32 PICKMAN RD - BUILDING INSPECTION The Commonwealth of Massachusetts -
�; i ty Board of Building Regulations and Standards Y )F
Massachusetts State Building Code, 730 C'MR SAL 1
y\� fib„' tri.vrJ 1 r 'lll/
J Building Permit Application To Construct, Repair, Renovate Or Demolish u
(Die- or Two-Fumih•Dwelling ;
This Section For Official Use Onl
Building Permit Number: Date Applied: _
1>�C,�►.� L�r'(]� tom',., �� � f
Building Olticial(Print Ntune) D" Si g talu -6' Ume
SECTION I:SITE INFOR3IATION
I.I Pro�pert i an Address: 1.2 Assessors Nlap& Parcel Numbers
�01 /lc� - ,
I.1 a is(his an acceted p street?yes_ no_ Map Numher I'urccl Numt r —
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check iYes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1.1 Owner'of Record:
1` rCLbelle Go✓mao Sao" /Y;,� 0/9 6
Nmne(Print) Lily.State,ZIP
22. Pickvhon Rd. `8 !L-J-3471-
Nu.and Street rclephone Finail Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Aiteralion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: — 6o
Brief Description of Proposed Work':
C'dr,0 ol,J Qe orox l7 So
r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcnn Es(inmted Costs:
(Labor and .Materials) Official Use Only
I. Building $ a 3 1. Building Permit Fee: E Indicate how fee is determined:
'_. Electrical g ❑Standard Citffown Application Fee
❑Total Project Cost'(Item 6)x multiplier
i. Plumbing g 1.
---.-
_. Other Fees: $
a. Mechanical (11%AC) $ Lis(:
?. \Ieehanical (Fire _ -- -- --- - -
Sulvession) $ Toral :\II Fees: $
o. T al Pr 'ect Cost: S t7a3y Check No. ---('heck Annount _ -----Cash \mount
❑Paid in Full ❑Ou(standing BaIMCC Due:
C/ Ta iic,t- V 7-/�
I�V.g; `Z To
L _
SECTION 5: CONSTRUCrION SERVICES
5.1 Construction Supervisor License(C'SL) (?7aaS11
License Number F.vpicUiou Dale
Nanc of('SI. I loldcr
}Pe Description
No. and Street
r, (Ile �� O�7" — li ITnreslrietcJ llluildin�s tipIo J5,0110 eu. 11.1
_ . V y - R ItesIricted I l2 I:anvil r Dttellin
l'ini Gaff t.Slue.LIP tit Mason
RC Roo in C'oecrin
W'S Window;md Siding
SF Solid Fuel Burning Appliances
ti81-6sy.ss68 I Imulmion
'I'cic hone ('.mail address U Demolition
5.2 Registered Horne lmpr YInient Contractor(HIC)
p - 'tome�� „ It 76-l`'nv Groull I IIC Registration Numhcr Expiration Date
1IIC C'ompan) Name or I IIC Re-gislru Name
D�
N and Street Email address
` PPY 736-6
City/Town.State, ZIP Telc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.1.c. 152. 1 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 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
I, as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI 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.
Powe✓ %lam IC e Prvroclet! 6rot o // '.:2 I/
Print Other's or Authorised Agents mne I!:feet 011ie Signattue) Data
NOTES:
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 Home Improvement Contractor(HIC) Program),will LL)i have access to the arbitration
program or guaranty fund under\I.G.L.c. I12A.Other important information on the HIC Program can be found at
tttttt n,.i., It ot.i Information on the Construction Supervisor License can be found at o\ttt.nias;
2 When substantial work is planned, provide the information below:
Total lloor area Csti. ft.)________(including garage, finished bnsentent'attics,decks or porch)
Chess living area I sq. It.) Habitable room count
\umber of fireplaces. .- _ _ --- Number of bedrooms
iNumberofbathrooms --- _. --- N'umberofhalfhaths
F pe of heating s)stem .. ._ . _ _ Number of decks, pordtcs
I'\pe of cooling i\stem! _ - Enclosed Ope❑
1. "fofal Project Square Footage- ma) be substittncd for"Total Project Cost'
CtTY OF SIV-ENfs 1.1 USACHUSET['S
8t.azoiG OEp.1Rnj&N-r
120 WASHLNGTON St'REgT, YO FLOOR
TIM (978) 74S.9595
KIMBERLEY DRWOLL FAX(978) U)Og."
