81 FREEDOM HOLW - BUILDING INSPECTION The Commonwealth of Massachusetts `REG IV@.
Board of Building Regulations and Standards
d9a / Massachusetts State Building Code, 780 CMR
'Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or DeN&AM10 All: 41
One- or Two-Family Dwelling
QQ QQ This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1. SITE INFORMATION
1 1 Property Address: 1.2 Assessors Map& Parcel Numbers
I rr� ��V �wIIno
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 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[
2. Owner of Record:
S. h r, U. ` (A.a�e f— e"
Name(Print) City,St�alte,ZIP
it
No.and Street elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Spceify: G ✓L t4
Brief Description of Proposj Work':
1 ZP- ia'�i d'1J
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ Q� — 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: �7 -
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ !
❑Paid in Full ❑ Outstanding Balance Due:
5 1 1 -7 St�J-r Tb GONT
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) No I
�1'11 kol id d I, License Number Exp�r hon Date
Name of CSL Holder
I ��'�� � 'gyp{-� List CSL Type(see below)
1-pn 6 � - Dtc �� Type Description
No. and Street -
DOM- U Unrestricted(Buildings u el ing cu.ft.)
1 alb—� R Restricted 1&2 Family Dwelling
City own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
Y�� RR�t//�� 11 II `^ SF Solid Fuel Burning Appliances
1 D( Sq pO I N-f 0 ➢ i\W 2X MSS ��7t^ 1 Insulation
Telephone Emad a s D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Exiir-tion Date
HIC Company Naaxpr�e or Registrant Nann
No.and Street Email address
L. rAer YV\ �1�OS ��l •� ��1
City/ own, State,ZIP Telephone
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 g [FOR BUILDING, M PER(IIT
I,as Owner of the subject property,hereby authorize i-� 'a/y r �d�/L� / / c 'Q�
to act on my behalf, in all matters relative to work authorized by this building permit applicatio V//
Print O is Nal e(E etronic Signature) ate
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information
conta ned`in s-application i rue a7 accu to to the best of my knowledge and understanding.
ace
Print Owncr s or Au orized Age ame(Electronic Signature) 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.c. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.>ov/d s
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) ^(.P- (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 halfibaths
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 SM.ENI, NLkSSACHUSETTS �
BUILDIING DEPARTNWNT
120 WASHL-IGTON STREET, 3° FLooR
TEL. (978) 745-9595
FA.e(978) 740-9846
�IBFRt F-Y DRISCOLL
MAYOR T Hoal tsST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 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:
�bX AY uG�-
(name of hauler)
The debris will be disposed of in
1�✓L ,', 1 yt A lX . to v
(name of facility)
Lw-4, o� -
naiycl
(addressfacility) signa - e-ofperyi pplicant
a&
date
dcbri�ulT,dx
i CITY OF S.0 EI I, 2AXSSACHUSETTS
BUILDING DEPARTA[D4T
120 WASHLNGTON STREET,3so FLOOR
TEL. (978)745-9595
FAx(978)740-9846
Kl-,fBFRp EY DRISCOLL
MAYOR I Rs�toMAs ST.FtER
DIRECTOR OF PUBLIC PROPERTY/BuI DLNG COMNUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information �' l G n Please Print Leeibly
NaMe(Busimxs Organizatiorvindividual): y/�f) Lk)) d C& I 1 D; I�
Address: `1_ ST I I�DA o�l.y. Y � Ili
City/State/zip: n YAP, DI qb Phone#: :)L SGi a• 4� 7 l--/ 7
Are you as employer?Chec the appropriate box: Type of project(required):
I.J'4 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ I am asole proprietor or partner- listed on the attachedsheet+ 7• ❑Remodeling
ship and have no employees These sub-contractors have g, [] Demolition
working for me in any capacity. workers'comp.insurance, q. Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp, c. 152,§1(4),and we have no 12.❑ Roof repairs /
insurance required.]t employees.[No workers' )3
. L�ln�n r
comp. insurance required.) ,Other
*Any applicant toot chicks box d I must also fill out the section below showing their worker'compensalwn policy infortnatloo.
}I Inmuowtttts who submit this affidavit indicating they ate doing all work and then hire outside contractors mint submit anew affidavit indicating such.
