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18 PURITAN RD - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Stan RECEIVED CITY OF + Massachusetts State Building Code, 780CTIONAL SEM ICES.SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Reno v�t�OfA�e�Wlish a". S b One-or Two-Family Dwelling L 1 F1 This Section For Official Use Only Building Permit Number: Date A lied: I Building Official(Print Name) " - Signature ' Date j SECTION 1:SITE INFORMATION 1.1 Property Addres/s:- ///� / 1.2 Assessors Map&Parcel Numbers 15�- 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(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 OWNERSBZP' 2.1 Owner'of Re ord: bY.rJortc �7��n Z41 i d'r .S Sc, 1_CWI M14 Name(Print) City,State,ZIP /� 61 C' �- --- 7414- Fs3� No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 AI on(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: S tea Brief Description of Fro pose dWorle: E441,n� C e '1'( 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 g ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (RVAC) $ List: 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. Check Amount: Cash Amount: ` 6. Total Project Cost: $ c2 �1 ❑Paid in Full 0 Outstanding Balance Due: _S�rt -a1`1V l SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 9-7 G-7 - y 31 3 / License Number Expiration Date Name of CSL Holder Eric W.Palm List CSL Type(see below) No.and Street1lt9IF$ d . Type Description. Salem MA 01970 U Unrestricted(Buildings up to 35,000 cu.8 City/Town,State,ZIP R Restricted 1&2 FamilyDwelling M Masonry RC Roofing Covering WS Window and Siding �l I^r A,G'l,4lr.� SF Solid Fuel Burning Appliances { V1✓1 O I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) y 26?q A1lA0tICweatherization,LLC HIC 12 !(v Registration Number Expiration Date HIC Comp%y➢ *#&Re¢istrantName No,and Street al H97U 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 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 Er., G ` r4 /Vh to act on my behalf, in all /Imatters relative to work authorized by this building permit application. / Print Owner's Name(Electronic/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 cont in this ap 1'cab a and accurate to the best of my knowledge and understanding. 5�+y� ZG 11 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. ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dam 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 halfibaths 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 dome gm ro'vement Sam le Contract This farm sati55mdl6asic - . all ageroprotatbom +a7aitemmtsofdte staMsHomehnpmvapm Cdvtraaorl.aw(ryfGl, . 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Dare wfien mouaaed Hind:m7t be subnartaally mvtpleted Totvl Comtam Price and Payat®tSehedde The Canuaa0r agrees to pM'orm the,,.*,fambth themmerid and tahm specified above far the mad sum uF.Pa)mants will be made acconling m the wide:scb _ 5IM-Won sigdag tmoaaa °alto .