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10 PETER RD - BUILDING INSPECTION (3) The Coin mouweaith of\Massachusetts C ITYBoard of Building Regulations and Standards AL OF Massachusetts State Building Code, 780 CDMR �Revised iLlar d Mor 20(1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling This Section For Official Use Only Building Permit Number: t)5 Appliedi F , Building Official(Print Name) Sign Lure SECTION 1:SITE INFO 1.1 Property/o Pef Address:er- eaad 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(it) 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: 1.8 Sewage Disposal System: Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SECTION 2:, PROPERTY OWNERSHIPL 2.1 Ownert of Record: -0,9M 61 iG .O C)Aadr0 Safest /"4 0i970 Name(Print) City,State,ZIP to 17R 70 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ 1 Existing Building❑ Owner•Occupied Cl Repairs(s) ❑ Iteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ NumberofUnits_ Other Specify: Brief Description of Proposed Woi-0: -P J f3 .irn l .4 A Of o e-F ter r /-Q I r-Ao W SECTION4: ESTIMATED CONSTRUCTION COSTS- Estimated Costs: Item Official Use Only. Labor and Materials 1. Building Z 7 — 1. Building.Permit Fee:S Indicate how fee is determined: 2. Electrical S ❑Standard.Cityfrown Application Fee ❑Total Project Cost(Item.6)x multiplier x 3. Plumbing i 2. Other Fees: S t. Mech:mical (IIVAC) 3 List: 5. ,Mechanical (Fira SnP iressinn) _ 5 Cotal All Fees: S_ . Clieck No. Check Autount: _ _Cash Amount. r, -I'ufal Project Cost S f e-Z7 ❑ Pu,l in Pill ❑ Outstandm IS,iLuice hw: _ __ --__ - _ rLe r sEcTION 5: CONSTRUCTION SERVICES 5A Cotstruetioat Supervisor License (CSL) _� 1" -- S 7 ! License Number Expiration Date — Mane of CSL I folder List CSL'Type(see below) `� G�1�!✓/'�-� Olr✓L Type _ Description No. and Street U Unrestricted f Duildin s up to 35,000 cu. tt. A)AV-11vn C-00G3 R Restricted 18r2 F;unil Dwcllin Citylrown,State,ZIP IV[ �blasonr RC Roofin Cc', \VS Window and Sidin SF Solid Fuel Burning Appliances tot0—P7y— 500 0X3 V I Insulation I'de hone Email address D Demolition 5.2 Registered Hone Improvement Contractor(IIIC) l609w6 IoowQ� reelY� O r np C?XO /0 HIC Registration Number Ezplrauon Date I(IC Company Name or IIIC Registrant Nam . . Sol Se if /)Tv— No. an�L kaIr ,1�Aigvt� Email address City/ own, State, ZIP Tzle hone 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 Issuayf of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorize t9)leIA �o col r O ff? to act on my behalf, in_I/lr a all matters relative to work rauthorized by this building IF permit application. Q0MrAtC, AAAa see c�yillV--ed— 0/1& Print Owner's Name(Electronic Signature) Date SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION Fentering name below, I hereby attest under the pains and penalties of perjury that all of the information s application iis/trrue and accurate to the best of my knowledgeand understanding. l Y �/TvI:J '�)�`' /�udwrired:\�ent's Name(Hlectronic Signal ) Date TES: I. 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 Hume 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 II1C Program can be found at www m;us.euvoca Information on the Construction Supervisor License can be Found at w\vw.nctsS.,.ar�dL 2. When substantial work is planned,provide the information below: Total floor area(Sq. (t.) (including garage, finished basement/attics, decks or punch) rcoSS living area(Sq. ft.l _ habitable room count Number of Number------ Number ofbedroortts ------- VuntbcrutbachrnuntS Numberoflt;dBbaths I'cpe of heating system -- ----_._-- Number of deck,' porches I',pa ,rFc,nrling ;ti';tcm Fncloscd Ppol t `I',rt tl I'I.,j.rt Oyu fro f n,rt tie" nt.ty he 5tIh;titur d t )r l',,t.tI I iujert Co;t'• _ . . . I /r1VY' CITY OF S.1 zm2 ass.'ICHUSETTS BLtLONG DEPAILTUJUNT LVGTON STREET, 3 FLOOR �h.. `-~ TEL (978) 745-9595 KIJIDERLF-Y DRISCOLL F.VC(978) 740-9345 PL�Y01i TFIOSNS ST.PIERAS DmECTOR OF PL13UC PROPERTY/BCILOLYG COSLNIISSIO. E. Construction Debris Disposal Affidavit (required for all demolition and renovation work) !n accordance will, the sixth edition of the State Building Code, 730 ChtR section l l 1.5 Debris, and the provisions of tbiGL c 40, S 54; Building Permit k is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by b1GL c 111, S 150A. The debris will be transported by: (name 01'114ulor) The debris will be disposed of in (name of facility) (�dJres.t of t�.ility) signature ofpermi plicant s!G//-> late -- 1 `I The Commonwealth ofMassaehusetts Department of Industrial Accidents Office of lnveogations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ((j� / Please Print I eeibly Name(BtuinessAimmalatioaftdivtdual): Po LiEg- N om cz j`Ef cac'N� C. izot)12 Address: 2S- 116VAr0rA2, .Shut= 8110 6LttZ /eft l/01 City/State2ip: Phone #: G 1C' - C2y 51AL0 Are pd an employer? Check the appropriate box: Type of project(required): 1.Cff I am a employer with_ P� 4. 0 1 am a general contractor and 1 6. ❑New construction employees(f dl and/or part-time).' have hired the sub-contractors 2.0 1 am a sotc proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contracion have 8. ❑ Demolition working for me in any capacity. workers'comp•insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself - ._. yse (No workers'comp. e. 152,§l(4),and we have no 12.[�--RooF repein-"-_- insurance required.)r employees.(No workers' 13. hcr l�l�/NDolr/S comp. Insurance required-1 •Any applitaat Char checks bus al tutor also fill oot the swim below showing;their worker'mmpeasuoo policy mftanna too. t Hameownes who submit this anidarir indicating they are doing W wait and thin him outside coovactos mutt mubmtt a neo afiidavit indicating saw. lContoem s that check ails box vma handled an aUtlonal sheer shooing the name of the aubtooinson and their workers'comp.policy information. lam an employer that it providing workers'compensation Insurance for my employees Below is the poUcy and fob site Information, Insurance Company Name: NRRL 5V1i-t-C W04CESTW_ _ Vj C-d notary a o.sett use.a. W� OAt7 O O �y 795 Exp r tion Dare '01 / 5 Job Site Addres 10 Pe.+er ,2.oaA City lwzip S a l Eevt MA 01 q'7 D 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 fitu up to f 1,500.00 and/or one- ear imprisonment,as wcU as civil.penalties in the form of a STOP WORK ORDER and a fine of up to b250.00 a e ' lator. Be advised that a copy of this statement may be forwarded to the Office of Invcstigahons o c D for coverage verification. I do hereby e u er e p and penalties of perjury that the Information provided above Is true and correct: Dow 'f 71J l3 OJfleMl use only. Do not write in this area,to be completed by city or town ofJiciaL City or Town: Permit/License Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.CltyfTowo Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: POWER-1 OP ID: EL CERTIFICATE OF LIABILITY INSURANCE �,E(09119/12 ' 19/12 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 Uau of such endorsemen s. PRODUCER CONTACT Lacher&Associates Ins Agency PHONE F Lacher Insurance Group AIC No: 632 E Broad St P O Box 64398 ADDRESS: Souderton,PA 18964 Chad Lacher INSURERS AFFORDING COVERAGE NAIC$ INSURERA:Harleysville Worcester Ins Co 26182 INSURED Power Home Remodeling INSURERS t Harleysville Preferred Ins.Co 36696 Group,LLC Power Home Remodeling Group, INSURERC:Nationwide Mutual Ins Company 23787 Inc. INSURER D: 2601 Seaport Drive Ste B110 Chester,PA 19013 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: 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. MLTR SR ADULSUBF TYPE OF INSURANCE POLCYNUMBER IMMIDDfYYYY1 (MMIDIVIVYYY)�EXP LIMITS GENERALLIABILITY EACH OCCURRENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY MPA00000089793N-1 09/22/12 10/01/13 REMISES Ea ooanenc $ 100,000 CLAIMS-MADE FXI OCCUR MED EXP one arson $ 10,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/DP AGG $ 2,000,000 POLICY X JECPR0- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT e ado 1,000,00 A X ANY AUTO BA00000089796N 09/22112 10101/13 BODILY INJURY(Perper.on) $ ALLOWNED SCHEDULED BODILY INJURY(Peraalderd) $ AUTOS AUTOS HIREDAUrDS NON-OWNED PROPERTY DAMAGE $ AUTOS Peraa UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 C X EXCESS LIAB CLAIMS-MADE CMBOOOOODS9794N 09/22112 10101/13 AGGREGATE s 10,000,000 DED I I RETENTION$ S WORKERS COMPENSATION X WC STATll- OTH- AND EMPLOYERS'LIABILITY A ANY PROPRIETORNARTNER/EXECUTNE YIN COOOOOOB9796 09/22/12 10/01113 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDEDT © N/A (Mandatory in NHl E.LDISFASE-EAEMPLOYE $ 1,000,000 eyyees de.vlbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB 1$ 1,000,000 A Mass Auto Policy- - BAOOD00018227P "' 09/22112 10/01/13 �Llablllty 1,000,00 Limit -TI DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ADach ACORD 101,Additional Remark.Schedule,N more spael.required) CERTIFICATE HOLDER CANCELLATION SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Salem 120 Washington St AUTHORIZED REPRESENTATIVE 3rd Floor Salem,MA 01970 ; 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD Office o?`"CO nsumer Affairs d An �sigulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 '-Home Improvement Contractor Registration Registration: 168616 Type: Supplement Card POWER HOME REMODELING GROUP LLC Expiration: 3/18/2015 ALLAN COLPITTS _ 2501 SEAPORT DRIVE STE 8110 CHESTER, PA 19013 - -Update Address and return card. Mark reason for change. sCA1 o 20M5n1 [� Address 0 Renewal D Employment lj Lost Card pia,,,#egistra ce of Coosumer ntinirs& 8usioess ReginatioaLicense or registration valid for individul use only MEIMPROVEMENT CONTRACTOR before the expiration date. If found return to: tinn: 168616 Office of Consumer Affairs and Business Regulation Type: 10 Park Plaza-Suite 5170 Expiration: .3/18/2015 Supplement Card Boston,MA 02116 POWER HOME REMODELING GROUP LLC. ALLAN COLPITTS 2501 SEAPORT DRIVE STE B110 CHESTER,PA 19013 _____ Undersecretary Not valid w' ut signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-001979 ALLAN K COLPI)rTS 3 CHRISTIAN DR g NASHUA NH 03063 Expiration Commissioner 05/07/2014 Dominic 0011010 3066812 NATIONAL H£AbQUAaIuS March to,20i3 L801 Sa:iponl)&-. 888aREM10DEL "" e Wcelst le G _. CUSTOM REMODELIN AND IMPROVEMEN7'AGREEMEN7 Maw}& " Project Number,30-68812 .oamw.a+*'+aov euyats lnrormaaon hoe eem Dominic Dunedin (978)30a31711 Wlhu's Ceti) - domdndMYa , EM%Adirs>1 10 Pater Rded (781)3074930(laYre09.C-10 Sate..MA,0197e (a17)3Ba.7§all(ponrtnic`s wa"k) Ceamy:Etser Township: Buyer(s)listed above hereby jointly and'severailysgmes to purchasethegoodsand/or thefont antiwar Home Remodeling Bra up("Contractor")in:aocorose 8 wltn the prices and terms described on the bnitt and time following tour pagos,af this agreement and any specification tons whton are incorporated as-part of the Agreement(calteegveig this.. "Agreement"):This Agreement represents-a taah sale of goods anti ser'vises1 Buyers) ancing'to pep the ey see the gouda, and servicas.purchased as deseri(vstl herein,regardless of timing or approval of any financing Buyers)maysesk fnrtheir pumhose.:Problems and Inquiries regarding thta Agreement should be directatl antractof at 1-688.735i8335. ruche C purchase Price: - ;Y8,279:88 1 Pro installation inspection Data."; a:00 Oar pM wl[I� on Tlfu all 0,N VeM mIE 11+9aa Down Payment: Estimated project Start:6 to 7 weeks' 8alancce Dueon 'SIS,273.88 act Completion:2 to 4 days Estimated Proj Substantial Compta5on; Method ofPayment Other a iem naafm.ms4r Damps aapgfa