50 FREEDOM HOLW - BUILDING INSPECTION (9) (�Q The Commonwealth of Massachusetts
Q � �
Department of Public Safety
IUP Massachusetts State Building Code(780 CKIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1: LOCATION(Please indicate Block p and Lot B for locations for which a street address is not available)
56 Tk /, U0 U11/T>1J , �4C5a/ 6-Ulu� F,fTt//ud/i U
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
Edition Of NIA Stata COLIC used If New Construction check here❑or check all that apply in the two rows below
Existing Building Rcpa it tirl rUteralion ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Cha nge of Occu pa ncy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes JIV No ❑
Is an Independent Structural Engineering Pe Review ryuired? - q .ram Yes ❑ No j l/
Brief Description of Proposed Work: kay( /i }f ��7/j�G/,S'
1LC �9 V Rcf6e 44A
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 7800,IR 34) Cl
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❑ B: Business ❑ E. Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ I-k❑ M: Mercantile❑ R: Residential R-'I❑ R-?❑ li-3 R-1❑
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 ❑ ILIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Trench Permit:
Water Suppl Flood Zone Information: Sewage Disposal: Licensed Disposal Site
Public Check if outside Flood Zone❑ Indicate municipal A trench will nut be I
private❑ Or indentify Zone required-R'or trench or specifv or On site system ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: yA ijnp,ri, , ........ .", r
Not Applicable❑ Is Structure within airport approach area? Is their review eontpleled?
or Consent to Build CoCIOscd ❑ Yes ❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
lid itiun of Code: Use Group(s): 'I pe of Construction: ___ Occupant Load per Flour: -- _—_..
Does the building conlaio an Sprinkler System.': _Special Stipulations
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name:md Address of Property Owner
Nu 6r 13D wt=voal /F=V)
Name(Print) No.and Street(,jf//T/q City/Torun 'Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) a-mail address
If applicl le, the property owner hereby authorizes
Name Street Address City/Town State Zup
to act on the property owner's behalf,in all natters 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 and skip Section 10.7
10.1 Registered Professional Responsible for Construction Control
Nm�hS;(Re,i trant Tele h pne No. e-mail a r• s /' Registration Number
Street Address City/Town State Zip rOv Discipline Expiration Date
10.2 General Contractor
4E Wdflq
Company Name
r,j i3uH9
Name of Person Responsible for Construction License No. and Type if Applicable
-027&
Street Address s I� City/Town State Zip
Telephone No. busi iess Telephone No. cell e-mail address
SECTION 11:M 11tk1i15'(kA1'Ii;Mw\PION 1\SUR:\.NCH:\fP11'4\\•fl' 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 uance of the building permit.
Is a signed Affidavit submitted with this application? Yes MNo ❑
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor '1 /+fit J1
and Materials) Total Construction Cost(from Item 6)=$ 1P 7,"lU
1. Building $ 730 ` Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ al-02) appropriate municipal factor) =$
3. Plumbing $ lwoo
4. Mechanical (HVAC) $
Note: MinimumIc�
fee=$ (coat. n1 'cipalily
j
5. Nlechanical Other $ Enclose check payable to /
6.Total Cost $ /a Qgrl (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 isn trueandaccuri-t-e-RA t1le best of my knowledge and understanding.
�� ✓W W u� ! d !d C77/IZ-GwfL U'�l �
Please print and sign ram Titl• Telephone No. Date
Street Addr"s City/Town .Star Zip
D
Municipal Inspector to fill out this section upon application approval:
Name Date'
` :�lassachusctts - Dcpat-tmcnt of Public Safer .
Board of Building Regulations and Standards
�f Construction Supervisor License
License: CS 34839
Restricted to: 00
s,
JOSEPH F MALONEY n,
17 JUNIPER RD
NORTON, MA 02766
Expiration: 10/25=11
('.......,mrr Tr#: 7498
Office of Consumer Affairs&B smess Regulation
HOME IMPROVEMENT CONTRACTOR
RegistratLi,on t" 1 1_156<r%. Typ
e:
Expiration 12/92012 Individual
�qw.
OPH Registration:
Y k ,-1I -
JOSEPH MALONE.Y,
17 JUNIPER RD -\`" -�' �, 7
NORTON,MA 02768� Undersecretary
CITY OF SALEM
'# p PUBLIC PROPRERTY
a.�r.. DEPARTMENT
.�w:i ntI r:Oxtu�n t
�Itt,w
11C.WASH.-NI;w^SIXEL•T s S,tt r.w,M.t11.u.nt a I IN J197:
"1%"n78)15.9595 o P tx. 9711-740••l346
1Yorkers' Compensation Insurance :OitOdavit: Sul liferVContractors/Electricians/Ptumbers
\ ) ylicant Infttnnalion ��/j�/y� Pleas Print Le 'bl
Nit Inc lnnanle�fi t)r;lanlratinNlndty'dual):_ �l tJ � l'v U!L1
Addre.m 11 Jrl�IUfP€1�
Cily,Starc,/.ip! Waply 144 Phone it: JI/if e7t 7/07
.are 10111411 euyployer?Chuck the appropriate boss:
Type or project(required):
1.0 lam a empluyur with 4. 0 1 :on a gcncnl contractor and 1
nploycus(full and/ur port-tima).• have hire)the sub-contracture fl' new LO11•�tructtun
2 I.Int a sole proprietor or partner- listed on the anachtnl sheet : 7• ❑Remodeling
ship and have no mnpluycvtt These tub-contractors have d. 0 Demolition
working for me in any capacity, workers' comp, insurance.
