5 SHILLABER ST - BUILDING INSPECTION (2) `r� 35
—q1 `� Ilct:. Cjc 8-S iz
The Commonwealth of Massachusetts NSPEC710NAC ERVICE R
� Board of Building Regulations and Standar
'< Massachusetts State Building Code,780 CMR,7h,edimtiogn y 2 'M'NJ_W ITY
Building Permit Application To Construct,Repair,Renovate(Xi�emo_Itsha. ; ;Reviseed�Jamrary
One-or Two-Family Dwelling 1,2008
This'SectionFor,Of icialUse:Only
Building Permit Number Date Applied:
Signature.
"Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE IIYFORMATION '
1.1 Property A s: )Ck 1.2 Assessors Map&Skre"Jonders • '
... fa— _ _•.-__. _<_ _ M Number ... - �. ceP 1Ndmb
- - Lla Is this an accepted stree[7 yes_"no—�--- ` Map
1.3 Zoning Informations 1.4 Property Dimensions: .
r Zoning District Proposed Use Lot Area(sq ft) .Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided' Required a Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTYOWNERSHIP', '
2.1 Owner'of Record:
S,. ern mnn QeJt�o S fit;1 l ct 6-e--1
Name(Print) - Address for Service: -
Signature Telephone
' SECTION 3:DE$CRIPTiON OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building O . .Owner-Occupied ❑ Repairs(s) O 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units / Other ❑ Specify:
• Brief Description of Proposed Work-2: 5 i, i e2 - lZefo P
51�GI -3o X2 S/1, . cI-e
SECTION 4:ESTMATED CONSTRUCTION COSTS r-
e Estimated Costs: I
Item Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee.$ Indicate how fee is determined.
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x roulhplter x
3:Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List "
F
5.Mechanical (Fire $ - • '
Suppression
Total All Fees:$
0 a Check No. Check Amounts Cash Amoimt:
6.Total Project Cost: $ 7DQ • ❑Paid in Full ❑Outstanding Balance Due.
rnf�\Ltd tN 6C5C SI'ZS�
SECTION i,CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiation Date -
Name of CSL Holder Efic - ' Uk
31f10D1►Sftd List CSL Type(see below)
Address , Sdem MA 01970 -T > , Desciiofion'.
U Unrestricted(up to 35,000 Cu.Ft
Signature !� R Restricted l&2 Family Dwelling
M -Masonry Only -
RC R idential Roofing Covering
Telephone WS Residential Window and Siding
n 7 ,�y y_ �/ SF Residential Solid Fuel Burnie Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) y�
illdntiu Weatherimion_T.T.(
HIC Company Name Wff�IamYCIlUC Reg' -on Number
Address
Expiration Date
Signature ,. � Telephone -� - - -
SECTION C WORKERS'COMPENSATION INSURANCE AFFIDAVIT 25C(Q) ,
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 o e building permit.
Signed Affidavit Attached? Yes.......... No...........,❑
SECTION Tat OWNER AUTHORIZATION TO BE COMPLETED WHEN',,
OWNER'S AGENT OR CO�N/TRACGTOR APPLIES.FOR'BUH DING PERMIT
I, S�M inGr— /LC' dI -o as Owner of the subject property hereby
authorize EL L Pk to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owuer - Date
SE/CCTIO147b:OWNERr OR!AUTHORIZED AGENT DECI:ARATIOI4
I, �(. f'c as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. //77
El , L Cci
Print Name
lI. �,�1
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) - - (including garage,finished basementlattics,decks or porch) -
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths) a s„
Type of heating system Number of decks/p"orc6es`i UU V )I- L)r,
Type of cooling system Enclosed Open
�rrae 3. wt 1�U31:)'Total Project Square Footage"maybe substituted for"total Project Cost" ecu 5 l C u)
CITY o S.'1I:E;tif, il'L3SS 3CFilirSE I'TS
� BUILD,NG DEPIRIZIEDiT
• I2()WASHINGTON STREET,3m FLOOR
TEL(978) 745-9595
FAX(978) 740.9946
1CIJ(BERI-Sy DRISCOLL 'IHob, ST.PIERRH
JAYOR .
