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35 MASON ST - BUILDING INSPECTION -* 2S The Commonwealth of Massachusetts Board of Building Regulations and Standards INSP CTIRVI ES Massachusetts State Building Code,780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolisl814 NOV 2 4 P 2 U One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Appli 1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 3 5 mA So I L]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 2.1 Ownerr of Record: �j f L Ew 5�{ ✓ ✓�}"��1 Name(Print) City,State,ZIP -zGr Y.>7 3 No.and Sneer Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ I Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units ' Other ❑ Specify: Brief Description of Proposed Work : o r [/ s Q if— SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard Cityaown Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ /Olr• ❑Paid in Full ❑Outstanding Balance Due: ZSCD--)T t zz SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Sj797?Efie W. Palm s3 �a License Number Expiration Date Name of CSL Holder 3 Mon 5`ftd List CSL Type(see below) q No.and Street sEdemType I I Description U Unrestricted(Buildings up to 35,000 cu.ft. Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Atlantic Wa dwrization,LLC HIC Registration Number Expiration Date HIC Company Name or HIC RegisfflKle AVCnUe No.and Street SateM Email address 5�� HN-s�y� City/Town,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 Issuan f 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 1,as Owner of the subject property,hereby authorize Z-�-r i C. (9,�--I to act on my behalf,in all mattes dative to work authorized by this building permit application. Er �w slt / //A�l/r Print Owner's Name(Electroric Signature) Date SECTION 7b:OWNER'OR 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. / Print Owner's or Authorized Agent's Name(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/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost" i - -• ---� . a�L �e:rver a CERTWICATE OF � ABOU�Y 9,NSURANCE OATS 1 THI5 CERTIFlCATE I3 ISSUED AS A MATTER OF 1NFORAtAifON 03-72-2D74 NO RIGHTS UPON THE CER77FICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTIEND OR ALTER THE COVERAGE, AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHOR2ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. iIMPORTANthe T: If the cartiandfrc nd holder is an ADDITIONAL 3NSURED,IDepoficy(es]must be endorsed, if SUBROGATION t5 WA1VE0, not cote rights terms and rhT, ons Dfthe policy,certain Policies may require an endorsement A statement on this cerflficete does I not PRODUCER rights to the cerhTicate holder in flea Df such andorsemem(s). PRO W CER I EASTERN INS GROUP LLC NAM cN-.A- 233 44EST CENTRAL ST PHONE FAx NATICK,MA 01760 IAO w.Enc rAt Nm: I E-PA aces I mSUflER(SI AFFOROPIG COVERAGE f.\SUA ERA:AMERICAN ZUgiCk INSURANCE^ NAIC: LNSUflED .RAMPANT ATLANTIC WEATHERIZATION LLC INSURERS,: 61 REAR JEFFERSON AVE INSURER c: SALEM.MA 01970. - INSURER D: U:SURERE: COV B IN$UAEA F: C I THI5 ABOVE O CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN SSUED i0 THE NSURED NIAMEO CONTRACT OR OTHER DOCU ROD INDICATED.I tNIITH RESPECT OTOITHSTANDING ANY WHICHH THIS CERTIFICATE h4AY E ISSUE ORREMENT. TERM OR CMAYDITION OF THE INSURANCE AFFORDED BY THE POLICIES DESCRIBESUBJECT ANY CONpITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN gEDUCEDBY PAID CLAIMS. E TERMS, EXCLUSIONS AND INSR LTR TYPE OF INSURANCE ADO SUB DCYE� E ppllpy ,..P GENERAL DABIUTY 1 SR 4W POUCY NU156EA' Po "'ER' ttd D urnns 2071"ERCULL 0oVERALLw31LRY EACH OCCURRENCE S CUIEfS?1AOE❑ OCCUR 0q.1AGETOAENTEO S MEOEXPIx Frf a,eRersPN 55S�-�'' FERSONALEADV INJURYS M7:aC{1gEGATEUMRAPPUESPER: GENERALAGGRSOATE IS, f �POLicy 2CT LOC f FRODUCIS-COMP.OP AGG S A OMOS0.ELUIBE.rrY S AVY AUTO COM4D{J�..,SINGLS I IMM S �^LL C.WrEp SCNEplllp UTpS AUbS BODILY IMIURY IP-pbmn7 S kCiSO AUTOS SYNEO BOO ILYWURY(Pe,egAM) S 1 I P90 'RAGc S u6fBRELIA LU18 OCCUR S I EnCE55 DAB CL1DdS•fdADE EACHOCCURRENCE S 1 10E0. RSTENTIONS AGGREGATE S I WORKERS CO1dPENSA, IS AND E)dPLOYERS UABILnY { AV(PAOPRIETCAlIARrnERc rR: ,Y ITORYL 11YCSTAN- OTH. 0-4CERMU13- ExclupECT%ECUTrv�N1F .