3 MOULTON AVE - BUILDING INSPECTION (3) y- ► otA'I
The Commonwealth of Massachusetts RECEI EO
Board of Building Regulations and Standards ��p
B j Massachusetts State Building Code,780 CMR,7 h ediMPUTO NflYNIUSE
ITY
Building Permit Application To Construct,Repair,Renovate Or of Jai. .1�is l l�rr�rary '
One-or Two-Family Dwelling +!!; " '7.' r 1,2008
This Section For Official Use Only
Building Permit Number: " Date Applied;'
Signature •. ,.�u-u.ti.." �,u-, �D��-7��
* Building Commissioner/IfiVectorofBuildmgs Daze `
SECTION 1:SITE INFORMATION '
1.1 Property Address: 1.2 Assessors Map&4brdaldfinalBers '.
fy
Lin Is this an accepted street?yes_ no Map Number P cel Number
1.3 Zoning Information: -'J 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.G3,a 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 yesO
F,SECTION 2:1.PROPERTY OWNERSH3P'
2.1 Owner'o{�te�prd:
0
f� _ 1 t✓1 CO ✓Yla 173 /JZou (lam .
Name(Print) Address for Service:
� ► q )t 7YV - Fs3( 3
Signature- - ... Telephone
SECTION 3,'bESCRIPTION'OF PROPOSED.WORK2(chmkall that apply) ,
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: /o W c, /0 5-e Glal(5 -t
SECTION 4:ESTIMATED CONSTRUCTION, ,
Estimated Costs:
Item Official Use Only.
Labor and Materials :' %
1.Building $ =" 1. Building Permit Fee:$ ' Indicate how fee is determined;,
e 2.Electrical...-, : „:, r $,%r ,° , . ❑Standard City/fownApplicationFce
❑Total Project CosT3(Item 6)x multiplier ` x
3.Plumbing $ 2 'Other Fees: $
4.Mechanical (HVAC) $ List:
. .
5.Mechanical (Fire $
Suppression) Total All Fees:$ '
0v Check No. Check Amount Cash Amount:
6,Total Project Cost: $ 30Q6 . ❑paid in Full 0 Outstanding Balance Due..
.SECTION 5: CONSTRUCTIONSERVICES
5.1 Liceused,Constrn&WSirpervisor(CSL)
e� a!V•,•� .j4401TU392H1
License Number _ Expiration Date -
Name of CSL-.Holder t.._ (A
., ;> -<•p3!l`�irttrn'.�iI:CCI' List CSL Type(see below)
Address SBIPaD Q1�0 �T ` ..:'.' . Des Description
U Unrestricted(up to 35,000 Cu.Ft.
Signature R Restricted 1&2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
n ,?y �, - SF Residential Solid Fuel Burning Appliance Installation
Y— D itResidential Demolition
51 Registered Home Improvement Contractor(RIC) y�
Atidiltic Weadwintinn. )'.Llt on Number -
HIC Company Name Wff�t Jacge___ Re gi ti
Address MA 0197(I 3 ��
Expiration Date -
Signature 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 Issuance o e building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION lad OWNER AUTHORIZATION TO BE COMPLETED WHEN f
OWNER'S AGENT OR CONTRACTOR APPLM,FO&BUILDING PERMIT
I, r u 14,, 7CV1 11 1 HCkt O rO f6-�4d as Owner of the subject property hereby
authorize C(', 1— to act on my behalf,in all matters
relative to work authorized by this building permit application. .
`/
Signature of Owner ' Date
SEE/CTION 7b:OWNER':OR AUTHORIZED AGENT DECLARATION -
( wit C� as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name /r /
y
Signature of Owner or Authorized Agent Date /f �
(Signed under the pains and penalties of
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"may be substituted for"Total Project Cost"
Li 'i�r r
CITY OF S.0 Em. �LASSr1CHLTSEITS
BL'iLD .IVG DEPARTSIMNT
• a 120 WASHLNGTON STREET,3"o FLOOR
T`EL (978)74579595.
