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16 SCENIC AVE - BUILDING INSPECTION (2) � �-5 c 'rile con»numvealth of;Massachusetts {,� ERv ES +L� Board of Building Regulations and Standards �NSQ Q,T� LH l [Massachusetts State Building Code, 730 CMR Revised.tlur2011 Zb Building Permit Application To Construct, Repair, Renovate Or Demolish One-or Two-Fancily Dwelling This Section For Official Use Only Building Permi Number. Da Applied: Building Ot'ticiel(Print Name). Si lu Date SECTION 1:SITE INFORJIATION' 1.1 Prop rty Ad ress: 1.2 Assessors Map& Parcel Numbers I.1a Is this an accepted street?lies no Map Number Parcel Number — i 1.3 Zoning Information: 1.4 Property Dimensions: Tuning District Proposed Use Lot Area(sq It) Frontage(II) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard i Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L a 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 ycsE3 SECTION I: PROPERTYOWNERSHIP�' ?�1 I '�Owf Rord: < fSGneite val k tneP(Prit nt) City,State,ZIP l G -<�?P —wp scenI C � al 0 455711- No.and Strict Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing BuildinvyD- Owner•occupied .0— Repairs(s),0 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ NumberofUnits__�_ I Other ❑ Specify Brief D tion of Proposed Work i'acre 12 G it SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) I. Building S t I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cosr3(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: .S 1.11cchanical (FIVAC) S List: i. Mechanical (Fire S Tutal All Fees:S . Suppression) Check No._Check Amount: Cash Amount: G. 'futal Project cost: ) It ;)J-- ❑Paid in Full ❑Out5tandiag Balance Due:_ A koi- ead wjwe,4, F 1 r:jfi SECTION 5: CONSTRUCTION SERVICES > 'J 5.1 C'uastructioti 5'u`lie'Mior Liecnse(CSL) License Number Expiration Date Name of CSL'tldlder «rtll List CSL Type(see below) (J —z-3 eogi -T Type Description No.mid Street U Unrestricted ffluildin s up to 35,000 cu. I1.) �Cjj /Y✓�N/ ✓ °GI R Restricted 1&2 Family Dwellingj Cilyrruwn,State,Zip bt Masonry � RC Rooling Covering WS Window and Siding SF Solid Fuel Burning Appliances -17g5q 3a5z I Insulation 'f0c hone Email address D Demolition 5.2 Registered dome Improvement Contractor(HIC) /6J6/4 t- mcdail r HIC Registration Number Expiration Date IIC Cumpam Name or 1I1C Registr• it Name N No. `o'0SirS`;r e 5 -IN90.3o52 Cmuil address t cif rrown,State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(hLG.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 AUTHORIZATIONTOBECOMPLETEDWHEN. OWNER'S AGENT OR CONTRA&0fit APPLIES FOR BUILDING PE"IIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Nmne(Electronic Signature) Date SECTION 7b:OWNERI ORAUTHORIZED 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. I I' rat Owner's or Authorized r\gent's N• c(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/hcr 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. I42A.Other important information on the HIC Program can be found at www.mass. �oL 6y!Information on the Construction Supervisor License can be found at oww.mass."ux:!.ILs 2. When substantial work is plumed,provide the information below: Total floor area(sq. 11.) (including garage, finished busemenUattics,decks or porch) Gross living area(sq. It.) Habitable room count Number of fireplaces. Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Nimtber of decks/porches Type of cooling system Enclosed Open I. "rood Project Syuare Fouctye"m;ry be suEstiuitcd tiu"total Project Cnit" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information as f ' (� / Please Print IRQibly Name(Bmineworga�niiationtindividuaq: Powc-r, (l om G 1<CmcotFuk6 G�f 2arJ/� Address: 21-0/ SfFPA2T JUITC 800 City/State/Zip: Phone#:__G/s p7q_yS ,Gto Are an employer?Check the appropriate box: Type of project(required): 1. I am a'employer with 4. ❑ I am a general contractor and 1 employees(full author part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner• listed on the attached sheeL t 7. ❑Remodeling ship and have no employees These subcontractors have 8. ❑ Demolition working for the in any capacity, workers'comp.insurance. 