12 ROCKDALE AVE - BUILDING INSPECTION (2) kr `
The Commonwealth of Massachusetts
rl'a Board of Building Regulations and Standards RE E i V TY OF
„ Massachusetts State Building Code,780 CMR INSPECTIO : �. I3ES
evrsed Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fancily Dwelling 7515 OCT 14 A
:This Section For Official Use Only - -
Building Permit Number: Date Ap ied:
/040/6
I Building Official(Print Name) - Signature - - Date
N SECTION 1:SITE INFORMATION
1.1 Prop aAdcfress: c ,G Ie A 1.2 Assessors Map&Parcel Numbers
Lis 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 OWNERSHIP[
2.1ai1 rr of ecord: c\ ve rNI�Gjf �
Name
(P nt XA: City,State,ZIP
IZ a7 ,a/lr, AL-el 979- 79Z9`
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other pecify:
Brief Description of Prop o/-d/)VorV:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials - Official Use Only
1.Building $ 30_ — 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost?(Item 6)x multiplier - x
44.Plumbing $ 2. Other Fees: $
.Mechanical (HVAC) $ Lis[:
5.Mechanical (Fire - - _
$
.Suppression) Total All Fees:$ - -
Check No. (I) Check Amount: Cash Amount:
6.Total Project Cost: $ .3dw 13 Paid in Full 0 Outstanding Balance Due:
SECTION5: CONSTRUCTION SERVICES -
5.1 Construction Supervisor License(CSL) 0 7 q 7-7 (-1/Z 3//�
` License Number Expiration Date
Name of CSL Holder
Eric W.Palm List CSL Type(see below) I*( yL
No.and Street 3 Hilton Street Type Description - -
U Unrestricted(Buildings u to 35,000 cu.ft
Salem MA 01970
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
9^ �'A/A ��K SF Solid Fuel Burning Appliances
/ 1 "/ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Atlantic Weatherizatiun,LLC 1147,0
HIC Registration Number Expiration Date
H[C Compygy.AlNT116 I31GIRM&Name
No.and StreetSaleM 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 a 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 E4,t O r P4/kl^
to act on my behalf,in all matters relativeto work authorized by this building permit application./
Print O is Name(EleUmnic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION .
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contain din this a;cat a and accurate to the best of my knowledge and understanding. 2
/0 1
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
4l-!; > ;nass. ,o,:ioc:Information on the Construction Supervisor License can be found at w.�•v:.mass._a�dclus
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross Iiving 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"may be substituted for"Total Project Cost"
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Contractor Arbitration
The Home Improvement Contractor Law provides homcowners 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 contra I�giayrsulrLdit�the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office pf o r Affairs and Business Regulation and the consumer shall be required
to submit to such arbitralip(r.a6 tiStl, a ch1>setfs General Laws,cha er 142A.
cc
Hoeneown s Signature Contractor'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(Le.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 othermatters on which the homeowner and contractor lawfully agree may be
added to the terns of the contract as long as they do not restrict a homeowner's basic consumer rights. Ifyou have
questions about your consumer/homeowner rights,contact the Conslnner Information Hotline(listed below).
Execation of Contract
The contract must be executed in delicate and should not be signed until a copy of all exhibits and referenced
documents have been attached Parties are also advised notto sign the document until all blank sections have been
filled in or marked as void,deleted,ornot applicable. One original signed copy of the contract with attachments is to
be given to the owner and the otherkept 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 Payments ,
A contractor may not demand payments in advance of the dates specified an 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 foods not yet due be placed in a joint escrow
account as a prerequisite to continuing 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 free copy of"A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline
Office of Consumer Affair and Business Regulation
10 Park Plaza Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCABR website at htto:/Jw%%�v.mass.gov/ocabr/
If you want to verify the registration of a contractor or ifyou 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 htm:1/%"vw.mass.eov/ocabr/ _
Go online to view the status of a Home Improvement Contractor's Registration
htty)://db.state.ma.us/homeimprox,ement/licenseelisLasi)
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
onsumer plaint Section
ffi oroey General
617-727-8400
AND/OR
Better Business Bureau
509-6524800.508-755-?549 or 413-734-3114
v®oa 11-II/ M10
ICI
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress.Street,Suite 100 �
Boston,AM 02114-2017
www massgov/dia
wworkers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers.
