198 NORTH ST - BUILDING INSPECTION (2) The Commonwealth ofMassaclmsetts INSp CEIV
Board ofBuilding Regulations and Standards EC TI NMUCTNtL3PRiAI11S
Massachusetts State Building Code,780 CMR
1((��''s. USE
Building Permit Application To Construct,Repair,Renovate Or Demo`hsh�N vis - 2y y
1.One-or Two-Family Dwelling
This Section For Official Use Only
Building PeimitNumber D Applied:
� �
vp.' Building Sigaahue « . Dater
SECTION 1:SITE INFORMATION
t 1.1 Prop Address: 1.2 Assessors Map&Parcel Numbers
9
_ )ro, 1 to
Llals this an accepted street?yes no Map Number ParsxdNumber
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Ares(sg ft) Frontage(ft)
1.5 Building Setbacks(8)
l Front Yard SideYauds 1. . Rear Yard
Required - Provided . Acquired Provided Regtured ` Provided
1.6 Water Supply:(tvLG.L o.40.§54) 1.7 "god Zone IpformAtloP.: � 1,8 Sewage Disposal System:
❑ Private❑ Zone: _ Outside Flood Zone? :.CheckifyesD ' Municipal D On site disposal system D
SECTION2: PROPERTYOWNERSHB?'
2.1 Owner'of Record„
Tih%Q (4 S JQ �Ghr //yl
Name(Print) �,U✓ City,State,ZIP -
/9sr AkrA S f.
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOIW(check all that apply)
New Construction 13 Existing Building❑ Owner-Occupied 13 Repairs(s) ❑ Alteration(s) D I Addition ❑
Demolition . [3 Accessory Bldg.❑ NumberofUnits -' Other Specify
BriefDescription ofProposed Work. !
SECTION 4.ESTIMATED CONSTRUCTION COSTS
Item E m'm t Cow' p;` Official Use Only
abor and Materials
1.Building $ 1. Building Permit Fee:S _ Indicate how fee is determined:
-Electrical $ ❑Standard City/1'owu Application Fee
❑Total Project Cost'(Item 6)x multiplier x.
3.Plumbing $ 2 OtlterFees: $ ''
4.Mechanical (HVAC) .$ List:
5.Mechanical (Fire -
Suppression) $ Total All Fees:$
6.Total Project Cost $ r Check No.M�c'1 Check Amotmt Cash Amount
❑Paid in Full ❑Outstanding Balance Due: `_ -
M0At_e:0 --I fz
SECTION 5: CONSTRUCTION SERVICES
51 Contraction Supervisor License(CSL) 'k 7 0/ "7 aZ 3 / ► .
LiremNumber Expiration Date
Name of CSL Holder
_! ISst CSL Type(see below)
�/i
Eric W.Palm
No.and street 3 Man Street .F Type Description .
-•, U unrestricted m'1 to 35,0110 on.IL
Calern MA01970 , - R Resinoted Mirdy Dwelling
City/fown,State,ZIP .. ! MMasonry
RC Rooting Covering
WS Window and Siding
SF _ SolidFaelBmningAPpliances
Vt n I Ia�dation
Telephone Ema7address D I Demolition
5.2 Registered Home Improvement Contractor(MC) ( 20
Atlantic WcatherltahuL,i,,..
H[CRc&trationNumber Expiration Date
MCCompavyNameorHI venue
salem "ri.c 01 9
No.and Street .. Email address
9
city
frown,State,ZIP Tel�one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFMAVrr(NLG.L 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 oftheLtisaance e building pem»L
Signed Affidavit Attached? Yes.......... No........—13
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOQR BURDING PERMT.
I,as Owner of the subject property,hereby authorize r G I a�Y1'6
to act on my/bebaK in all matters relative to work authorized by this building permit application.