4._QBuildinz addition-__—_- - — working comp.insurance 5• We ate a wrporauon audits - required.) officers have exercised they ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LE)Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.(No workers'- . 13.❑Other tromp.insurance required.] ;Any applicant Cher checks bone al oast also fill out the section below showing their wotke s'compensation policy infxamdoo. - t Homeowners who submit this affidavit indicating they am doing all work W than him oatNde contractors most submit a caw a®davft WimmW inch lCmmscmn that check this box must attached an additional sheet showing the name of the snit-wwaama and their workers'comp.policy information. I am an employer that fir providing workers,compensation htsuranee for my emplayem Below is the policy and job s&e Ixformadan. Insurance Company Name frARLE SIJI/-LE L✓U�G��T�� I�IrJ CQ Policy/f or Sctf-ine.Lie.Al: W` WV�. �' a 17 r ?-/ Expiration Date. /® Job Site Addles City/StatdZip. 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 andhtr one_ ear imptisoomaot,as well as aivil.pertalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a y e ' razor, Be advised that a copy of this statement may be forwarded to the Office of Investigations o the D for ce coverage vtttificatiolL I do hereby a un er p and penalties ofperfury that the lnformadon provWed above Is true and correct matte# Offieihl use only. Do not write in dris area,to be completed by city or(own ojliciaL City or Town: Permit/1-icense Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: _ phone N: POWER-1 OP ID:AW • iAC 0° DRTE(MMNO/YWT') `,. CERTIFICATE OF LIABILITY INSURANCE 09/11/13 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, j IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. It SUBROGATION IS WAIVED,subject to the tome and conditions of the policy,Certain poifcies may require an endorsement. A statement on thle,ceT9ficate does not confer rights to the certificate holder In Usti of such endorsement a. I - LanODUCER cher 8 Aaeocletes Ins Agency215.923.4378'CAME _ Lacher Insurance Group 215-723-8B04 °HpN FAX Ne; 632 E Broad St P O Box 64398 Souderton,PA 18964 -i Chad Lacher WSURERSAFFORDINGCDVERAGE Nacn INSURERA;Harle _Harleysville 26182 INSURED Power Home Remodeling Group, INSURER 8:Harleysville PreferredIns.Co 36696 LLC.Power Homo Remodeling Group, INSURERC:Nationwide Mutual Ins Company 23787 , Inc. IJSURERD: 2501 Seaport Drive Ste Oil INSURERS;Cheater,PA 19013 INSURER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD . 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 WMOFINSURANCEADUL .I POLICYNUMBER OffiWouffinm ImovaurrymLIMITS GENERALUASIM EACH OCCURRENCE S 1,000000 ..I B X COW4ERCIALGEIIERALLIASILTrY PA00000089793N-1 10101/13 10101114 ✓R6� e S 100,000 CLAWS-MADE X❑OCCUR MED EXP eraan av 10,000 PERSONAL&ACV INJURY $ 1,000,DO GENERAL AGGREGATE'. $ '2,Oo0AO GERL AGGREGATE LIMB APPLIES PER. ) .PRODUCTS-COMPIGPAGG f 2.000,0 POLICY X PR0. LOC t S AUTOMOBILE LIABILITY Ea NEO Mn 1,000,00 A X ANYAUTO A00c00089796N 10/01113 ;10101/14 BODILY INJURY(P VA ) $ - AUTOS m A NON•OYa1FAUTOmauleD BODILY KRAAY(Per=W" $ HIRED AUTOS AUTOS AAIAGE 8 S UMBRELLA IJAS X OCCUR EACH OCCURRENCE $ 10.000.0 C X °Icy CLAIM844ADE CMOOD000089794N 10/01/13 10/01114 AGGREGATE 3 10,000,000 ON 4 WORKERS COMPENSATION X O1H- AND EMPLOYERS'LIABILITY A ANYPROPRIETORNARTNEREXECUINC YIN COD000D69795 10/01M3 10/01114 EL EACH ACCIDENT S 1.000,00 OFFICERNEMBER EXCLUDED © NIA (Mandmoryin NH) EL DISEASE-EA EMPLOYE S 1,000,00 0 CRIPDON DFO be E.L.DISEASE POLICY DAIR S 1,000,00 A Mass Auto Policy 00000018227P 10101M3 10101/14 Liability 1,000, A NY Auto Policy AAOO00007484OR 1010IM3 10/01/14 Limit DESCRIPYMCFOPERATONSILOCATWNSIVEIUCLEB(AaeehAWR0101,Addltlond ttamdre SODRN1o,anwh apap la regWretO CERTIFICATE HOLDER CANCELLATION SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVER®. m ACCORDANCE WTOTHE POLICY PROVISIONS. Salem 120 Washington St AUTHDRLIEDREPRESENTATNE• - - - - - 3rd Floor ,Salem,MA 01970 @ 1980.2010 ACORD CORPORATION. All rights reserved. . ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD : Batch Order#/Line#,Qt. U,Factor(U.S._/1 P) >!' ,Solar Heat Gain Coefflcrent; Piping . Visible Transmittance, Contlensation Resistance �['�Y'✓'.