17 MOFFATT RD - BUILDING INSPECTION 2-
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The Commonwealth of viassachusetts RECEIVED CITY OF
W
Board ofBuilJingRegulationsandS"�r�IONAL SERVI[Revisedthjr
SALEM
Massachusetts State Building Code, 780 CMR'- 101Building Permit Application To Construct,Repair, Re��a �r�gtto�9sh
One-or Two-Family Dwelling
N This Section Focofficin!UseOnty;
Building Pemiit Number. DateApp t
DuilJing Official(Print Name) Signature Date
_ SECTION[ SITE 1NFORtNIATION
1.1 Prooecty Add�rLe�4�n, - 1.2 Assessors btap&Parcel Numbers
l7 /I/af+a74 V.
I.is Is this an accepted street?yes_ no_ Map Nwnber Parcel Number
1.3 Zoning Information: 1.4 Pra�ertylDimehltloms *I
LuningDistrictc - Proposed Use LotArea(sgft) rFmntnge(11) ..
1.5 Building Setbacks(It
Front Yard _ Side Yards Rear Yard -
RequireJ Pmvidai -Requtred Provided. Required Provided
L6 Water Supply:(M.G.L c 40,§SJ) 1.7 Flaod Zone Information: 1.8 Sewage Disposal System:
Public Q Private O Zone: _ Outside Flood Zone? Municipal Q (ht site dis sal stem O .
Checklf esO.- .- P� Pa !Y
SECTION2:PROPERTY;OWNE1 ..PL.
2.1 Owner'of Record:(
r/ t >k
'time(Pony Ct!y,stme.ZIP . ..
r o _ 975 Shy r75
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check an that nppiy)New Construction Q Es(sting Building❑ 1 Owner-Occupied Q Repairs(s) 13 1 Alteration(s) 0 Addition ❑
Demolition Q Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work': t
SECTIO 4:ESTIMATED CONSTRUCTION COSTS- = . -
Item Estimated Costs: Official Use Only
Labor and Ma terials)
I. BuilJing S _ - 1. Building Permit Fee.$ - Indicate how fee is determined:
2.Electrical S ❑Standard Cityfrown Application Fee-
❑Total Project Cost.'(item 6)x multiplier x
3.Plumbing S 2 Qther Fees: S �/^/
4..cchanical (HVAC) S List: 7 0 , a
5.:\lechanieal (Fire -
Suppression) 5 Total All Fees:S
6.Total Project Cust: .S (1117do. i Check No.I ! Check Amount: Cash Amount:
0 Paid in Fall ❑Outstanding Balance Due:
xy.�(ed
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su ,ervis'ur Niecuse(CSL) Q f�7 �j y t5 (p
�:;,; JAi U! I , -�-Number=— Es imtion Date
License tunher P
Name of CSLFluWerf �-. rIt J`7 LislCSLType(seebelow) Vy
S nc�lT.t1'i111B Type Description ..
No.and Strect 3 I tOB tree( '� U Unrestricted Buildin a tc 35,000 cu.11-1.MA 01970 R Restricted I&2 FamilyDivellin
Maso
Cityrrown,State,ZIP M Roo
RC Roolin Coverin
WS Window and Sidi
SF Solid Fuel Burning Appl"wnm
Tcle hung
Email address D Demolition
tContractor(HIC) 3 /2
improvement $
Home r U
5.2 Registered Flom p /�Z
g
FIIC Registration Number Expiration Date
tuC Company Nam IC N,
—•— Email address
No.mid Street
City/Town, State ZIP Telephone-
SECTION 6cwORKERSLCOM1iPENSATION INSURANCE AFFIDAVIT(IYIG.Le.1$Z§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 lsluance a building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION lac OWNER AUTHO1tITr110NTO BE.COMP�ETED.)VHENs:-,'
O\vNERIS AGENT OR CONTRACTOtTC A4PLiES F'ORBIJ10ING.PERT I&
1,as Owner of the subject property,hereby authorize
�r l
t9 act on m//y�� behalf,in all mattersrelative to work authorized by this building permit application.
Date
Print Owners Nano(Electronic Signature)
SECTION In.OWNERi OR AUTHORIZED AGENT DECI.ARATION
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 rue and accurate to the best of my knowledge and understanding. /e /
Date
Print Owners or,\uth or,zcd Agent s Nano( ecuonic Signature)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or anowner who hires a..unregistered contractor
Home-Improvement Contractor(HIC)Program);will�have access to the arbitration
(not registered in the
fund under M.G.L.c. Id2A.0therimportant informmafion on the HICYrogram can be to nt7 at— "
prusiam or Guaranty
wtvw miss gov'oca Information on the Construction Supervisor License can be found at ww%v mass.^ovh os .
