29 PLANTERS ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts, RECEIVED CITY OF
Boazdof Building Regulations and StandardqNS?ECTIiCFliL �ER`1S`tEL�M
a,,Vt •': Massachusetts State Building Code,780 CMR
.j Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate 2 9
One-or Two-Family Dwelling J[Y V
- •This Section For Official Use Only
Building Permit Number: Date plied: 1 qq
Building Official(Print Name) - Signature Date
SECTION 1:SITE INFORMATION
1.1 Property e�¢dress• �� 1.2 Assessors Map&Parcel Numbers
L l a Is this anlaacccept�ed street9 yes_ no Map Number Parcel Number
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❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'o Record: C �a/ G„
N-r YLt
Name(Print) City,State,ZIP
.24 47y(c� 5/ 9757-3-78. 9G ffr
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of P�(loseWork :_,
G /
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ C00- I. Building Permit Fee:$ Indicate how fee is determined:
�.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 -
Sup ssion $ Total All Fees:S -
Check No./13 Check Amount: Cash Amount:
6.Total Project Cost: $ 36vv— ❑Paid in Full ❑Outstanding Balance Due:
V)Pr 1 i✓ 'Y)
A�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) p.7 p77 y/Z3
License Number Expiration Date
Name of CSL Holder
Eric W.Palm List CSL Type(see below)L( ez—
No.and Street 3 Hilton Street Type Description
Salem MA 01970 U Unrestricted(Buildings up to 35,000 cu.ft
R Restricted 1&2 Family Dwelling
CityiTown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I IInsulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
—Atlailtic Weatheriutt Expiration LLC �Re Z U /ti /(r
HIC Registration Number Expiration Date
HIC CompagyAlafgq�r l FA Name
No.and Streelt !!t.�Clecellm`ie[StHI 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 completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance,04he 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 E/ -t G 194/I'1^
to act on my behalf,in all matters relative to work authorized by this building permit application.
AInL u 1 4�28
Print Owner's Name(EleMnic Signature) Date
SECTION 7b:OWNER`OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain d in this acatu a and accurate to the best of my knowledge and understanding.
Print Owners or Authorized Agent's Name(Electronic Signal=) /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
tLv.,,w.mnss.govibca Information on the Construction Supervisor License can be found at vr;v:v.rruss._ov%dns
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 Contractor La\v provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is not 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.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the caatr¢Ft•�.j(tayyfEb3"c dispute to a private arbitration firm which has been approved by
the Secretary of the Exediruve OIl'SSce- of o r Affairs and Business Regulation and the consumer shall be required
to submit to such artl5tatWP:afRblol� Wachusetts General Laws,cha er 142A.
. tqt appt� ii0 •
1nl�N�
Homeowvets Signature Contm'ctor'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 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 Food previsions 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 othermatters 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 homeowner's basic consumer rights. If you have
questions about yourconsumer/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 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,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 folly 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 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=tinning the contracted work- withdrawal of funds from said account would require the
signatures ofboth 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 fiee 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 http://www.mass.goy/ocabr/
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
617-973-8787,888-283-3757 or visit the HIC website at htro://www.mass.ao%,/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
http://db.state.ma.us/homeimnrovement/licenseelist.asn
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
y oasuiner plaint Section
Y.•. ., ' lfi _ mey General
617-727-8400 _
AND/OR
Better Business Bureau
508-652-4800.508-755-2548 or 413-734-3114
Version 21-11272010
\ The Commottwealtlt ofMassachusetts
Defiartmeut ofdudustt falAccidents
1 Congress Street,,Suite 100
-80ston, MA 02114-2017
Www-
vIdla
Workers'Compensation Insurance Affidavit Builders/Contractors/E►ectricians/Plumbets.
TO BE FILED WITH TITS PEMMITTING AUTHORITY.
A licantinformation
Name(Business/Organization/lndividual): Atlantic Please Print Le 'bl
�� aczu.LL G
Address: 51 R Jetffef- t, Ac me
City/State/Zip: "
Phone#: � 79 - 7y4 _ � �� �
r
e
employer?Check the appropriate box:
employer tfh _mpl.Yees(tuuand/b,part time)-. Type of project(required):
sole proprietor or partnership and have no 1 7• ❑New construction
capacity. employees working forme in
[No nrorkers'comp.insurance required.] - g- ❑Remodeling
a homeowner doing all work myself.[No workers'comp,insurance required.]r
9- ❑Demolition a homeonmer and will be hiring contractors to condom all work on my property. Itrill 10❑ $ ddition
ure that all contractors either have workers'compensation insurance or are sole Butldin arietors with no employees. 110 Electrical repairs or additions
a general contractor and I have hired the sub-conhacturs listed on the attached sheet. 12.❑PluMbing repairs or additions
se sub-contractors have employees and have workers'comp.insurance.: 13-❑Ro repairs
re a corpom[ion and its omcers have exercised their right of exemption per MGL c.
§I(4),and we have no era to ees.
P Y [No wrorkers'comp,insurance required.]
"Any applicant that checks box KI must also fill out the section below shorting 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 indipiine such.
