39 STATION RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards igp CTIERV CES
Massachusetts State Building Code, 780 CMR
Revised.tfew 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish M) FEB 2 3 P 1 02
One-or Two-Fainily Avelling
Mi i This Section For Official Use•On1y
Building Perrriit Number: Date Applied r t
1 oZ
r
Building Official Name).
1 .....: D
(� SECTION 1:SITE INEORnNIATION:
1.1 Proper Ad s• 1.2 Assessors Ma &Parcel Numbers
Lin Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Prope WOO At
otp-
"Coning Drstnct Proposed Use Lot Area(sq R) Fronmge(R)
I.s Building Setbacks(R) .
Front Yard Shia Yards
Rear Yard -
Required Provided -Required Provided. Requited Ptovtde:d
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zomn _ Outside Flood Zone?
Check If es❑.
Municipal O On site disposal ❑ -
.
SECT[ON2r PROPER'!"Y.OWIVERSH/Pw -
2.1 qskaert of Recor .
rw ' • ✓7
N�me any -
Ctty,State,ZIP -
39 ��. ha..� gas yati- 9yz3
No,and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK)(cheek an that apply)New Construction❑ Existing Building❑ Otvner-Occupied ❑ j-Repairs(s) ❑ 1 Alteration(s) O Addition ❑
Demolition ❑ rAccessory 21dg.(7 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS = .
Item Estimated Costs: OfDelal Use Only
Labor and Materials)
1. Building S 1. Building Permit Fee:S Zh. ►ndicwe how fee is determined:
2. Electrical S ❑Standard CityfrowmApplication Fee-
J. Plumbing S
O Total Project Lose(item 6)x multiplier x
2)Qther Fees: S
4.Mechanical (HVi\C) S List.
5. AIeehanieal (Fire
Su ressiun) S Total All Fees:S
6. Total Project Cost: Soty� - Check No.11 "Check Amount: Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
i
i
:t r•a ::
SECTIONS: CONSTRUCTION SERVICES
?3�IVs.1E 4910 fiction:Supervisor License(CSL) y b� !y
License Number Expirdtion Date t
�'�! [� e�P35L9JhjIdr�L3 l.istCSLType(see below). LA,
Eric W.Palm Description .
Type
No.and Street 3 jh(OA treet D Unrestricted Duildin a to 35,000 w. lt.
Salem NIA 01970 R Restricted 1&2 Famn7 Dwellin
City/rows,State,ZIP M Maio
RC R22a Coverin
WS Window and Siding
71411- 8!H I l Solid Fuel Burning Appliances
t'/ Insulation
Tcle hone
Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
FIIC Registration Number Erpimtion Date
1IIC Cumpany Nam IC gi N
Email address
No.mid Street
own State ZIP Tel hone
SECTION 6-WORKERS,COMPENSATION INSURANCE AFFIDAVIT(M:G,I:.cc 132 25C(6)},
Workers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit willMult in the denial of the lssuance a building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7ae OWNER AUTHO111ZAT10N TO BE.COMPEETED
R AP .WHEN!:
OWNER'S AGENT Olt CONTRACTOPLIES.FOR BU
ILDING.0ER6IIf
1,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. 2/
r r - Dote
Print Owner's Name(Electra a signature)
SECTION 7b:oWNEW OR AUTHORIZED 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 to and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent s Name( cctromc Signature) -
ate
NOTES:
I. 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 nor have access to the arbitrationgram can
program or guaranty fund under�LG.L.c. Id2A.Otherimpoltani mformafion oche HIC-Pro betoiinTir "
www nrtss t:uv'oca Information on the Construction Supervisor License can be found at wwtv.mass.eo�:!dns
t 2. When substantial work is planned,provide the i (ncludinglgnrage, finished 6asement/attics,decks or porch)
'rota)floor area(sq. ft.) Habitable room count
Gross living area(sq. RJ lumber of bedrooms
,Number of firepluces Number of halflbaths
Number of bathrooms ,Number of dccksl porches
Type of heating system Enclosed Open
'type of cooling system
j. "Total Project Square Footage"may be substiuuted ror"futai Project Cost"
Massachusetts Rome Improvement Sample Contract
V��
satisfies aR basic requirements of the state's Home Improvanmt Contractor Law(MGL chapter 142A),but does not include sromdard
ro protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of"A
setts Consumer Guide to Home Improvement"before agreeing to any work on you residence.You may obtain a free copy by calling the
Consumer Affairs and Busi a Regulation's Conamms Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website.
Homeowner Information Contractor Information
one _ Company Name
ri V(4; u e 6v �:L fr'�
Street Address(do tutea Pat OOiee a Comicim/SauspersmJOvou Name
i; / 3e fre 1-scn-7 4 r-c_
Ciry?gyat Stnte Zi Cade aarmess Addnss(Tsc y�ust incI deaenaddress) -
a mow, f�'l a/9 -7 o
Daytime Phone Everdn Phone City?own Suite Zip Cade
z cr7,� - 7sty- RA13
Maihng Addozefftdiffimentfv above) Business Phone I Fdeai Employer M or S.S.Number
. r..wgmw.ron ram eves ��•®mc awpm4a�xx� 2 ex.
wee<mt®mrem�e.w /y� o JT� 6
The Contractor agrees to do the following work for the Homeowner.
(Describe m derail the work to cimpletd,specifying the type,ban,and grade of materials m be used, dd'" al shose if ec�sser}•.)
Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will
and will be secured by the contractor as the homemetices agent: be adhered to unless circumstances beyond the wnbactots control arise
(Owners who secure their own permits will be T �,�a
excluded from the Guaranty Fund provisions of Datc whm wntr wct ,ill begin wntmcted work.