I No workers'comp. iilyurance 5. 0 We at*a ctn7wrstion and its 9. ❑ OuiWing addition
requirud.) ofecers have exercised their 10.0 Electrical repairs or additions
3.0 1 wn a hnmcowner doing all work right of exemption per VIOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.§I(4).and we have no 12.0 Ruul'reprirs
insurance required.) t .mpluyccs. (No workers'
comp. insurance rcquirud.) 13•O GOItr
4ny.yiphcad tliW etecb boo nl muY a6u till auI iho kcnan bcluw dwwiny�huir wwkul cuntprntation pdiey inrurmWiun.'I lumw,wan wMt a,dtmil thin olTdavil indicating they an Joins all work and then hire twnide euurnuaq mut auhma a now om,4vii ir,Jtetalny etch.
•r.mtnch,n OhW'I"ck Ohio boa mot auxhod an aedittwul..hcot.huwilq aat nan10 otlhr aabcenlranod and new wurkon'comp,pWtcy mrorteah .
/alit can aalplayer dlat It previdigll workers'conopenrot/on lururnnce for ray ernp/uyeer. Br/utv/s the pu/fay unJ/cab xif�iaforrnutios
Insuranct:C'unipany .Naine:
I'ulicy it or Scif•ins. Lic.o: -.._ . .. _ Expiration Date:
Job Situ Address: City/Slaleizip:
Attack to copy of Ilia workars'cumptimatlon polio) declaration puke(showing the policy numbur and expiration date).
I-uilurc to sccuto wveruge as required under Section 25A ult.IGL c. 152 can lead to tits imposition of criminal penalties of a
tine up ht..1.5n0.00 umliur sae-year imprisomncnt, u.v wen car civil penalties in the Turin of STOP WORK ORDER and.1 fine
of up to i250.00 it Jay,lyainht lilt violahv. He advised that a copy of this smtcmunt may be lurwardcd to the(Alice cat'
I'll r111-VII-1113 el'tlle I)IA for nlsuracce coveraya terilicanun.
/du/rereby r ertify turder die p ins to perndtirr ttf per/tlry that the infurintiNen provided ubuvr is true and c ea ruet
Datc.
t1/jlriuf nee only. /)o nor w•rkY in 14/r area, lit be rmap/cled by city car to vm u//iriuL
i
('itr or fawn: _. Permit/Lleunse M_ I
Issuing Aulhi rity (circle line);
I. I(uurJ „f Ileahh 1. Ihtildio; Dcpartincut 1. (:it)r'faun Clerk J. Electrical Iulpeclur i, plwnbiny Insyceror i G. I)ltivr
t'.,nl.lci I'tnun:
Thane•y; .
I
Information and Instructions
\I workers' compensation for heir ctll
a,S.Ic I)u:u iClts Ucricral Laws chapter IJ2 I'cqulrCs all employers to Provide cuntmc[of hire,
s.
I'ursult to This.could,an emP&via is defined as,. every person in the service of another under ally
aaprdas or implied, Jral or written."
.\n elnpfuper Is defined as"an individual, partnership,.lssoclatwn,corporation Jr tither f legal eased or any two r t more
a he foregoing engaged in a joint enterprise- and including the legal representatives to"deceased employer,or the
ICGCIVCr Jr lluplCe uI �gl IlldividuJL plumerAip,;IssaCIA110a or other legal entity,employing employees. However the
owner of a Dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling huuse of another who employs persons to do maintenance,construction or("Puir walk on such dwelling hoot"
or Jn the grounrls or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152. §'_3C(6) also states that"every state or local licensing ag the commonwealthhfor
"gey shag withhold the issuance
renewal of r Ilceose ur permit to operate•huslaass er to construct buildings In or or
2ny
a
Igh he insurance
rpplicunt"Ito has iCiL nha produced
a23C(7)sbatesle v Neithece r he on monwealth nor any of its political giubt ivisreds'+hall
kdditiunully, . P
enter into any contract for the performance ut'Public work until acceptable evidence ofcunlPliarlce with the insurance
requirements of t his chuptar have been presented to the contracting authority."
,gppgcanu
Please till out the workers' compensation affidavit cocnspolyhona numbet{a)along with fheiring tile boxes that `certificrteLs)Of
y to your on O)mQ if
necessary, supply sub•contraclor(s)numc(s),address( )' P with insul;tnce. Limited Liability Companies(LLCworWrit'Limited
com pens"obility e ituullnce(if ao)LLC oroLLP does have
than the
members or partners, are not required to carry
enmplmyees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
employes for confirmation is tiun of insurance coverage. also be sure to sign gad date the affidavit. The affidavit should
he relunmd to the city or town that the application o ���regarding the lnnit or icens aw or if yis ou are ng(reyuired to obtauested,not u)lu workers'
of
Industrial Accidents. Should you have any 4
at
compensation policy, please call the Department the number listed below. Self-insured companies should enter their
self-insurance license number on the approptiara line.