Contractors that check this box must attached an additional sheet showing the name of the sub-e cont actoctairs and state whether wnot those entities have
-employees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number. or
li aonratiorr.an earploper atatis providing workers'compensation
irrjor insrr.-ancefor'try employees Below is the police and job site
Insurance Company Name:_ '7 UV-i C,�
Policy#or Self-ins.Lic.#: ,�[j 2-70 fa
n n Expiration Date:_,3 'a d ///
Job Site Address: - tX r�Q h l�S / j414
Attach a co City/StateiZip: Slt e M J
copy the workers compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a foe 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.A copy,of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under t/re pours and pegalhes ofperrry that the information provided above is true and correct
�ignature• -di"ir �1� aAd �`t Q
Phone#: _ '
Date: l Irk
=r'
only: Do not write in this area,m be completed by city or town official.
n'
Permit/License'd _
ority(circle one):
ealth 2.Building Department 3.Cityfrown Cleric 4.Electrical Inspector S.Plumbing Inspector
on:
Phone#•
ACGIR&
CERTIFICATE OF LIABILITY INSURANCE DATE iMM lIff ""
FAtlant:La
CERTIFICATE IS ISSUED AS q MAl"fER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE XOIAER.THIS
TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
RTANT: If the certificete holtler is an ADDITIONAL INSURED,the policy(ies)mus[be endorsed. If SUBROGATION IS WAIVED,subject to
erms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
icate holder in lieu of such endorsement(s).
ER
GOMACT
rn Insurance Group LLC PRONE Construction
est Central St (800)333-7234 FAX
E-MAIL
k to 01760 INSURER(S)AFFORDINGCOVERAGE NAICy
I SURERAAMbella PrOtectIon ins. Co. _1360
tic Weatherizatioa INsURERBSTautIl-us Insurance Co
ar Jefferson Avenue INSURERC:
INSURER D-
Salem MA 01970 INSURER E:
COVERAGES INSURER F:
THIS IS TO CIESOICATENUMBER LSTSR F IN 2015 REVISION NUMBER.
-
WDICATED.CNOTIMTHSTANDING ANY(REQUIREMENT, TTERMSORDCONDITION OF ANY CONTRACT OR OTHER DOCNUMFM WITH RESPECT TO WHICH PERIOD
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.
�ILTR TYPEOFINSURANCE A
POLICY YEXP
NUMBER POLIOY EFF PO C
GENERAL LIABILITY MMfDO p LLmns
Y COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A CLAIMS-MADE ®OCCUR 500042816 /20/2015 /20/2026 REMISES Ea a arence S 50,000
MED EXP(Any one perspn) S 51000
PERSONAL B ADV INJURY s 1,000,000
GEN'L AGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE S 2,000,000
POLICY :� PRO. LOC PRODUCTS-COMPIOPAGG S 2,000,000
AUTOMOBILE LIABILITY S
A ANY AUTO COMBBIINI ING LIMIT S 1 OOO 000
ALL OWNED SCHEDULED BODILYINIURY(Perpilial $
AUTOS AUTOS 020015971 /20/2015 /20/2016
•� HIRED AUTOS s's NON-0WNED BODILYINJURY(Perrypderd) S
AUTOS PROP YOAMAGE
a,aCcidem S
K UMBRELLA LIAB a OCCUR PIP-Basic S
EXCESS UAB CLAIMS-MADE EACH OCCURRENCE S 3,000,000
DED RETENnONS 600058654 AGGREGATE S 1,000,000
WORKERS COMPENSATION /20/2015 /20/2016
AND EMPLOYERS'LIABILITY S
ANY PROPRIETOR/PARMER/IXECUrNE YIN WC STATU- OTH-
OFFICERIMEMSER in NiCLUDEW
(MandNIA
atory H) E.L.EACH ACCIDENT $
11 Yyes,dasc,Ipe under Eli-DISEASE-
OESCRIPTION OF OPERATIONS belw EA EMPLO S
POLLUTION LIABILITY ELDISEASE-POLICY UMR S
12003711613 0/1/2014 0/1/2015 GENERALAGGREGATE
$1,000,000
EA POLLUTION CONDITION SS,OOO,OOO SCRIPTION OF OPERATIONS I LOCATIONS I ES VEHICL (ARart ACORDIM,Addition)Remadm$phedule,ffmamspaoelsrequlrer0
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 ACCORDANCE WITH THE POLICY PROVISIONS.93 WASHINGTON STREET
SALEM, MA 01970 AUTHORIZED REPRESENTATIVE
)RD 26(2010105) 111 Noegei
12517nlnmi n, TT,e AI+-rTRn name�nq innn nem ronieh�nei mat 88-2010 ACORD CORPORATION. All rights reserved.
vva s yl
CER a IFICATE OIL LUABILUTY IGt(�1(9��d���
DATE/It9114/QpJYYYY)
T. ATE DATE I5 f55UEp AS A WIATTER OF INFORMATION QNLY AND CONFERS NO RIGHTS UPON THE CERTIFCATE HOLDER. IS
THIS CERTIFICATE
IDES NOT INSURANCE
DOESIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR PRODUC R AND THE C TIFIC TE OLDE .
