31 PICKMAN RD - BUILDING INSPECTION (2) ,r
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The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
SALE
' Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling _
This Section For Official Use Only g+
Building Permit Number: 1,Wate Applied: - a r+t
' /ate o In
_i.BuildingOfficial(Print Name). T' Signature - $fl1e 3,
= SECTION 1:SITE INFORMATION
N
1.1 Property dd ess: 1.2 Assessors Map&Parcel Numbers
3 � �2 u4aN
L l a Is this an accepted street?yes_ no Map Number Parcel Number tV m
1.3 Zoning Information: 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.G.L c.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 yes❑
Ow v SECTION 2: PROPERTY OWNERSHIP'
2.1 er'of Record:
5a 1..ePP? #14 (2197 U
Name Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ eration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: C_.
Brief Description of Proposed Work :
ce, I— v z oal�
SECTION 4:ESTIMATED CONSTRUCTION COSTS ..
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ _ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x'
3.Plumbing $ 2. Other Fees:-$
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ '�140 0 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES'
5.1 Construction Supervisor License(CSL) S-) / 1--)
License Number Expiration Date
Name of CSL Holder Eric W.YaIni
List CSL Type(see below)
3 H11t0I1 Strt:Ct No.and Street T Description
Salem MA 01970 , U P
Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
"{ ,"1 `"f I insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Atlantic WeAffizatioti,.LLC
HIC Compa(AIR a ""Vame HIC Registration Number Expiration Date
No.and Street 01970 Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.i 25C(6))
Workers Compensation Insurance affidavit must be com ed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance;re building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
(� Z
I,as Owner of the subject property,hereby authorize y—i �a J/V✓!
to act on my behalf,in all matters relative to work authorized by this building permit application.
VVA^A'\a , f`aA /0 3 /
Prim[Own is Name(Elecronc ignature Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contai74 in this apt(_; atiq�t""i$ and accurate to the best of my knowledge and understanding.
erb-Al �� (tiys,+ 0i3 /tj1
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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/doss
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"
Massachusetts Home Ina rovement Sam le Contract
This form smisfies all basicrequiremenm of[be mates Home laumannert Coapagorlaw GL
him Ugeropmteq homeowners.Seek legal advice YOU iineteoo (M t¢14dq);tent don ootfododeslmdard Malem b'uett'Consumer Guide to Ffame be 'Y. Any'pesan planrriag homeimpmvemenq shodd fire ahwinampyaf^A
ORrm of Coosum¢AffairsaM 9usineaR pmvenrem"beforenredngto any nook anyo¢revdmcn
aSWatio,'s Corium¢g Informmian Hadiac ed 617-973.8787 or may obtain a geo copy by
1-8gg_2 caning the
Ifomeowaer Information 53-3rs7 oron ourwebate.
CoahsetoiInformanon
'! Name 1n
V0Y1 rJC. Q rt/iv c
er ompany Name
Su Addeesc(d. tine Pon OFfire as:addtew)
,3 reT Cootractarlsdelenow p�►}�' .
Averille
State zip Code/ �Q im 9 9asin Andres;huen e � .aim
DaflimpeP-h7mep �
Ewtung Phew Ciry/roaa Stine
• CYO $p Cale .
illniEng Address Qt ditierem fmm abova30) -I'
._ Busmen Phme Fednal my.ID arh'.b'.Numb.
. ^• .. v rmrrq°mauremne"e nostepv,eemtvaxierag
F`A�aan6Y
. lmpmrriemaae°nawe
e,aQE tii@+am v®[e
The Cantneloragraes to d,the fanowiogworlr for theAomemvrrer.Inacnhe in de4 drewark w roepleted,aped
. u2 5'ms the type,brand,midgradeof mataidsto be .k=addfti=l lihms- __ ).'.
Required Permits-The following bwld'm . . .
and s01 be secured by thementractooasthehommmumeesagent: beach ertdsoUtand to utllacd mPhill teumsrances Schedule-The following suhedidill
(Owners who secure their own permits will be beyond the counse 'smormlarise
excluded from the Guaranty Fund provisions of �(/ ZO
Al chapter 142A.) DazerAm contractor tsnll began oomierkd iwrk
�o �re when T contracted svod;swll be substantially completed.
