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29 SUMMIT ST - BUILDING INSPECTION fZ The Commonwealth of Massachusetts PECTI �a Board of Building Regulations and Standards ONA� $FQALEM In) Massachusetts State Building Code,780 CMR tB�p SEP 3 vt SdLEy 2011 1®®®� Building Permit Application To Construct,Repair,Renovate Or Demolish a �� One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: 3 ) Building Official(Print Name) Signature ' (�W Date SECTION 1:SITE INFORMATION 1.1 11 opyy Address: 1.2 Assessors Map&Parcel Numbers Z�1 J d rn rvt l r S7`� l.la 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 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 yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owper'off��ecord: (` N�A 0 I07n IZICrt LCu,�Ii( I�l •JA M Name(Print) City,State,ZIP ZI -TVM M I,r S�< q78-W-019n3 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ FExisting Building Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work: 3=R F LG ' f SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ ® 5''y 3 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ©1 r 4 ❑Paid in Full ❑Outstanding Balance Due: -�r1�DWfJEYI- tl 1 0I �z SECTION 5: CONSTRUCTION SERVICES q p 5.1'r^yC/t'onstruction Supervisor License(CSL) 0 5-n 1 _ (' I RO-K ,'r (�//I'� o Y[,a�/�( License Number Expiration Date Name of CSL Holder l List CSL Type(see below) V 18_k/ftid I ry u— it, Type Description No.and Street - yp /, n�L� � � ►�t //1 ()-176 � U Unrestricted(Buildings u el 35,000 cu.8. [S/ H' I ' ' Q7 �j R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding 'OO - SF Solid Fuel Burning Appliances Sb8' W V t7 S� I Insulation Telephone Email address D Demolition 5.2-Redgstered pm, t Contractor(HIC) Vh llw DIUAA/4+ HIC RegistrationNumber Expiration Date HIC Corn y Name or HIr�C Registrant Name 7V3 Jl i d Street Email address ik-"DnA rn 017f Z sob 2$11-cq a Ci /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-.........Cl 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 to act on my behalf,in all matters 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 in,name below,I her y a e and r the pains and penalties of perjury that all of the information contained in this application is tru an ac ura to the best of my knowledge and understanding. 9 -30 -t y Print Owner's or'Authorized Agent's N e lec o c 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. 1.42A.Other important information on the HIC Program can be found at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/d�s 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" The Commonwealth of Massachusetts Department oflndustrialAccidents -- Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information j Please Print Legibly NStrie(Business/Organ za(ti�on/Individual):�D�. iffL— MOM L7 � �0 PC( (A/� VIO Address: 2501 S,rptyy pz r btz l cer J u mit City/State/Zip: 6+0 M IL P11 N013 Phone#: Are yga an employer?Check the appropriat^.box: Type of project(required): 1. _ _I am a employer with 157 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for mein any capacity. employees and have workers' y Building addition [No workers' comp. insurance comp. insrrxr,ce t ❑ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11. Plumbing❑ g repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the sect on below showing they workers'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 most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job sue information.su ce ' i � 1 ( /A/r Insurance Company Name:. (7{}i21, f V lfl-l-� I IKIIO K-C(�{'I�12 Policy#or Self-ins.Lie.#:('Z©L y O d (6�Yv ,017 Expiration Date: Job Site Address: J U YYI IYI J T 51, City/State/Zip: . I Le(Yl t t 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 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA r insurance coverage verification I do hereby erti an t e pains and p es ofpe-jury that the information provided above is true and correct Si tJ Date: ) D r Phone#: ZOD —D1 rJ� Official use only. Do not write in this area,to be completed by city or town gjhchd City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Office of Consumer Affairs d Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement'Contractor Registration Registration: 168616 Type: Supplement Card Expiration: 3/1 812 0 1 5 POWER HOME REMODELING GROUP L C tin _ L MARK MORDINI 2501 SEAPORT DRIVE STE 13110 CHESTER, PA 19013 Update Address and return card.Mark reason for change. CA 1 120M-05111 D Address ❑ Renewal ❑ Employment Lost Card V+EE l�[iJYLJIN✓2LUkGl,LUL Py� /"u/42I.TC - Mce of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration 168616 Type,. 