DIRECTOR OF P<;BLIC PROPERTY/BL'IIDnVG COtiM[155IONER
NVtirkers!Compensation insurance Affidavit; Butiders/Contractors/Etectricians/Plumhers
Aprtcaot InformaEien -__ Please Print Leeibiv
Atlantic ltieaiitcfization,LLC
Nal11C(Ousintss%OrganizatioNlndividuaq:
Venue
Address: Salem MA 01970
City/State/Zip _ Phone#: 9?I- 7 y y- S l Y3
Are yo n employer?Check the appropriate box: Type of project(required):
1. .1 otn a employer with 4. ❑ 1 ant a general contractor and,1 6. ❑,New construction
employees(full and/or part-time).' have hired the sub-contractors '
2.111_am a soleproprictor or partner listed on the auached sheet.: 7• ❑.Remodeling
ship'and,havenoemployeea Them sub-co ntractorxiiavo..-__ 8. ❑ Demolition-
working for inpny capacity. workers'comp Insurance 9, ❑Building addition
(No workers'comp.insurance 5. ❑ We are acotparahon tied Its, !0.❑Electrical repairs or additions
required j officers have exercised then _ . .
7.❑ 1 am a homeowner doing all work right of exemption per MOLL' 1 i.❑Plumbing repairs or additions
myself.[No workers.corilp. c.152,¢i(4),and we have no 12.❑Roof repairs
i 'insuraneeretjuiredJt!. employees:'[No�vorkeis' 13.0Other
comp,ias'M e,rcouired.J
"Any arpllrwt that chicks box Al moot also fill out the sectiao betowihowing rhea workers'uompenaaiun polity infwmatioa
t I IMM%v enwho submit this a0lEavit indicating they ate doing all work and thin hire ounWo runuactora must submits near affidavit indicating such
Cuntmiiis that chuck this bwt must attached an mWoml shad showing tho nww of IN suhconinctart and their workers'comp,policy inro !ion. .
lam yn employer that lrpravlding>vorken'rampeusatlon ltiuurancejor say emplayeim Below;is the polity and Job rite
lnjornrution ;
Imurance Company Naiile: fa/I
Policy 4 or Self ins.Lic:#: �y�� Expiration Date:
Job Site Addr ss > i t 116,
1 A (1 e_ City/Stute/Zip 5�1 6�
,attach a copy of the workers'-compensation'poliry_dedaratlan.page.(showing the policynumber and expiration date).
Failure to secure coverage as required under Section 25A of MOL e.,152 can lead to.the imposition of criminal penalties of a
tine up to S1,500,00 and/or one•year,imprisonmcn4.as well as civil limIdes in the form of a STOP WORK ORDER and e fine
of up.to$M.00'a Jay against the violator. Be advised that a copy of this statement may be forwarded to the Of ice of
investigation!;of the DIA for insurance coverage vcnncation. - -
/do liereby certijyunder the paL�t�s and pAr es ojperJury 1/raf!/re injennbrrar praJfded a ve is it a uud correct
Sitp mire• ( c '%ta/' � / `�`
Phone q•`.. -% ^) e �=!/i =Fl y.3
OJTciul use only. Do not svelte in this area,to be cbrarpleled by city orjown official
City oe'rown: Permft/license
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 M.
,I
Massachusetts Home Improvement Sample Contract
adard
his fan sadsfies eU basic regnvpmenls ofihesme's EoneTmpmvemeatCmhncmrlmv Q. ..
langmgc fo pmhct homeowners:i3eekiegal advice lfvecesm �P 14v`)•bat A-
-of
domnotiacivdos
- Ma49af'yusWS Con=+�GStide Home ''y-ao'PmsooP)eoninghomeirnpxovnnencs should 6rstobtamawpy ofA-
Iq Tmpmvemevt"befom egeeingto myworkonymmresidance.Yonmay obtamafree copyby ca0ing the
O&a aCConamcAffalts and HtL�messRegulation§CoasumerInformadon BotIlve at 637-973-8787 or I-g88.28}3757ar on ourwehsi[e.
Homeowner hiformatloa ,, Contractor Informaiioti
. .b'deerAdmm(domta[t�eaPoa/Ofnm./H/mcod@assl Cooaactod8alepmrod
l/A
f5ty?own Stem Tryrade Busmew Admen(mustivcluoeesaeete
Salem AMA 0197O
Dny0me Phone
S"7
3 Phwe CnyRown SmR-- Y-)o y Zip C•tle.
M^Bine Adtlmn(amffermtfiom ahmk) Bmhers Phooe PetlwaFmployerIDor S.S.NumW .
- I,prtpdmnmmw home amervw.meee�lgmm®,gq 2dmDer E�dte
men m
° Y2o�CI
The Coatnetoragrees to do the following worklbrthe Homeowner.
(DO Cnbein ddm7lbe nvdcm comPletmL V=ifyhtglhe type,brand,and grade of maaahb m be nttd•x.