Thhe Contrtu prim PeymmtSchedule
e Contraq¢agees to pmfo.mthe %mrL fmnisbthemmaW=d labor specified above loot the total smroE
Payymm'ennttss�iill�be made according!,the fdlowingscbelhde: �. e
S-(.2(L(�_~upon Alining com act(not to Col Ill of the toed MUM ce
_ Pri gi the cost ofspeoaz only hems,whichever isgpem¢)
S
by !._Il'_/ ¢upon completion of
by&; !/S—jor upon completion of
upon cempletim bftheemoratt. (Iawfmbids`deormding full Mn con mnUMiscomPleledto6a0
.The foponi W Parry's satisfaction)
oWeted beforemm.(aV u' rat man be special: s r ilatil d - -
eantra.ed nark begins in oN.
.to men we cmnWeioo schdWe(••) i. 'S d
pal
(') °�°g°a f1Oi0C mad(")tavrequun fletaoy,del ordoan-pay im,required by the eonuaotmhei'orenark
not coined belpeat¢af(a)one third ofthatotd tomcat Prim or(b)the actual eon ofaay madd mgiosmey
ssfiieh mum 6espatial wdered in advance weep ducomplatimuchl equipment a rgammnedemetedd
E=pmsw -u ron ,aadad lwm
to tract nA ❑N �v i
agreest besolely rasppnsiy forcompl n fthe work dewrbedre � t
paw/sobcontrattoruhlrad b}•vie contractor.The ceottattarfunh¢a garAess oFtheactimu ofany third
a r 's greambesoldy responnlde torah paymmBlo all mbmntrattors for
ContmctA¢epmnce-Upon sipniog,this dpmmeut becemesa binding rontraq uud¢lasv. UNessometsvise noted
mntmct shdi notimply ear any dim oo oth¢secudry7,t¢est dss hem placed an the reddmce.Revirw We f,limvin��tltis document,l6e
orefulty before dgning this mnaaq. � gaautiom and notices
° Dont be Pmuued into sigoingthe contract Take time to read and fully,dead it. Ask utstiom ifsom
° rh.
ggth mntmctorh�°.Arnw.,n,e.— vtmtrsttCq nhing isunmmcorsto beregmtBred svrthh •�eY1-.Thelasv segoires most homeand
ationbywd rwnbattarhave insurance? Asl;the Cmtrattort¢hisinsuraucem �' u8617-g73.8787 or 888.283-3757.
sceacopyofa'pmofofinsmance^doamtrs2 :, mpaaY into®atian so that you cm rwnfum mvemge,or ask to
° Guide
in thrights.,1 resPonabihties Read the hnportaotlnformation on Weteverse side ofthis fort,and gar acopy oflhe Gnomic¢
Guide to the Home Impmvemmt Contragarlaw. -
You may cencel thisagreernmtiFithas been signed m a place oth¢dra I the tamhactalsnormd Iace ofbusin
mnhactorin xritivgat his/h¢main office or breach office by ordinary,mail p ess,pmvilkd younotify the
third business day following thesi ' gorthisa Posted,by tdegmm sera or by delivery,not later than midnight ofthe
greemmt Sa the allnked notice ofwncdlatimr f,mr forgo esplannim ofthis right DO NOT SIGN T mob, CONTRACT dF TAERE ARE g stt
rev uw�d eepicrordmcaaaaymm ee LANK SPACE$..som?teo-dad vgmL Om mPSdm9S°b Wcimmwnm.IheaW.®ayrhwtd betepth'deoauumr.
Hancetm¢sSr Pi I�Q�/Y�e
I ' tt � 1i4
Catra igmO I � I03
Iv(Dale
Date
Contractor Arbitration
The Home improvement Contractor Law provides homeowners with the right to initiate an arbitration action Ias an
alternative to court action)if they have a dispute with a contractor. The same right is=automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both parties 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.
f
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,thecontraemr may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the.Executive'Offidd of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbin oila.as,provided Io Massachusetts General Laws,chapter 142A.
f'1 V I w
Home hers Signature Contra to s Signature
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowners rights under the Home Improvement Contractor Lowy(MGL chapter 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 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 worlmtanship 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 lawfiilly 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 consumer/homeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in duolicate and should not be signed until a copy of all exhibits and reierenced
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 allachments is to
be given to the owner and the other kept by the contractor. Any modification to the original contract must be in wvriting
and agreed to by both parties.Contracted work may 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 him/herself to be financially insecure. However.in instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work Withdrawal of finds Gem said account would require the
signatures of both parties.
