50 FREEDOM HOLW - BUILDING INSPECTION (5) The Commonwealth of Massachusetts
r 1 Department of Public Safety
1 J �UY Massachusetts State Building Code(780 CMR)
I4d Building Permit Application for any Building other than a One or Two-Family Dwelling
;(This SectiomFoi;Official Use Only)�
Building Permit Number: -Date Applied Building Official
. - .. _ . . .
y SECTION 1:LOCATION(Please indicate Block#and Lot,#for locations'fri which a street address is not:available).
50 CIr e" Aat`Oyl tarsi 20'7 SIR•1-elsi etiul�7
No.and Street City/Town Zip Code 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❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change 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? 1� Yes ❑ No ❑
Brief Description of Proposed Work: Irlee �i�1-Ckun 0-A i' Js eUt l� Si9wt C EiS E'X.S fi Wi
SECTION 3:COMPLETE THIS SECTION IF EXISTING,BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USEOR 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 HEIGHTAND AREA'S
. - 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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
L• Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 O R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and(Tease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IH0 IIA ❑ IIH0 IIIA ❑ IIIBD IV ❑ VA ❑ VB ❑
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❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %1A Historic Conunission Rev lew r'ro ess:
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:
SECTION 9:,PROPERTY OWNER AUTHORIZATION ..
Name and Address of Property Owner
C s-oP- mffo[6y 6190-7
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: LA SA IR C 4L 0 AOk.C0 M
Yo S'A 20— 2_gW 1 t EA14
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized'b 'this building permit application.
SECTION 10 CONSTRUCTION CONTROL(Please fill out A`ppendtx 2)'
. �,
If build is is less than 35,000 cu:fC of enclosed' ace eiiid/6rnotunder Constn"on Contr6l tNeirclieckCeie:O'and`ski .Section 10.1 '
10.1 Re istered Professional Responsible for Construction Control:'-. -
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor'
&Z" 1cej0Qy.nCeT'Ne
Company Name
&ere tMeK;c C S 6 67;ko Oil /(f Ya Z
Name o Person Responsible for Construction License No. and Type if Applicable+
(GYec.tfYSr IM"��O}'+� NO— B/F�S
Street Ad ress City/Town State Zip -
7kj -M I S5'2- C(7-7 29_ 3 9-5-7 r�uuc�Cnc�lclfs�.we}
Telephone No. business Telephone No. cell e-mail address
SECTION'11:.WORKERS'COWENSATION INSURANCE'AFFICIAVIT M.G.L.c.152. :25C 6 - -
A Workers'Compensation Insurance Affidavit from the NIA 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 Ek—No ❑
SECTION 12:.CONSTRUCTION'COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Nlechanical (HVAC) $ Note:Minimum fee-$ con ct municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING'PERMIT APPLICANT
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 acc to the best of 1 knowledge and understanding.
Q50%, lMCW� urstC 791 -5�- I53Z
Please print and sign name "Citle Telephone No. Date
44 6.r�r,t S+ �uct,rblG�t�► � &/q Vs_
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: tom- "r✓ J
Name Date
CITY OF SALE.M, jL1SSACHUSETTS
4 . y BUILONG DEPARTM&NT
130 W.ISHINGTON STREET, 3° FLOOR
TEL (978) 745-9595
FAA(978) 740-9846
ECI�iBERLfoY DRISCOLL
AkYOR THOJtAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUMONG COS12,IISSIONER
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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 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)
�-
_— --(address of facility)
si amre of permit applicant
date
d.bns.io''•bx
CITY OF Si1=N1, l%'L1SS:iCHL'SETTS
BUILDING DEPAItT%W-NT
120 WASHIINGTON STREET, 3'o FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
NJ.,tgFRT RY DRISCOLL
MAYORTHoistAS Sr.PtERRa DIRECTOR OFPUBLICPROPERTY/lIU DL4GCONWISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Amilleant information Please Print Legibly
v Vn111C(Busit)yyyUrgani¢�ationlfndividual):SeY tliCe I /41 Y I L INS (�P) T.VYYG
Andress: ?3C0114t , S47
City/State/Zip:L4#1Aid=& 402— Phone!{:�_�/ S�3 —t55Z
Are you an employer?Check the appropriate box: Type of project(required):
1.13-1 am a cmploycr with t/ 4. 0 I am a general contractor and 1 6. ❑New construction
employees(thll and/or part-time).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner• listed on the attached sheet,t 7. ❑Remodeling
ship and have no employees These sub-contractors have V. ❑Demolition
working fur me in any capacity. workers'comp.insurance. 9, 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
J.0 I am a homeowner doing all work right of exemption per MOIL I LEI Plumbing repairs or udditions
myself. [No workers'cutup, C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.) I1.D Other
•Any uppllcum that Owks box rl must atws fill out th,icetioo bclowshowing thelf worker'compensadun poacy intumia:fom
'IT'"auwners who submit this affidavit indicating ihey am doing all work and then him Qllide cantmctam most submit a new affidavit indicating such.
:0,ntractota that chwk this box most attachod oo additlunul,boat showing tho mama of the subaontractom and their worked comp.policy infomution,
l ran an employer that is providing workers'compensadet hisrarance for my employee., Below Is the poBry and Job sits,
information.
Insurance Company game:
Policy N ur Sclf-its.Lic, n:LUU-t� 60 1 kQ 12-011 Expiration Date: /0/3 12013
Jub Site Address:,yO f lee",,L k JI0W i1Dk,� 20"1 City/State/Zip:600e/h', U.1"&07
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 it line
of up to 5250.00 a duy against the violator. [It advised that a copy of this statement may ba forwarded to the Office of
Invesligulitns of ale DIA for insurance coverage w:rificaliun.
aaaaaaaal
1 do hereby cert under r s u s ud penalties ufper/ury drat the htfunrradon provided above is true and correct.
