42 MOFFATT RD - BUILDING INSPECTION e Commonwealth of Massachusetts RECEIVED
'p Boaz i of Building Regulations and Standards INSPE TIDNW-STRVIC ES
kli1 Mass tchusetts State Building Code,780 CMR SALEM
vised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demo]i'All 3EP 12 A (r 5 b
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dat pplied:
Building Official(Print Naime) Signature - - Date - -
SECTION 1:SITE INFORMATION
1.1 Property Add r 1.2 Assessors Map&Parcel Numbers
rna
1.1 a Is this an accepted st{eet?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Us Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard I Side Yards Rear Yard
Required Novided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§ 4) 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 Owner`ofR cord:
ILA 0970
Name(Print) City,State,ZIP
91793
No.and Street Telephone Email Address
SECTIONS: D ESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing B ilding❑ Owner-Occupied ❑ Repairs(s) ❑ eration(s) ❑ 1 Addition ❑
Demolition ❑ *essory Bldg.❑ Number of Units_ Other Specify:
Brief Description of Prop ed Wo kz:
.: SECTION 4:ESTIMATED CONSTRUCTION COSTS .
Item ( Est mated Costs: Official Use Only.
abo and Materials
1.Building $ 9 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard CityfFown Application Fee
2.Electrical I $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing I $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees:$
q Check No. Check Amount: Cash Amount:
6.Total Project Cost:I $ (� ❑Paid in Full ❑Outstanding Balance Due: '
:Y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction SuI etvisor License(CSL)
_e o o er lie W.Palm
Number Expiration Date
Namf CSL Hld E � 'i
Mon St(Cet List CSL Type(see below) LA
No.and Street Sa 1f.jA 01970 Type . Description -
U Unrestricted(Buildings up to 35,000 cu.ft.
City/Town,State,ZIP I R Restricted 1&2 Famil Dwellin
M Maso
RC Roo in Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
D I Insulation
Tele hone Email address D Demolition
5.2 Registered Home!Improv meat Contractor(HIC)
.. ifignI l
HIC Company Name or HIC e e HIC Registration Number Expiration Date
t
Avenue
W.�0197� 't(?y Email address
Ci Town,State,ZIP Telephone
SECTION 6:WORKE 'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.§ 25C(6))
Workers Compensation Insurar affidavit must be completed and submitted with this application. Failure to provide
this affidavit will resu4I in the denial of the Issuan of the building permit.
Signed Affidavit Attached? es.......... No...........❑
SE ION 7 : OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize_ C r f C rG,l VI'+�1
to act on my behalf,in all matter relative to work authorized by this building permit application.
��
Print Owner's Name(Electronic Si ture) '—
Date
S CTION b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name be-low,I hc reby attest under the pains and penalties of perjury that all of the information
contained in this application is te and accurate to the best of my knowledge and understanding.
Prmt Owner's or Authorized Agent' Name(Electronic Signature Date
NOTES:
L An Owner who obtains a bui ding permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in th�Home I nprovemerit Contractor(IBC)Program),will not have access to the arbitration
program or guaranty fund un let M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Ilnformat on on the Construction Supervisor License can be found at www mass eov/dos
2. When substantial work is pla tried,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementiattics,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 I Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
Massachusetts home Ira rovement Sample Contract
This farm satisfies all basic requvemrns of the ales Home Impraveornt Cmmector Iavv(MGL chapter 142A),but does not include standII
ard
language to protect homcewners. Seek legal a vire i-necessary, Any 1 unmoor
home improvements should firm obtain a copy"da
h'iasachusens Consumer Guide to Home fmpra mrnt'before agreeing to any urork on yorresidence.Yaumay obtain a free copy by yelling the
OtfiCe OfCannimer Affairs and Business Regal 'nos Consumer Information Hodina at Sl7A]3-a9g1 or 1-888-2931 ,.ar an our weostre Homeowner Information Contractor Information
Nam
Company Name
tcvrtij Atlantic WeadwizAdon,LLc
strett Address(doom dl ice Box add - ceuuaoo�/Sid
.