Additional information
If you have general questions or need additional information about the Home Improvement Contractor Law,or other
consumer rights,or if you wish to obtain a five copy of"A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Wormation Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plana,Room 5170,Boston,MA 02116
617-973-8787.888-283-3757or visit the OCABRwebsiteatlatr.:f;r.s nas.+:mi crc_
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 improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-Ora-8787.888-283-3757 or visit the HIC webshe at i ts ?s.w,�•:Baas -o�uo abri
Go online to view.the status of a Home improvement COnlydCter'a Registration
ntin:'di.�tate:ma.us%heneinmrow�emenb'limnsezlisazsn
For assistance with informal mediation of disputes or to register formal complaints against a business call:
Consumer Complaint Section
Office of the Attorney General
617-727-9400
AND/OR
Better Business Bureau
508-652-0800.508-755-2548 or 413-734-3114
Vesion 2.1-uM2010
r
The Cornrnorrwea&h ofHassachusetts =
0eParfteftt 001dustrialAccidents
Office ofluvestigations -
1 Congress Street,Suite 100
Boston,DMA 02114-2017
Workers' Compensation Insurance Affidavit. Buiide s/Contractors/111eciriciansld'lumbers
Annlicant Information
PPease Prm#I.e bl�
Name (Business/Organiution/individuai):_At--Iahi;( C-Ae✓;Tn irin �
Address:
City/State/Zip: -e ly, Q/of O Phone it: 0/7 9 7t-/t j. �r/y 3
Arse yo employer?Check the appropriate box:
I.12 1 am a employer with_A 6� 4. Q I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
Ship and have no employees These sub-contractors have
working for me in any capacity: employees and have workers' 8' Demolition
[No workers' comp,insurance comp.insurance t 9. ❑Building addition
required.] 5. El We are a corporation and its 10-El Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their
1 LQ Plumbing repairs or additions
myself. [No workers'comp, right of exemption per MGL.
insurance required.]t c. 152,§1(4),and we have no 12.[,_].., Roof repairs
R�
employees.[No workers' 15•LJ'Uther 1 wS u a i
comp. insurance required.]
'Any applicant that checks box n1 must also fill out the section below showing their worker'compensation
policy htfotmation.
t Homeowners who submit this affidavit indicating they are doing all wort:and than hire outside contactors must submit anew affidavit indite
`Contractors that check this box must attached an additional sheet showing the more of the subcontractors and state whether or not those antltim eve
employees. If the subcontractors have employees,they rmstprovide their workers'comp.policy number.
9 __an p<ryer that tsprovrdatg workers compensatton ursurartce for my employees. Below is the policy and job site
rnjonruuton.
Insurance Company Name: 7 r t,r r e/,
Policy p or Self-ins.Lic.#: p
2 Expiration Date: 3/aO//,5--
Job Site Address: 3 r
Attach a cro City/State/Zip:_ —a /Q��
py of the workers'compensation policy declaration page(showing the policy number and expiration date).
*74
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.
" ,,rcreay e Yderihe is a elites of er uty that the to ormatron provided above it true an4 correct
Signature' %.-a'
Q Date:_. ._ ... .�L ._/3. 1 -
Phonek: / 7 Fr• 7Z/L/- ?/It 3
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):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5:Plum:bing spector
6.Other
Contact Person:__ Phone#•
YINSURAN DATE
I HIS 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 1s an ADDITIONAL INSURED,1hepolicy(Iles)must be endorsed, If SUBROGATION t5 WAIVED,'
subject to the terms and conditions or the policy,certain policies may require an endorsement I A sta tement an this certificate does not confer rights to the certificate holder in I of such endorsemerd(s). �
PRODUCER
EASTERN INS GROUP LLC CONTACT
NAME
233 WEST CENTRAL ST PHONE Fax
NATICK,MA EMAI
01760 C NA.Euc ry N .
vc R
WSUAEAIS)AFFORDRIG COVERAGE
INSURER A:AMERICAN ZURICH INSURANCE COMPANY NAICA
LVSURED
ATLANTIC WEATHERIZATION LLC INSURERS:
61 REAR JEFFERSON AVE - INSURER C:
SALEM,MA 01570,
Will D.
