3 FREEMAN RD - BUILDING INSPECTION (2) e '
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I'he C'omnlona'call Is of bl:usachusclts
hoard oflluilding Regulations and StandardsCI I'1' l)F
Massachusetts State Building Code, 7SO CNIRS,\Lli,\I Permit Application To Construct. Repair. Renovate Or Demolish a
Om,or rnv-kamo(v Dn cRinn
This Section For OI'ricial Use 0ol
Building Permit Number: Date Applied: _
L�sStvLL.' �t�r 2-t K�
(budding Olticial(Print Nine) Signa Oule
SECTION I: SITE INFORRI I
I.I Property Address: 1.2 Assessor� lap St Parcel Number
If'e2 _ 'N7t ! _
L la Is this an acce ted street? es no Map Number Parcel Number
L) Zoning Information: 1.4 Property Dimensions:
Laning District I'ntpowd Use Lot Area(s4 11) Frontage(It)
I.5 Building Setbacks(R)
Front Yard I Side Yan)s Rear Yard
Re411ired Provided Required Provided Rquirud Provided -
1.6 Water Supply:(M.G.I.c. 40,§JJ) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
2nne: Gutside Flood"Lune?
I'ttblic O Private O — Check il'yes0 Municipal On site disposal s)stem O
SECTIONS: PROPERTY OWNERSHIP'
2.1 Owner'of Re ord:
Sessr ��e 671-C <61/C 41,
Mune(I' nt) 'ity.State.ZIP
�/��
Nu.an $Ireet telephone Email Address
SECTION): DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner•Occup(ed O 1 Repairs(s) ❑ Alteradon(s) O Addition O
Demulilion O accessory Bldg.O Number of Units Other ❑ .Spccily:
Brief Description of Proposed Work':
SECTION 4: ESTIJIATED CONSTRUCTION COSTS
licit Estimated Costs: Official Use Only
L,tbur mid Materials)
I. Building S 1. Building Permit Fee: S Indicate how tee is deterntineJ:
( Standard City:Tuan Application Fee
'. I:'leetrical S t
❑Total Project Cost them 6).x multiplier --x
1. 1'IumMng S '. Other Fces: S_
J. \Lcch.utical Ill\ \C) S
�il,ncssionl S total \II Fees: S—_---_—_--
Check No. _ ('heck :\ntwml: _ _....._. ( .iih \Iwnutl:
n Tutu) Project Cost: i / 11 Zl
/ O" 6 d ❑Paid in Full ❑OmstanJing Ouhmce Doc:
SECIION5: ( 0NSI'RU(*,ri0NSFRVI( FS
7 .)J5.,
ee
rs
FNpirati, —.D.
-ni te
5.1 ('otistrut'lioil %uljcnisort,iceiise((Si.) -2 93Y
-5 1 0,11tru,"oil Sul) i,or I., I.( I I()N q. RUCH()N
l' RN I
2 0
D "Pit
csk:ription
,No-ind Sirv-vt lorc.NtriOvd I lituldinut iih to 35.0110 c11 111
"it..
lie,iricwd 1&2 F.I.,
M-
L SI'lle./111 Mason
I(C R,xitin 01%crin
AS A indow.uid Sidm
SF .Solid
SF olid Fuel IlurninsApplialiccs
-7e'l 7
Imulaiiiin
I Qlkrholle Is mail address D Demolition
$1 R Istered Home ImljrQv ement Contractor(HIC) e a S-�--,c;y VV
177- ✓ ,�'_s /C Cl C-75 ,A IV IIIC l4k:gi,tratiun Number —Fifiratioll Wit:
1114'Vollipj1�Name or I IIL'I(cj1styunj Name
No Street' Email address
Mid -,Vr?/ 7C�
City/Town,State,ZIP relephone
SECTION M WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 153.1 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 .......... a No...........0
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CO TRACTOR APPLIES FOR BUILDING PERMIT
r.