Ciryrtown Stare Zip Code Smium Address(mvsn ire o e snot I adadJrs's)
Daytime Phpne? o ( 9Evening phone Cilymiui
Sale Zip Cps i
Meiling Address(it diaemnffom abpve)
Bmiomphmie FederelEmplaMID.,SS.Number..
. law rtvveu Wa,mmrlame 11a@��mmmrCmeWvray,N®Lv fAyavnEY
v,aYE a2ivnnm v®Ev-.
The Contractor agrees to do the FbIbmingworhforthe Hameoarrier.(Desenlse in detai/l the xork to compitted,specifying die matedait to be used, •.odd" I h n'f )
�l aft w A7Y) I-t 9
,/ r
=�ede
im-'hefollowingbuiIdea permnmqmdPraposed SmrtandComple6mSchedule-The fvaowinaed by the contractor as the homed 1;scheduleill
beadhered to unless circumstmnces 6eyopd the contractors control arisesecuretheirownpermits the Guaranty Fund pro -
r.142A.) ../� Date when contractor will begin contracted work:. S&o Datewhm conmacted avmis will be subs antially completed.
oontract Priceaed payment Schedule �t
The Contractor agrees to Perform the work,finish he material andlabm specified above for the total sum of, !/U
Payments will be made according to the following S holutc:
5.7cr/r r
upon signing contract(net ra am d 113 ofthe total contract price or the costofs -
pecialorder items;whichever is greater)
S by_/_f ur -
Cy , upw cam Ieion of
S by1/&d or upon Cora letim of
s 9�.
upon completion of die contract- ( mv forbids demanding fullTd5ro'
et until mnbact is completed to both —
parry'ssetishction)
the following matemd'equilmnt mutt be special Sr
ordered befine the contracted work begins m oser m obe
NOTES.,C)net m ee all fmarma charges P91aw f
net eacem the that my deposit ordotxs-payment fegWrrd by the conuanlm before wink begins may
. wich ma,besmpeemcival aorrdered in advance m:
dvanrem: esraal theCOmmpplttrfaicoa srrhedulee.aenW can ofmry special egWPmun meonom rrsede nmsaiol
a:
a r s Wn o nn i try oR
Subcontractors-Theeonhamora ^ es s the. u be n chetl r' h' a ct
greuWor.mlely *par lstobe thely M moeibed regardless oftheactiow Of MY third
materpact/subaonuneor .uti)whisythepmmactor. The tremor Cunher agrees to be splet
_ "ads a i yrespannble torah Payments to all subcontramom for
ContractAccepmnce-Uponsigning,this document omaabinding contract under raw. Unless otherwise noted within this document,the
contract shall sigililYning
that MY lien or other secmity'nteresthas been placed on the radcoee, Review the tollmving Cations and mI
careCWiy before signing this cantrae.
• Don'be Presstuedmro signing the=U=Take time to read and fully wderstand il. Askquestionsifmmethingis unclear.
• Make suite the CtOF h4a validHome'am lqpmt "o . The law requires most home imp n went contra 1, and
subcoo moOrS to be registered with the Director -Home Impmvemmt Commoor Regishatime You may m
registration bywritingto the Directorial 10 Park -inquire aboutco293-37 a
• Does We contractor have insurance? Ask the Cartra4orforhis 17inamnawm ao02mfommtiov uthazl au an confirm
73.