Applicant Information tbiI
TO BE FILED WITH THE PERTTING AUTHORITY.
Please Pnnt Le�bly
Name(Business/0 eantzation/Individual): Atlantic
ni R Jeffim-M Avage
Address:
City/State/Zip: Phone#:_ q 7 8 - ?q 4
Am you a employer?Check the appropriate bmu
Type of project(required)-
1, am a employer withemployees(full and/or part-time).- 7. New construction`
_.❑1 am a sole proprietor or partnership and have no employees working forme in
any capacity.[No workers'comp.insurance required.] - g- QRemodeling -
3.®1 am a homeowner doing all work myself.[No workers'comp.insurance required]r 9. ❑Demolition
4.❑Ian a homeowner and will be hiring wrtmuors to conduct ali work on my property. I Hill 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. ,
5.®1 am a general contractorand i have hired the sub-contractors listed on the attached sheet 12.❑Plumbing repairs Or additions
These sub-contractor have employees and have workers'comp.fi surm¢;% 1 -❑ repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. her
152,§1(4),and we have no employees.[No workers'camp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing theinvorkers'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 indicating such.
-Contractors that check this box must allached an additional sheet showing the time of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
i
I an:an
ation. per Mar is providing workersinformation.infor compensation insurancefor uty employees Beloly is the policy and job site
iott.
Insurance Company Name:___ zuy-,c,
Policy--.'.'or Self-ins.Lic.#:_ ,��j 2-70 f a 7
QQ � � /_ 9 n 1 Expiration Date:-
��``,�
Job Site Address- . �� F(G _City/State/Zip-
Attach a copy.of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,ys25A is a criminal violation punishable by a fire 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 foe 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. f
I do it may certify under the paints and peualries ofperpurry that the information provided above is true and correct,
J �t�� �d� •f'(�� /
Sitmature: _ ')� Date /0!/Z.
Phone#: 7YQ-Ply $
Official rite on!}: Do not write in this area,lobe completed by City Or town official.
City or Town: Permit/License# _
Issuing Authority(circle one):
1.Board of Heath 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#
`°�a�® CERTIFICATE OF LIABILITY INSURANCE
DATE(696)lOOry"
THIS3/3/2015
CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELQW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUIHOR2ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPOf2TAN7: If the certificate holder is an ADDITIONAL INSURED, the policy(Fes must be indorsed.
. IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this Certificate dloes not confer rights to the
cert(ficate holder in lieu of such endorsement(s).
PRODUCER
CMA WE.—HTACT Construction
Eastern Insurance Group LLC PHONE
233 West Central St (600)333-7234 FAX
ADOR Al N '
AD OR
Naticl P4fI 01760 wsu AFFOROWG COVER/1GE NAIC0
INSURED 1 SURERA-- rbella PPOteCtj,OA =A8. Co. -1360
Atlantic Weatherization INSURERBNautilus Insurance CO
61 Rear Jefferson Avenue INSURERC:
INSURER D:
Salem bdA 01970 INSURERS:
COVERAGES INSURERF:
THIS IS TO CERTIFY THAT THE POL C ES OFI NSURACATE NNCMEB STED B OW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
is REVISION NUMBER:
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.