Required Pomahs-The fallowmgba0dingpe+mits are requited Proposed Start and Completion SchedCle-7hafoIl
end will be secured by the contractor.as the hameowm's owing schedule will
ttr, be adh to uvleas chc®smnces beyond the contractors control arise
(Owners who secure their own permits will be
- excluded from the Gaarenty Fnnd provisions of G 1 Dahwhen contractor;&begin contraded We&
MGL chapter142A.) - -
Date nfien contracted Work will be substantially completed.
Tvml ContractPriec and PaymedgSeheduh,
The Contractor egasmperSsrmthe wad;famish themeteriet and labor specified above for the let.,somof-
. .Payments will ba made according to the following schedWa: .
a apoa Milan eoalric[(nat6-aztFed 1,3 of the total contmelprim gf We conof special aedmiaano6 whicbevmis greater)
- S d)'//m upon completion of
s Yetlb.0 by St) t �o mmwnple3onue Tv . ( �l/r f,
00
S.yew. upon completion Lfihecommet(Lawfmbidsdemandig P full a Comp paaysmdsfection)
_ I, v ]'m®lentil watractis Completed to both
the talfoovin8materiaVequiPmeet mvsthespeciaf S mbepaid for .
ardent hrfineme covuaetetl wo»<begivs iaoder _
m One the compledon scbedufe'(••) S to be paid . .
NOTES:(a)lacnot
texiee ll the anremeiget Ce)lawrequ'vea rho any deposit ordowa-MmemmquirtN by me canaecrar began w uk .aotewerd negmatrr•P! ay
(a)on>mid afore mail mnoea pdm m(b)the aenW rue of my special apdPmav m cmmmtmdo material
Which rnmhosamidar8e¢d in odvmaemmr aMCampledonrrbednie -
P,xorea Wnrmnty-H irnnt tube
nmvttlM ba tR ten 1 ❑N ❑Y !Iltenns f
PmWos b bo m The eoudacmrnge.ambe aolelyxasponnblefor compleaon eFthc w•rlc drsmved mammas ofmc vcdons af9Dy dtird Milexin6cIIIIJA rudIizW bymeemenaatar. The an pr Rather egoism besolelytetpausible fora0payntemsm all subeent,'Ws for
materials and labor render thae Agreement . '
CaattamAaepmvee 1)poas�uag,th'hdoc®mtbetxmesabmdmg oantraGtmder]aw.Unless oWerwuxaoted within this dom®m4the
wntractsball Cot imply that
any IGa uother seaairy inmrathas bean placed on Weresid®ce Revinv the fogmvmg cautions nadno6ca cme6dlybefine slgnivgtb0 contract
• Dual be pr=Mvd onto s!gsmgihe eogracL Take time toread and fally mtdaamnd it Ask
• Maim sureWa tractu l e'J'd Hom i tpteslmas ifsomeWiagisturrlear. . .
subcmtramms to be re 1 °nt -'Thelmr-quueamwthomehapmvementaono-eamamd
gs[med Wffi"eDi'dwofHomehnpmvmleatCmt WW,,Regmmdoa Ymrnayinquireaboutcona eor
reglMmbywdthtgto Wei`4;; retlOPmkPhva,Room5170,Bosma MA02116arbycalliog617-973-8787m888-293-3757.
•. Does We tssatractorhave iosur9dce7 AsktheCmbactorforhis haandnce companyintomadmso that You ran wnfirm coverage,or ask m a maeopyofa"pmofofinsueertce'document
• rAme sespona'60i3a.Read WClmpmmatlofoanetimondaerevmseadeofdds form mdgaaeopy of me Covrm(3lddem� c
Tagvj eme6t Contrammlmv.
You may eaucel this agmemmttI lhas beasid atnplemotherthmthe
egve canhaaors notmol pMcc ofbumcss,pmvhted ymmtify the mn4actor invvritmg ethis/heran joffia orbranrhoffia byotdipnty mill pasoed,by telegramseat or by de3very,gotlate Wan�dnightofthe
th'vdhusinaa dayfallowiag the siguing 2,1 agreement See the attadled notice oftaac.Aatim fo�form explanation vfWis right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY gI ANI{SPACES!!!
",'w,iMOldnW[plwLpa,7n�re/e �✓emeempruaaa+igvea one wPrm•de eo mbemmanmm. ,e/raw R/�kc,prMn�e.oma.m.
. - HomeoWatrs Signrtere
Date _ Date
Contractor Arbitration `
The.Home Improvement Contactor Lawprovides homeowners with the right to initiate aaarbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is nn1 a jWmatieally afforded to a
contactor,however. The contractor would have to resolve any dispute helshe has with a homeowner in court unless
- both parties agree to the optional clam provided below. This clause would give the conha','ator the semeright to -
arbitration as a afforded to the homeowner by the Home Improvement Contractor Law.