70 park Plaz ite 5170 Expiration 3118/2015.:: Supplement Card Bos n, 02I] POWER HOME REMODELING GRbUP LLC. MARK MORDINI 2501 SEAPORT DRIVE'STE;B110 -� .>_� CHESTER,PA 19013 Undersecretaryvali it out signature t Massachusetts Department of Public Safety ` Board of Building Regulations and Standards _ - Construction Supenisor " ' 4 x License CS-057845 MARK E MORDIITA 18 NEVaLL DR N ATTLEBORO$rA Expiration Commissioner 09/18/2015 POWER-1 OP ID:EL ACORo CERTIFICATE OF LIABILITY INSURANCE DA Y, `--� o sn911v2014ota 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 IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: Lacher&Associates Ins Agency PHONE FAX Lacher Insurance Group Ic No E#,216-723.4378 Arc No: 216.723.8604 632 E Broad St P O Box 64398 E�AIL Souderton,PA 18964 ADDRESS: Chad Lacher NSURERB AFFORDING COVERAGE NAICA INSURER A,Harleysville Preferred Ins.Co 36696 INSURED Power Home Remodeling Group, INSURER B:Harleysville Worcester Ins Co 26182 LLC NsuRERc:Nationwide Mutual Ins Company 23787 2601 Seaport Drive,Suite B110 Chester,PA 19013 INSURER D.Pennsylvania Manufacturers 12262 INSURER E: INSURER F: 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. ILTR NSR Y EX TYPE OF INSURANCE AOOLa BR POLICY NUMBER POLICY IOIriri MMMDNYY LIMITS A X COMMERCIAL GENERI LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMSMADE OCCUR MPADOD00069793N 1010112014 10I011201$ A ISES(-RE. RT 1,000,00 PREMISES —E rD ce $ MED EXP(Any one person) $ 15,00 PERSONAL B ADV INJURY S 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000300 POLICY JET LOC PRODUCTS-COMPIOP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000 Ea.dent) B X ANY AUTO BA 00000089796N 1010112014 1010112016 BODILY IWURY(Per parson) S ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per acddeM) b OERT HIREDAUTOS NON-OWNED PAUTOS PReraccident) GE S $ UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 10,000,00 C X EXCESS UAB CLAIMSMAOE CMB000000897S4N 10101/2014 10/0112016 AGGREGATE $ 10,000,00 DED RETENTION$ S WORKERS COMPENSATION XI PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER D ANY PROPRIETORIPARTNERIEXECUTIVE YIN 2014006620967 10/01/2014 10/01/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMSER EXCLUDED? NIA IMyendatory in NH) E.L.DISEASE-EA EMPLOYEE S 1,000,00 UDEbe under SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 ', B Mass Auto BA 00000018227P 1010112014 10/0112016 Auto Liab 1,000,00 B NY Auto BA 0000007484SR 10/0112014 1010112016 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Romance Schedule,may be attached If mare apace Is required) CERTIFICATE HOLDER CANCELLATION SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Salem 3rd Floor AUTHORIZED REPRESENTATNE 1 Washington St C �� ,Salem,MA 01970 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD about:blank CUSTOM REMODELING AND IMPROVEMENT AGREEMENT anyone)'information and Description of in*Property: Project Ndmber.31-24763 SePiembmQO,2014 rqP a'Aprb,(MI Rick Coughlin 19781 3369903 IRk',Cedf 29 Summit St Sala.,MA.01970 Q-bb F County:Esa.. Township: Buyer(s)listed above hereby jofmly and severally agrees to purchase the goods andror Cameos of Power Home Remodeling Group and its vendors('Contractor')in accordance with the prices and terms described in this 5 page document and the Product Specifications,which are incorporated as part of the Agreement(collectively,this'Agreement'). This Agreemenl represents a cash sale of goods and services. Btfyer(s)agrees to pay the cost of the goods and services purchased as described herein,regardless Of 1lming or approval of any financing Buyers)may seek for their purchase. =fty—n : 510,543.81Pre Installation Inspection Dates: : b0.00fat lee nee=n to l5s am