�i t Data:
Phone;l: `l OL 7 7 3 /✓
opicial use only. Do not write in ads arery to be completed by city ar fewar n/Jlelut
City or'ruwn: _ Pormit/l.fcemse 4
Issuing Authority(circle one): ----__—
1. Iloard of Ilealth 2. Building Department 3.Citylfown Clerk 4. Clectrical inspector 5. Plumbing Inspector
6.Other
Contact Pcnon: __ _ ____ __ Phoneth
ACORD. CERTIFICATE OF LIABILITY INSURANCE SATE /D
O1J08/2013013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATEDOES 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),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: 8 the eertlHcate holder Is an AD T O INS RED,the poliey(Ies)must be endorsed. I SUBRO A710N IS WAIVED,aubleet 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 GONTACT
NAME:
Duffy Insurance Agency, Inc. AP/CON Exl• 781.593.1200 No:781.593.7260
317 Broadway L5AADDRESS:
Wyoma Square INSURERISI AFFORDING COVERAGE NAICit
Lynn, MA 01904-2602 INSURER A: Safety Insurance COmpany _ 39454
INSURED Service Painting Co Inc INSURERB: Safety Indemnity Company 133618
93 Collins Street INSURER C; Associated Employers Insurance
Lynn, MA 01902-2247 INSURER 0:
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: 92 REVISION NUMBER:
THIS IS TO CE TIFY HAT THE POLICIES OF INSURANCE LISTED -ELQ AVE BEEN ISSU SURED NAMED A80VE 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 PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE INSRI WVD POLICY NUMBER MNUD0NYYY MMIOOIYYYY LIMITS
GENERAL LIABILITY SMA001090 101231'2012 10/23/2013 EACHOCCURRENCE $ 1 000,000
X 1 CON"RCIAL GENERAL LIABILITY PREMISE$ Eg M:U— S 100 OQO
CLAWSBMADE91 OCCUR MED EXP(my we Damon) $ 10,000
A PERSONAL$ADV INJURY $ 1,000,00(
GENERAL AGGREGATE S 2 000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG It 1,000.000
X POLICY I IJECT 7 LOG — $
AUTOMOBILE LIABILITY 621219 02106/2012 02/06/2013 EA acclJami $
ANY AUTO BODILY INJURY(Par person) S 250,00
B ALL OS X SCHEDULED II 'N B�TODILYINJURY(Pet wiftn p $
S00,00
X MR6DaT ONOSWNED PROPERTp1 0it—F i 250 00
(
AUTOS UMBRELLA UAS OCCUR EACH OCCURRENCE IS
'EXCESS LWH CLNMS-MACE AGGREGATE S
DEO I I RETENTIONS I Is
WORKEAND EMPLOVERSENSATION WCCS00601801201210/03/2012 10103/2013 X ORY LIMITS ER
RS COMPENSATION
YIN
ANY PROPRIETORMARTNERIEXECLITI EL.EACH ACCIDENT S 100,00
C OFFICER/MFMBER EXCLUDED? VIM NIA'
(Mandatary in NH) EL,DISEASE.EA EMPLOYE. $ 100,00
GYyaSCRIPTI NOFO
OEGCRIPTION OF OPERATIONS CaIow E.L DISEASE-POLIGV LIMIT S SOD,OOO
I
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ANacB ACORO 101,AtltllilPnal RamarNa 9FNeJale,If more apace le raquUoU)
e: SO Freedom Hollow Unit 207, Salem, MA
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH TH POLICY PROVISIONS, f
City of Salem AUTHORIZED EPRESENTATIVE 1
Building Department
Salem, MA
(P1988.20 0-ACORD CORPORATION. All rights reserved.
ACORD 26(2010)08) The ACORD name and logo are registered marks of ACORD -
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Moynihan Lumber of Beverly Designed: 12/28/2012
Mike ^ ^ Printed: 12/31/2012
Swan-mswan@moynihanlumber.com
Tel:1-978-279-2318 Faxa-978-279-2390
This drawing is an artistic
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Moynihan Lumber of Beverly Designed: 12/28/2012
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Swan-mswan@moynihanlumber.com LJBJ�Tel:1-978-279-2318 Fax:1-978-279-2390
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u.S.Department of tabor 1S SNI1100£6
Occupational Safety and Health Adrnintstralion 31AOW 35HO30
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has successfully completed a 1"our Occupational Safely and Health �9
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Joyce Bilodeau
From: Thomas St. Pierre
Sent: Tuesday, January 22, 2013 7:45 AM
To: EastCoastPro@aol.com
Cs: Joyce Bilodeau
Subject: RE: Unit#207, 50 Freedom Hollow, Salem MA
Thank You
From: EastCoastPro@aol.com [mailto:EastCoastPro@aol.com]
Sent: Friday, January 18, 2013 1:01 PM
To: Thomas St. Pierre
Cc: Lasalacal(cbaol.com
Subject: Unit #207, 50 Freedom Hollow, Salem MA
,Dear Tom,
Please note that Barbara LaSala, who lives at Unit#207, 50 Freedom Hollow, Salem, MA has obtained approval from the
Board of Trustees of the Village at Vinnin Square Condominium Trust to replace the kitchen cabinets in her condominium
at the above location and to install a corian counter top.
If you have any questions or need additional approval, please call. It is my understanding that George McKie of Service
Painting will be doing the work, and we will obtain an insurance certificate from his company.
Cyndy
Cyndy Anselmo
East Coast Properties, LLC
400 Highland Avenue, Ste 11
Salem MA 01970
Tel 978-741-2003; Fax 978-745-9684EastCoastPro(cDaol.com
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