1,as Owner of the subject property,hereby author'
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Naiiie(Electrunic.Signature) Out*
SECTION 7b: OWNEWOR AUTHORIZED AGENT DECLARATION
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 accurate to the best of my knowledge and understanding.
r z
Print 0k%n;:r*i or (Fkutrollic sitillattirk!) Data
VOTES:
%n 0%%ocr who a building permit to do his.her own %%ork,or an owner who hires an unregistered contractor
e 1
(not registered in the Hume Improvement Contractor(HIC) Program), will W� have access to the arbitration
program ur guumnly fund uoder.M.G.L. c. 14I.A. Other important information on the HIC Program can be (ouild a
i Inrormation on the Cunstruoion Supervisor License :an be round at,, imi,; �i!-% It,,
I.
substantial work is planned, pru%ide the int'Urmation below:
2 lien fluor area
(,4
at floorarca(44. 11.) 1 including garage. finished basement attics.Jocks or ror0i I
total
no t�. .... . ikibitabit rouni comit
Gross It%ing atea 154. it.I .... . ..
\11111ber ot,Iirejllnc" \(1111her kit bedroottis
Numher oI hadiroomi \untbcrulhallhudu
I 11cofliv.1ting i),Ivol \twihcrol Jocks porches
I jwofcoohllg y,Mfl 1'110o'cd
I fol,il Project Squme I ootaec-mat N:,uhiututk;J Iksr I'olal ProiM ('01C
` A '
CITY OF S-V-&%f, �tiL�S3.,CH[,'SETTS
!3L'ttOL`1C CEP.%A-nMN r
I '0 T.I NNGTON STxj", 1"FtCCR
� 1tL �978) 7,iS-9S9S
'U1WERr YQUXOLL F.IX(973) 7a4984
NWOn lha�W Sr.Ft><Rts
01RUTCA 01V PL SLIC PROF IIITV/St:MDLYC C031311SSlONEA
Construction Debris Disposal Atfldavit
(required for all demolition and renovation work)
In accordance with the sixth edition otlhe State Building Code, 180 CUR section 111.3
oebris, and the provisions of,titCE a 40, S 14;
9s work shall be y Permit 4is
ibis work issued with the condition that the debris resulting from
disposed of in a 1 11, S I10A. properly licemed waste disposal facility as defined by NICE c
The debris will be transported by:
(n-une ut hauls) —
na debris wi II ba disposed of in :
n,
(Jddreu arfJwhiy�
" nrra of^ermtf J —"
� PPhunf
�J(e
•
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CITY OF S.UE,%Is NL�SSACHUSE"ITS
t ' 1f UCILOING DEPARTMENT
120 WASHNGTON STREET 31O FLOOK
\ TEL (978) 745.9595
F-vot(97,-3) 7$0.9844
:<I.\10 E 7LEY 0 RISCO LL
AkYO Z Tti034►3 ST.PTEQRB
DIRECTCR OF Pt:Ill.IC PRO PEATY/8CII.0IN ,CONNISMONEA
Workers' Compensation InsuranclI A117duvitr 13uiltters/Contractors/Electrlcians/Plumbers
%pl)lle:lnt Infnrmailnn rLf�L /' q P►cese Print Luoihty
Nmnalnminu,oUr�tmntirLrm77lividu.d)//: / /
Address: qn0i,, fat
City/Sratc/Zip:_15dA rr/ C J Phond M 7` d
,Arc gnu an employer'!Check the appropriate bait
I. I am a employer with a. ❑ I an a general co
ntractor and t typo or project(required):
amplro cas(fall and/or part-time).* have hind the sub-contractors 6' ❑Now construction
1.0-I M11 a sole proprietor or partner• listed on the attahect r 7• ❑ Remodeling
,hip and have nu employees These sub-contrahave 8 Otmalition
working liar myin anycapacity. worker'comp, ce. ,(N o workeri com insurance J. y ❑Building addition
p. ❑ We ors a enrpaead itsc ircd.i officer have exetheir 10.0 Electrical repairs or additions
3.�] 1 am a homeowner doing all work right of exemptioGC I I.❑Plumbing repars or additions
myself.(No worker'cutup. c. IJ2, It(4)a andve no 11.❑Roof repairs
insurancareyuired.l r omployecs. [Not w 'nurancerd.) I3._QOthcr eat G1Vb
tiny applham eW eh.aYa bee of mlmt alw nil uw ihv wetius buluw ahowiny Ihair rwbn'compnueun pulpy Mtlrrmuuon.
