80 FREEDOM HOLLOW - BUILDING INSPECTION - iN
r The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY S M
Massachusetts State Building Code, 780 CMR
Revised dMar 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 A plied:
Mal
Building Official(PrintName) ' i ure Date
SECTION 1:SITE INFORMATION
1. Property Addre s• 1.2 Assessors Map&Parcel Numbers
Frt°p���1
1.1 a Is this an accepted street?yes - no Map Number Parcel Number
: 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Regdned 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 ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: p/�
Name(Print) City,State,
�ZIP
P �-
�Ro al (
No.and Street Telephone Email Address , CfD Nil
SECTION 3:DESCRIPTION OF PROPOSED W RK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : 90AINA4tj r A TE 4,r&T_RvO A I3P J J,1
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ i S o QO 1. Building Permit Fee:$ Indicate how feeds determined:
2.Electrical $ �Q.J ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ • Z 000 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Five Suppression)
$ Total All Fees:$
�1 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �OI C�Q V 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) OW,
j 0 I
&<',A4 License Numb r Expiration ate
Name of CSL Holder
• �� List CSL Type(see below)��
No.and Street Type Description
� VYN A- U Unrestricted(Buildings u to 35,000 cu.ft.
015 2 R Restricted 1&2 FamilyDwelling
CiLA tyrFof%m,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/'�� S n^�l SF Solid Fuel Burning Appliances
13 �Cy I Insulation
Tee hone Email address1 `J D Demolition
5.2 Registered Home Improvement Contractor(HIC) j t] L 6'S -7 t D 3 p zO
1 P 0T:! 1 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant N
I � r r-,aArtl
No and Street Email ad s
4, v� D15 �7 ?g1- 7-- , 4ot�
Ci /Tdwn,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit most 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 Owner of the subject property,hereby authorize Q4os`J
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name bel ereby attest under the pains and penalties of perjury that all of the information
contained in ' app r o tru and accurate to the best of my knowledge and understanding.
�g kO.0 013
er's or Au riz�ej gem (Electronic Signature) 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"
CITY OF St1LE�I, l L LS&. CHUSETI'S
`. BUMOLNG DEPART L&NT
120 WASHLNGTON STREET, 3'D FLOO&
TEL (978)145-9595
FAr(978) 740-9846
KIN
BERLEY DRISCOLL THoMASSTPman
MAYOR
DIRECTOR OF PUBLIC PROPERLY/Bl:IL17L`JG COJ12MISS[ONEA
Workers' Compensation insurance Affidavit: Builders!Contractorr/Electrlcfans/Plumbers
+nrtalfcant in(ormattnn / 1_ Please Print Legibly
Name 1Busiixns//O^^rgani:aliJn Individual): l T1`U� /l ��lJ l
Address: �`O l3 J /a✓Li� —' I .
City/State/Zip: —n to Phone M: CA \rr*_
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employee with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ lain a solo proprietor or partner- listed on the attached sheet t �• G.J«�madeling -
ship and have no employees These subcontractors have N. ❑ Demolitiort
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers'comp.insurance 5.'❑ We are a corporation and its
officers have exercised their 10.❑Electrical repairs or additions
required.) .
).❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,}1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 11..) ❑Other
comp:insurance required
-Any applkurd shot chwlts boa s I must also fill out the action below showing(hair waken'compensation polley intlurnatfon.
'I lemauwra•n whosubmit this amdavil indicating they ars doing all work and thin hlrs"1814e contractors must submit s now,affidavit indicting such.
�roitl tors thel chcrls this box mml 30aa110d un uUtIunul shoal shuwing tho nano of tho subcontractors and their workars'comp,policy informadon.
lain(on employer that/s providing workers'compearallon huuranee for my employees,• Below/s the pollry and Job site
informullom 'j" � T
insurance Company Name:
Policy U or Self-iim Lie.N: �^ / Expiration Date:
Job Site Address: D F e1` :C .n4 4I 1 10 City/SlahuZip:
,kt13cIs a copy of the workers'com pens a(to a policy declaratlon page(showing the policy nu mbar and expiration date).