The ocatrector audthe homeowner herebymudmlly agree in advance that mthe event the contactor has a dispute
coaceming this;contact,-the 0ontractormaysubmitthe dispute to a private arbitration firm ydrich has been approved by
the Secretary of the Bilecu Ne.Gilice of 6retu nerAffairs and Business Regulation and thelconsumer shall be required
to submit to such cirri ' n as provided io Massachusetts General Laws,chapter 2A.
Hat � u Laws,
Homeowner's Signature - .. ComracWts Signature
NOTICE:The signmaes of the parties above apply only to the agreement ofthe parties to alternative dispute _
resohttoninitimed by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the penes. '
Homeowner's.Rights
A homeowner's rights under the Home Improvement Contractor Law(MGL•chapter 142A)and other consumer
protection laws(Le.MOL chapter 93A)may not be waived is any way,even by agreemen�.1 However,homeowners
maybe excluded from ceaaintights if the contractor they choose fsnoj�roperly registered as prescribed bylaw.
Homeowners who secure their own building permits are automatically exomded from all Guaranty Fmdprovisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a -
timely and workmanlike mamez Homeowners may be entitled to other specific legal right4 if the contactor
guarantees or provides an express warranty for workmanship or materials. In addit on to ggetamees 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 other matters on which the homeowner and contractor lawfully agree maybe
added to the terns ofthe contract as long as they do not restrict a homeowner's basic consumer rights. Ifyou have
questions about your consumer/homeowner rights,contact the Consumer Information Hotlbe(listed below).
Execution of Contract
The contact must be executed in duplicate and shouldnot be sieneduWil a copy of all exhibits and referenced
documents have been attached. Parties are also advised not to sign the'docume t until all blank sections have been
filled in or marked as void,deleted,or not applicable. One original signed copy ofthe contract with atmchmems is to
begivento the owner and the other kept by the contractor. Any modification to theoriginalcontractmust.beinuaitng_.._ _. ..
and agrees!-to by both parties.outrectedwotKtWytotbeginimtipbotri'pa=tes have reeeiv� a fidly'exc cut a d c opy of
the coulrac;and the three day rescission period has expired.
Accelerated Payments -
A conhactormay:not demand payments in advance ofthe dates specified on the payment schedule in cases where the
homeowner deemshim%eselftobe financially Insecure. However,in instances where a contractor deemsMm/herself
to be financially insecure;the contractor may regmm that the balance of fonds not yet duej a placed in a join escrow
account as a prerequisite to contirmngthe contracted work 4Rrmhdrawal of fonds from said accoum would require the
signatures ofboth parties.
Additional Information -
If you have general questions or need additional information about the Home Improved Contractor Law or other .
consumer rigbts,or ifyou wish to obtain a flee copy of-"A Massachusetts Consumer Gmd to Home lnprovement"
contact _ +
Consumer Information Hatpin
Office ofConsumer Affairs and Business Regulation -
10 ParkPlam,Room 5170,Boston,MA 02111 j
617-973-8787,888-283-3757 or visit the OCABRwebsite at ht�t ://wvnwmass.gov/ocabri -
Ifyou want to verify the registration of a contractor or.ifyou have questions or need additional information specifically
about the contractor registration component ofthe Home Improvement Contractor Law,cbPtact
Director of Home improvement Contractor Registration l
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116, 1 i --
617-973-8787,888-283-3757orvisit the HICwebsiteathtt ://www.m*.eov/0cabr/
_Go onlime to view the starts of aHome lmpmvemen Contractor's Registration -
htlgJ/db.sste.mats/homeirgprovement/licenseelist.aso
For assistance with informal mediation of disputes or to register formal complaints agains'a business,call:
ii
.. Consumer Complain Section - j .
Office ofthe Attorney General
. .. -
617-727-8400 ;
ANDIOR-
Better Business Brrem -
508-6524800;508-755-2548 or 413-734-3114 '
Vas10n2.1-rrn7nme
t
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS487977
ERIC W PALM
- - 3 BILTON ST Salem MA 019707 -
Expiration
Commissioner 04/23/2016
�Fanrntorrrnea��a`)CAa:urrC1Irrretb
Ofr,,,of consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR Type.
istration 142089
- xpirabon 31J2I2016:-. Ltd Liability Corpo•
ATLANTIC WEATHERIZATION L L.C. .
ERIC PALM - .
61RJEFFERSONAVE ��--
SALEM,MA 01970 Undersecretary