50 FREEDOM HOLW - BUILDING INSPECTION (10) � The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM dMar
Revised 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: ate Applied:
Building Official(Print Name) Signatu Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
if if I kf0/�fiUJ 31
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: .I
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:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP' —7
2.1 O t ' f R cor SA-Lem, /V/7 n Tl?
Name( rint) R t c ti4 City,State,ZIP
SD ✓icc�l� Hollnc� 3/ 9'I��9y-IZ66
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) EeT Addition ❑
Demolition If
Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
!c 1 Poo—<In4i 4 (tl 011116 6/) -S wloi-h
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 31 r 2,SID.00 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 3SDD.0J ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ Z 0 DD -pJ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
qS �q Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3e�, V J ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction
/Supervisor License
'(CSL) St2U d6, J
Ff'6iV1(rS /fIC��VMiG(� J✓. LicenseNNumber on Date
Name of CSI.Holder ',
!e-rat List CSL Type(see below)—�
No.and Street Type Description
i9`t-1 A AAA
y, I q 6o U Unrestricted(Buildings u to 35,000 cu.ft.)
f t� , N l l'' V "I R Restricted 1&2 Family Dwelling
City/To n,State,I lP M Mason
ry
RC Roofing Covering
` �l WS Window and Siding
n \ i, r - SF Solid Fuel Burning Appliances
(g�'d3(—q�t) 7✓�CLo` oyi,(,f— �71�'dq/AS`U)1/(.{App.- I Insulation
Telephone Email addres— D I Demolition
5.2 Registered Home Improvement Cot/�trector(HIC) 131 74j' 6
A4/ rOYMif:&l�t�EYS 0/ �tGtn(i1 rF.�ru�fGF J� HIC Registration Number Expiration Date
HIC om an Na HIC RegistrantN
NA an Stre t Email address
� 6y l81-, 31-gdDo
i��ct��t�., i� �} D I q
City/Town, tate,ZIP Tele hone
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 APPLIES FOR BUILDING PERMIT
I,as ner of he subject property,hereby authorize Fr am C/ ( e (mil)/n/(
to ac on y eha , in all rZ,,
ve to work authorized by this building permit application.
� nt Owne's Name(Electro G "liafld _ ° Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By enteJir
y name below, I hereby attest under the pains and penalties of perjury that all of the information
i tarohis application is true and accurate to the best of my knowledge and understanding.
Print er's or Authorized Agent's Name(Electronic Signature) Fj-aN(,i.5 0 U M Dt 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..ov�/oca Information on the Construction Supervisor License can be found at www.mass.goy/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"
51304
FRANCIS MCCORMICK JR
6 SERENA TER
PEABODY, MA 01960
1/5/2013
8349
Office�J(cuhi`BRirYf�A?1S(S{'S'ffi'1SIf6iAeYf7tY�A(A541Pt�°
''-4'�= HOME IMPROVEMENT CONTRACTOR
-' I Registration-IMPROVEMENT
Type:
a
_., ' Expiration: 9/6/2012 Private Corporatioi
M8 �RMICK BUILDERS GROUP, INC.
FRANCIS McCORMICK JR.
6 SERENA TERRACE
PEABODY, MA 01960 Undersecretary
CITY OF S.Uzm, N'LXSSACHUSETTS
• BUILDIING DEPARTNMNT
120 W ASHL-IGTON STREET,Yo FLoop.
TEL (978) 745-9595
FAX(978) 740-9846
KINfBERLEY DRISCOLL
MAYOR THostAs ST.PiERteB
DIRECTOR OF PUBLIC PROPERTY/BUUMMG COMWSSIONER
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:
N0411Si d& NA-6!1
(name of haute
The debris will be disposed of in :
Ifo✓ SI&,('&Il A
(name of facility
(address of facility)
signature of permit applicant
k sj--"
date
dcbri,lUo
The Conrnfottwealth of Massachusetts
_- Depm•tinent of lirdttsh•ial Accidents
_ _ Office of Investigations
600 Tf7ashington Street
Boston,11D1 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/El lectricians/Plumbers
Applicant Information Please Print Le iUl
Name (Business/Otgauizatiou/lndividual): Mn "J
Address:
City/State/Zip: S. IAA m� dl ' Phone* 7gI'd3�-tl�r3U
A,rc �an employer'! Check the appropriate box: Type of project(required);
1.LI✓ I am a employer with ,- 4• 0 I am a general contractor and I 6. ❑ N w construction
employees (full and/or part-time)? have hired the sub-contractors
listed on the attached sheet, 7. odeling
2.El a sole proprietor or partner- These sub-contractors have S, emolition
shipip and have no employees and have workers'a
working for me in any capacity. employees9. ❑Building addition
insurance.omp.
[No workers' comp. insurance c 010.[ ectrical re nits or additions
i 5. We are a corporation an
required.] d iLs p
3.❑ I qu a homeowner doing all work offieLm have exercised their 11. lumbing repairs or additions
right of exemption per MOL 12.0 Roof repairs
myself. [No workers' comp.
insurance required.]i C. 152,employees.
[ and we have no 13.0 Other.
employees. [No workers'
comp.insurance required.] _.__ :._._
•Any applicant thatchecks box At must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit Ihis urGJnvit indicating they am doingall work and then hire outside contmctma most submit a stew-o8idnvit indicating such.
tContractoni that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees- if the sub-contractors have employees,they most provide their wadk=,O oomp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and/ab site
information.