F.ax(978) 710 9836
KI\IgFRt EY DRISCOLL oNtASST.Flsxnx
aMAYOR ,
DIRECTOR OF PUBLIC PROPERTY/BCIIDINGCOJWISStONER`
Yorkers! Compensation insurance Affidavit: Builders/Contractors/Electrief4i s/Flumhers'
4ntfli6 t information Please Print`Gea IX
Maine(nusitxss0rganirationlindividual): ATIA►tTtn WEAT-11ERI T
--�v�'rv'"atGTf IiTG1�rG1S!IONr LLe
61RJEFFERSON AVENUE
Address: SAL€M, AAA 91970
(978) 744.8143
City/State/Zip. FA Mflh#45-2200
,ire you employer?Check,the ppropriate box: Type of project(required):
1, am acre to er with 4. 0 I am a general contractor and P Y 6. ❑New construction
employees(full andlor part-time):* have hired the sub-contractors
2.[] 1 nti a sole propneiorur pnnner- listed on the attached sheet.t Z ❑Remodeling
ship and have no employces These sub-contivctom have 8. [] Demolition, I
,workingforme is an ,ca aci workers'comp.insurance°, 2
y p ty. . ❑Building addition
(No workers comp:insurance 5. We are ecorporation and its"
required i
officers have exercised theft,. 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MdL I I.0 Plumbing repairs or additions
mysel P.[No workers'comp. c.,152,q 1(4);and "we have no' 12,0 Roof repairs
msurane6rcquiredjt' zmployzes; [No workers' I3.00ther
comp.insurance requircdij...
Any opplicun that shucks bore ill must also fill uut thesection below showing their workets'.compensadon policy inf inmodom
I inmeowiuns who submit this aMavis indicating they am doing all work and then hire outside contractors mutt submit a new affidavit indicating such.
` Conlrxion that check this box must attached an additional shoctshowing the name of the sub-icomrscaorr,and theirworkers`COMP.Policy infomution..
um art cur !d er that is, rbvldlu Ivoikers'core ensddun tirsarance or M ere !u ees Belutt>'%s tha o/1 'and ob site
?,Y P X P , I y P Y . P �S I
orrirulion
insurance Company Name: -
;_..,.. 2
Policy N or Sglf uts.Lie.N: .7��J ?"Z D /'�20 Expiration Date:
Job Site Address: 3 lkloU rY City/Staw/Zip: Sal"�� l Dom/
Attar h a copy of the.iv'orkers'cotnpensatloei policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Scclion 25A of MGL e. 152 can lead to,the imposition of criminal penalties of a
title up to S 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$230.00'a day against the violator. 13e advised that a copy of this statement may be forwarded to the Offee of
Inv�stigatiolis olatlrc DIA for insurance coverage ventication.
I do fierebycertify uitdtr die pubrs air d penu! s of perfary that the lnfonnatlou provided above leis true and correct
Si nnure•. paid: :. G
Phone -
oviciul use wrty.:.Do not write in this area,to be cuarpleted by city ur sown off eial
City or Town: Permiti[.1cense
Issuing Authority(circle one):
1.Bourd of health 2.Building Department 3.Cilylfown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: ___„__,________ Phone fh
----• -• - 1L/ LV12 / : Lt : ,l Ht•1 rauc 00/Ubb rax server
,--,WON
A�O�RD® CERTIFICATE OF LIABILITY INSURANCE o„2.2g,4
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)mustbe endorsed. R 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 fieu of such endarsement(s).
PRODUCER CONTACT
EASTERN INS GROUP LLC NAME:
233 WEST CENTRAL ST P E Ea: FAX NA
NATICK,MA 01760 E-MAIL
INSURERS)AFFORDING COVERAGE NAiC9
INSURER A:AMERICAN ZURICH INSURANCE COLIPANY
INSURED INSURER B
ATLANTIC WEATHERIZATION LLC
61 REAR JEFFERSON AVE INSURER C:
SALEM,MA 01970 INSURER O:
NSC Owy CERTIFICATE NUMBER,
UREfl E
INSURER F:
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.
INSR TYPE OF INSURANCE ADO SUB
mSR YNO POLICY NNABER POUCYEFF -POLICY EXP
MMIDDMIW NAVDDlYYYy LIMITS
GENERAL LIABa1TY
EACH OCCURRENCE S
COMMERCULL GENERAL LULBIIIW DAMAGE TO RENTED
CLAIMSMADE❑ WA;UR c S
MEDEXP(At,v.eFw.i S
PERSONAL 8 AOVINJIIRY $
GENERAL AGGREGATE $
GENL AGGREGATE LIMIT APPLIES PER: PRODUCT$-COMPAP pGG $
POLICY PRO
JECT LOC $
AUTOmwI,,UABLRY
ANY AUTOeNeD SWGLE LIMIT $
ALL OWNED SCHEDULED BODILY IMURY(P.,person) S
AUTOS AUTOS BODILY IWURY(P.a.ewl) $
HIRED AUTOS NONOVMED
AUTOS OPE V AMADE $
S
UMBRELLA LUI9 OCCUR EACH OCCURRENCE $
EXCE55 DAB CLAIMS-MADE AGGREGATE S
DED RETENTION§
*$500,000
WORKERS YERS! ASM !06�E
TATU-
AND PROPAIETORTA BILITY
H.