Failure to see ure covemgo as required under Sec lion 2JA of MGL c. 152 can lead to the imposition of criminal penalties of a
vino up to S1.500.00 and/or ale-year imprisonment,as welt as civil penalties in the form o f a STOP WORK ORDER and a tina
of up to SM.00 a day against ilia J ator. Ile advised that a copy of this statement may be forwarded to the Officc of
Invesligations of the DIA for in nce coverage verification.
Ida hereby certify ld b obis a s all/re hifornrallon provided ubuve is true and correct.
o Ito:
�� ZSl 13
i' o ,i• O f
OJ/icful use wily. Do not write in this errs, o be completed by city ur town n/JtcluL
i
City or rown: Permitif.lcense.a
Issuing.\ulhority(circle one):
1. Dourd of Health Z. fluildinq Department J.Cityi fmvn Clerk J. Liectrical Inspector 5. Plumbing lnspectar
6.00er ---_—
i
Conlact Person: _. _ . ._.. .__. Phone lJ:_
CITY OF S,�LEM, UNSSACHUSETI'S
BuiLD IN,G D EPA RTNMNT
F• 130 WASHINGTON STREET, 3" FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KLNjBERLEY DRISCOLL
THOStAS ST.PtERRS
MAYOR
DIRECTOR OF PUBLIC PROPERTY{Ht'1LDCv'G COMMISSIONER
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:
S4%9 �j CC9AS �✓CA �
(name of hauler)
The debris will be disposed of in
T�V1
(name of facility)
(address of facility)
i
4ignpp ra I '
date
debri,afra«
Rightfax C1-2 8/30/2013 4 : 39: 52 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
T IFICATE IS 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(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to
the certificate holder in lieu of such endorsements .
PRODUCER CONTACT
NAME:
NICHOLAS A CONSOLE INS PHONE FAX
1 S3 ANDO VER STREET UNIT 208 (A/C,No,Ext): (AC,No):
EMAIL
DANVERS,MA 01923 ADDRESS:
27DKX INSURER(S)AFFORDING COVERAGE NAICA
INSURED INSURER A: TRAVELERS INDEMNITY CO.
STORY,GRANT DBA STORY CONSTRUCTION INSURER B:
INSURER C:
INSURER D:
15 GRAND VIEW PLACE INSURER E:
L YNN,MA 01902 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POUCHES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 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 MY
PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. UMNS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD SUB POLICY I DATE POLICY E(P DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MNTDDtYYYY) (MNTOmYYYY) LIMITS
GENERAL LIABILITY ACH OCCURRENCE $
COMMERCIAL GENERAI.LIABILITY
CLAIMS MADE �OCCUR. DAMAGE TO( RENTED $
REMISES(Ea occurrence)
MED EXP(Anyone person) $
ERSONAL&ADV INJURY $
SELL AGGREGATE LIMIT APPLIES PER'.
ENERAL AGGREGATE $
POLICY [:]PROJECT 0 L OC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE.AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
(Per accident)
NON-OWNED AUTOS PROPERTY DAMAGE $
(Per accident)
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS CLAIMS-MADE AGGREGATE $
DEDUCTIBLE IS
RETENTION $ IS
A WORKER'S COMPENSATION AND Y WC STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-5B646595-12 10//22012 101/1/2013 LIMITS
ANY PROPERITORIPARTNERIEXECUTIVE N/A E L.EACH ACCIDENT $ 100,000
OFFICERIME MEER EXCLUDED'
(Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 100.000
If yes,describe under EL DISEASE-POLICY LIMIT $ 500.000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOMER AFFECTING WORKERS COMP COVERAGE.
THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR STORY,GRANT.
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED
ATTN:BUILDING DEPARTMENT BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
120 WASHINGTON STREET 3RD FLOOR AUTHORIZED REPRESENTy,1VE
SALEM,MA 01970 %�.;
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 AGO RD CORPORATION. All rights reserved.
Rightfax C1-2 8/30/2013 4 :39: 52 AM PAGE 1/002 Fax Server
FAX
To: STORY GRANT DBA STORY CONSTRUCTION
Company:
Fax: 9787409846
Phone:
From: Assigned Risk Workers Compensat
Fax:
Phone:
E-mail:
NOTES:
Certificate of Insurance 5B646595 10-02-2012
This communication,including attachments,is confidential,maybe subject to legal privileges,and is
intended for the sole use of the addressee.Any use,duplication,disclosure or dissemination of this
communication,other than by the addressee,is prohibited !f you have received this communication in
error,please notify the sender immediately and delete or destroy this communication and all copies
Date and time of transmission: Friday, August 30. 2013 4:39:18 AM
Number of pages including this cover sheet: 02
08/29/2013 10: 45 9782234038 Consoles-Insurance #6179 P. 001/002
CFR Insurance Agency, LLC
Nicholas A. Consoles Insurance Agency Inc.