^..IT$ ER I IMen:e:mrin er,� i I J6z u6 03.20.2014I 03-20.2015 E.L.EACHACCIOENT $.500,000!I>vs,t` SB270121 Dom- IPMV FOFEAATION EL OEiEASE-EA glFLOYEE S300,000 c L paEASE•Palo uMlr g500,000 I DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES$ (Al1aeH ACOAD lO1,AtlURbrm1 RAmarly SeHetlVia,it more M I' fiETm regWretl7 I i 1 -C-ERTIFIC TE O CITY OF SALEM CANC ELATION 93 WASHING TON ST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE' SALEM,MA01970 CANCELLED BEFORE THE pIRAT10N DATE THEREOF, I ,NOTICE WILL BE DELIVERED IN ACCORDANCE Y?ITH THE` i POLICY PROVISIONS. AL7Mp R®REPAeSENTATYE ACORD 23(2010l03) The ACQRD name and! Dace re i r d ma-2610 ACORD CORPORATION.AI!rights reserved i D9 9 stared marks Of ACORD THIS CERTIFICATE IS iSSUED'AS q MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFlCATE HOLDER-nyM CERTIFICATE DOES NOT 3/10/2014 AFFl SUM kh OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY BELOW. THIS CERTIFICATE 01 INSURANCE DOES NOT CONS REPRESENTATIVE OR PRODUQ TOTE A CONTRACT 8 THE POLICIES IMPORTANT: If the certificateAND THE CERTIFICATE HOLDER. BETWEEN THE ISSUING INSURER(S), AU the terms holder is an ADDITIONAL INSURED, the AUTHORIZED and conditions of the'Poiicy,pertain policies may require an endorsement A statement on this certiflcate does not confer rights to the policy(fes) must be endorsetl. If SUBROGATION IS WAIVED, cerOficate holder in lieu ofsuch'endorsem PRODUCER am. a). subject to Eastern Insurance Group LLC CO a Construction 233 West Central Street PHONE , (508)651-7700 FM Ep ILA: Not Natick MA 01760 INSURED INSURER AFFORDING COVERAGE INSURER A:Arbella PrOt@CtiOII ICURalII3. NAICa Atlantic Weatherization INSURERe Arbella Inotgct2. Cc' 1360 61 Rear on Avenue IN URERCNautilus Ins Ins CO. 0017 urance Co INSURER D; Salem COVERAGES Lii' 01970 INSURER E: 'CERTIFICATEINUMBER3taster ao14SU F: THIS IS TO CERTIFYITHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED ITITO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N0TIMTTISTANDING ANY REQUIREMENT, REVISION NUMBER:C CLUSIO TE MAY O ISSUED OR MAY PERTgjN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE LEXCLUSIONS AND CONDITIONS OF SUCH POLICjES.LIMI'1SSHpWN MAY HAVE BEEN REDUCED BYS DE MS ON OF ANY LION I RACT OR OTHER OCUMENT WITH RESPECT TO WHICH THIS R TYPE pF INSURANCE TERMS, GENERAL LIABILITY POLICY MBER POLICY MUC EXP X COMMERCIAL GENERAL UMRS A I ERAL uOCCUR : EACH OccURRENC= s 1,000,000 DLAIM6dLipE ®OCCUR 500042816 /20/2014 /20/2035 MI S 50,0p0 MED IXP(An anp �) S PERSONAL B ADV INJURY 51000 GEN'L AGGREGATE Ul APPLIESS 1,000,000 POUCY a LOC GENERAL AGGREGATE S 2,000,000 v PRO- AUTp1AOB1LE LIA81lJTY PRODUCTS-COMPJOP AGO S 2,000,000 B ANYAUrO S M N SING UNIT AMom D SCHEp 10i 1 000 000 X AUTps X AVfO$U� 02 0 0158 71 BODILY INJURY(Pe parsa0) S HIRED AUTOS X A��WNED /20/2014 /20/2015 BODILY WJURY(Pvactid eNl S X UMBRELLA LU18 X OCCUR PROP RTY11 S A EXCESS UAB PIP$aala S GLARAS-MADE EACH OCCURRENCE11000,000 8 000 DER RETENnONg S 1,OQQ,QQQ AMDEM9IFORKERS COMPENSATION 600058654 /20/2014 AGGREGATE S 11000,000 AND EMPLOYERS•LIABILITY /20/2015 ANY PROPRIETORIPARTNERREXEMMVE YIN VrG STATU- S OFPICER0AEL1eER FKMUREO (Mandatary in NH) iER NIA