51 MEMORIAL DR - BUILDING INSPECTION The CommonwealthofMassachusetts RECEIVED
Board of Building Regulations and St�TIONAL SERVI FOR
7 CMR M Massachusetts State Building Code, LITY
USE
Building Permit Application To Construct,Repair,Ret t% geVo0b a LkvisedMor2011
One-or Two-Family Dwelling
This Section For Official Use only
Building PennitNumber DafeApplied
l (1 Budding Official(Print Name) Signature
�+✓ !'n Date
SECTION 1:SITE INFORMATION
1 1.1 Pboperty dress: i �r 1.2 Assessors Map&Parcel Numbers
Mats ttbisan accepted street?yes no' Map Number ParcolNumber
13 Zoning Information: 1A Properly Drmenslousc
Zoning District Proposed Use U;t_A a(sq$) Frontage(g)
1.5 Building Setbacks(ft) -
FmntYard Side Yards. Rear Yard
Req�' Provided ReiN6ed Provided Required' Provided
1.6 Water Supply:(hLG.L a.40,§54) 1.7 Flead Zoas Information; 1,S Sewage Disposal System:
Public❑ Private❑. .. t Zone:' Outside Flood Zone?. Munn On
_. , .. Checkifyes❑- �. P�❑ site disposal system ❑
SECTION2: PROPERTY OWNERSEHI
Na OJl
e i of R d �Imo, r
Name t) - Ury, ate6Z ..
�L Mf,t2!on-0 Q/. 978 • 3yja
-
No.and Street Telephone . .Emat1 Address -
SECTION 3:DESCRIPTION OF PROPOSED WORle(check all hat apply)
New Construction 17 Existing Building❑ Owner-Occupicd E3 1 Repairs(s) ❑ teration(s) ❑ Addition O
Demolition . ❑ Accessory Bldg:❑ NumberofUnits- Other Specify
Brief Description of Proposed Work.
n ... A �'.
t' je C LI.
-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
abor and Materials Official Use Only
EMech (,Fire
$ I. Building Permit Fee:$ Indicate how fee is determined
$ ❑Standard Ciwy own Application Fee
❑Total Project Costa(Item 6)x multiplier x
$ 2. Other Fees: $
al (HVAC) .- $ List
al (Fire- $ r Total All Fees $
6.Total Project Cost $ �t CkeckNO' Check Amount Cash Amount
O 7t`� . . ❑Paid in Full i ❑Outstanding Balance Due:
MA
SECTION 5 CONSTRUCTION SERVICES
51 Construction Supervisor License(CSL) G,7 q -7
1 ' J . , 1 D
i i:• ; License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
c r1 Eric W+Palm
No.and Street 1Ype .- Description
3 Hilton Stied u umeabieted uildings up to 35 aoo cu.&
%dem MA 6I970 .R Reslricfed18dFamrl Dwelliv
Citylrown,State,z I P _ tit Masmary
RC Rootia Covering
WS Window and Siding
wf �11A —J SF . SolidFuelflmomgAppliances''
1 w c I I Insulation
Tdephone Emaladdress D I Demolition
5.2 Registered Home Improvement Contractor(HIC) ! o�Q 3 )Z &
Atlantic WeatlluttaGuiy t,,...
HIC Registration umber . ExpoationDate
MC Company Name orillaMeMWAMEM Avenue
No.and Street Salem.MA 01970 Email address
frown,Stma,ZIP Tel oae
SECTION 6-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLGJL r.M§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial-ofthe issuance�pfie building permit
SigaedAffidavitAttached? Yes.....,....01 No...........❑
SECTION 7a:OWNERAU'THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORA+P-PLIES FOOR/BUHAING PERMIT
I,as Owner ofthe subject property,hereby authorize zf (G 1 u l Yl 1
to act on my behalf;in all matters relative to work authorized by this building permit application.
KJ, "oij 3
hid Ownees Name(ElectnwicSignature) i Date
i
SECTION W.OWNEle OR AUTHORIZED AGENT DECLARATION
4 .
By entering-ray name below,I hereby attest under the pains and penalties of perjury that all ofthe information
contained in appliis accurate to the best ofmy knowledge and understanding.
1?dmOwner'sorAulhorizedAgent'sName(ElectronicSignalure) - Date
NOTES:
1. An Owner who obtains a building permit W do his/her own work,or an ownerwho hires an unregistered contractor
(not registered in the Home Improvement Contractor(FIIC)Program),will not have access to the arbitration
program or guaranty find under NLG.L.o 142A.Other important information on the HIC Program can be found at
v/o www-mass.eoca Information on the Construction Supervisor License can be found atwww.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.&) (including garage,finished basement/at6es,decks or porch)
Gross living area(sq.&) Habitable mom count
Number offireplaces Number of bedrooms
-Number-of-bathrooms— Number-of half/baths
Type of heating system Number ofdecks/porches
Type of cooling system Enclosed an
3. "Total Project Square Footage"maybe substituted for'Total Project Cost'.