IMPORTANT:II the certificate holder is an ADDITIONAL INSURED,the oli
terms and conditions of the policy, orsein Policies may require and endorsement A statement on this Certificate does not confer rights to the
P Cy(fes)must be endorsed. if SUBROGATION IS WAIVED,sukgectto the
certificate hoiden in lieu of such endorsemen s.
PRODUCER
CONTACT
EASTERN INS GROUP LLC NAME:
233 W CENTRAL STREET• PHONE
(A/C,No,Ext): FAX
NATIM MA 01760 E-MAIL
22lyfl,W ADDRESS:
INSURED INSURER(S)AFFORDING COVERAGE NAICx
ATLANTIC WEATHERRIZATION L.LC INSURER A: AM7RtICANZOR[CA INSURANCE COMPANY
INSURER B:
INSURER C:
61 REAR JEFFERSON AVE 'INSURER D:
SALEM.MA 01970 .INSURER E:
COVERAGES INSURER R
Y D ENT TNATTHE POLICES OFINSURANt�LLSTEDB CERTIFICATIENUMBER:
REVISION NUMBER:
TED.No
AFFORDDsy T,Nr,TI0MISS CONORION OFANYCOMRACf OR OTHER DOCUMENT UI Reap ECfTOWH�®CERTFRIATE MAYBE SUED OR MADYpEflT44L 7R gyE SUBgHCE
PAIDRDFDBYTHE POLh:iES pESCPIeED HFAEN ESUBJECi TOALL THE TERM%IONCWSIONS AND CONDITIONS OF SUCH POLICIES LEI SHDWN MAY HApBe THENSURAY
PAID CLAIMS.
PISfl
LTR TYPE OF INSURANCE wn SUB L POLICY EFF DATE POLSY EXP GATE
R POLICY PLUMBER D!`ADD1YYW) (PAM1pD1YYY57 GENERAL LIABILITY LOifi6
COMMERCIAL GENERAL LIABILITY =ACH OCCURRENCE S
CLAIMS MADE 0OCCUR. DAMAGE TO RENTED
PREMISES S
(Ea occurrence)
' ED EXP(Any one peraml) $
POLICY ®PROJECT
GEN'L AGGREGATE LIMIT APPLIES PER: _ ERSONAL&ADV INJURY S
®LOC ENERAL AGGREGATE 5
AUTOMOBILE LIABILITY PRODUCTS-COMPNOPAGG <
ANYAUTO �•
ALL OWN COMBINED SINGLE S
OWNED AUTOS LIMIT(Ea acNidem)
SCHEDULE AUTOS 'BODILY INJURY S
(— HIREDAUIOS (Per Person)
�( NON-OWNED AUTOS BODILY INJURY S
(Per accdent)
PROPERTY DAMAGE $
(Pm accident)
UMBRELLA LIAR OCCUR
EXCESS LIAe CLAIMSAAADE EACH OCCURRENCE S
DEDUCTIBLE AGGREGATE s
RETENTION S $
A WORI(ER'S COMPENSATION AND y
EMPLOYER'S LIABILITYa WN 320/2016 WC STATUTORY i 07HER
ANYPROPERRORPEYECUTIVE UBoB2T0121-15 03120/2015 0
OFFlCER4.1DdBER EXCLUDED? MN -OMIT$
(Mandatory E.L EACH ACCIDENT E 500,G00
Dyes,dean+„e OF O E.L.DISEASE-EA EMPLOYEE
DESCRIPNCN OF OPERATWNSbeidw S 500,000
DESCRIPTION OF OPERATIONSR.00A7tONBNEHNCLES/REBTRICilp7V5lSpEC)AL ITEMSEl.DISEASE-POLICY UMIT S 5DD,000 THIS REPLACES ANYPR[OR CERTWICATE ISSUED TO 77IE CER7iFIGTEHOLDER A FFECITNG WORKERS COMP COVERAGE.
CERTIFICATE HOLDER
CITY OF SAL EM CANCELLATION
93 WASHINGCONST SHOULDANYOFTHE ABOVE DESCRIBED BEFOR pOUCiES BE CANCELLED
FXpIRAT10N DATE THEREOF,NOTICE WILL BE DELIVI !
IN ACCORDANCE VJI7H THE POLICY PROVISIONS. E
_ !
SAL.EM,MA 01970 AUTHORIZED REPR n q VE s : -
,CORD 25(207D/D .: w:. . .�--.`.`.-•v:
5) The ACORD IIame aotl lOBD are -:•" .:..reeisteretl mars of ACORD •^'' '--` .-.-...�,,,,,,,, 1 I986�2070 ACORD CORPORATION. AU rigl,Lq reserved_
iVlassacnuse:ts-Oe;artment o4 Pu:iic Safety
Scam of Building ;eguta:bons and JCa1.` ,QcidS
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3 HWTON ST r
Salem MA 01970=
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ATLANTIC WEATHERIZATION-LLC.
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61RJEFFERSON AVE-
SALEM,MA 01970 Uade uetary