'I r,vnau+r,an oho rul+mit this uileAvit indicalny ihry at*doing oil,wra and then hit*",side M centrictms Mimi"'hank a new No 01vit'his b ml)Jaril indlaing ruck
I',mn+cwn oxMimsatauhed an Wduivrud.heat rhuwiny the nwne ariha mb.unlnctun anJ Ihair wnhm'comp,puliry,.l= uaq.
!fins un nnpluyrr that/s pravldbox worker'cumperrat/on Grsuranee/br my saris,yrr
inforntutlan. a Brluw/it rho policy and/ub site
In,unutce Company Name: Co G _.. �✓�
Policy J or Self ins. Lie. 4:r EApiration Does: q
Job Sita,Address: 221"Iti�rvrrryw/ Cityi Stuta/Zip:
.uracb A copy of the workers'compenutloe policy declarullon pjg@(showing the policy number and exploration data).
F'silure to sccury coverage as required under.'icclion 1J.A of VGL e. 152 an lead to the imposition of criminal penalties of s lire up to i I,JCOAO and/or mte•year imprkanrncnC as well is civil penalties in this farm of a STOP IVORK OROEA and a lino
of up to S_')0.00 i day against the violator. Ile advised that i copy of Ihis,talement may be furwordcd to Ilia 011ica of
lave,li gaiumn ol'dic MA for insursnee coverage vcriticatiun.
!Flu lrtrrby rvrriy nda the poi wed pnm///ri•r�pvrjury r/ruI der irrfurnrut/rat pruvidrJ ubuvr i true and cam
era
�1rti
IJa W:
21;�,t
0//Ai41 me o,+ly. /).a,for nrirt ire thin irru, la.5r cmu /'tdd 5Y f ir
P ' Yur ronn,r//lriu[
City nr fmni;
— - i'ermit/r.lccnre i
L,uin�.\ul barily (cirNa nnc); ..._ -
i. IJuard nl Ileahh !. ILlilillnq Ocp.lr tment 1. ( ;ly,'I'uun Clerk
0I licr 1. iilectricll I'npcl bir i. I'biohim„ Inrptcmr
.i.
07/03/2012 08:47 FAX a 001/001
ACORD
CERTIFICATE OF LIABILITY INSURANCE
DarE IMMIDDIYYVr)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER2THIS
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 ON PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the POIIGy(Isa) must be entlarsetl. M SUBRtheOGATION IS WAIVED, subject to
certificate
terms and Conn lieu of the Polloy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endDrsement s .
PRODUCER COOTA Themas GOchis NAME;
W. Gochis Insurance Agency PHONE _--.. .. '- -- .-.
Ag Y (7B1)272-9306
_1ACC.IL.9m)I__' Pla�l@a);17e 1)zT2-i36E
113 Cambridge St. EOgRE '---- -
ADDgeas:
PRODUCER 00OBEB
TOMER-1U.D0.00 . _ _
Harlington _MA OiB03 INSURERS)AFFORDING COVERAGE
IN8URR0 . . FL4754
ICq
INSURER A:COmmerOe Ins_._ Co_ _
Vincent 9imeener DEiA: V.S. Construction NSURERe:42 Meade Rd. - --
INSURER C;_
_ — ---
INSURER O; ----_ ---- ----
Billerica M INSURER E;A 01821 —..