assach>(flselts;Hoaaae
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en. l�l 1 ?,1 3 z
The Contractor amen•
rDercdbe in tlerol Nea� ;(a�Mefollsp-ioga the forrheHomeowaer.
coatoMoi,spL�fiinS the ng,6nmd.and gxde of my edak ro bema4!4EaJ_LemJ -
9
Requiredpetmlm ThefWlowio :. .
andttil(hesecmed gbV1Tmaepam[itsarerey(ored pre
(OtrDers ohO by c000aumas thehomeonaers poxd Smrtaad C:i: Ir Mon SdtedWe- .secure their ownlierati(5 tea be munless The folimtio_eschedule niN
excluded from the Gus Permits
will be f ct�Pstznms 3aad me mnozuaYs cn
bIGL chapter j-' Provisions of 2 naal arse
q Date ohm mntraclartilll begio Connected nark
Total Contra'P- �Darenfim cooaaued nml;Coll be
the Conoamor agg rod P°}•menesdedide . n,n..-.riaiii•ctmtplered
RMorm thettart,filial be
mmedal r -
pa}men[s hill be madea attdlahwspedJiNabuxeforthetoral -
mardinetgthefoiloLtip sum of -�
f//t gsehedWe
_ —Won si-tming
manaet(not to eccad it ofthe taral coaoect price Sr the muofspeoai arderh
Or Upon mmpleden of �`� 0Prs•nbbibeasr sm al _
upon Uampiedon of L� .
upon C001Pledoaofthe O
Thefollmvuer¢aeriatr cnnoa2(lan•Porhids dgtmtt ..,
r em fullpa}m'ytmOT Coatraais mmpl mboth
a:aedheramthecon Pm (begimrpxiy S mb4 ' ,�'///yy,rtt Pd+4'•s satisfaction)
m men the °mtidull•rosin aAe• / Nid _
WaPlaienschedufe('•f
NOTES:(')Jwiuding all
must rear,Pec
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Hared tmpnaable forcUmPledon of[he anr<dasvibedr enn rem a tin edm[M1 cnn n
tl n6a u his r ,Ymeesmhesotel•' re£ardless ofthe actions of any mirtl
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connect droll Cot im Lmmq rhq dogonembecamaa 6iadm - - so6matramors for
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a — t a_talidHom Cot }rmdmdsadit qdt u rsmbe reatsrered rah the m Co aauor emn n.The htn 9 esdnns ifsomeWiogis tmdear. {rs�soahon b}nnongmthe orofHonce lmpmlvail Connzporgea ��mosthomeimpmeammt e Doathemo Dlreetorm id PmkPlaa,Room SltO, soadon. You map- mahacloaand
tmgbr hatxinsgrantto A_l-the Contragorforhis iusutancrpm 4 471,6 orb-ca1(mg 671-473Q37gor SSg.T�etor
o Rnouryttl 'probfoflnsDrdnee••damipenC ; pany(nfhnettido so that au ae-37i7.
aurrinhuavd Fell ambiliec Read tl[e7m } too Confirm eoeero�e,or Guide to tito a Ln paa Cot hlformmion m rya m a ask io
praremmt CmtoactarIzo_ oral oftbis form and eta g mp}•oftheC
Yau map motel this •. ;. - . <,, onsumer
caatraaor(n aVddn a-�` °e°t ifit has bem signeduaplam otherthap
ihirdb gat htglt[be - o�ttmhraach o6mb,-,dioart%tne�i7 mno-°cmtsnotma] it Ill
minps, ,ided
trsmes da-tollmimgthe st m eement.See We wed amiceof b}•delit led youUmidof
DO NO aomP afthis Pastetl.b}'lalerioJn 6i or 1°0 }ounotiPr the
T SIGN THIS CQ rxJtcdladon Form tar ,not 1 _eht ofthe lnaidmp�3 m]3 er45e(p>aa�y^IIL` NT'RACT IF TgERE: A1ry BL- ao aplaaaCoa ofrlr(s r; t '.
�Permamn;ud t�miF old,r,irets�mnti< 41VI{SPACESt:t�
�/ry.�� � 7beLtmW'aialhtxptyr(M c-..�.i,.
HamemlDer'S S- am, ^•�"• n i� (.t.
a gnaaaa -
Dare
Contractor Arbitration
The Home Improvement ComractorIaw provides homeowners with then me ri right
ta tomanon action des an
alternative to mat action)ifthey have a dispute with a contractor.The same right is ryQt automaticalla•afforded ro a
contractor however_ The courrectorwould have to resolve any dispute he/she has with a homeowner in court notes ,
both pules gag cc tG the optional clame pmvided below. Tbisclause wmu d ghve the contractor the same riaht to t
arbitration as is afforded to the homeowner by the Home Improvement Cohhactor Law-
The contractor and the homeo++verhereby mutually agree in advance that in the event the contractor has a dispute
conceminethis contract the contractor pay submitthe dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of ConsumerAffahs audBusiness Regulation and the consoner shell be required
m submit to such arbitration asptotit0ed7uivtasaohusens General Tawsc . ter 142A .
s I�� w / ConRacmr s Sieneture
Homeownees Signature
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner tray initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homemener'sRights
A homeowner's rights under the Home Improvement Contractor Law(ivIGL chapter 142A)and other consumer
protection laws(i.e MOL chapter 93A)may not be waived in any way,even by aereemetn However,homeowner
may be excluded from certain rights ifthe contractorthey choose is notproperly registered as prescribed by law.