pTl} R Vas,dasaibe under EL EACH ACCIDENT S RESCRIPTION OF OpEpATIONS belpx EL DISEASE-EA EMPLOYE S C POLLOTION LIABILITY 0/1/20 EL DP IPL200378602 ISEASE- OUCYLOAR S 13 0/1/2014 GENERAL AGGREGATE DESCRIPTION OF OPERATIONS/LOCATONSIVEHIC EA POLLUTION LES CONDITION $1,000,000 Atta $1,000,000 ( ah ACORD 101.Addl6anal Remade Sahedale,IT,nala epees la Mquflaa) CERTIFICATE HOLDER 1 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SAI,EM THE EXPIRATION DATE THEREOF, NOTICE WILL BE 93 MkSHINGTON STREET' i ACCORDANCE WITH THE POLICY PROVISIONS, DELIVERED IN SALF-M, k% 01970 - AUTHORDFD REPRESENTATArE ',CORD 25(2090/05) Ronald Cltsaves/S� �� • NS026 nmMSf m ©9988-2010 ACORD CORPO ��_ Tl.e eCA i❑Damn anN Innn aro e" RATION. All ri h . w�of ernan 9 13 reserved. 1 Massachusetts -Qeaarttrenxaf Public Safety Board of Building Regulahons and Standards Construction Supervisor License: CS-087977 ERIC W PALM 3 HILTON ST Salem MA 01970= Expiration Commissioner 04/23/2016 ..._ - - J r Vour/r+nrunerr�l�rs`6i/SO.iSaCw1P!!J .. Office of Consumer Affairs&Business Regolation . ME IMPROVEMENT CONTRACTOR - istration: 142089 Type' . iratfon: .3/12Y2016 Ltd Liability COIpOc; vp ; ATLANTIC WEATHERI7ATION L.L.C. ERIC PALM -- - 61RJEFFERSONAVE SALEM.MA 01970. - Undersecretary Massachnsegts$once I� '�oveffient Sa le �olatract This formsatisfial basctega6anWm at'theatates Home lu^gnogempWd:a humeoivaem See$ �Pmvemem Gouttaca:I ,v - - . .- iVfe64dchtaalsCenaa¢erG1}darn Flom IMMAIT•'Anypeasm phmdttghomGL�'��AIbutd°eenotma6tdestandatd OGaeofCo¢somerpfFaoymWldwdntse ammngmxopnmkmYaorraidWtmP¢You sbouidflatobta}na Wpyaf A Homeowner RagdaumbC�nso¢erinfoxmmian Hodb,eatG7TAf3.g787 yr 14 aw Own freecom byallingtbe IoformeHoa _ 2as3m eras arcwnhsite a Me - Contractor;iaforn}atioa Suss Address(doom umaPaa OltmeD@ i�-�. ,- i _ _. addres) CamagmrS �d . } CipdToan a¢ �j 40 Aveme. : q zip c Code emmesdddress(mat- DMimel'hone -( - &aainel5teie I 4 �� - zc s- ys,3 G4•rTona Sme Mzilioe Addiess(hdt$amt nmintasPhaae - Pederal Ioammorsm lanatbm a mi®en®e ^°xteramaaszrvale treY - r<amme W.n m the foaondngiro forlheAomeotvq. ma '3VVII �JIOc.!�j Pt GC1I la y[ (✓ t antnia[slelx / v:caaa;,; i t ham- t Required Pefmits.7ha NI I . andm7lbeseWred °amo,mldmgpemdcsare tegmred Pmpnsed Sm+tmdC _ (Owners who bYd+acmaaaarasdtehatneonae{sagWC be oatpteffmSahedale.7ye escludedfrosntheratheiro}Ynperm. will be adltaedm°d°ss beyondthecea�aG.aam}�s�jm arise Gna!'aaipFuadpinsisiolssof �zs bIGL chapter I42A) Dateubea ecaftwor�nill / beg^Wotmcted and: DatevomWnnaaedi,arY.aitl6es¢ Te nnctor dWand PavmmrSchednle _ baindaljy cempleted TheCmtraaoragees to edom P 1hesWrl4 fisvicd dtemetedd so dlabmsPm*d aboveforthe Low 1. Paym®ts ipll be mademmid)og to U.&I alvin,schied jc samof: ° traa(m[m asnWH lr3 oftho mml mnaaetPdcegtitecoscof tea`—•—�!arupone°mp7etioa of sPaml mdeitems a}de5avaisgec°v) /�. 0 orupea compledm of n / S — je>-yr ! ri upmcomplaiienofthecootray (Gam Gubidsdemaodm Theraa g fitG p°Ym®j mal contract iscomP)ded m boW to�meeRaen heainsm s rohawiar Perty'ssaasfaanm) Wo>plaimschrdde(") S / i�----. NOTES.im brclurTi an --�imd�m aS Tmaneeebyga(.•) eaYd°Pnsh ordoan r nota�WeFaaterorCa)mu thiN orthatobl WamaPdeeor(b)the�a}maeit��ed '. nidehmmbespeaid ordered inadsaaceromea the°amplaion Wmacrorbefomuaie 6e3tasm� Esnresrt xhea.A. Woipmmt or�in myamatedet Y° ia•-Is 1 S hWntWet Tx� hh d lry Ne nr.... n . ❑v � ' Pam/subcenmctar h11yy a°lacs to hesde}piespaaa-b}efm�plcem of We mL b)the Wnaaetor The mntacia fmdteragro�mfuaold• desmhed regaed)ea°Ftheamiouq aFGeV Will ConaaaA.cce i rs i Srrspoav-6le for ptmW-Upon si5at)ag•ibe dommentbeWmasa ' °G IaYmWmto all mbWntraaorsfor Wnhau sbdl m[implY tlu[atrpliW