see a copy Ofa'pmofofinalfm¢^docl�ent. - comp
y y coverage,or ask to
• Knowyom rights and responsibilities. Read The mporant Information on the reverse sidebftiris form and get acopy of be Connuner
Guide to me Herne Impmvxmeat Contrzmorlaav - .. ,
You may cancel this agreement if it has been signedal place other than the conbacmrsnormal• laceofbusines,
contracmrinvvritingat hislher main office or bmncho cab ordinary S Provided Yhes aify the
third business day following the signingY my mail posted,by telegrmn seat or by delivery,notlarerthan midnight of the
oCihis agreem ot.See the attached notice ofcencellation farm faran asphnetron of this righL
DO NOT SIGN THIS CO CT IF THERE ARE ANY BLANK SPACESM
iva mmaea mPksofihocaosmy raw beee•gims and vypsd-Om ram.asovaaoro Webmm w.lheaWa
��r�p�mW'shvoW 6ckNi6v�
Homcownv's Signature
Contras er's Signature
Dare
Daze.
Contractor Arbitration. ' .. .
The Home.lmprovement Contractor Law provides homeowners with the right toinitiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same r'i bt is not automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she h is with a homeowner in court unless
both parties agree to the optional clause provided below. This clause would gi the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.. -
The contractor and the homeowner`heieb'y dii6ally agree in advance that in the evint the contractor has a dispute
concerning this contract.the con—octof q)ay,submit the dispute to a private arbi Lion firm which has been approved by
the Secretary of theExecutive Office of Consumer Affairs and Business Regula'on and the consumer shall be required
to submit to such arbitration as pro'vi 111 Massachusetts General Laws,chank r 14o2A.
",A tn�rJ!V1nnrn �_
Homeowner's Signature Contract is Signature
NOTICE:The signatures of the parties above apply only to the agreement of th parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative d iipute resolution even where this
section is not separately signed by the parties. -
Homemvner's Rights
A homeownerss rights under the Home Improvement Contractor Law(MGL cbe pter 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 properti 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 specifi -legal rights if the contractor
guarantees or provides an express warranty for workmanship or materials. In at dition to guarantees or warranties
provided by the contactor,all goods sold in Massachusetts carry an implied wit rranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homemn and contractor lawfully agree may be
added to the terns 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 Inforn kation Hotline(listed below).
Execution of Contract -
The contract must be executed in duplicate and should not be signed unlit a cop y of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the docurnei t until all blank sections have been
filled in or marked as void,deleted,or not applicable. One original signed cop3 of the contract with attachments is to
be given to the owner and the other kept by the contractor. Any modification tc the original contract must be in writing
and agreed to by both parties.Contracted work may not begin until both parties have received a hilly executed copy of
the contract,and the three day rescission period has expired.- -
Accelerated Payments -
A contactor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herself to be financially insecure. However,in instanct s where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of funds i iol yet due be placed in a joint escrow,
account as a prerequisite to continuing the contracted work- Withdrawal of fun ds from said account would require the
signatures of both parties. ,.
Additional Information
If you have general questions or need additional information about the Home It iprovement Contractor Law or other -
consumer rights,or if you wish to obtain a free copy of "A Massachusetts Con umer Guide;to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affairs and Business Rej plation
10 Park Plaza,Room 5170,Boston,MA 0 116
617-973-8787.888-283-3757 or visit the OCABR w ebsite at hu r.—r
If you want to verify the registration of a contractor or if you have questions'o T need additional information specifically
about the contractor registration component,of the Home Improvement Contra tor Law,conacc.
Director of Home improvement Contractor Re,otration -
Office of Consumer Affairs and Business ation'
10 Park Plaza,Room 5170.Boston,MA 0 1116 -
617-973-8787,888-2833757 or visit the HIC website at ism`r:«ae.rvass.ec..>'icabia
Go online to view the status of a Home Improvement Contractors Registratio:.
ininJ!uistatz.ma.us�naneia:pnreiuent�lkenseelst.xsti. . - . . .
For assistance with informal mediation of disputes or to register fimnall eompl 'ns against a business,call:
Consumer Complaint Section .