( exceed lt3 oFthemml InatullCt pria-qt)repona S by fspecial ankrhenu•wbieheverblimser) compietim of �'�"� 6y�i �17� coupon-owes.of S upon completion orlimeme et,()aw forbids denav tullpaam�� trmv7 con �y enefallauivgmaujdr ///,,yyyrrt vaammmpl m hothpmtyssaUdilebmr) entered beflmfhecan egtdpmemnnm heapecial s tob6pad dr TO meet the Weed°nor bemamorde YOTFS:f°)Intludingyl fircncacM1 �� not exay N- area(°,,hW.yaire:Na �a r -gimteraf(a)meyhird°fdntanl ey�tmdnnn.pavmenr reQdredbp N°mmaerabefarawar4 ' a= wbnh coon hespecial oNaed in advaaa tomar Necnmd�eamap dW alcmtafam special egdpmme ormwyp vredemaraid Sb ndld M1eN rh vaam agees ro besold r ° v rM x Pane/ bin nactar e1 lla I Yrmponvbtefineampimm oFN rk drsenLyr Lit 61'N Woo'^ t Tmmnaaaorfiather °8ardle6 ofrheam third gpees to besddyrespooabte fmdl Paymmtsrodl subcpotra aounWi Contract Acce hove- - crors fin mnrma sha11 oa[ann y Wazm 9�e,this docmnam bmomesa bia ' _ aonrct oromersenui p�nt6meid . ,Revoa,theisonatb,within this do,,, the mreFWly 6eFore signing ads contract. tYfntete¢has heat 1 dmm.Reviewthefallowingcyrtiom and nodcas Don't be ptes¢ued Into Sigma the ° Malx��..ae mavaaarhas g C0°°aa'7alrotimeto rmdand fWly tmdaazaod it Adr subcavtaaarsmbe validA e1 tptadp¢s ifmmedtmg is wdear. regatered\nh the Dr r on.The lmv regtsaanav bynridngmthe rectoroFHam°fmWvv®at CmoaatorR � mach°meimpta\cmrntemuaaorsand ° Daa the coovaaorhavemsntThatrace�Adcll��A�'RO0"r 3I70,Bmton,,Mp 00.116 (�g 6®97i3 87m88& sceempyofa'pmpfofin CLvvaavrfmhisimumoW mmpmty iofammfion so tlmt vv®° I:aou•}nurri stuaare"documra4 > mnfum co\emge,orasl.10 Guiderothe tibo elmrr�a\onaz��ae�Re��ef01Panaaz7nFmmerianmthe ree'mseside P 'emmtCwaonortaw- ofthfs form and gdampy oflhe Conauner You may tnooJ Ibis ataeetvmtiFitbm Gem sigoedaza third lam hlarllerma111 calIv Pthatbanammnvaaarslmmtdplaco0 third business o�combrzach olice byoNmaryatarT fbusmesr,pm\ided You noGfr the •fo¢owing ate signing OF this agreemcol Sce the paged,by tell seatorby delivery,not later DO NOT SIGNTIIISCONq•�Cq• ed0°°aofemcdladmfomtforaa ®ddghtofthe r„aideady e°p�nram°°°°>�e¢aW TARE ANY BI,- mplaoadan ofadalight /� / ®mere>ed+izm°mmps>nvvusautseme�aa:n:a�eoR�sseddx�CES!!m�ne Hame0ener s Stbmatum II// II Imo_ � C.ttaams, grNpue ► /� / Contractor Arbitration The Home Improvement ContractorLmvprovides homeowners with the right to initiate an arbitration argon was an altemative to court action)if they have a dispute with a contractor. The same right is n9I automatically afforded to a. contractor,however. The conractorwould 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 con>ractorthe same right to arbitration as is afforded to the homeowner by the Home improvement Contractor 1za,- The contractor and the homeownerhereby mutually agree in advance that in the event the contractor has a dispute mncemingthis contract the conractor Fray mbn*the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Offce 4f CousumerAffaiirs and Business Regulation and the consumer shall be required to submit to such arbindon as pYot"iilild7u Massachusetts General Laws,CIP er 142A. i Homeowner s Signature Contractor's Signature NOTICE:The signatures;of the parties above apply only to the agreement of the panics to alternative dispute resolution initiated by the contractor. The homeownermay initiate alternative dispute resolution even where this section is not separately signed by the parties. Homeowners Rights A homemner's rights under the Home Impmvement Contractor Law(MGL chapter 142A)and other consume 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 ifthe 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 worltmeatilm 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 warantem or%%wranties provided by the contractor,all goods sold in Massachusetts carry an impliedwananty 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 