,MAYOR TRO-%&U ST.PMUA
DtRECTOII OP PLauc PROPERTY/BCQ.DLNG COJCV(SSIONER
Construction Debris Disposal Atitdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit g is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as defined by NIGL c
111, S I50A.
The debris will be transported by:
it fa lob
(name ullauler)
The debris wi 11 be disposed of in
ff L. tfayv �s 6e�s p1,1 _
(name o' f facibly,S
�Ps�bo�u � A
r�ddre,a or r,�ll„y)
+ tlnamro at Permit ipplicont
,ld(a
: ' CITY OF SALEM
,
`M*41 PUBLIC PROPRERTY
DEPARTMENT
wl l Y'iA14..11
\11t,M
11.^ WA ItnTbl,/•\j1:/Ck 1' • j,IIPN, .M.111.1t.111 4 I t,3177:
�V'urkers' Cumpensalion Insurance Utldavit: 1lu11derslCuntrac torsi Clr tricla nil Plumbers
� 1 )Ilcan In nnnutlo
(1C AC)
PI • .� In Le 'hl VdInC I IL1u,,,,y1)raanv,linrvinJ„"Ivull: I PU A/
I�OW1P 2Plhnr/B lI[1 �v4Jl�
�ddre.w as-o S eG ou
cly,star�.ii Ches /IP
. P t p.4 q'I Phone i/!
in rmployor:' Oven the apprnyrlols bow
I LlQ 1 :Ins 1 umpluyur with t OG %- 4. Q 1 ,un o junutal cnnlrulor end 1 l y ufpr4)uur Owivirrd):
Linyscir.
uyvca(lull und/ur pwwinle).c hairs hired Iha.wuh-cunlracwn /t• ❑�'aw cunsuuctiun
a Iola prnptiur,w ar partner• liathd on theanachcd..hoot t y, ❑Retnodeiin�
nd hairs na umpluycaa These iub•contracran have
ng lily Ine 1n any capacity, wvrken'comp, Insuranceg' ❑nemolirion
uritcra'cutup, insurance J. Q We an a crnporefion 4nd in Q' ❑Building addhiuts
c,)J >Ircers 11ave usulcic,vl Iheir to' Electrical repairs or additions
humcuright of utatptioe pur XML II.Q I lumbin rc.(Ko workers'cump• c. 1!7, t}1(4),and we hove no Y pairs ur additions
CY fCyYlred.l r ;mpluycas.(No workers' 11• wl•rupairs
coin(, invurancu re 13 Q Other
�'�'9 ,'piw'ua11hW t1:etMr bN AI m W till gtllR'd.(
I I.n„w,r M1rn v uW.,l u 11" tirU halt aWr,wa tW alatntil lAif ele,hvlr iMllulin , My rwYWc',unrf>♦nuwlua lwai,r,nri,rinw,itrr►('w1rwn,ry 1AW,11,y,a this bon null unatld ,A ua,:d,�uait,•j Jwee all.w;aW rMr 11W uWuda furrncnn T
hwt Burin 1M nWN o/1M,ua•snr wr whn4 a nw alnaara inJlaar„ry•wa.
/nrn all ellip/oyer thud h prul'idini,ivurkeq'culnpetlfnl/en/IAf4/nnCe`eI my r/A ,M 1119w%,Awl'Camp.putter rnrlirmMuts
inr/urnrwbna p tme 9Aurr/s/Ar pulley unJ/a1.,its,
In,uranccC'umpauy.Vamer YnPt^hs ' -
I'nlicy4urSvlf•ina. Cic.M1�01I�'6p—pZO—W —'J
3� fJ -
D /n� dd J Eapiruhon
sub Sira \dJrcvf: V (G��N?6tn —�
\Irish1rcis City,ylalclzlp: N �j��l yy of the warkan'wmpunfallnn pulse) duciuratlun page(showing rM policy number and urpbarlua dare).