INSURER E:
CO R WsuaER F:
THIS IS TO CERTIFY TIiAT THE POLICERTCIES EcREVISIp ABOVc ICIES O. INSURANCE LISTED BELOW HAVE R.
FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM VE BEEN ISSUED TO THE INSURED NAMED
CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY CONDITIONM OR ON PERTAIN,THE
INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO A
CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ALL S. TERN15, EXCLUSIONS AND INHR
L TYPEOPINSURANCE AGO SUB PoUCY EFF POLICYEXP
GENERAL LIAe1LRY SR Will PCUCYNUMSERI IMWDOMNYY} AlNO
uMRs
COMMERCIAL GENERAL LIASILRY EACH OCCURRENCE $
CL1S-L^Si❑ OCCUR F GEE TO RENTED S• e ,
MED EXP Any mellervNl) S
PERSONALSAOVINAIRY S
GENL AGGREGATE LIMIT APPLIES PER: -ENEAALAGGREGATE 5
POLICY PRG- PRODUCTS AGG
JELi LOC S
OMCBILELIABLRY S
ANY AUTO ataS�l(itl@DSLYGLEUMR S
All CVr1EG H'Ell SO OILY anti
Per
AUTO; .UTOS I Peal S 1
H1,?ED AUTOS NON-0YAVED eCORY1WURY1Perx¢EpAq S
Al
di OP RTY xMAGE s
I UMBRELLA UAe OCCUR S
EXCESSI CIAeISJKOE EACH OCCURRENCE H f
Ivi RETEMIONE AGGREGATE S
WORKEGCOMPEHSATYJN S
AND EMPLOYERS'LIABILITY
A.W PROPRIETOR?AATNv YW X VICS TATU- OTH.
EXCLUDHD7 I
OFF!CERAR Ef.3ER ��XECUT ITOAY L INI N/AI Cdl�S ER
fMan:armYrn N}O t�l 6ZZUB 03.20-2014 03-20.2016 E.L.EACH ACCIDENT $500.000
0 09 HCRIPTIO yrs, N RIPTIOe u F 58270121
F RATICHSYJvx EL.DISEASE EA EMPLOYEE $500,000
EL DISEASE-POLICY LIMB $500,000
DESCRIPTION OF OPERATIONS!LOCATIONS)VEXICLES(Attach ACORD 1H1,Al AAmerl¢SCJIadYIa,i}mvra apace b regWretl}
E F CA E R i
CITY O. SALEM �CA
A ON?3 WASHINGTONST ANY OF THE ABOVE DESCRIBED POLICIES SESALEM,MAOt970 ED BEFORE THE EXPIRATION DATE THEREOF,! NOTICE VALL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORREU REPREEENTATT,IVVEE
ACORD 23(2070l05) The ACORD name and logo are registeredgmarks Gf ACORDCORPORATiON.AMl rights reserved
I �
MassachlseTs-Gapanrnsnx—*., Safaty
Board of Building Reguintons and Scaadards
Cnnstrac!ann supenitor
Llra95a:C .087M -
4r
MC%PALM -
S HELST 1
Salemlem MA MA 01970- v :
-n ri::. p!raf;cn
Ccmr..'3sssiionner' 04/23/2016
e lGiorxnrwxnea/�ofGAlauadir e(IJ
# 0'
rAMEiMPROVEMENTCONTRACTOR iatra0on 142W9iration: 311212016 Ltd liabTity Coryo
ATLANTIC WEATHERIZATION L:LC.
ERIC PALM
61RJEFFERSONAVE
SALEM,MA 01970.