-'Contractor that chick this box must attached an addilional sheet showing the twine of the subwntrrctor and their worker'oamp;policy infmmatioe.
l am an employer that is.providing workers'compensation hisarancefor my employees Below is the policy and fob site
information. —Q� 1
Insurance
ce Company Name:- �(L/
Policy#or Self-.ins.Life.H: ,�ll�i Expiration Date: a
Job Site Address: _ 1 7 / �' F��� ��� City/State/Zip:
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 ofcriminal penalties of a
fine 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 a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may he forwarded to the Office of
Investigations of the DIA for insurance coverage vcrifieation.
do hereby certif ider the palas and penalties of perjary that the informadon provided above is//true and correct
SiL aturc Date:
P on x.
Official ase only. Do not write in this area,to be completed by city or town official
City or Town: _., Permit/License#
Issuing Authority(circle one):
1.Board of Ifealth 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Office of/Ir�::�r:�eriturvil/I ol'(l llruocltacll!
C Consumer Affairs&Business Regulation
UOME IMPROVEMENT CONTRACTOR
Registration: '128634 Type:
Expiration: 512/2017 DBA
ED BYRNE WINDOW CO
EDWUND BYRNE
756 WESTERN AVE
LYNN,MA 01902
Undersecretary
M111chusetts-Department of Public Safety
Board of Building Regulations and Standards
License:CS-p10870
EDMUNDJBYRI% ,�•- ��.
t8 Woodrow Terr4ee �f ;
Lyon MA 01904
Expiration
Commissioner 07109=17
i
E.B.Window and Siding Co. Invoice
E A
,1 756 Western Ave Date
Rt 107 z` z Invoice# ;�
Lynn MA 01905 4/18/2016 52558
Rep
Bill To,
John Wagner
81 Freedom Hollow
Salem, MA 01970
Y Q P O No A Terms
r ;Due DateF = Account# i` if Project
4/14/2016
.,Description Oty air Rate ' , `dAmount
u
Furnish and install Harvey Classic Replacement 4 482.00 1,928.00
Window
Matching grid pattern to existing 4 22.00 88.00
Full screen upcharge 4 0.00 0.00
All windows are to have Low E glass, Argon Gas and 0.00 O.00T
carry an Energy Star rating
Seal Windows in and out using Tite bond lifetime 0.00
sealant
Take away all job related debris 0.00
Note: all sizes on file ready to order
Any building permit required to complete project to be 50.00 50.00
added at cost to the final payment
t 11 0.00 O.00T Ili
acceptance of proposal �- W/�
authorized signature
Sales Tax 6.25% 0.00
Thank you for your business. Total $2,066.00
Payments/Credits -$500.00
Balance Due $1,566.00
Phone# Fax# E-mail Web Site
781-592-9747 781-592-9746 ebwindowa msn.com www.ebwindow.com
Massachusetts Department of Public Safety
$1a Board of Building t ..__P g Regulations and Standards
License: CS-103018
Construction Su a
Supervisor
STEPHEN J DRIVE �'r
4 HENRY STREFX "t
SALEM MA 019to
U71
`
Commissioner Expiration:
O6/29/2077
,,AA Vlte tpomvneonarea�¢�(�q�,r/zueetta
�\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
O OVEMENT CONTRACTOR before the expiration date. If found return to:
76148Type: Office of Consumer Affairs and Business Regulation
W)Req',,alr'aMtjPoa:
xpiration'-=4P 7! 017 Individual 10 Park Plaza-Suite 5170
Boston,MA 02116
STEPHEN J.DRIVER�� ._�-
STEPHEN DRIVER
4 HENRY ST T
SALEM, MA 01970
Undersecretary Not valid without signature
Marcia Kirkpatrick
From: Cyndy Anselmo <cyndy@ecpllc.net>
Sent: Friday, April 29, 2016 10:39 PM
To: Marcia Kirkpatrick
Subject: 81 Freedom Hollow,Salem
Hi Marcia
The Board of Trustees of the Village at Vinnin Square have approved the request of the owner of 81 Freedom Hollow to
install windows in his condominium. The windows will be installed by EB Window of Lynn.
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
cyndy(n ecpllc.net
t