INSUREq P;
COVERAGES CERTIFICATE NUMBER:CL127300651 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANDING 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,
I TYPE OF INSURANCE — POLICY EFF POLICY E%P -- — "-- -- - -
POLICVNUMeBR
GENERAL LIABILITY MMro MMIDD T LIMITS
EACH OCCURRENCE $ 300,000
X COMMERCIAL GENERAL LIABILITY CE�TO TO REN NER CE TED- —' -- --
A CLAMS-MADE LX OCCUR DHDXX 3/3/zds2 3/3/2013 P9IMISE6(Ee eeelgrIge) _- 9 — 100,000
MEO EXP IAnr ano Feregnl S 51000
---- PERSONAL&ADV INJURY S 300,000
GENERAL AGGREGATE S 600,000
GEN'L AGGREGATE -LIMIT APPLIES PER PRODUCTS-COMP/OP AGO S 600,000
X PRO- S
POLICY LOC - "--
AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT
ANY AUTO 'Ea"C"eml $
_ ALL OWNED AUTOS BODILY INJURY per pm¢on) S
SCHEDULED AUT09
BODILY INJURY(PerPwMgnp S
HIRED AUTOS
PROPERTY DAMAGE $
(Par awidenl)
NON,OWNED AUTO$ t
9
UMBRELLA LIAa OCCUR EACH OCCURRENCE S _
EXCESS LIAe CLAIMS-MADE AGGREGATE S
DEDUCTIBLE S
RETENTION S
WORKER$COMPENSATION WC STATU- DTH. &
4N D EMPLOYERB'LIABWTY YIN 10RY LIMIT$__ ER.
ANV PROPRI ETOp'1AR1NERIEXECUTIVE ---"-'-- -
OrnOERIMEMBER U(CLUDED7 Nla EL EACH ACCIDENT S
(Mandelary In NH) EMPLOYE s
Ilyya¢ tlee""under EA_DISEASE.EA
PBS�RIPTION OF OPERAYMNS W. E.L.DISEASE-POLICY LIMIT, S
DESCRIPTION OPOPERATIONS I LOCATIONS/VENICLES IARegN ACORD 101,Addlllonel Remark*SgheCule,If mere apace le MgNnm
CERTIFICATE HOLDER CANCELLATION
(978)740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem Ma ACCORDANCE WITH THE POLICY PROVISIONS.
Building Deept
3 3'reeman Rd AUTHORIZED REPRESENTATIVE
Salem, MA 01970 �M
ACORD 25(2009/09) ®1988.2009 ACORD CORPORATION. All rights reserved.
INS026(2EDBOB) The ACORD name and logo are registered marks of ACORD
RightFax C1-2 7/5/2012 4 :28 : 31 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDD/YYYV)
TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT H
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE 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
he 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 endorsement(s).
PRODUCER CONTACT
NAME:
PHUNIE
W GOCHIS INS AGCY INC FAX
(AIC,No,EXtI: AIC
113 CAMBRIDGE STREET
PRODUCER
BURLINGTON,MA 01803 CUSTOMER ID N:
29WKK INSURER(S)AFFORDING COVERAGE NAIL#
INSURED INSURER A: CONTINENTAL CASUALTY COMPANY
SIMEONE, VINCENT DBA V S CONSTRUCTION INSURER B:
INSURER C:
INSURER D:
42 MEADE RD INSURER E:
BILLERICA,MA 01821
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO 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 CONTRACTOR 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_ LIMNS SHOWN MAY
HAVE BEEN REDUCED BY PAN CLAM.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER rmmmYYYY) (MMIDmYYYY) LIMITS
GENERAL LIABILITY ACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED $
CLAIMS MADE E]OCCUR. REMISES(Ea occurrence)
MED EXP(Any one person) $
ERSONAL B ADVINJURY S
GEN'L AGGREGATE LIMIT APPLIES PER ENERAL AGGREGATE $
POLICY E::]PROJECT [—]LOG PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT E.accident)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY IS
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LAB OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKER'S COMPENSATION AND X WCSTATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB-5B271873-12 03/152012 03/152013 LIMITS
ANY PROPERFORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000
OFFICERIMEMSER EXCLUDED?
(Mandatory In NH) EL DISEASE-EA EMPLOYEE $ 100,000
DESCRIPTION under EL.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION under
OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THISREPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SIMEONE,VINCENT
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM MA-BUILDING DEPT SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED
3 FREEMAN RD BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACOORDAAbE WITH THE POLICY PROMgt9 IS
AUTHI RE ESENTATIVE 1
SALEM,MA 01970 �� _ :
ACORD 25(2009109) 1988-2009 ACORD CORPORATION. All righ served.