Office of the Attorney General
617-727-8400
AND/OR .. _
Better Business Bureau
508-652-4800.508-755-2548 or 413-7; 114
Version 2.1-11/11''2010
The C'orrzznonwealtlz ofMassaclzusetts
t -OePartment oflndustrialAccidents Pr�ni Fnrtr=
®ffzce of Investigations
I CortgtessStreet,Suite IOO
Boston, MA 02II4 2017
Workers' Compensation Ynsurance Affidavit licant Information • Builde s/C'ontractors/Electricians/p
lumbers
Name (Business/Organ ization/Individ Please piing Legibly
li allik iq.'
ua1): - _ sdtticfl[%1ifCP.!.i,
Address: l = •efrers&,3cafiue
Sale t MA 1970
'
City/Stateolp:
Fr
-a em to er. Chec&the a Phone#: 97is. 7uu,_
p Y 2�appropriate box:
m a employer with 4. [� I am a general contractor and I (re uired):
ployees(full and/or TYpe of project qPart-time).= have hired the sub-contractors 6. ❑New construction
a sole proprietor or partner- listed on the artacheil'sheet.and have no employees These sub-contractors have �' Remodelingking for me in any capacity employees and have workers' 8. Demofition
workers'comp,insurance comp. insurance.= 9.ired.] ❑ Building addition
5• ❑ We are a corporation and its 10.0 Electrical repairs or additions
a homeowner doing all work officers have exercised Ureir
elf. . workers'comp. right of exemption per MGL 11.0 Plumbing repairs or additions
ance required.]t c. 152 1 4 , 12.
§ Oand we have no �❑�Roo airs
employees. NO workers' 13.��mer Z7w1S
*Any applicant that che comp.insurance required.] wlufi '
cks box�l must also fill out the section below showing their workers'comoensation policy information.
Homeowners'Contractors that checsubmit
icb h,s bothis
x must attached an additional sheet sho in the Dame of the sub outsidethen hire contractors
and s t submit a a whether or no
employees. If the sub-contractors have affidavit indicating employees,they must g such.
Provide their workers'comp.policy number. t those entices have
Mfor a employer that is providing workers compensation insurance for my employees Below is the oh and
-job
Insurance Co � 9 P c1 Job site
mpany Name: �v,.y-. C� _
Policy .'or Self-ins.Lic.2-
Job Site Address: Expiration Date: aaZ/�
Attach a copy of �` � Cily/State/Zip:
Failure to secure coverage and/or erage as required and under Sectioone-year imprisonment,n�A of pensation Policy declaration c 1�2 can ad o the imposition ofG
fine u to . g policy number and expiration date).
as well as civil Penalties
Of up to$250.00 a ay against nst the violator. Be dvised that a copy of this statement may f STO d WORK
in the criminal penalties of a
investigations of the DIA for insurance coverage verification. ORDER and a tine
o the Office of
1 do hereby certi u r tjte a
!ties of er'ary that the in ormation provided above is true and correct
iienature:
'hone 9: 7� 7G/G/- Date.
Official use only. Do not tvrite in this area,to be completed by city or town offrciaL
City or Town:
Issuing Authority(circle one): Permit/License
6.I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing L her
Contact Person: a Inspector
phone m•
Massachusetts-Department-of Public Safety
�f Board of Building Regulations and Standards
Construction Supervisor -
License: CS-087977
g
RRIC W PALM S- 1
3 HILTON ST S °
Were MA 01976
=. Expiration
Commissioner 04123/2016
(J�e�ODURO/rrrMOl��.oh4'lalJ?tlrHJC�J
-Office of Coesumer Affairs&Bus,uess Regolafioa i
MEIMPROVEMENTCONTRACTOR s
gfstration: 142089 TYPe '
piratj . 3/I j 016 Ltd Liability Co�po:
ATLANTIC WEATHERIZATION L.L.C.
ERIC PALM
61R JEFFERSON AVE
SALEM,MA 01970- - Undersecretary
s