by Disease $ __._, 1,000,000 policy limit
Bodily Injury by Disease $ 1,000�OOb each employee
C. Other States insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.
All information required below is subject to verification and change by audit.
ClGi asihcations Premium Basis Rates
s__. ..... __. _._.._. __. _ ..-.. ... ._.. .. -. . .. _-.. - . .........._._ ,,.
Code Estimated Per s100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
i
INTRA 50459
I
INT
ER
SEECLASS CODE SCHEDULE
Minimum Premium $575 Total Estimated Annual Premium $10,152
Deposit Premium $10,707
GOV GOV
_STATE.CLASS,
MA 585i State Assessments/Surcharges
!....._._...—.._. ._ _ $9,667.00 x 5.8000% $555
^ d."�_�` �_ILI�C�st
This i' including all endorsements,Is hereby countersi ned b 10/Dili 4
policy,� 9 Y 9 Y -� A;nnanzee Signature�' Data -
Service Office: Admiral Insurance Agency Inc
54 Third Avenue 70 Munroe Street Unit D
Burlington MA 01803 Lynn, MA 01901
WC 00 00 01 A(7-11)
Inciudes copyrighted msterhii of the motional council on compensation Insurance,
used anth Its pemMaston.
E.B. Window and Siding Co. Invoice
EUr'-11W 756 Western Ave
Rt 107 Date Invoice#
Lynn MA 01905 6/5/2015 51090
Bill To
Barbara Schwartz
50 Freedom Hollow #314
Salem MA
P.O. No. Terms Project
Description Qty Rate Amount
2'6 x 68"RH 6 1/2 908 Fiberglass insulated door Masonite exterior 1 0.00 0.00
paint white/Interior paint White 15 light grid between glass entry
single cyl deadbolt
Provia Spectrum storm door full light roll down screen brass hdw 1 0.00 0.00
Install above 1 0.00 O.00T
Total Project 1 2,200.00 2,200.00
0.00 O.00T
acceptance of proposal
authorized signatu
Thank you for your business. Subtotal
$2,200.00
Sales Tax $0.00
Total $2,200.00
Payments/Credits -$700.00
Balance Due $1,500.00
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindowrdmsn.com www.ebwindow.com
Marcia Kirkpatrick
From: CyndyAnselmo <cyndy@ecpllc.net>
Sent: Thursday, July 09, 2015 10:17 AM
To: Marcia Kirkpatrick
Subject: 50 Freedom Hollow, #317, Salem MA 01970
Please be advised that Barbara Schwartz of Unit#317, 50 Freedom Hollow, Salem, MA 01970 has approval from the
Board of Trustees to have a new door installed in her unit.
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
c'y1ldvLweenlle.net
i