INSR A LTR TYPE OFINSURANCE S AOUp EFF POLICY EXP
GENERAL LIABILITY POLICY NUMBER D LIMITS
X COMMERCIAL GENERAL LIABILIrY EACH OCCURRENCE 5 1,000,000
A CLAIMS rnAOE ®OCCUR 500042616 /20/2015 PREMISES Eaowmenre S 50,000
/20/2016 MED EXP(AaY Anapenum) Is 51000
PERSONALS AM INJURY Ic 1,000,000
GEML AGGREGATE LIMB APPLIES PER GENERALAGGREGA7E S 2,000,000
POLICY X PRO- LOC PRODUCTS-COMPIOp AGG S 2,000,000
AUTOMOBILE LWBIUTY $
Cam IN end
L MR
A A"ry AUTO amdam IN LE 1 000 000
ALL OWNED X SCHEDULED BODILY INJURY fPerpersm0 S
AUTOS AUTOS
020015871 /20/2015 /20/2016
HIRED AUTOS v NON-0WNED BODILY INJURY(Peramden0 S
AUTOS
PROPER raTYDAMAGE S
X UMBRELLA LIAR X OCCUR PIPAask S
.� EXCESS LIAS CLAIMS-MADE EACH OCCURRENCE S 1,000,000
DED RETENTIONS 600058654 58 65 4 AGGREGATE S 1,000,000
WORKERS COMPENSATION /20/2015 /20/2016
AND EMPLOYERS'LIABILITY S
ANY PROPRIErORIPARTNER(p(ECUnyE Y/N STATU- OTH-
OFFICER/MEMBERIXCLUOEDT ❑ NIA EL EACH ACCIDENT 0"*,dmry In NH)
$
DESCRIPTIOON OF OPERATIONS bob. E.L DISEASE-EA EMpLO S
POLLUTION LIABILITF E.L.DISEASE-po, , — B
PL200378613 0/1/2014 0/1/2015 GENERALAGGREGATE
$1,000,000
EA POLLUTION CONDITION $1,000,000 SCRIPTION OF OPERATIONS/U1CA710NS/VEHICLES(AIatl,ACORp Tp) Addition al ReAradm Sabedule,if mare spare is mquim.,0
RTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.93 WASHINGTON STREET
$ALEM, M 01970 AUTHORP.EO REPRESENTATNE
IRD 26(2010f06) John Hoegel/PMA
126 r�mnnsl m 7T,u A"UII n na.na 01988-2010.ACC)l CORPORA7TON. All rights reserved.
anA inns aro roniafc�aA mae7,e of Arngn
`. CERTIFICATE Off LIABILITY INSURANCE
• s° ERTIFI DATEOI WDOA-YYY)
CERTIFICATE
Doe fS ISSUED AS A MATTER OF INFORNIAT►ON ONLY qND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
THIS CECATE DOES NOT gFFlpMAT1VELY OR NEGATNELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED A THE POLICIES BELOW.
OR P CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUINGRAGE AFFORDED
AUTHORIZED REPRESENTATIVE
IMPOOR P ODUCER ND THE CE T1EIC TE OLDER
terms and co it the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the
' terms and conditions of the policy,certain policies may regU-ne and erttlorsemerlt A statement on this certificate does not confer rights to the
certificate holder in lieu of such en 'Ort"'Ten s.
PRODUCER
CONTACT
EASTERN INS GROUP LLC NAME.
233 W CENTRAL STREET PHONE
(A/C,No,Ext): FAX
(A/C,No):
NATICK,MA 0I760 E-MAtL
22MLW ADDRESS:
INSURED INSURER(9)AFFORDING COVERAGE MAICI
ATLANTIC WfiATHERIZATION LLC INSURER A: AMBRtCANZ[nuCH INSURANCE COMPANY
INSURER B:
INSURER C.
61 REAR JEFFERSON AVE 'INSURER D:
SALEM.MA 01970 INSURER E:
COVERAGES CERTIFICATEINSURER P.
