32 OSGOOD ST - BUILDING INSPECTION The Commonwealth of Massachusetts
` Board of Building Regulations and Standards FOR
j Massachusetts State Building Code,780 CMRRECEiVED MUNICIPALITY
S RV� ES USE
( _ Building Permit Application r Two-Family
Repair,l2("�J �oif a RevisedMar2011
v) One-or Two Family Dwelling
NThis Section For Official Use
BuildingPemdtNumber: Date A Led:
��T Building Official(Print Name) - Signature Dee
t SECTION 1:SITE INFORMATION
1.1 Pr Address:Address / 1.2 Assessors Map&Parcel Numbers
Lla Is this an"led street?yes no Map Number - Parcel Number
13 Zoning Information: 1.4 Propeqtybrmensrons:
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.G.L c.40,§54) 1.7 Flood Zone Information; L8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site
Checkifyes❑ P disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
21 Owflfrt of Record: e4i.7
Name(Print) City Statc�ZIP
9 3
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply)
New Construction❑ Existing Building❑ Owner-occupied ❑ 1 Repairs(s) ❑ [Alteration(s) ❑ Addition ❑
Demolition . ❑, AccessoryBid&0 NumberofUnits - Other Specify:
Brief Description off roposed Work:
r/i wt/ Ce w U cCf
cur
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
_(labor and Materials Official Use Only
1.Building $ / 1. Building Permit Fee:$ Indicate how fee is determined:2.Electrical $ ❑Standard City/1'own Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (RVAC) $ List
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount Cash Amount
6.Total Project Cost: $ A10, ❑Paid in Full ❑Outstanding Balance Due:
M12� tt_C-=V ` 127-
r ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 7 9 -7 a
License Number Expiration Date
Name of CSL Holder
• +iIQr7?a'1a,. Ust.CSL Type(see below)
��
No.and Street 0r+ , Description ,
u Eric W'.Palm•"3 Hilton Street
j ' • FJ 0 r-.i , r U Umestricted uildin to 35000 cu.tt
Salem MA 01970 R Restricted l&2 Family Dwelling
'd /rown,state,ZIP M masonry
RC Roofing Covena
WS Window and Siding
1 ✓I V l a SF . Solid Fuel Burning Appliances
_r b V I a I Lvsidafion
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) 2-03
Atlantic wtiatherualivii,i, Iq
HIC Registration Number ExphationDate
HIC Company Name or HiMeffisMIRIM AVCnUe
3tnVt>r
No.and StreetMA .1� Email address
atyrrowA State,ZIP T�elhone
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 denialof the Issuance a building permit.
Signed Affidavit Attached? Yes.......... No.
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner ofthe subject property,hereby authorize• ' f'rG i�a/t n
to=actyf,in all matters relative to work authorized by this building permit application.
Pdnt 0 mer's Name(Elect(onic Si a _ _ Date - -
SECTION 7h:OWNER!OR AUTHORIZED AGENT DECLARATION
By enteringmy name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in 's applica is mvt accurate to the best of my knowledge and understanding.
�! N�J,P1
Print Owner's or Authorized Agent's Name(Electronic Signature) - Date
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 can be found at
vrnw.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,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"maybe substituted for"Total Project Cost"
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Contractor Arbitration
The Home improvement ContracwrLawprovides bomeowners with the rigs tto initiate an arbitration action ins I
alternative to court action)ifthey have a dispute With aconnactor. The Same right's"0 automatically afforded toa
contractor however. Thecomrectonvouldhavetoresoh'eanydisputehelshehaswithahpmeplVnerincourtaaless
both patties ape to the optional dause provjded below.This clause would&e the contmetorihe sum..right io
arbitration as is aEprdedto the homeownerby the Home Improvement Contractor Law.
The contractor and the homeownerhereby mutually agree in advance that in the event the contractor has a dispute
concerning this commcr the c'oneaceprplay submitibe dispute to a private arbitration firm which has been approved by
the secretary'of the Executive Office of ConsucserAffil s and Business Regulation and the consumer shall be required
to submit tosach arbitration asproviit a-hiviasmutseasGeneralLaw%ch r14A
Homeowner's Signature Contractors Sranature
NOTICE:The signatures of the parties above apply only to the agreement of the patties to alterative dispute
resolution initiatedby the contractor. Thehomettamermayinitiatealternativedisputeresolutionevenwherethis
section is.not separately signedbytheparties.
Homeonner'sRights
A homeowneetrights under the Homelmprovermt Connector Law(MGL chapter l42A)and other consumer
protection laws(ix-MGL chapter 93A)may not be waived in any way,even by agreement However.homeowners
may be excluded from certain rights ifthe contractor they choose is not properly registered as prescribed by law,
Homeowners who secure their own building permits am automatically excluded from all Guaranty Fund orov isions of
the Home Improvement Contractor Law: The contractor is responsible for completing the work as descn'bad,in a
timely and wrorimumfilm manner. Homeonmers may be entitled to other specific legal right;it the contractor
guarantees orprovides an express warranty for w•ori manship or materials. In addtnon to guarantees ornarranfres
Drovided by the contractor all goods sold in Massachusetts cum an impliedwamenty of merchautabifify'and fitness for
a parricutarpurpose_ An ammretationof other matters onwhich the homeowner and contractor lawfullyaLmw may be
added to the terms of the contract as long as they do not restrict a homeowner's basic tousmnarrights. ifyou have
questions about yourconsumedhomemvner tights:contact the Consumer Information Hotline Qisted below).