Print Owa esName(El=bmcSi ) - D2t0
t
SECTION 7hi OWNERr OR AD7$ORIZED AGENT DECLARATION
By entering-my name below,I hereby attest under the pains and penalties of perjury that all ofthe information
contained in app nisftWpn
to time best of my knowledge and undersfanding.`�-
Print Owner's or Authorized Agent's Name,(ElechomeSignature) - - Date
NOTES:
1. An Owner who obtains abmlding permitto'do his/her own work,or an ownerwho hires an unregistered contractor
(notregmicred in the Home Improvement Contractor 0MC)ProgramN will not have access to the arbitration
program or guaranty fiord under MQL.a 142A.Other important information on the HIC Program can be found at
www.mass.eov/ocainfommatiouonateContractionSupervisor MeensecanbefoundatMDM .mass.gov/dos
2" When substantial work is planned;provide the information below:
Total floor area(sq.ft) (including garage,finished basement/atfics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number ofbedrooms
-Nuumber-of-bathrooms— Number-of-haif/batbs
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".
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Contractor Arbitration The Home Improvement Contractor Law provides homeowners with the right to initiate au arbitration action(as an
alternative to court action)if they have adispute with a contractor. The same rigbt is not automatically afforded to a .
contractor,however. The contractor would have to resolve my dispute he/she has with as homeowner in Mortarless
both patties 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
concenhing this cop 4 the ycaruacmtOia'S`•sihbmit the dispute to a private arbitration firm which has been approved by
the Secretary of flie l:xecutivef0co$Fonsumer Affiuirs and Business Regulation and Ole consumer all be required
m submit to such afbitr§hbn3a�pYvtd In Massachusetts General Laws,ch ter 142A.
Hour owner's Signature Contractor's Sigrature
NOTICE:The signatures of the parties above apply only m the aareement of Ole parties to alternative dispute
resolution ated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately aimed by the parties.
Homeowner's Rigbts
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 anyway,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 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. 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 bomeownees basic consumer rights. If you have
questions about your consumer/homeowner rights,contact the Consumer information Hotline(listed below).
Execution of Contract
The contract must be executed in duplicate and should not be sighed 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,ornot applicable. One original signed copy of the contract with attachments is to
be given to the owner and the otherkept by the contractor. Any modification to the original contract must be in writing
and agreed to by both parties-Contracted workmay 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
homeowner deems bim/herself to be financially insecure. However,in instances ivhere a contractor deems him/herself
to be financially insecure,the contr-actormay require that the balance of finds not yet due he plated in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said accoruttwould require the
signatures of both parties.
Additional Information
If you have general questions or need additional information about the Home Improvernmr:Contractor Law or other
consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home hnprovement"
contact:
Consumer Information Hotline
Office of Consumer Affair.and Business Regulation
10 ParkPlaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCA13R website at httD.//% h�iv.Maz.Pot,/ombr/
If you want to 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 lmp nvement Contractor Registration -
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 orvisit the BIC website at htm-/A%mv-mass.rsov/pcabr/
Go online to view the status of a Home Improvement Contractors Registration:
httn-//dbstate macs/homeimnrovement/licenseelistaso
For assistance with informal mediation of disputes or to register formal complains against a business,call:
Consumer Complaint Section
Office of the Attorney Generai
617-727-WO
AND/OR
Batter Business Bureau
508-652-4800,508-755-2548 or 413 734-3114
v�wzt-nrJraro
The Commonwealth of Massachusetts
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/Orgmization/tndividual):
Address: 61 3eff-er3-0>.• A--e-
City/State/Zip: Sale •n " O j9'7d Phone #: cf 7 k-7qi/- klit 3
Are you anemployer?Check the appropriate box: Type of project(required):
1.Ly0r am a employer with oZ J 4. ❑ I am a general contractor and I 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
shipand 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.t
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 1 I.❑Plumbing repairs or additions
myself o workers' com right of exemption per MGL
Y � P• 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13. ther T,IIISt�/47�0i,
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 most attached A additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors 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: !! Q Zc-t r%Cti
Policy#or Self-ins.Lic.#: p J 8aZ 70 I Z Expiration Date:
Job Site Address: / /y4rT�. City/State/Zip: SQ /'ear
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 ;der thins nalties ofperjury that the information provided above is true and correct.