P.nluru lu,acute cis,eruge as required under Sucliun?)r\ vl'.NUC u. i f2 eau load to the im
etil,yt r,SI 00..rclay Idui uue•yeu unpriwmmncnt ua cv'cll air civil punalhcs in Iha lunn ufa STOP %VURK UROEA and a Pine
position of cri roinal panalties of s
i up rn i11Q )f),, Jay lgaiov1111e v',lLuot tic advt.,cd that a copy,If lhty .wivinunt may bu lurwurdud la the Ullica ut'
lil,i\II�Jllnlb VI ;Ila Ot,\ :Or in.,u.1c„ „,vcru3u ,a11i,uhun.
/Flu herrAy,.rti/I•rurd.r dhr point vnJpalu/lief u
/prr/nry thud thr iu/unn4Non L prvriJr,/above it true nnr/conrc4
b_ '11 n,: t��
„rit*in rhir un•u, to Ar rvn,ylrrrd D y oily up torrn'YJA iuL
fist or I'n1rn:
L.uin ----- P,nniul.lcvme
y l ulhnnly (eirele nnvl;
I I[,,.trd v(Ifr.,hll Lllinhbn� U,p.,rlu,enl L1:it1.'lo"1r Clerk t. l••Ic,fri,.111u,1„Wr i.
G. 1)Iryrr
I PhtmLinil In,yector
10 1%r:uu:
—' �� I'hn n,• 1•
Information and Instructions
V.usJChu;aus t.]Cneral Laws chayrcr I 32 filled A s. employ`wn in theto �san'Je at Ira herentnletr nny Cuntnet of Itire,s.
in tin lurtt
I.
JelineJ Js • every p• .
I'u r.0 J+N ro uua +Mule, p _ two Of mJrc
.press Jr ❑npheJ, Jral Jr wnnan." oration ur other legal Cnnry,of ill Cr of the
�n C,nplupar is JetineJ a"an individual, Purtntrship,.tssaetauaa.gory ea. However the
,ssoetattua fir athof Itgal Cnaty,fimPlay'^{a^Iploy
A the t,uego,,,g finyageJ n a tutor enterprise, Jnd uuloJ.11 the loyal rcpratenwlivas la a Jeceaslo amp y '
CCmver Jr oust..ui'.m indivrJU,41, p,umellhtp, who resides therein ur he
occupant of the
uit work on well dwelling hair."
of such employment be Jeemfid to bt Jn employe."
to Woos w do Malmo nunce,Cunvttuctian of rep
owner at a dwelling hots."havin{not more than thrn Jparanenu
,hve tt utg huu;t of another who fi uAs y+nt�hercto shall not beeatw
Or ,us rho.rounds or building apP start or Iseal Ileensla{attsssy shag withhold the Issuance or
>lGL Chapter I y2. �33C(6) also states that''sysry uirtd:
renewal of a license or ptrr Ills Its operate s huslnose or to construct ce'if aet with theslnsuranecoverage lrsg111 or fir
VP produced jlClvl abatesvlNeuher he Commonweuhh our any of iu political rubJivisions shall
do
t Ilcent wtso has not p
Wditiunuhy,.%IGL Chapter I)_ i- ubltc work until acecpuable evidence of CuutpliwtCa with the uuunne
enttr into any Contract fa the parfamsanet of p
ra ter into
enu of this chapter have been presented to th(Contractin{authority,"
�pDllsanu checking the boxy that apply to your situation and,if
ensation atnJavit catnpletely. M nwutsar(a)stood with their Cortiftctlte(s)of
Plettse till out the workers' cumD namo(s),addtsu(as)and p puuton)lips(LLP)with no employees other than the
naCess ry, supply sub-contractot{s) have
insuranao, Limited Liability Companies(LLC)or Limited Liability artmont of Industrial
netnban car parmors, ors not required to carry workers' eonsptnay be
s bmitted to the Dap tl LLP doss
entployea,a policy is required. 9e advised that this alfl be l tray requested-not the ))aparttnunt of
\CCiJanu for eantlrmation of inauranee.overage. Also be sun to sl{r and Juts the ul'tldavl4 TU stlltlovit shoo
lie rage, for the pannit tx license is Bain{req to obtain a workars'
ho IulttmeJ to Ills city or town that the app aaatioas regarding the 1uw car if you its requiredanise should enter their
Industriul,li"IJants. Should you have any 4
culnpenaatiun policy, plea call the 061111 aria'at he number listed below, Salf•ina comp
self•insursnct license number on the a ro riute line.