Homeowner who secure their own bolding permits are automatically eccluded from all Guaranty Fund provisions of
the Home improvement Contractor Law•. The contractor is responsible for completing the work as described in a
timely and%%;rkmanlike mmmer. Homconner maybe entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for w•orknanship or materials. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matter on which the horueownerend contractor la f illy agree maybe
added to the tents of the contract as long as they do not restrict a homeowner's basic consumer rights- If You have,
questions about your consumer/homeowner rights,contact the Consumer Information Hodine(listed below).
Execution of Contract
The contract must be executed in duniicate and should not be signed until a copy ofall exhibits and referenced
documents have been attached. Parties ate also advised notto sign the document until all blank sections have been
filled in ormarked as void,deleted or not applicable. One original sinned copy of the contractlAth attachments is to
be given to the owner and the other kept by the contractor.,Any modification to the original contract must be in writing
and agreed to by both parties.Contmetedwork may notbegin tmyl both parties have received a fully executed coRY of
the contract and the three day rescission period has expire
Accelerated Payments
A contractor may,.not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems hilt berelf to be financially insecure. However-in instances where a contractor deems himlherel f
to be financially insecure the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted wodc Withdrawal of funds from said accotmtwould require the
signatures of both parties. .
Additional Information
If you have general questions or need additional information about the Home improvement Contractor Law or other
consumer rights,or ifyou wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement"
contact -
Consumer Information Hotline
Office of Consumer ASaits and BusmessRegtlation
10 Park Plaza,Room 5170,Bosnia 1v1A 02116
677973-8 i8Z 888-283 37i7 or visitthe OCABR website at"'i^:: : :vrsr c;._r•=..• d`.'
If you want m verify the registration of a contractor gar ifyou have questions or need additional information specifically
about the contractorrezistr dou component of the Horne lmprovementiCont mctorLaw,contact:
Director of Home lmprovement ContrtictorRegsuation
Office of Consumer Affairs and Business Regulation
10 park Pine,Room5170,Bostin_MA O2116
617-97a-8787,888-283 37i t or visit the BIC web site at 1i 1in_:."2-t c-r-,:as_all vi"can r
Go online to vietv the status of a Home Improvement Contractor`s Registration:
-- -':-w r•u:%tmmeirn m•iaiir.-d��lissis*t
For assistance�isth informal mediation of disputes or to register formal complaints against a business,call:
Cons inner Complaint Section ..
Offite_pfthe Attomev General
617 727-8400
AMOR
Better Business Bureau
508-02-4800:508-7352548or413-7i4-3114 t;�i�2I-llJ2plp
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
i Congress Street, Suite 100
Boston,MA 01114-2017
wwmmass�gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Naive (Business/Organiationtindividual): Atlantic WeathrrizAuuii.
Address:
611 JeffersOnAvenue
r 91-non
City/State/ ' Phone#: 7 S-: qqq- �` 3
Are you employer?Check the pproprlate box:
Type of project(required):
I.2fam 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 a sole proprietor or parmer- 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' g ❑ Building addition
[No workers' comp. insurance comp.insurance.t
required.] 5. ❑ We are a corporation and its 100 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.[]Plumbing pairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑R pairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13. Others/G !/`�
comp, insurance required.]
"Any applicant that cheeks box#1 must also till 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 t/tat is providing workers'con[pensation insurance for my employees. Below Is the policy and job site
information. /
Insurance Company Name: 2 r t V i ,
Policy or Self-ins. Lic.#: /y5IS,2-70 /a � Expiration Date:
5-1
c310ZOI/
Job Site Address: J l /& r /
I 7G 4- &I - City/State/Zip: 3-C, I017 „ 4 G/cj 7 0
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 certl&a er the paips,an i ies of perjury that the information provided above i pI and/correct.
Signature: C : 3 C �J en Date
Phone
Of
r1clal use only. Do not write In this area,to be completed by city or town oJreia.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
page 3 of 4
f
- - enx of oubiic Safet Massachusetts -OeparrM y
5o2rd of E10ding Regulations and Standards
Constriction Supervisor -
License: CS487977 s^
o, ;v
ERIC W PALM
3 HILTON STs 's
Salem MA 01970=
Expiration
Commissioner 04=2016
--- e`Fo,,,,,,�„« ,lU,
_ office of Consumer Affairs&.Busi8m Regala6(m .
MEIAAPROVEMENTCONTRACTOR
Istratlon: W089 TYPE-
piratlon: ;3/12Q016. Ltd Liabiray Cerpo-
ATLANTIC WEATHERIZATIONLLC. -
ERIC PALM - -
61RJEFFERSONAVE -
SALEM,NIA 01970. - Undersecretary