Signature: ,p Date: b1A 9,
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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
-- --•- 1 4A oul Vol
CERTIFICATE OF LIABILITY INSURA1UCEDATE T TE DO E IS ISSUED AS A MATTER OF INFOR6fAT10N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS Y)
CERTIFICATE IFI DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
,; THIS CERTIFICATE OF INSURANCE DOES NOT CONSTIME A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
DUCE D CERTI CATE OL E
IMPORTANT:If the certlfifate holder is an ADDITIONAL INSURED,the oli i
sand to conditions of the policy,certain policies may require and entlwsyemer'Must d. A statement on�this certificate tllDes notNconterOrighbtseW to thecertiticate holder in Ifeu of such end certain n s.
PRODUCER
CONTACT
EASTERN INS GROUP LLC NAME:
233 W CENTRAL STREET PHONE FAX
(A/C,No,Exi:
-
NATICK,MA 01760 E-MAIL (A/C,No):
-
22MLW ADDRESS:
INSURED INSURER(S)AFFORDING COVERAGE
ATLANTIC WEATHERIZAITON LLC INSURER A: AMERICAN ZURICAINSURANCS COAIPANy NAICp
INSURER B:
INSURER C:
61 REAR JEFFERSON AVE INSURER D:
SALEM,MA 01970 INSURER E:
COVERAGES INSURER F:
CERTIFICATE NUMBER:
T O ANYREQUI 6Y TERM on POLM.�S OF eISUggNCE MSTEp 6EL0 HAVE SEEN ISSUEDTOTHEINSUReD NAMED ABOVE FORTHE POLREIRSICY R10p INDICATED NOTWITXSTANpD1G
AFFORDED BY'OIE POLICIES DESCRITIONSED OF ANY CONTRACT OR OTHER DOCUMENT WRX
PAID CLAIMS. HEREIN IS SUBJECT TOALL THE MM%IXCLUSIONS AND CONDIIWNSOF�pCAT Y BE ISSUED OR MAY PERT
SURA
MSR LOUIS SHOWN MAY HAVE BEEN REDUCED BY
LTq TYPE OF INSURANCE ADD SUB POLICY EFF DATE POLICY ExT DATE
L R POLICYNUMBED1YYYY GENERAL LIABILITYR RUhD ) fMMOOTVYYTT LIMITS
COMMERCIAL GENERAL LIABILITY H OCCURRENCE
CLAIMS MADE ®OCCUR. $
AMAGETOoccurD $
REMISES(Fa occurrence)
GEN'L AGGREGATE LIMIT APPLIES PER: ED EXP(Anyone person) $
POLICY 0 _ ERSONAL a ADV INJURY S
PROJECT®LOC ENERAL AGGREGATE $
AUTOMOBILE LIABILITY PRODUCTS-COMP/OPAGG S
ANYAUTO .
ALL OWNED AUTOS COMBINEDSMGLE $
LJMrr(Ea accldeN)
SCHEDULE AUTOS - BODILY INJURY
HIRED AUTOS (Per person) $
NON-OWNEDAUTOS BODILYP/JURY $
(Par accident)
PROPERN DAMAGE $
cc
UMBRELLA LIAB OCCUR (Per a ideN)
EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE
DEDUCTIBLE AGGREGATE $
RETENTION S S
WORKER'S COMPENSATION AND
$
A EMPLOYER'S LIABIL SA $
ANY PROPERROAIPAATNERlEI(ECUTIVE YM UB-SB2T0121-15 p9/2OIIp15 J[ WC SIAMOAY OTHEfl OFF!CERY.IEMBEfl EXCLUDED? WA 03/20/2016 OMITS
(Mandatary 1n NH) E.L EACH ACCIDENt
oyes,aesalbeuMer S 500,0p4 DESCRIPIICN OF OPERATIONS below E.L.DISEASE-EA EMPLOYEE S 500,000
DESCRIP77ON OF OPERATIONS/LOCATIONS/VEHICLESIRESTRI E.L DISEASE-POLICY LIMIT THIS REPLACES ANY PRIOR CERTIFICA CTIONS/SPECIAL ITEMS $ 500,000
TE lSSIIhTI TO THE CERTIFICATE HOLDER AFFECID.G WORKERS COMP COVERAGE.