Insurance Company Name: ^- I'rla✓d�✓21 1
Policy#or Self-ins.Lie.4: Y�VI �— ✓ / - Expiration Date:
Job Site Address r 1���t� O/I A( y �I / City/State/Zip M
. � 1'/,/t ti i
Attach-c-copy o'f the-wor[ter-s—Compensation policy declarabon-page-(showing the-policy nuntberand expiration date)
Failure to secure coverage us required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
Sue up to$1,500.00 and/or one-year imprisonment,us well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be,advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certif a or the pains and penalties of perjury that the infornhation provided above is true and correct
Date: 5 elo
i atu e: - ` ,
Phon #: "
Official use only. Do not write in tits area,to be completed by cloy or town official
City or Town Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.BuiIding Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other.
Phone#:
Contact Person:
FROM WATER STREET INSURANCE AGENCY (TUE) AUG 23 2011 3:00/ST. 3:00/N0. 6310000682 P 1
Acc>ko CERTIFICATE OF LIABILITY INSURANCE
. `I " w ' I..._ 8/23/11
THIS CERTIFICATE TS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poliey(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s)-
PRODUCER CONTACT
NAMFI
Cocoa Insurance Associates Inc HONE
dba Water Street Insurance Age
_IM Nn Eek (7811 245-0888_ Ni: (781) 246-3926
EdaWL ""
ADDRESS: Carmen@getineUrancohere.COm
27 Water Street PRODUCER
.CUSIOMERLDa: 3470 ..-._...._ — _...,._._
Wakefield, MA O18H0 INSURER(S)AFFORDING COVERAGE NAICA
INSURED INSURER A:Travelers _
McCormick Ktchens INsuRERe:
1161 Broadway INSURER C, _
Saugus, MA 01906 INSUR9I o:
INSURER E— _.�_._.......
INSURER F: _
COVERAGES CERTIFICATENUMBER: _ REVrSION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDNG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WIFIICI'I TI IIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY TI-C POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONOTION$OF SUCH POLICIES L MITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
N5R 4[OL SUER POLICY EFF PIXICY EXP I
LTR TYPE Of INSURANCE IIxCA n pOUCY NUMBER IMMIm ml,J,_m[v U4 , UNITS
L GENERAL LweluTr ! racuoccuRRENCE I: S 1,000,_000
A XICOAMERCIAL GE NF PAL LIABRITV I :168041A672077 7/B/11 7 8 12 PAE*G TORENTEO
/ / PNEMISIS_tta.Dacuasocal 1 a _300�Q 0
OLAIMSNADE X OCCUR ! I.M:uH_xP(AryorePmaD.) 1s __5,00,0_
PERSONALS ADV INJURY S 1,000,000
I CENERALAGGREGATE �$ 2,000,QO0
GEN'LAGGREGATELMTAPPLIESPER PRODUCTS-COMPICPAG4 S 2,000,000
)( POLICY I,OC $
AUTOMOBILE LIABNITY I COMB INCD SINGL E LIMIT
IEsacciWnl $
.. ANYAUM I -- .._.I_._.-__
,uLOWr•ED AUTOS
BCD ILYINJURY(Pm RRoa) '$
SCHEDULED AUTOS BODIL Y INJURY U'er acadeAl)'$
PROPERTY DA+ACC S
HIRED AUTOS j H'BIdW14acU
NONOWLEO AUTOS
$
UN6fELU LIAR OIxUR 1 EACH OCCIIRRF-NCF. S
EXCESS LIAB . . . .__
CLAIM$-MADE M"A;Rf-GATE §
DmlX:neLE '
�S
RFTFNTIDN § ._.._.__.,_. .,. $
NORNFRS CONPENSATION ! 'IEUB-3727T336 7/8/11 7/8/12', MSIATU- . !"I
AND EMPLOYERS'LIABILRY YIN i ..IURYJJAaILI�!tJZ... .. ..___
A v;YPnCf`RIL RJPARTNER ZCVTNE _E_U EACHACUYOEM ,§ 100 OOO
OFFICE.RAIFWER EXCLUDED? NI NIA
(Merdenry In TIN) B,L DISEASE-EA oaPLrnrq s 500 000
H yea,dmmibo umm f`I �. .. __
DESCRIPTION OF OPE RATIONS nAIPw E,L.OISULSG.PO(ICYUMIT § 100 000
I i
I I I
ESCRIPTION OF OPERATIONS?LOCATIONS I VEHICLES (Aroch ACOAD tot,AMIII ?Rena Ass e,If morn:Paco IR mgtlhid)
Init 314
:ERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF TIE ABOVE DE SCRIBED POLICIES BE CANCEL LE D BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE OEUVEREO IN
Village at Vinin Square ACCORDANCE WITH THE POLICY PROVISIONS. '.
Condominium Trust II
50 Freedom Hollow Or AUTHORIZED REPRESENTATIVE
Salem, MA 01970
Carmen Cocoa
®198a.2009 ACORD CORPORATION. All rights reserved.
\CORD 26(2009/00) The ACORD name and logo are registered DharkM of ACORD
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