2. When substantial work is planned,provide the information
below:.(including garage, finished basementlattics,decks or porch)
Total floor area(sq. ft.) - Habitable room count
Gross living area(sq.ft.) Number of bedrooms
Number of fireplaces Number of halflballis
,lumber of bathrooms Number of decks/patches
Type of heating system Enclosed- Open
Type of cooling system
J. "Total Project Syu:ue Footage"may be substituted for Total Project Cost"
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esc]uded fromt5ene f�eirowrt Peamits wm he adhaed to(mlesseh� Ib�dmehefa➢�gschabuewill
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_-'ate tvh®embachw Uall
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Total Coo
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the x'mkft�,Ban] &eomhval and}abor - �lewb®—baged Work�ffl�eabalana ��aed.
aymmrs mdl hemedeacmpyagrodtefoU sPd•ed ahoveforlhe
S °dgsdtedoiC toml atm of _��)��
5----__upm si@omg cmaaCt(aot m exceed]g ofthe total emtrtict
Sby mupm C*Vetim of pdm2tbemgofr dmda +O4 aMebevcts )
by 4 1 orupm mmpletim of
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mnbact shall mt®plythat agmng;the dommmtbeeamaar'aPaavbleforellparmmhtoall for
mF IIy 6etore9gbmgtbis orothersmaity��b��oed on tbetedd®��o�etstseaotedwitbm Wis
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Contractor Arbitration - -
The Home Improvement Contractor Low provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The some right is not automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the coohpCtFof.�}Sayjithe dispute to a private arbitration firm which has been approved by
the Secretary of the Execuf;A-O ce I ol}Sulmer Affairs and Business Regulation and the consumer shall be required
to submit to such ari).�4¢p#ta(Rj#o j�n�]$�'s'achusetts General Laws,ch er 142A.
� ,
Homeowner's Signature Contractor's 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 may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement However,homeowners
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own 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
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty forworkmanship or materials. It addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry art implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consmner/homeowner rights,contact the Consumer Information Hotline(listed below).
N
Execution of Contract -
The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced
documents have been attached Parties are also advised not to sign the document until all.blank sections have been
filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with 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-Contracted work may not begin until both parties have received a fully executed copy of
the contract;and the three day rescission period has expired)
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
a homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint esraow
`account as a prerequisite to continuing the contracted work Wrthdrawal of fiords from said accountwould 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 if you wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline -
Office of Consumer Affairs and Business Regulation
' 10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCABR website at httv://m%iv.mass Gov/ocabr/
If you wantto verify the registration of a contractor or if you have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law,contact:
Director of Home Improvement Contractor Registration `
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the HIC website at htm:/Avww.mass.sov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
-
httn'//db Mate maus/bomeimnrovement/licenseelisLaso
For assistance with informal mediation of disputes ar to register formal complaints against a business,call:
•� "� onsufuer plaint Section
ffi orney General
617-727-9400
AND/OR
Bever Business Bureau
508-652-4800,508-755-2548 or 413-734-31 I4
Vasim 11-1122r2010
The Commonwealth of MassachuseUs
Department of Industrial Accidents
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):
pdlintic WeathctuAwtt,LLC
e eIJt)Li AMILIC
Address: Salem MA')1970
City/State/Zip: Phone #:
Are yo n employer? Check the appropriate box: Type of project(required):
4 I am a general contractor and I
1. am a employer with�� . ❑ 6. ❑New construction I
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I a sole proprietor partner-
shipip and have no employees
These sub-contractors have yees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
o workers' com insurance comp. insurance?
[N P• 10, Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof r pairs
insurance required.]t c. 152, §1(4), and we have no �iS�fG 1 f
employees. [No workers' 13. ther �t
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 ibis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box most 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: O U
` 3IZ0� 7
Policy#or Self-ins.Lic.#: l �a 7 O /Z I Expiration iration Date:
I �Ct-!P �
Job Site Address: 1 -7
/ t011�� 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 certi under the pains and penalties of perjury that the information provided above is true and correct.