terms of the contract as Iong as they do nut restrict a homeowner's basic consumer rights. If you have questions about your consamedhomeowner rights,comact;tlte Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in du lip and should notbe signed until a copy of all exhibits and referenced documents bane been attached. Parties we also advised notm sign the document until all blanksections have been filled in ormarked as void,deleted or not applicable. One original signed copy ofthe eontractw4th attachments is to be given to the ownerand the otherimpt by the contractor:Any modification to the original contractmust be in writing and agreedto by both parties.Contracted workmay 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 ofthe dates specified on the payment schedule in cases where the homeowner deems bimlherself to be financially insecure. However,in instances where a contractor deems himlherself to be financially insecure,the contractor may require it="balance of funds notyet due be placed in a joint escrow account as a prerequisite to continuing the contracted work. Withdrawal of fiords from said accountwouldrzgwe 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 ifyou wish to obtain a free copy of"A Massachusetts Consumer Guide to Home Improvement" i contact . Consumer Information Rode Office ofConsumer Affairs and Business Regulation 10 Park Plays,Room$17%Boston.MA 02116 617-973-8787,888.2833757or visit the OCABRw•ebsiteatS•nn-ir-,%,,i.ma;z._r._:c ice: If you want to verify the registration of a contractor or if}vn 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 Room517%Boston MA 02116 617•973-8787,898-283-3757or visit the HICwebsiteatham:cow;wy.ma»sociocab: Go online to view the status of a Home Improvement Contractor's Registration: - -�'d'c �^�.•ma-ac:lm*rirt-+mvamervliccrt;ulu,-asn i For assistance with informal mediation of disputes or to register fmmet complaints against a business.calk Consumer Complaint Section Office Of the Attorney General 617-027-9400 ANDIOR Beact Business Bureau 509-6524800.508-755-254&or 413-734-3114 vasroaat-itmn�to �-�� �Txe�oaa�trrae�l�ar r �1easrE#Se Print Eoem, „ ; _t' per+ice rs#m te�egva�acaat # ag 111Z�� Name 1ems Zlbt9..��_oay➢y �a+tizaeonittdiy,�t us'1: At18t1t1C Weatherjratiut;,LLC Address: 611i Jell Venue `gig y/�Lte(Gip: 6+-e_ rota^sl e ;Payer?Check axe Phone gj y-j ! Ll I aru a aPS�t�ate box: employer 4. ® i am a g• employees(full and/orparntime.c have general contra and i Type of project(required): proprietor or ) hired the sub contractors ❑New constriction ship and have no Partner listed an the attached sheet. ry. soda employees These sub-contractors have ❑Remodeling r ng for me n any capacity. employees and have vrorlters' S• ❑Demolition Ct`ia vtodrer'comp.insurance Iequired] comp•insurance t ®Building g addition 5. ® We are a corporation and its 10.i�Eleettical A am a homeowner doing all wont officers myself.(N O workers'ca have exercised their rep 3s or additions insuratrrce requited, ' right of emption per Mi al 1110 PIumbing repairs or additions t C. 152 1 a § ( ),and we have no 12•Q Roof repairs employees.11\10 workers' 13., ther NSr t./ct `�aY aPFlicant that check box:i CO '�'ice-'etlprced.] AOhJ Hoateatwers�eho submie this must�o flll out rite section belov�sho 'Caatrattors that ch ai8davit indipting tbeY are doirt� °nog theirtvorke3`compensation li inPo em is �this box must attoch d all tvodtand bust(dre outside con Pa � rmatioa P Yees. ifrhesufi-conaacmrs �anadditiona(sheershowin �rsorsmastSubmit aneu•affidaritindi have employes,tltey must mvi g dte nameofdre sup-conazctots and state wuetherornot tiwse 6a enti• g such. F de their aodcets•rnmp.policy aumher. have �wtsotze;trpfayertiecYispro9dtazrtgwoa•�er,'ca�_ -- - olio:,,.agar. �ezasz +,v�zsrararuejc; %'zye.