MGL chapter 142A.) I
44 Dme whm connacted work will be wbsmntially completed.
Total Contrm Price and Payment Schedule
The Connaaor agrees to perform the work,fimnish the material and labor specified above for the tram sum of. :7— y(�• -� (•)
Payments will be made according to the following schedule:
$ Mr ' —upon signing contract(non to exceed 1/3 of the total contract price S the cast of special order items,whichever is greats)
$ by_q/_��/�or upon completing of _) 1 /
$�/'��r�,��,afly�''� by yLl�/14eor upon completion of *9 / 4/ O P7 C(/yr7 n/ �j
a_mw�_impon completion of the contract. (law forbids demanding fill paym t until contract is completed to both parry's satisfaction)
The following material/equipment must be special $ m d m
ordewl before the ormrctd wark beg.in order eP
to area the completion schedule.(••) $ be for
NOTES:(•)Includingallscience charges(••)Law requires dun any deport or dawe- mmr required by the a moor home work began may
mat excel the greener of(a)we-thad of the total wnceer price Or(b)the actual cart ofany special equipment m wmom made minimal
which mat be special mderd in advance to men the completion schedule.
Erato,Worainx-1 an egress warrmw being org,itted by the can",un-90 tho❑V (all ferries of the warem"manhe attached to the t)
SubwnirctOn-The contractor agrees to be solely responsible for completion of die work described regardless of the actions of any third
party/subcontractor utilized by the contractor. The commaor further agrees to be solely responsible for all payments to all subcontractors for
m I d labor order this statement
Contract Acceptance-Upon signing,this document becomes a btndurg covbact under law. Unless otherwise noted within this document,the
contract sball not imply that any For or other scantly interest has bcm placed an the residence. Review the following cautions and notices
carefully before signing this contract.
• Don't be pressured into signing the contract Take tine to read and fully understand it Ask questions if something is unclear.
• Make sure the contractor h va1'd Ho Ian ant Contractor Registration. The law requires most home improvo io mmreaors and
subcontractors 10 be regnstered with the Director of Home Improvement Contractor Registration. You may inquire about contractor
registration by writing to the Director at 10 Park Plan,Room 5170,Boston,MA 02116 in by calling 617-973-8787 or 888-283-3757.
• Does the wntretor have insurance? Ask the Commctor for his insurance company information so that you can confirm coverage,or ask to
see a copy of •promfofinsurannce"document.
• Know you rights and responsibilities. Read are Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home hnpmmmmt Contractor Law.
You may cancel this agreement if it has been signed in a place other than the contractor's normal place of business,provided you notify the
contractor in writing m his/her main office or branch office by ordinary mail posted,by telegrmn seat or by delivery,not Imer than midnight of the
third business day following the signing of this agreement See the attached notice oftxncellating form for an explanation of this right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACESM
Two mmiirnl roPi�s of NewnovctmwrxmmPktN antl opal One wP'.lodd gomihebe TheaMenpy dbe' We
Homeowner��Sgnatiire� s
I Contractor's Signature
Z ?��
Doe me
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contactor. 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. t
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract,the contractor may submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shalt be required
to submit to such arbitration as provided In Massachusetts General Laws,cha ter 142A.
Homeowner's Signature Contractofs 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.Fund provisions of
the Nome 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
guaties
express warranty for workmanship or materials. to addition to guarantees or warranties
tees or provides an P provided
p xp ty
provided by the connector,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.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 your consumer/homeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract most 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 most 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 on 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 funds 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 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 if you wish to obtain a free 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,.889-283-3757 er visit the OCABR website at httodhrnom.mass.zov/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 H1C website at hup/Avew mass.eov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
hup•l/db state ma usthomeimprovement/licenseel ist aso
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consumer Complaint Section -
Office of the Attorney General a
617-727-8400
AND/OR
Better Business Bureau
508-6524800,508-755-2548 or 413-734-3114
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I. o�q I am a emoloyeraaith :�•� employees(full and/or art' F7n
f proleCt(regnirad):
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�.�l am a sole proprietor p New Construction
p prietor ar artnership and IFave na employees avorkino forme in any rapacity.[No aeorkers comp.insurance required-] Remodeling -
3.�1 am a homemwer dotn.-all work myself.(Igo worker'c¢mo.insurance required]t Demolition4.i 1Iam a homeomer and%%ill he hirkiconuactars to conduct all%cork on my amper.y til! Buildine
ensure that all contractors either have'acoda:rs'compensadon insurance or are sole a addition
Proprietors with no employees. I i LQ EIectrical repairs or additions
v.Cl 1 am a general contractor and 1 have hired the su'o-eontmetors listed on the"anached sheaf 12-❑Plumbing repairs Oradditions
These sub-contractors have employees and have workers'comp.insuanc:_ 13-❑Roof.repairs
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A�wtS a cony oPth_ .vorh,s compensation 01:c _
p Y decla ration gage(si ov i:g Ize policy nanther and e- t.�t on d_te)-
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and/or One-year the imprisonment,as Weil as civil penalties in the mrm Of STOP tYOR1C olation ORDER land+%nine of up to 3350.00 a
day against the violator A copy oftltis statement may be forwarded to the Office OfInvesti�lions of the DU:for insurance
coverage verification.
IOo"hereby cerf%" adQr tlre�cyFs r
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1 - ERIC W PALM r ''
3 JMTON ST _
Salem MA 01970-
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istration: 142089
- piration: .-;3/1212016 Ltd Liability Corpo-
ATLANTIC WEATHERIZATION L.L.C.
ERIC PALM
61R JEFFERSON AVE g �
SALEM,MA 01970- Undersecretary