City or Town Offlelals
Please be sure that the affidavit is complete and printed legibly. The Department has provided u spars at the bottom
of the affidavit for you you to tll out in the event the Office of Investigations has to cuntact you regarding the applicant
1'I:use be sure ro till.in he permit/licens l number which will be used as a reference number. in addition,an applicant
that must submit multiple pennio'licetlse applications in any given year,need only submit one affiduvit indicating current
"Job Site Policy informati n(iftile tif cd necessary) and
t has been officially tamcped or corss"the ked Ibyshe c ry or"iownt Inaptbe p provided to th in e
ur
Y
town), A copy
rifapplicant as proof that a valid affidavit is on f)la for future permits or licenses. A new affidavit must he filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venturo
f i.e. a dug license a Permit to bur leaves eta) said person is NOT required to complete this affidavit.
I he I)i lice of would like to hank you in advance fur your cooperation and should you butt a ny questions,
Investigations
please du nut hesitate to give us a call.
fhc l)aparanalt's address, tdlephune and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accident
office of lavesidgadons
600 Washington Street
Batton, MA 02111
'rel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.maw.gov/dia
CITY OF & .&M, 1�L-kss.A cfiusETrs
OULMLNG DEPARTM NT
120 WAiHLNGTON STRM, 3" FLOOR
` TM (978) 743-9595
FAX(978) 740.98U
Ki1BERIBY DRISCOLL
MAYOR THOmU ST.PtEx a n
DIRECTOR OP PLBL[c PROPERTY/BC1t.DLNG COMMISSIONER
Construction Debris Disposal Affidavit m
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It L5
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
l 11, S 150A.
The debris will be transported by:
fto� �
(name o haular)
The debris will be disposed of in
(name of facility) —,,---
Q'lud�y/�SCoTI
(address of facility)
signs re o .pcimit applicant
data
139
"—y 36 36" 30" 12" 24"
19" 69z' 1
3 18"T18" 3 " 36"
�. W3630 W3012 1230 CW2430R
. _..W3612 X 24 DP i_.. . .B18L D618 0-GI�JL S� BSS3 4? -
b
l
A I � OWi
I
a) I C W W
W W N N _
N N -
N i
W � J
N
N
� S4
O O p p_
� O �
C C cl
�TT f
;IL2
1811 12"
30"
This is an original desi n and must Designed: 3/29/2011
All dimensions size designationsg
given are subject to verification on "�9 not be released or copied unless Printed: 3/29/2011
job site and adjustment to it job � ; applicable fee has been paid or job
conditions. order placed.
Design3 All Drawing#: 1
Joe Maloney
General Contractor
17 Juniper Road
Norton MA 02766
508-285-7107
Proposal
Ann Selby March 31, 2011
38 Phillips Beach Ave.
Swampscott, MA 01907 11-7
Job location: 50 Freedom Hollow, Unit, Salem,MA
Kitchen Renovation
Remove and dispose of existing cabinets and counter tops.
Supply and install new Am oodmark"Han atural Maple" cabinets.
Cabinet layout will imilar to the existing. n�w. Y0510.00
Or
Supply and install n Kraft Maid Beal M e" cabinets. Cabinet layout—* be
similar to the existin not
liel ( $11730.00
Included in prices above are: ` J
1. The kitchen walls and trim will be prepped for and painted. The walls will be
painted with Benjamin Moore eggshell latex (color to be determined). The °
trim will be painted with Benjamin Moore semi-gloss latex (color-to be
determined).
2. Plumbing and electrical labor needed to complete the kitchen.
3. Building permits.
Not included in prices above: counter tops, appliances,sink, faucet, handles or
knobs for cabinets.
1.
Payment schedule: 50% deposit/25% at start of work/remainder upon completion
of work
Additional information pertaining to this agreement: ALL MATERIAL IS
GUARANTEED TO BE AS SPECIFIED AND THE ABOVE WORK TO BE
COMPLETED IN A SUBSTANTIAL WORKMANLIKE MANNER. ANY
ALTERATION OR DEVIATION FROM ABOVE SPECIFICATIONS
INVOLVING ADDITIONAL COSTS WILL BE EXECUTED ONLY UPON
WRITTEN ORDER,AND WILL BECOME AN EXTRA CHARGE OVER AND
ABOVE THE ESTIMATE. ALL AGREEMENTS ARE CONTINGENT UPON
STRUMS,ACCIDENTS OR DELAYS BEYOND OUR CONTROL.
Joe' . ey Date 1
Acceptance of Proposal
Above prices, specifications and conditions are satisfactory and accepted. You are
aut orized to do the above work. Payments will be made as outlined.
)ion Selby S Dat