ANY PRDPg1ETOR.PARTNEq/EXECUTN�VM _ LPAIT$ '
OFFICERMEMBER EXCLUDED? L_J N/A 6ZZLIB 03.20-2014 03.20.2015 ACCIDEN
(MartlWM in NM)
IIyes,tlesaiIX,Under 58270121 -EAE0 RIPNO OF OP RATIONSSE-POLI
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AH8Ch ACORD 1M,ABtlabmI RaIml SCrasub,amore apmd)
E T
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCREIVMATH
93 WASHINGTON ST CANCELLED BEFORE THE EXPIRATIO
SALEM,MA01970 NOTICE WILL BE DELIVERED IN ACCOPOLICY PROVISIONS.
AIfTHORQED REPRESENTATIVEACORD Y5(2010105) The ACORD name and logo are register®etd9mrksfof/AVACOH'D•'CORPORATION All rights reserved.
A CERTIFICATE OF LIABILITY INSURANCE DA'�'MwDw3yn
3/11/201
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(les) 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 E. C
ME: onstruction
Eastern Insurance Group LLC PHONE (508)651-7700 19
233 West Central Street - AIL
Natick MA 01760 INsuRERA INSURERS AFFORDING COVERAGE NAIC p
Arbella Protection Ins. Co. 41360
INSURED INSURER Arbella Indemnity Ins Co. 10617
Atlantic We
atherization INSURER C.-Nautilus Insurance Co
61 Rear Jefferson Avenue INSURER D:
INSURER E:
Salem MA 01970
INSURER F:
COVERAGES CERTIFICATENUMBERMDLaTER 2013 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRA TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
CT 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 N ft REDUCED BY PAID CLAIMS.
buuH
R. TYPE OFINSURANCE POLICY NUMBER POLICY EFF M1OLD EXP LIMITS
GENERAL LIABILITY
EACH OCCURRENCE E 1,000,000
X COMMERCIAL GENERAL LIABILITY
PREMISES o G a .a E 0,000
A CLAIMS-MADE OCCUR 500042816 /20/2013 /20/2014 MED EXP(An one person) E 5,000
PERSONAL S ADV INJURY E 1,000,000
GENERAL AGGREGATE $ 2,000,00 0
GEN' GATE LIMIT APPLIES PER:
POLICY X PRO- PRODUCTS-COMPIOP AGO E 2,000,000
POLICY
AUTOMOBILE LIABILITY LOGE
COM INED SING LE LIMIT
Ea ecclaent 1,000,000
ANY AUTO
B ALL OWNED X SCHEDULED 020015871 BODILY INJURY(Per person) E
/20/2013 /20/2014 BODILY INJURY(Per accident) E
X HIRED AUTOS X NON-OWNED
AUTOS Pa e¢ItlentOAMAGE E
E
X UMBRELLA LIAB X OCCUR PIP-Basic
A EXCESS LIAB
EACH OCCURRENCE E 1,000,000
CLAIMS-MADE
AGGREGATE $ 1,000,000
LIED RETENTION 600047820 T/20/2013 /20/201q E
AND EERS YERUV SATION WC STATU-ANDEMPLOYERS'LIABILITYANY.PROPRIETORIPARTNERIEXECUTIVE YINOFFICERNEMBER EXCLUDED? NIA E.L.EACH ACCIDENT E
(Mandatory In NH)
yas,a -be untler E.L.DISEASE-EA EMPLOYE S
DESCRIPTION OF OPERATIONS belax E.L DISEASE-POLICY LIMITC POLLUTION LIABILITY PL20037860010/1/2013 GENERAL AGGREGATE $1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Ada0lonal Remarks Schedule,If more apace la required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF SALEM ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET
SALEM, MA 01970 AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PDIIL �a`�'-+-a ~ 'V1%'4'A_
ACORD 25(2010105) 01953.2010 ACORD CORPORATION. All rights reserved.
INS025mm�nstm rHa er-nan nano anal lnnn aro ronicanmd mark¢of eCr1Rn
Massachusetts Home IaxaifroveHaeIIt Saaaauei- Coaatract
F
foam sads8az all bane regairemcom of We smm'a Home hapmvemant Cmstramor Law(MOI-chapter 342A),fiat does nottnelude steodad nagMengto ceeth Golders.SeeBlegal advieeHnuasnry. Any paran Pl®oinghoma impmvemenn Should first obtain a copyof°A echasetrs Consumer Guide to Home bapmvement°hefom agrecmgto anywotkoayourtesideme.You mayebtain a free copy by tallvug the
of Co aAtlbirs and Business Regulation'sCensnmerlofmmation Hodineat617-973-g787m 1-888-283.3757 am ourweh Hit
Homeow CHntrocfer MfOrmatlon
eme CampaayNmm ..