t,lty or'Cowr officials The Oeparmtant has provided u space at IN bulletin
rioted legibly. the apPUCCUI ,
IvlCnse he jute that Iho afflduvit is wmp3vent td p applicant
of the JiriJavit 1'ur you to lilt out in Ihs avem the Oltkt of Investigations has to cunlaet you regarding
v year, need only submit una -1111dpvit indicating c`it f
Pleas, be+u(n ro All in the parmit/ltCenss nwnbar which will be uaad Js a refers�e Itunlbar. In addition,in aP
JnJ under"lab Sim Address"the applicant should write"all lnay ba p o (' Y
that moat subtnp muttipla pannie'lieattua apPliewioM in any given
car marktd by
Iht sit or town rosy be provided to the
policy information Iif ncceasary)' Y
lawn).,,A cuPy of dst uftlduvit that has been offleially stamp' business first be t tilted
out
tack
t
applicant is proof that a valid Jf ftduvit is on rile Ica iesn patfori fir licenses. t new a1usirig t must be titled nut fiat
y tar. �o'harc a home owner
at cilixcn is obtaining a Itcenul os permit not related to any,
I i C. .t Jug Iicmtdl nr permit to burn leaves ate.) sat ape'+Jv iaC Ou reuur co t uau m anJhhualJdy o haw.n yuesuoru.
I ItC )dice ,.I Inva+IigJliuna 'wuld tt�t w tlwnk y' y p Ymmimmommom
Ju nul havtata to grve us a CJII.
the Uepu. If"Ill's aJdrass, telcphune Jntl fax number:manwealth of Mt»chuse"
The COtnrtl
DepOfleee of Isaves aadonaden�
600 Washington Street
Boston, MA 02111
ra a 617.727Fu 7
00 Cat 02 or 1-877•MASSAFE
1A W W.n11S1.jov/die
i
POWER-1 OP ID: EL
4`vrrn CERTIFICATE OF LIABILITY INSURANCE °A 10126r11
lons
.i 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)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 215-723-0378 NAMe Chad Lacher
.� Lacher&Associates Ins Agency 215.723.8604 PHOI.@
Lacher Insurance Group A Ne EeIT: NP
632 E Broad St P O Box 64308 E
Souderton,PA 18964 "Opp'
Chad Lacher INSUREMS)AFFOMINOCOVERAGE NAICt
MURERA:PennsyivanlBManufacturers 41424
INSURED Power Home Remodeling INSURER B:Pennsylvania Manufacturers 12262
Group,Inc. INSuRER c:Ironshore Specialty Ins.Co. 25445
2501 Seaport Drive Ste B110
Chester,PA 19013 INsuRER D:
INSURER E:
o1511RER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUE°TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
1 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCE POLICY NUMBER MMIOD/YEYYY MMATDIYYVY LMITS
G'ENEtALL1AMLITY EACHOCCURRENCE $ 1,000,000
A X COMMERCIALGENERALLOBILITY 8211OD-66.2096.7 09/22/11 09122N2 pREMI S Es occMrenm S 300,000
CLAIMSMPDE I(OCCUR MED EXP(Anyone person) S 10,000
PERSONAL BADV NJJRY $ 1'000000
GENERAL AGGREGATE $ 2,000,000
GOTL AGGREGATE LRAIT APPLIES PER: PRODUCTS-COMPIOPAGG S 2,000,00(
X POLICY PRO- LOC $
AUTOMOBILE LMBEJTY COMBNED SNGLE LMIT