orolhtrsagnja•i°tatathash��pl�mW�e erg ateFullp 6eforesi in t}Nessothene�¢o;ed smtbm dtisd En gthisWnmet ra5id®¢RaviesvWafolloaiog the eaudmsand n001®ar4 ° DonY he ptesmred mto si - '@ai¢g the WatrdccTaLx dmemreadmdfnll and ° � Jid Homa lmmnvemm r Y etsmafl}t. 9uesdtws ifsom acantreaorsrobere � eddngismUear- geaeredaidtOeD The]mv tagis^a^^¢6Y tsmmgmthe °�0r°�o°mL^pmvement Contractor �O homeimpmymWi Wn°°cmm and °a o aattarhateinapaDnrem?ASlt the Caatramor��6iPs170.Bostm.bIA0211R 6w6my g61�IA73�or8882gi 3757, ° 'pmoFofinturmce^doameot t^aca¢ceWm�Y}nfomatim so ihetvou iCnowwwridusaad25potm3ilitisRaaddtelm °�eaofamwvaroge,oral};m GuidetotheHomeha p°uaatiafatmmimoa}hemxrsegdeofthis i pmvament Conmawiav- _ fmm u¢dgaatmpy afihe Cottsuma Youm.-}•caned this a9uemWtifitbasbmr Wntraetorin nridpgat hiWherimin office or6rmapfaceother than thecontreclots nomd 'Wild business dayfoUm+iog tbesigoin ofdds c6 oAice by urdmmymaG paged,bptd_ Plata ofbushtess,pmvitied}auaotitvthe attaUted nmia°faa��at orb ebsxiy,nm lm¢thao midnight ofibc DO ROT SIGN* �� Scetba eeliadon hzm farm suamaw_}m- THIS CONTRACT IF•rpa��. emlmadm aftbisd t taaar0eeamaa�c¢sp;,p}y} oe avpF 1 � LANK SPACF,Sfly � ro�raelieetgtaFdaWivame Come- ------------------------------ Date Contractor Arbitration i arbitration The Home improvement Contractor Law provides bomeoavnmswvnh the ri8htto initiateanutomaticaliaction afforded as alternative to court action)if hale a olisPntewvnb a contractor_The same riaJu Il% contractor.however. The contractor would have to resolve on}•disputehelshe has with a homeowner m count tmless both parties a to the optional clause providedbelowY. This clause would 0ve the contractor the samerightto }ee arbitration as is affordedto the homebwnerby the Home Imoroverneut Contractor Law. wThe r anti the homeowner hereby mutually agree in advance that in the event the contractor has a dispute _ is contrac4 due contractor may submit the dispute to a private arbitmuon;firmwehichtras been approved by Secretary of the•Fxecutive Offh j of Consumer AfFaits and Btrsmess Regulation and the coilSamersball be requited sunnJ/ch arbitration, blassachuseus General Laws chapter 142A s a signatreConhH $7)3tre P e sigmnures of the patties above apply only to the agreement of the parties to altettltmve dispute resolution initiated by the contractor The homeowner may initiate alternative dispute resolution even where this section is not separately stored by the parties: Homeowner's Rights ter 142A)and other consumer A homeowners rights trader the Home Improvement Contactor Law(MGL chap protection laws(i.e.Mi GL chapter 93A)may not be waived in my way,even by asreement as oweverlprescrib home my owners may be excluded from certain rightsjifthe contractor they choose is not properly regist ered Homeowners who secure their ono building permits are automatically excluded from all Guaranty Fund provisions of the Home improvement Contractor Law. The contractor is responsible for completing the work as described,in a timelc and wvorimranlila:manner. Homeowners may be entitled to otherspecific legal rights if the contractor for arranties guarantees or provides an express eiatreaty for work mtansldp or materials. in addition to guaranteesrch provided by the contractor,all good's sold in Massachusetts tarn'an implied warranty of merchantability and fitness for a particular purpose. Aneatunemtionofothermattersonwhichthehomeownerandcontractoriawfnllyan_reamaybe added to the re®s of the contract as long as they do not restrict ahomeownars basic consumer sights. Ifyou have questions about your consumedhorneowaarrightst contact the Consumer Information Hotline(listed below). j Execution of Contract