Execution of Contract -
The contract must be executed in duplicate and should not be signed until a copy of all evltibits and referenced
documents havebeenadached Parties are alsoadvicednotmsigaihe document until all blanksections have been
filled in ormarked as void,deleted or not applicable. One original signed COPY ofthe contraclwith attachments is to
be given to the owner and the otherloept by the contractor. Any modification to the original contractin ust be in writing
and agreed to byboth parties.Contracted wort may notbegbr until both parties hserecetved a fully executed copy of
the contract,and the throe day rescission period has expired
Accelerated Payments
A contractor may not demand payments in advance ofthe dates specified on the payment schedule in cum where the
ItomeownerdeemshirMrerselftobefinencialb'ittsecute. Hmvetrerin instances where a contractor deem him/herself
to be furancia0y insecure,the contractormayrequire that the balance of funds notyet due beplaced in ajdmt escrow
account as a prerequisire to continuing the contracted work Withdrawal of funds Epm said accmmtmotadrequire the
signatures ofbotn panes•
dditional information
Ifyou have general questions or need additional information about the Homehnprovemeht Contractor Law or other
consumerrights,or ifyou wish to obtain a flea copy of"A Massachusetts Consumer Guide to Home Improvement'
contact
Consumerlolormation Hotline
Office of Consumer Affairs and Business Regulation
to ParkPLv2,Room 5170,Bosmn.MA 02116
61i9rA787,988-283-3757or via it the 0CABR webs itea'.i:a,: iv:v:.rEli _o• :e.�i+r
IfyOu want to verify the registradon of a contractor orifyou have questions or need additional information specifically
about the.contractorregisttation component of the Rome liaprovement ContractorLaw.contact:
Director of Home Improvement Connector Registration
Office of Constmrer Affairs and Business Regulation
to ParkPtam,Room 517%Boston,MA 02116
617-973-8787,888?83 37Sr orAsit the IN w'ebsite at iitn 'u-•ac.m==�nriovab
Go online to view the smms of a Home Improvement Cormac or's Reeisaation:
-t•�-r;ay.....:-an�u�imp•tin-mv;:-.•ptrric.as.Jst.�:. ., - -
For,assistance with informal mediation of dmPul or to registerformai complaints apinst a business calb
Comsiimer Complaint Section
Offid0the:Attomey General
617-727-8400
AND/OR -
Better Business Bureau
508-6514800,50S 755-548 or413.7rh3114
vmadzt-m�±n�ta
The Cotntnoarvealtlt oflMlassachnsetts
13epartmerr$of IndustrieAccidents
Office oflnvestigadons
1 Congress Street,Suite 100
Boston,MA 02114-2017
Workers'Compensation Insurance Affidavit.,4SBuild s/Contractors/Electricians/Plumbers
Applicant Information
PIease Phut 1;eeibly
Natne(Businesstorganiyationlindividual): Atlantic Wtdthcfl[aWUu. LIA-
Address: 61 R Jefferson Avenue
_ o
City/Stage/ 'p: ��� '�
Are you employer? Check the ro mate box; Phone'#: q-
PP P '
IV
I• am a employer with= 4. [1 1 am a general contractor and I Type of project(required):
employees (full and/or part-thne).x have hired the sub contractors 6• New construction
2.[] 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub contractors have
working forme in any capacity. employees and have workers' 8' Demolition
No workers' comp, as
comp.insurance.i 9. ❑Building addition
required.] 5. Q We are a corporation and its 10.0 Electrical repairs or additions
3.�] I am a homeowner doing all work officers have exercised their
myself. (No workers' comp. right of exemption per MGL I LEI Plumbing airs or additions
ins
required)t c, 152,§i(4),and we have no I2.[]R p
employees. 1No workers' 13. Other 4 41 )
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers•comperusation policy information.
f Homeowner who submit this most attached
indicating theyare doing all work and then hire outside contractors must submit a new affidavit indicating such.
employees. that check this bmtmustattachedanaddidonalsheetshowing the name of The sub-contractorsandslatewhetheror not those entities Ian
employees. Iftfieaub-contractors have empla},ees,shay must provide Iheir workers'comp.polity number.
I ani an employer drat it providing workers'compensation insarmrce for eny employees Below is thepolicy mrdjob site
nrfOTnratlOA.
insurance Company Name: (i(V I C't
Policy or Self-ins. Lic.#: 61-70/a t
Expiration Date: c3 �{Q
Job Site Address: ��✓S� ST�
Attach a copy of the workers'coin P y �tty/State/Zip:— _ G
Failure to secure dive a Pensation olio declaration page(showing the policy number and expiration date}.
rag required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa
fine up to$1,500.00 and/or one year imprisonment, as well as civil penalties m the form of a STOP WORK ORDER and a fine
In es to bonsS250.00 a day against the violator. Be advised thata copy ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby..wa.----'
fy a er Ike pa San _
tea ofperjary that the mfornuttwn
Si nature: provided above is true and correc Phone#: J ate: U II f
Official use only. Do not write in this area,to be completed by city or town orldai
City or Town:
Issuing Autbori (circle Permit/License#
I. Board ofHeaitJt2 Building Department
h.Other 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
Contact Person
Phone#-
Page 3 of 4
tit Massachusetts-Department--4sf Public Safety
�f Board of Building Regulations and Standards
Construction Supervisor '}
License:CS41167977
EMC W PALM } {
3 HH.TON ST '� #
Salem MA OL970
rr s
8xpirarion
Commissioner 042=16
&7tr yourn�nirrrrml��o�''t3�l�a.:inr/FruPlG >'
fficeofCowan=Aftaus&Bud""Regatetioo .
Wirratu'l'on:
PROVEI TENT CONTRACTOR
tlon 142089 ryPg
:;311272016 Lid Liability Corpo�;
ATLANTIC WEATHERimnokl::LC.
ERIC PALM - - -
61RJEFFERSONAVE - _ r
SALEM,MA 01970. Underseeretary '