Signature e>sa� _ Date: 3/7
Phone#
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. Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
J
ACoORHCERTIFICATE OF LIABILITY INSURANCE F
1 DA7EIMMmDvrYY1
3/9/2016
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 policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject 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 lieu of such endorsement(s).
PRODUCER CONTACT
N ME: CORetrOCtiOR
Eastern Insurance Group LLC PHONE (800)333-7234 Fax N
233 West Central St MAI
ADDRESS!
INSU S AFFORDING COVERAGE NAIL
Natick MA 01760 INSURER AArbella Protection Ins. Co. 41360
INSURED INSURER B Nautilus Insurance Co
Atlantic Weatherization INSURERC:
61 Rear Jefferson Avenue INSURERD:
INSURER E:
Salem MA 01970
INSURER F-
COVERAGES CERTIFICATE NUMBER3daster 2016 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 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'TRNSR TYPEOFINSURANCE POIJCYEFF FOUCYEXP
POLICY NUMBERIMWDWYYrn nCwDC,rrr,I UNITS
GENERAL LIABILITY
EACH OCCURRENCE S 11000,000
X COMMERCIAL GENERAL UABILTV DAMAGEMRWM
PREMISES(Ea octane m $ 50,000
A CLAIMS4IADE OCCUR 500042816 /20/2016 /20/2017 PRE ISES(EaXP(Any mre ) S 0,000
X CONTRACTUAL LIABILITY MEDPERSONAL B ADV INJURY S 11000,000
X CG0001 10/01 FORM GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2,000,000
POLICY FX PRO- LOC $
AUTOMOBILE LIABILITY COaB�e°LSINGLE LIMIT 1,000,000
A ANY ALTO BODILY INJURY(Perperson) $
ALL OWNED X SCHEDULED 020015871 /20/2016 /20/2017 ( 0
AUTOS AUTOS BODILY INJURY Per aoWmw S
X HIRED AUTOS X NOI-OWNED -PROPERTY-DAMAGE
AUTOS Pee dent S
PIP c $
X UMBRELLA UAB X BeOCCUR EACH OCCURRENCE S 1,000,006
A EXCESS LIAR CWMS41A0E
AGGREGATE $ 1,000,000
LIED RETENTIONS 10,000 4600058654 /20/2016 /20/2017 S
WORKERS COMPENSATION ViC STAT_LEMU- DTH-
ANDEMPLOYERS'LIABIUTY YIN
ANY PROPRIETORIPARTNERIEXECUTAIE
ER
OFRCER EMBER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $
(Mandatory In NH) EL DISEASE-EA EMPLOYE S
ILyes,dex oo under
DESCRIPTION OF OPERATIONS kelow E.LDISEASE-POLICYLIMT $
B POLLuTIDN 2PL200378614 0/1/2015 0/1/2016
EA POLLUTION CONDITION $1,000 000
GENERAL AGGREGATE $1,000:000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ANaU,ACORD 101.AddMonal Remarks Schedule,B mom space k1 mqu0ed)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF EALEM ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET
SAL$M, MA 01970 AUTHORRED REPRESENTATIVE
John Roegel/SNE - -
ACORD 25(2010105) 01988.2010 ACORD CORPORATION. All rights reserved.
INSO2S nn,nns,m Th.ArnRn..�...e,...1 r...,,.�.,,ron;chro,1 nu.kc..F Arnwn
Massachusetts Department of Public Safety Construction Supervisor
) Board of Building Regulations and Standards p
1 Restricted to:
License: CS-087977 � Unrestricted-Buildings of any use group which contain
Construction Supervisor less than 35,000 cubic feet(991 cubic meters)of .
enclosed space.
ERIC IN PALM
I
3 HILTON ST
SALEM MA 01970 k ,
Expiration: Failure to possess a current edition of the Massachusetts
Commissioner W2312018 State Building Code is cause for revocation of this license.
DPS Licensing information visit:W W W.MASS.GOVIDPS
t
i
t CtJ1r.�ereurnnarrrr/H r�i �lrurr/rnJrlG � License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: _
M — ME IMPROVEMENT CONTRACTOR Office of Consumer ATfairs and Business Regulation
_registration 142089 Type: 10 Park Plaza-Suite 5170
plration: 3/122018-- Ltd Liability Corpor Boston,MA 02116
o _
ATLANTIC WEATHERIZATION LLC-"
ERIC PALM -
61RJEFFERSONAVE
SALEM,MA 01970 Undersecretary Not valid without signature