�✓��rt - _ yees Fad©av isthe-DO&Y raaae fao M. insurance tympany Name: C r-f-C ro-'icy 37orScIr.' >ns.i is r. SIB a 7 o If, r _ , Job site Aadress: p /- pirationDate P�1 r/'�ryh p A�`sch a cop ` ty/Stamfzip: Failure to secure coverage as a EQD E&3:8�Ort 3]ORey i �(/'e��1 a aea~araon,Page(showing the paidcy g�t6er and Of LIP up to S 1,SOO.CO and/or on ear imptigon3�t as wen as civil I52 can lead to rite imposition of c � �xn5x'a .on dEiEj. to,250.00 a day against the violator: Be advised that a co penalnes in the form of a STOP penalties of a L,vestigations of the DLA WORK ORDER and a fine for insurance coverage Py of this statement may be forwarded to the Go 'Jerehy setyz g verification Office of aerid*ea ft^�ffi`i'$f��ltddr'c eotn •�-. �,/ - — ro" :den r*CVa is r,3e eraas©sect o ' i 3�ZCd!ZF�rs�' i es;t.,� Danonr�uan£;�rs ea,ro b2 cam,,ew by sz y .o!"Ja 't ®r^n awt3: f 77771 asug Ei lt�orlL7(cs-ale ene): S W ='•'�Eat'e�of=e� L.�t181r1' - 61.Omer IRS' anent 3.FYt ,@s ex' Wl aa �terac �•£§eotetstsi- DaataeePersoad: Pecrbs 5.1�ytiyagi€assae2pE 1 Phone 4: i \JL—,.J aCr-`1-TIRE OF L OA-B44LUTY 1 -v I OA,e I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATl01! c L J c `�������� ! HOLDER, THIS CERTFlCATE DOES NOT AFFIRMATIVELY OR NEGATIVE as i2$pta I AFFORDED 6Y THE R(S), gs HERON* THIS CERTIFICATE OF INSURANCE DOES NOT CONEND OR STITUTE A ALTER ERTR ONLY AND CONFERS Nd RIGHT UPON THE CERIFICATE� I THE ISSUING IMSURERt$},gUTyORIZED REPRESENT AiIVE OR PRODUCER,AMO THE CERTIFlCA E HOLDER THE COVERAGE IISPORTAN T: If the cerdficsts holder is an ADf][iION!{L INSURED t = ACT$Ei4VEEN i I notcorder gh fed conditions oithe policy,cer,ain paicies may rE r h_pGlicY(es}must be, If SUBROGATION tSkVAllrEp, cerBfiicate folder in GL91 of such endorsemar [s},gWrean Qid" ent A statemEnt on this ce j PRDa c� rhBcate does ES TERN ERN INS GROUP LU3 12331VEST CENTRAL ST i NATIGIC,MA 0176 0 I SUREA(SI APP0.ROCJG COVERAGE I FSNLEM, NEIy INSI;RE4A_ArlE.AlG:r:3JRiCH INBUAMIC'-CifPMY I NAIL= 1 i1G tVF-ATHERIZgiION LI,C j !AR JE.=ERSON AVE I::sUAEae_ t MA 01E70. ! usuR I Is,J O I COVERACEe � I CERTIF CAT-NU&;BER• IINs.Jaa j I j ABOVE O CERTIFY THAT THE FOLICIES OF INSURANCE USTc I FOR THE POLICY PERIOD INDICAI- , REVISION NU 'BER. GOATRACT OR OTHER D ^ c r =D. N_OTW!T. D 6E-OIN HAVE BEEN ISSUED TO TH ,1\'SURAUCE O"UM-N I LVii-F{AESPE HSTANDING ANY REOUIREMEM, TEpfd OR E INSURED NAMED 11 AFFORDED BY.T,yE POLICIES CI TO iVHICH THIS CERTIFICAT_F. CONDITION OF p,NY 1 GOD!D!TIONS OF SUCH POLICIES.LIMITS SHOWN DESCRIBED EDE BEEN IS USUB E p I OMY BE ISSUED OR trAY P I �IN=R ALL THE TERMS. ERTAIN, THE L TYPEnFIM$UAANCE RDDU SUB AID CLAIMS. EXCLUSIONS ANp 2e119rAL UAe!UTr, II SRISVVD� FOUCYNUI£BFaj POUCYn POLICY-'-�YF I j Io~_•'L'�cuLCE�a LIrr3:Lnv I+ j t I(/<xoD><•rYn AmIm0p, ' L GCLLR I Was i EACHG CURflENCE ors s i 1 . I_A.rAG=mRs��n I ! j I racO P!Art aneGzssa10 IS !I II GEh'LACGRECATE UAJr<AFFU'S PEA: I I RWML ADVIA,VRY g i ! 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