CERTIFICATE HOLDER
CITY OF SALEM CANCELLATION
93 WASHINGTON ST SHOULD ANY OF THE ABOVE DESCRIBED pp
BEFORE TINE UCIES BE CANCELLED
HE IRATI
EXPON DATE THEREOF,NOTICE WILL BE DELNERELI
IN ACCORDANCE WITH THE.. PppVL910NS.
SALEM,MA 01970 AUrHOR12ED REPR - '-
ACORD 25(2010/05) The ACORD name and[ago are registered marks 01 ACORD
19W.2010 ACORp CORPORATION. All rights reserved.
CERTIFICATE ®F LIABILITY INSURANCE 3�/2W15"
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: c the certificate holder is an ADDRIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and condifions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu ofsuch endorsement(s).
PRODUCER
Eastern Insurance Group LLC NAME- Construction
233 West Central St PHONE Eel. (800)333-7234 FAX
E-MAIL X No:
AODR
Natick MA 01760 INSu S AFFORDING COVERAGE
INSURED INSURER A Arbella Protection InS. Co NAICA
Atlantic Weatherization
INSURER BNauti.lus Insurance Co 1360
61 Rear Jefferson Avenue INSURERC:
INSURER D:
Salem MA 01970 INSURER E:
COVERAGES CERTIFICATE NUMBERffASTER 201ININSURER F:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUREDEVN�OD NUMBER:
THE POLICY PERIOD
INDICATED. NOTW17HS7ANDING 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 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT E ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PgiD CLAIMS.
INS AD B
LT TYPE OFINSURANCE
GENERAL LIABILITY PODGY NUMBER MM�U EFF POLICY EXP
MAD LIMITS
X COMMERCIAL GENERAL DABILIIY EACH OCCURRENCE S 1,000,000
A CLAIMS{NADE PREMISE Ea 0
X OCCUR 500092816 /20/2015 /20/2016 $ 50,000
MED EXP(Any one person) $ 5,000
PERSONAL B AOV INJURY S 1,000,000
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY X PRO- LOC PRODUCTS-COMP/OP AGG S 2,000,000
AUTOMOBILE LUIBILITY S
ANY AUTO CO INFO SINGLE LIMIT
AALLEa academ S 1 000 000
ALITOS�EO X SCHEDULED BODILY INJURY(Parperson) S
AUTO-OSWNED
ANO
UTOS 020015871 /20/2015 /20/2016
HIRED AUTOS BODILY INJURY ParaccideM) S
PROPERTY DAMAGE S
X UMBRELLA LIAR X OCCUR PIP-Bask S
A EXCESS LIAB CLAIMS.MADE EACH OCCURRENCE S 1,000,000
DED RETENTIONS 600058654 AGGREGATE S 1,000,000
WORKERS COMPENSATION /20/2015 /20/2016
AND EMPLOYERS LIABILITY $
ANY PROPRIETOR/PARTNERIEXECUTIVE YIN WC STATU- OTH-
OFFICERIMEMBEREXCLUDEOi ❑ NIA
(MYyendaWy in EL EACH ACCIDENT S
0ESC ce RI�PTjOb and N OF OPERATIONS below EL DISEASE-FJ1 EMPLOYE S
3 POLLUTION LIABILITY E.L DISEASE-PODGY LIMIT S
PL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE
$1,000,000
:SCRIPTION OF OPERATIONS/LOCATIONS IVEHICLE$(AReeh ACORD 101,AddiOonal Remarks Schedule.R more EA POLLUTION CONDITION $1,000,000
space is raqulCONDITION
`RTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
93 WASHINGTON STREET ACCORDANCE WITH THE POLICY PROVISIONS.
SALSM, MA 01970 AUTHORLE OREPRESENTATIVE
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Licen License:
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License CS-087977 ,y '
ERIC W PALM 5 ''
1 - 3 14A ST '+
Salemlem MA 01970
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piration: 31-21M* Ltd Liability Corpo:{
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61RJEFFERSON AVE
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