Uadersecretery
h r_
* The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 201I
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) • Signature • --Ware
SECTION 1:SITE INFORMATION c r
1.1 Property Address-0 n ' 1.2 Assessors Map&Parcel Numbers "' o
ri
;76 r! a
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number r
1.3 Zoning Information: ' - - - - 1.4 Property Dimensions: Fr
W
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) CD
1.5 Building Setbacks(ft) r ,
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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 'Owner yf RecorlUQ /eN
Name(Print)) n n p City,State,ZIP
0 lit t�(.Qt I17C,), v- -6 '30g0
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ eration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify:
Brief Desc ' tion of Proposed Work':
41A t 41 (90E a t4� �6 �� l
SECTIO 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials F
1.Building $ 'I. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost;(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
,�1� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 3 U V U ❑Paid in Full ❑Outstanding Balance Due:
S't�tlT to �Zc�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S- I-) 23
License Number Expiration Date
Name of CSL Holder Eric W.Palm � ,1
List CSL Type(see below) v 1
No.and Street 31{i on Sued Type Description
Salem MA 01970 U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
6 I u V! J I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Atlantic. I T.( HIC Date
�� ra8 3 12 Registration Number Expirati n Date
HIC Com WeH 5nt Name
e
No.and StreetMlem MA 01970 Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be co pleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuanc f the building permit.
Signed Affidavit Attached? Yes ..........W No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN 11-F
OWNER'S AGENT OR CONTRACTOR APPLIES FORBUILDING PERMIT
I,as Owner of the subject property,hereby authorize r ail l
to act on my behalf,in all matters relative to work authorized by this building permit application.
MAVU ",/ d 1, �1
Print Owner's Name(EiVetronic Signat# Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print a Aut orized)q&WrMI(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
www.mass.eov/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"
I!�[assachlasetts l3o�e lIn rovenlent Salo le Contract'
lThisfotmsmisfieall be requiremwb ofthesmtes Home(mpmvemwt Comtra¢ortaw
Imtguagemprotemhomeowneas S,klegaladvim ifnecesea (bf(7,chapte 142AZ buraw not include standard
Masaefiutens ConsmnaGuideto Home fin rY.AnYPWsmtplamunghomeimprovemmmshould lust abatnacopyoF A
offift of Consume Affairs and Business R provemmt"beforeagteang to any work m yourresidmce.Yau
eyWmian's Coanmer Tnfotmmian Hodineat 617-973-9787 or1-889--o0�a tt�� Og me
Homeow¢ertnformation -83-37s7 oroo oawm#te,
- ContaactorInformatioa
Name
,�. ? Company Name
t Stren B
Address nre, apanofL /a CaotmnoNSdexpmon/ ,e.
P Co e ass Awenye
5 e zipde '1 asivess Addrea(mint ma e�
DanimePimnev'I` 8,radngP° �7 v. ..
��. � .. [t6?oust Sam LP Cade
Mai'ng Address(It di6erem fmm abo.")
Bmmea Phme Fedey Fav loyermorsS.Numhm
. "_.. •. ..`.. ..••.,....... - t+n tmwnwr®teem. n06�ameamte•+amasamxc s+wac,t�e
tncmmnrm.mmnem -
' vvad�maam®ev-
TheCantncmrngtees to do the fao0orringwyrk for the-Homeowmer -Matenbe m decilrbewark mcompknd•1P4nryktg dmtypgb r
road.aMgrade of vnffiiak mbeumd,&se dd" 1-h ts'f -- )
Requital Perini¢-The following bmldki penrdls are required. Proposed Start and Com 4tionSchedule-
andWilibesecoed by thecontra¢or as the homwnares agwt: be P The fallowiag sdredWe,,jlII
(Owners who secure iheirown permits will he adheredto anlesscircmttumtar beyond the contractor's rptttml mice
excluded from theGuareaty Fund previsions of - io ZU
74IGLChapter142A.) � .:. . ,Datewkwcontracior�sillbeginconttecteduark .
U ZZ Data when amtra¢ed cool wall6e sub#attialiycompined.