GmonrcmrzconaWrwt wawaam Pk.1�8liap i'n(B Raa1PR 590 aar8)'fUFlR!Iw?f edndlWls all @Ya94 F , r Buyer(s)hereby acknowledges receiptof a copy of the pamphlet, The Lead-Safe Certified Guide to Renovate Right", lnfommtn (sj of the potential risk of load hazard exposure from renovation activity to.be performed in Buyer's home, aE the r ittan above.Buyer(s)(ecelved this pamphlet on the date of this-ggrsament,..before commancement of .work. (Buyer's initials)., ' It Is agreed and understood by and between the parties that this Agreement constitutes the entire understanding between the parties,and there am no verbal understandings changing or modifying any of the terms of this Agreement Buyers) 1 hereby acknowledges that•Bu'yer(s)1)has mad the entire Agreement and has received a completed,signed,and dated copy;, of this Agreement,Including the two-accompanying Notice of Cancellation forms,on the date firetwri tan above and 2):was orally(Moaned of Mentor right to cancel this transaction.DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK . SPACES. Future promotions notappiitable. t I-have read and received each page of this 5 pageagreemont. Power Home Remodeling Group Buyer( dam � m((A�d1 m3 WA tmodeling Consultant Signature - Irving Espinosa ,Dominic Donadlo YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE.THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE NOTICE OF CANCELLATION FORM FOR AN E%PLANATION OF THIS RIGHT, March 16,201315:56 I�pl(�I��il�pi�(ill0l,�(((iI - Ilu'I fII I'ul�l �I I'I�II'I' page 1 of 5 ( NATIONAL HEADOUARTERS Dominic Donadio 2501 Seaport Drive,Chester,PA 19013 ,{ aj-�OWER 30-68812 •, ..4A-��g� - March 16,2013 888-REMODEL - • ,, �• s •• ��• MA HIC#168616 Project Specifications Windows: Kitchen 2 Pt Slider 2 38.5x34.0" WINDOWS: Models SL 2700 Styles Slider Types 2-Lite Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None Windows: Dining Room 1 29.0"x55.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None Windows: Living Room 2 29.0"x55.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood 1 Additional Details None Windows: Bathroom 1 18.5"x34.5" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None Windows: Baby's Room 2 29.0"x45.5" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None Windows: Master Bedroom 2 29.0"x45.5' WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None March 16, 2013 15:58 IIIIIII IIIIII I IIIIIII IIII II III III II III Page 2 of 4 NATIONAL HEADOUARTERS Dominic Donadi0 2S01 Seaport Drive,Chester, RA 19013 •,,.;� ., `nOWER' 30-68812 March 16,2013 888-REMODEL : ' MA HIC#168616 Project Specifications Windows: Dining Room Octagon Architectural 1 20.0"x20.0" WINDOWS: Models SL 2700 Styles Architectural Types Octagon Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood i Additional Details None 0 Windows: 3 Pt Slider Dining/Living Room 2 100.0"x54.0" WINDOWS: Models SL 2700 Styles Slider Types 3-Lite Configs 1/4-112-1/4 OPTIONS: ColorWhite/White: GridPallem: None I Removal Wood I Additional Details NoneILL] il March 16, 2013 15:58 IIIIIII I III II II III IIII IIII IIIII I IIIIII Page 3 of 4 NATIONAL HEADOUARTERS Dominic Donadio 2501 Seaport Drive,Chester, PA 19013 ($ �OWER'# 30-68812 Y,*tb R Harm Pm,oGelMG,uT,f 888-REMODEL - - - March 16,2013 •• • •• •�• - MA HIC#168676 Project Specifications Doors: Innocent Peek Grand Entry 1 XON80.0" DOORS: Models Dynasty Styles Entry Door Types 36"Series Conrigs Textured Fiberglass Options r��y�s,r� Innocent Peek: Expressions(Platinum)Color 2-Color Exterior Color Wineberry I Interior Color Cherry I I�IiI.AG E NOT Hardware Avalon Handleset: Interior Hancock Knob: Deadbolt: Satin Nickel I Additional Details Dynasty Accessories/Options KnockerlViewer No I Viewer No I Kickp/ate Yes: Satin Nickel I Mailslot No I Build 1 +"5� 1B�.. 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