Nel CO le-7a
Scat Address(do rent am a O}ficollmaddnn) ContreaodSdapeamd
3 matE.L7Jpffmw oa'
Ciry/fovm Smm Zip Code HuaneaAddnss(mueiocludea
Salem MA O1970
DaytimePhoue BveningPhone l;unfrose State ZipCmie
�L( - S3 is
Magi Address OldiHemu6omabove) Bad hom - .Fderd I MmS.9.Numba
❑°Ramaoaw°re®� a�ua,vwnsaesemaweee
aps.amem
. sgw..e,mwanm.mw r
..veaauuwae®sa (2-0
The Cmtrsctor agrees to no the following work for WeHameowne,
tnesm7m in dew8 tlrewmkmeompletd,spaifymg dot type,band,andgmded mataiah mbe usd,�seddii anal.xeas'F..........)
jjLowq cc(Cu lose Wa.M 11
Begdrsd Pamlts-Tiufoll=gbu>ldingpesmits marequbed Proposed Start and Co don Schedule.and wig be secured by them otoras the homeowners � The foacons schdde will -
agmC be tosmlas rdrcomstancesbryond the contraetors control stirs
(Owners who secure their owe permits will he
excluded from the Guaranty Food provisions of (� / Damwheo cmtraranr will hegira eontra cd work
MGL chapter 142A.) /
r Date whin contracted work wilibe substantially completed. .•
Totd ConhnmPrice end PeymeutSchadde
The Can(ramn agrees t plantar the work,famish the materiel and labor specified above for the total sum oe
(9
Payments will be madeaaordmg to the following wledub, - + -
S upon signing comxct(nor to exceed 113 of due total contract
price pj the conofSpecial aria items,whichever is greats)
S 6y00 / I Of upon complaint of
S Aw. by_J/or upon completion of
S 2Cb� upon completion ofthe cootradt (law mrbtds demendiag Shc payment until mtmu is completed to both parry's Ruslactlon)
The foOowina massriaVequWatcust bespais] S to be Paid for
Wde ed befor
e the cmouudwork begins in coda
to meat the emapledmsehWWe(°°) - 5 to hepaid[m -
NOTES:(h buludmgali fineneacha�a(v°)Iawmquires tlatany deposit adovaspaynumrequised by dot mutramabafom nark begiesamy- naexaedthc mwof(a)onethidofthe mW cmbaapdeea(b)dmaeMl cost ofmyspecial equipment weusmmmedematerial.
%Mcb mmt bespedal mdesd in advance m mCt the eompM.sehduio
$o w h i werea°mb 1
Sabeentnctom tb�emOr
agrees to hesdely respmstble for camPleh®efthewark desenbd regadiers ofthe emioas ofaoy shill pa'ry Iaadcoatraaorudlfz 40.contractor. The contractor fvrthsagersrohesaldy reapmabla for all payments to as subcentramors for
-- m te+°y mdlehor d m' sore t
Lanmact atnetaoa Upon 191.9,thus docaoeot beroms ebmdmg coetraetunda law. Uden otherwise noted widdn ids document,the
contra y of not imply that any lico n alhasectriry iuteresthaz hempmced w me reddmca Review Due foHowivg ceadons aunt notrrxs
carefully before dgniag the
contract.
ontratt .. .
Don't bepresented into signiogthe counam Take time to read and fully understand it Ask questions ifsomething is order.
° Melmmrethe contram [1111,111 ,old Horn r — - ti .Thebm mos[homaim
wbeootmaorsroberegrsterdwnhthe D)secmrofHomehMmv==Camremor provemmtcucter, rsand
registration"ties to theDirecter at lO Parkp R16orb Ca Yg6j7-9nquireabo 1OR-29 er,
lam,Boom 3170,Boston,MA 02116 or by ce8ing 617-973-8787 a B88.783.3757.
° seaaz the Off"roofof)mumnea7 Ask the Comecorforhis immmce tympany informed®an mat YOU can ccofi at coverage,or ask to
r�WYCHUreseeacopy ofa"proofafiusmanro^daenoeot
° Guiderothe Home "Uponnbddea Rmdthe(mportmit 5smatimmthewversesideofddsfowmdgdawpyrfthe Consmna
Improvement Contemn Law.