D CERTGY THATT EPOLICES OF INS111 1, 1J51 LIMBER:
TH REVISION NUMBER:
MIYREOUIflEMENT,TEFMDR CONDR7ONOFANYCONTpgCr ORE077H OOMMENr NDHR�pt-Cr TO WHICl17HI5 CgI{ A MAYBE i59U®Op MAY pERrgpL THE 6Y9tIHANCE
PFF CLAIMaV THE POLICIES DESCRIBED HFABN iSSUBJECTTOALL S REVISION
MO DINpICATOR.NDTWIIIfSTANOwe
PAID CLAIMS. THE TERM ENCWSIONS AND CONDITIONS OF SUCH POUGES LIMI SHOWN MqY HAyE9EEN a 11INS INSURANCE
INSfl
LTA TYPE OF INSURANCE ADD SUB POLICYEFFDATE POLMYEXPOATE
L fl POLICYNUMB1ai (N'.AODIYY
GENERAL LIABILITY m (11MU7D\YYVY) LLMnS
COMMERCIAL GENERAL LIABILITY - CH OCCURRENCE
CLAIMS MADE S
OCCUR. AMAGE TO RENTED S
11���--11dd4 PREMISES(Ea occurrence)
E IXP(Anyane person) S
D
GEN'L AGGREGATE LIMIT APPLIES PER: E EX a ADV INJURY S POLICY ®PROJECT MLOC GENERAL AGGREGATE S
l AUTOMOBILE LIABILITY PRODUCTS-COMP/OPAGG S
ANY AUTO COMBINEDSINGLE ALL OWNED AUTOS L4MTT(FaaccideN] S
SCHEOULEAUTOS BODILY INJURY S
r HIRED AUTOS (Per Person)
NOMOWNED AUTOS BODILY INJURY S
(— IP&acdderx)
PROPERTYDAMAGE S
(Par acddenl)
'UA46RELCA LIAR OCCUR
EXCESS LIAR CLAIM SNWDE EACH OCCURRENCE S
DEDUCTIBLE AGGREGATE S
RETENTION S S
A WORKER'S C0 PENEATON AND S EMPLOYER 7)UABILfTY
ANY PER YIN
YIN US-5B2T0127-i5 / WC STATUTORY OTHER
OFF fit CERb1E.iBER E%CLUOED? M I A 032fIr2075 03/2(U2016 1° ,LIMITS
(Mandatory iv NH) E.L EACH ACCIDENT
o yes.dI ION abler E.L. ISEASES 5uu'ac
OESCgIPi1CN OF DpERAT10N5 betavv $ SDD,DDO
DESCRIPTION OF OPERATONSnACATONSNEHICLEWRES RICRONSISPECIALITENS EJ..DLSEASE-POLICY LIMIT S 500,000
TRIS REPLACES ANY PRIOR CER7MCATE 6SUED To THE CE 7MCATEHOLDER AFFECRTNO WORE�RS COMPCOVERAGfi
CERTIFICATE HOLDER
CITY OF SALEM CANCELLATION
93 WASHINGTONST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLER r
BEFORE THE EXPIRATION OATERIEREOF,NOTICE WILL UELNEgf7]
IN ACCORDANCE Wl THE POLICY PROVIMONS.
SALEM,MA 01970
AUTHa it REPR _...A..W :. '
,CORD 25 20T0/0
'✓r"/!>-:.. '-',-'.`::;-;`.':"-act.
( 5) The ACORD name and Logo are .: ... :..... .. " •: `.:..'�= ses..nF.;�. .::
x:° 1
registered marks of ACORD T9aB':2070 ACORD CORPORATION. AU rl htsr
9 eserved.
Massachusetts-Department of Public SafetY
Board of Building Regulations and Standards ofrjce of consumer Affairs 8L Business Regulation
Construction Supen liar r-
ME IMPROVEMENT CONTRACTOR
License: CS-087977 listration'. 142089 Type,
% X piration* 311212016 Ltd Liability COTPO"-
FMC W PALM ATLANTIC WEATHER12ATIOWL.L.C.
3 BILTON ST
Salem MA 019707
ERIC PALM
61R JEFFERSON AVE
'I itl 1, Expiration
sALEm,MA 01970 Undersecretary
Commissioner 0423f20116
Unrestricted-Buildings of any use group which
C License or registration valid for individul use only
,contam less than35,000 Cubic feet(99 Inn)Of before the expiration date. If found return to:
enclosed space. Office of Consumer Affairs and Business Regulation
-Suite 5170
10 Park Plus
Boston,MA 02116
Failure to possess a current edlition of the Massachusetts
State Building Code is cause for revocation of this license. a Not valid without signature
For DPS Licensing information visit. w .Mau.Gov/DPS