Fabri & Rourke Insurance Agency LLC
153 Andover Street Unit 208
Danvers, MA 01923
Phone: 978-223-4037
Fax: 978-223-4038
FAX TRANSMITTAL
Date: 5--p-9113
FAXNumber:
Attention:
From: a Q
Subject: ,.S'zY
Number of Pagers:
Wi19)
08/29/2013 10: 46 9782234038 Consoles-Insurance #6179 P. 002/002
DATO(MMIPP/YY1'Y)
CERTIFICATE OF LIABILITY INSURANCE 8/29/2013
` THIS CERTIFICATE IS 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(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policypes)must be endorsed. If SUBROGATION IS WAIVED, sueJect 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 Ileu of such endorsements .
PRODUCER N Tara ChepFAX
es
Nicholas A COnsoles InenrancO Agency Inc PN . (978)aa3-4Q37 .10�8>=as-sale
153 Andover Street Unit III
INSURERS AFFORPItaGCDVERAGE NAIL
Danvers NA 01923 INSURER A:Northland Insurance Company
INSURED w4swItEiRptSatety insurance ComaRy 39454
Grant story INS C!
DBA story Construction INSURER O:
15 Grandview Place REI
y nn NA 01902 INSURM
COVERAGES CERTIFICATE NUMBER�ster 12-13 REVISION NUMBER:
THIS IS 7O CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 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 SY PAID CLAIMS.
INSR TYPE OF INSURANCE A POLICY pPDC E POLICY E LIMITS
T
GENERAL UAe1LITY EACH OCCURRENCE $ 11000,000
N 100,Q00
X COMMERCIAL GENERAL LIABILITY /21/2012 9/21/2013 S,000
A CLAIMS-MADE nX OCCUR 5160090 MEO EXPf one orsan $
PERSONAL S ADV INJURY $ 11000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG 2,000,000
X POLICY P P LOC $
COMSIN NGLE UM
AUTOMOBILE LIABILITY
SODILYINJumY(Porpamon) $ 100 000
9 ANY AUTO
ALL OWNED X AUTOSULEP b3PS20S 1/l2/2013 1/12/2P10 aOpwy INJURY IPer acddnn0 $ 300 000
PROPERTY MADE S 100,000
X HIRED AUTOS X NONOWNED
$AUTOS PIP-Bade
UMBRELLA LIAS OCCUR EACH OCCURRENCE $
EXCESS LAO CLAIM&MADE AGGREGATE $
DED ETENTIDN WC GTATIJ- O
WORKERS COMPENSATION
ANP EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT
ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA $OFFICER/MEMI E%CWPEOP EL DISEASE-EA EMPLOYE
(Mandatory In NH)
I(yBe.aaarba once/ E.L.DISEASE-POLICY WRT I$
DESCRIPTION OF OPERATIONS -low
DESORIP71oN PF OPERA7IONS I LOCATIONS/VEHICLES (Attach ACORD 101.AddlEonal Remarko scpedula,Irmom apace is r-quira4)
Job Site: 80 Freedom Hollow Salem Na
Workers Compensation Certificate will be issued by Travelers Indemnity, Policy No. UB55646595-12.
Effective 10/02/2012 to 10/02/2013.
CERTIFICATE HOLDER CANCELLATION
(978)740-9846 SHOTHEULD ANY EXPIRA7ONHIF DATEVT THEREOF, NOTICEIFS Be WILL OR DELIVERED BEFORE
ACCORPANCE WITH THE POLICY PROVISIONS.
City of Salem
Bldg Department AUTHORI2EP REFRESENTATIVE
120 Washington Street, 3rd Flo
Salem, MIL 01970 ,5
Anthony COnSoleo/JGET -
ACORD 25(2010/05) 0 1968.2010 ACORD CORPORATION. All rights reserved,
INS025(201005).01 The ACORD name and logo are registered marks of ACORD