You may mneel this agreemant Hithaz beta sigod ataplaceotha than ther�tmrdats uomrai piece afhusfaess,providd oua contnmor ks writing et his)hasuain officenbranch officeby otdma4'iceil Postell,by tdegmm 5eotnbY ddivery,nn mterihau the
third basinas day following Wesigping ofthis 'gbtofthn -
egrament Sea theatlazhdmdce ofceocellation Cann foranaxplanmion ofihis night
DO NOT SIGN THIS CONTRACT D7 THERE ARE ANY BLANK SPACES!!!Txo" •mpiw vluemsvea am benmpleed uddgxd,Oaewpyshodd g°mdebvmemena.Theeem -
mpe'shwNeekwr amttmr.
Homcowna s S /'a�u/m/ Coatraaor's/Sugoahue ../
Date I
Dam
Contractor Arbitration-
The Home Improvement Contractor Law provides homeowners with the right to initiate an�arbihauon action(as an
alternative to court action)if they have a dispute with a contractor. The same right is pgl automatically afforded to a
contractor,however. The contractor would have to resolve my dispute he/she has with ahomeowner in court unless
both parties agree to the optional clause provided below. This clause would give the contr,:letor the same right to
arbitration as is afforded to the homeowner by the Home ImprovementConttactorLaw. '
The contractor and the homeowner hereby mutually agree m advance that in the event the contractor has a dispute
concern'ningthis;conlrac;.tLe.eoatigctormaysubmitthedisputetoailm tearbitration5r hichhasbeanapprovedby
the Secretary of tiieEiceciifive Office of Oonsumer Affairs and Business Regulation and theconsumer shall be required
to t to each In provided in Massachusetts General Laws,uhapter 14 / .
Homeowner's Sigoanae .. tots Signature -
NOTICE:The signatmes oftheparties above apply only
to the agreement of the parties tq altemrtive dispute
resolor to each
by the contractor. The homeowner may initiate altunative dispute resolution even where this
section is notse arate]y signed by the parties. -
Homeowner's.Rigbts
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)'and other consumer
protection laws(Le.MGL chapter 93A)may not be waived in any way,even by agreement;.i 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 lmprovement 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 for workmanship 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. Aa mumeratim of other matters on whichthe 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 cousrmer/homeowner rights,contact the Consumer Information Hotlihe(listed below).
Execution of Contract The contract must be executed in d icate and should not be signed until a copy of ell 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 contact mugt.heiawritine._._ _.._.
and agreed toby both pares:"Contracted wofktnay nottieginim both parties have receiNTd 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 e6hedule in cases where the
homeowner deemslnm/herselfto be financially insecure.However,in instances where a contractor deems him/herself
to be financially insecure;the contractor may require that the balance of fmmds not yet duejbe placed in a joint escrow
account as a prerequisite to continuing the contracted work Withdrawal of funds from said account would require the
signatures ofboth parties.
Additional Information -If you have general questions or need additional information about the Home Improvemer Contractor Law of 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 Affairs and Business Regulation
` 10 ParkPlam,Room 5170,Boston,MA 02116 -_ .j j
617-973-8787,888-283-3757 or visit the OCABR website at t ttp://www.rnass.gov/ocabr/
Ifyou want to verify the registration of a contractor or if you have questions or need additipal information specifically
about the contractor registration component ofthe Home Improvement Contractor Law,contact:
- Director of Home Improvement Contractor Registration j
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 hM,1/www.m0s.gov/ocabr1 -
i
Go online to view the status of a Home Improvement Contractor's Registration: - -
htto-1/db smte ma usthomeimpmvemeni8icenseelistasp
For assistance with informal mediation of disputes or to register formal complaints again} a business,call:
Consumer Complaint Section ,
. Office of the Attorney General
617-727-9400
ANDIOR
. Better Business Bureau
- - 508-652.4800 $08-755-2548 or 413-734-3114 j i "
Version 2.1-tI Mele
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Ot6ce or Consumer Alfairs& CTOR
ME IMPROVEMENT CONTRA Type
gistration 142089 Ltd Liability CoRO -
xpiration 311?J2016 a
ATLANTIC W�7HER17ATION L L C.
�.: ERIC PALM �'�\ —
61R JEFFERSON AVE �.,, .Undersecretary
SALEM,MA 01970
IM Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Sisor
7
License: CS-0-0-,879I
ERIC W PALM
3 Salem
NL 11N ST = ?
Salem MA 0 . �
9121� >nu'� Expiration i
Commissioner 04/23/2016