The contract must be executed in g6li=and should not be signed until a copy of all exhibits and referenced ve been documents have been attached. Pariies are also advised not to sib the sigdocned copy of the con until all tract-urith attach sections ments is to filled in or marked as void,deleted4n not app&cable_ One original sie_nedcap-be given to the owner and the otherbept by the contactor. Any modification to the original contact must be in writing and instead to by both parties Contacted wvorkmay notbegin until both parties have received a fully executed copy of the contact and the three day rescission period has expired. Acceterated Payments A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems hmt/herself to b t financially insecure How•ev r,in instances where a contactor deems hitniherself to be financially insecure the contractor may re th require the balance of funds not}et dire be placed in a joint escrow,account as a prerequisite to continuing the contacted work. ZVithdawval of finds from said account would require the signatures ofbodt parties. i Additionallnformation ffyou have general questions or need additional information about who Home Improvement Contactor Lmv or other - consumerrights,orif}•oux,.ishto?btainafaeco_pyof A.Massachusetts consumer Guide to Home Improvement" contact - - j Can samerInfonnationHodine Office of Consumer Af aim and Business Regulation 10 park plena,Room 517%Boston,MA 02116 617-9Ti-8787,889-283-3757or visit the 0CABRwebsitaat"t:a: _'•'-'==="" " °_ ifyou Avant to verit,the registratio.b of a contractor or if you have questions or need additional information specifically about the contractor registration component of the home Improvement Contractor Lan:contact: Director of Home Imprm'ement ContactorRe_g'stmtion Office of Consumer Affairs and Business Regulation j 10 Park Plaza,Room 5170,Boston NNIA 02116 6173 8787,888 28r3T7 or visit the H(C websi teat!' Go online to view the am=oraHomeImpmveracruContat:torsRegisttadon: , 'i- - •-'a u_'ru ri^�r�r�•. _.--`licznse.iiat�_ complaints against a business,call: For assistance with informal mediation of disputes or to register format Cmtattncr Complaint Section i Office of the Attorney General 617-727-8400 ANDIOR I Better Business Bureau 308-653480o,508-755-2548 or 413-734-3114 The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): At6ofic W ti ,LLr, Address: 61 R kffWw Avalue City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. m a a with employer er 4. ❑ I am a general contractor and [ P y � 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance? required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 244t C(l Policy# or Self-ins. Lic. #: f-;- / Expiration Date: Job Site Address: 3 �— IXa 5°"\ 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 of criminal penalties of a fine up to $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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepainnss aandpenalties ofperjury that the information provided above is true and correct. Signature: ( ` Date- Phone#• !�' 7�- ? N Y - Ol 1,7 Official use 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 Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6, Other Contact Person: Phone#: 9�}t Massachusetts -DepartmentWf Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-(W977 EMC W PALM = S 3IMTON ST Salem MA 01970- _ Expiration - Conunissioner 04/23/2016 '�wxiuonweall�n�,C"llauarloade/b Office of Coss uner Affairs&Business Regulation § ! ME IMPROVEMENT CONTRACTOR Type: istration: 142089 hation: __3f1212016. Ltd Liability Corpoi ell ATLANTIC WEATHERIZATION L.L.C. ,y ERIC PALM 61RJEFFERSONAVE SALEM,MA 01970. Undersecretary _ i