Ee ecddeW 1,000,00
A X MY AUTO 151100-8&20496.7A 09122111 09122/12 BODILY NJ/RYtPer Garcon) $
ALL OWNED UT
CHEW LED BODILY NJJRY(Psr ttederd) $
AUTOS AUTOS
NON-OWNEp PRO E
HSiED Al1TOS AUTOS PsraotideM $
S
UNeRELLA LN9 X OCCUR EACH OCCURRENCE S 5,000,0001
X X EXCESS LIAR CLAIMS+dADE 01158200 09/22111 09/22/12 AGGREGATE S 5.000,00
DMX I RETENTIONS 10000 ID IS
WORNERS COMPENSATION X WCSTATU- OTFI
ANDEMPLOYERITUABILITY YIN
A ANY PROPRIETORIPARTNE�ECUBVE 07100.66.20$6-7A 09f22111 09n7J12 E.L.EACH ACCIDENT $ 1,000,00
B I a�e�ymem ExnuOeDa ❑Y NIA 107-66-2046a MASS 09/27/11 - OBP22J12
ITyos.desaiIn NN) ) EL.DISEASE-EA EMPLOYEES 1,000,
DESCRIPTION OF OPERATIONS We E.L DISEASE-PoLICY LMR $ 1,0D0,00
A 7S AUTO 1511°7.66,20S6-7B o91zu11 osn2/1a LIABILITY 'IA00,
i
DESCRIPTION OF OPERATIONS I LOCATIONS IW7C'i S (AaerII ACORD 1M,Add'Nonai RemeMS Schedule,it mon spelt is r"Wnu)
CERTIFICATE HOLDER CANCELLATION
SALEM
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
120 Washington St ACCORDANCE WITH THE POLICY PROVISION&
3rd Floor AUTHORIZED REPRESENTAT
Salem,MA 01970
-- 01988-2010 ACORD CORPORATION. All rights reserved. I
ACORD 25(2010105) ._ The ACORD name and logo are registered marks of ACORD
..........
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NATIONAL HFADOUAOTFgs - ' -- --- Ryan Dennis and Michelle Gorman
• _ 2501 Seaport Drive.Chester PA,19013 30-32174
888-REMODEL.^ "==== .z occaberiz,2011
Project Specifications
:1
I
._ Roofing: Side Porch i 1Ha.0'x1.0'
Roofing:Side Porch i t110.a"x1.0"
ROOFING:Models GAF Styles Flat Torch Down Types None Configs None Options None J Mstallaaon
Details None
i
• �aawatta�toN
Roofing: Main House 1 1700.Wx1.0"
Roofing:Main House 1 1700.0"x1.O"
ROOFING:Models GAF Styles Architechturai Shingles Types None Configs None
OPTIONS:Cot"Pewter Gray J Removal Standard Shingle/installation Details None -,
I
0" 5
1CORPOi;ATION
I Roofing: Main House 1 46.0'x1.0'
Roofing:Main House 1 46.0"x1.0"
ROOFING:Mafets GAF Styles Cobra Ridge Vent Types None Configs None
OPTIONS:Color Pewter Gray Jinatal/etion Details None - �,
I
GM MUEF{ACS
OORPOPATiON
I
October 12,20i 1 20:32 .,. InI�i�III�I�I�I��Iliiilfi{ir �Page 2 of 2
I!
Office of Consumer Affain&Business Regulation -
1
OMEIration IMPROVEMENT CONTRACTOR
h
I '. Registration TYPe-�
j Expbatl"=. 1&2Q73, Supplement
{ " ° POWER HOME REMODELIW-PROUP INC.
TED DOWf._
2501 SEAPORT DI�VE STE Bj111
° .��
CHESTER,PA 19013�,t Undeneerctary -
N[assachuselts- Department of Public Safetc
Board of Building,Regulations and Standards
Construction Supervisor License
License: CS 97225 s.
TED DOW 4
174 LUCAS DRIVE
STOUGHTON, MA 02072 `
z.
Expiration: 12/3/2012
CouVuisxi6nE•r" Tr#: 8049