�` i ryi.`-'T._'_ r ,ry .ya'f} gyro-, p(,"�.'m*y ° Wd.Y_ . ^{3j 'CrF � �YY.�a�..v.J� r .rreY� NP....�..k .ra r.L c rC f L }a yes y(d 6Z I , �aM�II yt3m+i�.� r SK`r`�. ; 't{ rl isCc3� .a..�J� �' `Y{t �e��'Fw*fb �sYt. r �•�r^..�'� �r �� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement:',Contractor Registration Registration: 168616 Type:- Supplement Card - i - Expiration: 3/18/2015 POWER HOME REMODELING GfOUP Ll C� JUSTIN SMITH W 2501 SEAPORT DRIVE STE 13110 ` CHESTER, PA 19013 `*f. Update Address and return card.Mark reason for change. SCn 10. 2oM-OW11 ❑ Address L] Renewal ❑ Employment L] Lost Card Mice of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR. before the expiration date. If found return to: ,, Office of Consumer Affairs and Business Regulation egistration 188616;_j Type: 10 Park Plaza-Suite 5170 Expirafic(rr 3G1`$/2015'? Supplement Card Boston,MA 02116 ' POWER HOME REM{1DELIN -t;RQUP.LLC. JUSTIN SMITH 2501 SEAPORT DRIVE STEBA10 ��6--->61aP_ CHESTER,PA 19013 Undersecretary Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License CS-093960 JUSTIN W SMIT1y 399 E Hartford Alien Uxbridge MA 01569 1,VIF Expiration Commissioner 01105/2016 - ` about:blank +oel+ t"tA h+r ataOd M' - p.�y..��,•, ^... DW*k,W MW***1Ee h:tyw!wr t%«v craw m "'�•+"[,)Wr K 3Yb7v:6 F*M4aty 9{,rylis ..i""f,.."..�"� CUSTOM REMODELING AND IMPROVEMENT AGREEMENT Suyerls)'Information and DmviplAn aIurr Froi Iy ProlectNumber 30.99026 February 11,2014 i+b*e.iarrtmv Derek White i971il 710 SS05 h 4 alk-S GO) devvmuss ' ahoo,<ont Janelle White un+aaev+ i Iit:.Nfie. 197d)72e.90U9 r;ylraris r:gitl Av 3aem,hek 01el0 county:lase+ Twarela : Buyers)bated above hereby jointly and severalty agrees to purchase the goods andtor services of Power Home Remodeling Group and us vendors(`Contraclor")in accomante vailt the prices and terms described in this 6 page document and the Product Specifications,which are incorporated as part of the Ague illem hoollecbveiy this-,Agreement l This Agreement represents a cash sa of goods antl services. Buyerts)agrees to pallthe cost of the goods and services purchased as described bolero regardless of te bring or approval of any financing Huyedai may soak for then purchase Epay:m-h e: 572.628,67 Pre Installation Inspection Dates: n. Estimated Project Start:6 to 7 weeks on 5T2,62667Estimated Project.Completion:1 to 2 days 0mptallOnyrneg:: -?�i+Vry rrn>I reNAPirvMm -hntxL] ninirxr�s Sae s.yi �dwnfcl,Nor Buyers)hereby acknowledges receipt of a copy of the pamphlet"The LeacSafe Certified Guide to Renovate Right" informing Buy s)of the polental risk Of toad hazard a%puslsrt from renovation achvlty tg be Perfofined in or at auyer(s)'Property at the a re vaitten zbove Buyer(_i+ecarved tics pan+nh'c1 on the date of this Agreement,before commencement of work. Buyer(s)'Initials. T Agreement constaulas the tinkro ag,etmen:and mtleriani ing beeveon the parries.and this Agreement replaces any and all poor negotiations,representations or zgleemome, either v.',,her or oral. No amendment,modification orvrawor of this Agreement shall be valid of effective unless,n«vt rp end signed by boll paffes Buyeris)hereby acknowledges that Buil 1)has read the entire Agrestnent and has received a competed.signed,and dated copy of this Agreement.including the two accompanying Notice of Cancellation forms,on the date first wetfen above and 2)was orally miter mad of hislher right to cancel this transaction Buyer(s)also agrees and understands hat,(8uyeusi finances the work with a third-party,the terms of that financing will be contained on separate documents including.any itnance charge, Future promotions not applicable I have read and received each page of this 6 page agreemen Pow me Re o ogling Grag> r Buyetle) Bu e 1 _p2f i l Ili y �1./`�"\� i0201Il14 '�� 102111114 Si t of R doling COnsullant Sig haWre 51 9 nalull an Hagerty Derek While Janette White •rtlU,110 DVYER{th AWY CA%"t M s ma 4*ACye8M AT ART win pli To M*WGKT OF THE yffIRD 111j"MU DAY +rFTWe THE OATS®F WA TRA=*.ctT1 .8;Gd6 ATMcif A M0TICIt OF CAK*LI AT;M1 FORM FOR AM ik)(PL ARATICN OF of M ONT.. theal yii,=41l-45 IIIIIIILIIII III)II) IIIIII III Page 1 of