Total Contract Ptimand PaymentSchedule
ThcConnwamagtees to perfatm the umd,famish the material ana)abor �77
- : spai6ed above fathe total sum of
Paymwpts�will be made according to We follmving scbemw -
upon silp,ing contracx(not(a acted 18ofthe mtal avmbam Prim aC the act ofspecal orde it- ant svldcpevg isgr
S eater)
SMMMpp,, by f_1_or aPoo tmmpl�m of . . I '-
-.'bY A2-/,7—Z-Ljr upon completion of
uponn emnpiedon of the contract (taw fwbidsdemaodin full
- g paymaa onto contract is completed m both partys antifacdan)
The fo8o"ing amemaYqufpmem most be special S
ordered before me mnuzaml and: tote paid f -
WmeCmee begunmord—
mnDknmschedWa(••) S Pad m
n"ndieg WItimnmebatgea( (.nwregwesma a�.depmit ordown•prymmt mgWrrdbymeeendwor berm"arkbegins an
net armed thegreae of(a)om.Wrdofthe total contract prima(b)theaennl cat ofany special egWpmmt y
amtnmomada ma
wtdeh m ea be special Wdeed in adsame to menthe cmgdcdm sWrod.le
Exn WS bean
4 h tdM by e `
a rs Thecontmclpt ❑b ❑ Nat agrees to hesol¢y twpow'ble faeomplwon of the work desmbed
pamhubcontractorold hp fheanttbamor Thecontra¢orfimhaa to ens oftheawons ofwythud
eri s n b u 's Btees to be solelytesponmble forali payments to all svbwntramors for
co.nof li sbal omnw-Upoa signing,this doamrnt 6emmesabhWing connam umde law. Udess oaersyse nmed vnWmthis documwt,the
carefuli before si oy that wylien or othasemuityintetesthas hem planed on dtettsidwaz Reviewlhe follmving eatdom and nonar
Y going thisconlmct -
DanY be ptessvredmto sigpiag the contract Take timeto read wdfWly wdetstaad it !¢k ue#iams ifsom
M=k•"^^ahecantmetnr hose val'dN t vemwt q etmag is unclear.
subemtrectotsto be reg#errd mth WeDtrectorofHome im strap .Thelaty requhes mo#home improvement contractors and
registatioa bYwddagrothe Diredoraz lO Pad:Plaa•Ro 5170 Bo#og,Mp0216m traalka 61 bslaaa
973 7�or888�¢ar
Does[be coatra¢ar have insurance? Ask the Cantractorfarhisinsntaacacom g 51-3757.
Zbw`
sxa copy ofn'pmofofiowtwce^doumtent' :' Pavy mfotmation so that you cwcaafiracovemge,arask to
[Cnorvynurriehts andtesponsrlb as. Readrbe Important lafarmazion on the reverseside afthis form and gu acopy of the Consume
Guideto the Home bra ra at
CoanemarU -
You may tames ihts ageemwt ifit has been Biped az aplatt otherthw the connaaot's normal lamof busm
contra¢or in wTitrall at hit/Itemain office orbtaach office by ordinmy mail P ess•,=PmIndedy�4oh1vt,;sentor
third business day fallowing thesigoimB oftbis age®cot Siniheamadted nodcc ofmome.IFation fmm tarwbyd�DO NOT SIGN THIS CONTRACTsPl
Tan idmdpi mPmafOe mint he TAERE ARE ANY BLANK SPACES!!!
amrDkad ooi ug¢d Ommpy lEovagoro@e heee n.¢Tlmr W
Homcoamer's Si - �� s
Coatm¢ars Stgtaare
Date _
.' haze
Contractor Arbitration
The Home improvement Contractor Law provides homeowners with the right to initiate an arbitration action I as an
alternative to court action)if they have a dispute with a contractor. The same right is pg1 automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both patties agree to the optional clause provided below. This clause would give the contractor the some right to -
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law.
The contractor and the homeowner herebymutually agree in advance that in the event the contractor has a dispute t
concerning this contract,the'cointractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the.Execonve'OHide of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbittatign.as,provided In Massachusetts General Laws,chapter 142A.
a
c � Q
Homeo�ignnatdaW R/ Contra to s Srgnet,
NOTICE:The signatures of the parties above apply only to the agreement of the parties to alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
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 any way,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 maybe
added to the tems 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 Information Hotline(listed below).
Execution of Contract
The contract must be executed in duplicate and should not be signed until a copy ofall 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 contract must be in writing
and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of
the contract and the three day rescission period has expired.
Accelerated Pavments
A contractor 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 instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of funds not yet due be plated in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of funds from said account would require the
signatures of both parties.
Additional Information '
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rights,or if you 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 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCABR website at_r.: w: r, .=s._o doeab_
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 Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plain Room 5170.Boston,MA 02116
617-973-8787,88&283-3757 or visit the HIC website at h ui://w::w:•::rw _o•.:oca'rr."
Go online to view the status of a Home Improvement Contractors Registration:
fiitO:i/di'�=tai�.ma.us(mnteimprm�enreay'Hsnseeiist-rso _ -
For assistance with informal mediation of disputes or to register formal complains against a business_call:
1 ,
Consumer Complaint Section
Office of the Attomey'Gencral
617-727-8400
ARID/OR
Better Business Bureau
50"52-480%508-755-2548 or 413-734.3114
l`mian I I-t IM'2010
The Comrrtoxwealth ofMassachusetls
Department of IndustrialAccidents
Office oflnvestigations
I Congress Street,Suite 100
1 Boston,M 02114-2017
Workers' Compensation Insurance Affidavit: Builde s/Contractors/Electricians/Plumbers
_lipnlicant Information
/ 1 �/ Please Prm#I,et?rbl�
Name (Btumess/onganizatioNlndividual): /G{h7yL WGQ h
Address:
City/State : Sct�.e 1,, 01/%7 0 Phone#: 9'7 • 7/iW. kjq 3
Are yo employer?Check the appropriate bog:
1• I am a employer with�_ 4. [] I am a general contractor and I Type of project(required):
employees(full and/or part-time).* 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 subcontractors have
working for me in any capacity: employees and have workers' $' Demolition
[No workers' comp.insurance comp.insurance t 9• ❑Building addition
3.❑ required.] 5. We are a corporation and its 10-El Electrical repairs or additions
I am a homeowner doing all work officers have exercised their
myself. 1 I.[]Plumbing repairs or additions
[No workers comp. right of exemption per MGL,
insurance required.]t c. 152,§1(4),and we have no 12.Cl Roof repairs
employees.[No workers' 13.L�'�lther
comp.insurance requrred.]
`Any applicant that checks box 11 must also fill out the section below showing their workers'compensation policy infwmation.
t Homeowners who submit this affidavit indicating they are doing ell'York and then him outside contractors mast submit anew affidavit indicating such,
.Contractors that check this box must attacbed an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub•mmmictoa have employees,they must provide their workers'_ camp.policy number.
J'am on ptoyer that rsprovrding workers canrpensatron arsurance f
rnforrnatfon. or my employees Below is the policy and job wife
Insurance Company Name: Z"r; e
Policy r or Self-ins.Lie.r: j�j� /
/ Expiration Date: 3I20115�
Job Site Address: 62 Q `c{N dyl �
—City/State/Zip: 2 .Qil-7
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 the insepalties of er itry that the Information provided above is true and correct
Si ature:
- ----. .;Date:_._._.
Phone P 9 7 7yy. 8'fy 3
Official use only. Do not write in thus area,to be completed by city or town offclal
City or Town:
Permit/License#
Issuing Autitority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:
Phone#•
!Wass2chusetts -rJepar:menf=2i o.,uiic SaYe:y
Board of BiAiding Regina*lens and Stmndards
Construction Supersisor
License.CS-087977
MC W PALM
3 HMTON SP - c
Salem MA 0197IV I
Com*nissionar O4f2312O16
tfim orCou=ner Afrairs&Business Regulation
ME IMPROVEMENT CONTRACTOR _ -
istration: 142069 Type: -
- piration: 3/1212016: Ltd Uabilitg COW
!
ATLANTIC WEATHERIZATION LI—C.
ERIC PALM -
61RJEFFERSONAVE �-
SALEM,MA01970. Undersecretary