l l i 510,543.81 Estimated Project Start:3 to 4 weeks mPletion' Estimated Project Completion:1 to 2 days ent Other aupx(sl aeivwak pe dcxad.rnae f'a,1aM Wn:Wauonaatee am Nor ur Me eascre noOres Conirtviorti[ptitdntM1„spalMn®kuxuxw rmPliamacDelrc/,Vn4neN,n Cmmuam Buyerfs)hereby acknowledges teceiot of 9 Copy Of the pamphlet,"the Lead-Sate Certified Guide to Renovate Right",informing Buyerfs)of the potential risk of lead hazard exposure from renovation activity to be performed in or at Buyer(s)'Property,at the aftgsp written above,Buyer(s)received tins pamphlet on the date of this Agreement,bafores commencement of work. Buyerls)'initials. This Agreement Constitutes the mite agreement and understanding henween the parties.and this Agreement replaces any and all prior negotiations,representations,or agreements,either written ororal. No amendment,modification orwalver of this Agreement shall be valid or effective unless in writing and signed by both parties. Buyers)hereby acknowledges that Buyer(s)1)has read the entire Agreement and has received a completed,signed,and dated copy of this Agreement,including the two accompanying Notice of Cancellation forms,on the date first written above and 2)was orally informed of hisfher fight to cancel this transaction Buyer(s)also agrees and understands that it Buyer(s)finances the work with a third potty,the terms of that financing wig be contained on separate documents,including any finance charge. Future promotions not applicable. DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK:SPACES i have read and received each page of this 5 page agreement rH Remodeling Group euyegs) 109/20/14 �.� JORM/14 Srgnatu a Remodeling Consultant Signatu Daniel Abate Rick Coughlin -YOU.THE BUYERIS),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO ALIDNIGHTOF THE THIRD BUSINESS DAY AFTERTHEDATE OFTHIS TRANSACTION,SEETHE ATTACHED NOTICE OF CANCELLATION FORM FORAN EXPLANATION OF THIS RIGHT. _ September 20,2014 11:28 IIBII I I III IIII I I I I!IiIII) II II Page 1 of 5 1 of 1 9/30/2014 6:43 AM f NATIONAL HEADOUARTERS Rick Coughlin 2501 Seaport Drive,Chester,PA 19013 a 31-24763 rTrPOWER'('- -• g September 20,2014 888-REMODEL - MA HIC#168616 PRODUCT SPECIFICATIONS Buyer(s)'Information and Description of the Property: Project Number: 31-24763 September 20,2014 Rick Coughlin Dare o/Agreement 29 Summit St (978133b-9903(nick's Celt) Salem,MA,01970 County:Essax Township: Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications (collectively, this"Agreement"). Pre Installation Inspection Date:Your pre installation inspection is tentatively scheduled for Sat 10/4 between 10:15a and 11:15a. Roofing-GAF Inclusions: Includes Timberline Ultra HD Lifetime shingles with 50 year non prorated labor warranty. Also includes removal of existing shingles, installation of F-Style drip edge, Weather Watch ice and water shield, Deck Armor breathable roof deck protection, Pro Start starter strip, Snow Country ridge vent exhaust,Timbertex premium ridge cap shingles, PowerVent intake ventilation, all flashing where needed and 6 nails per full shingle. All steep slope installation applications used only where applicable, roofs below a 4/12 slope and flat roofs do not apply. Clean up and haul away all job related debris. To protect our clients, Power HRG includes at no additional cost,the removal and replacement of up to 300 square feet of soft or rotted roof decking if needed. Any additional wood replacement needed, over and above the 300sq/ft we provide, will be done at a cost to the homeowner of$3.22 per sq/ft. (Buyer initials ) For Example:After the shingles have been removed, if we find there is a need to replace 325 sq/ft of wood, Power HRG will pay for the first 300sq/ft. It is the responsibility of the homeowner to pay for the cost of 25sq/ft of replacement wood at$3.22 per sq/ft,which in this example is$80.50. It is agreed and understood by and between the parties that the Product Specifications,along with the Custom Remodeling and Improvement Agreement,constitutes the entire understanding between the parties,and replace any and all prior negotiations, representations, or agreements,either written or oral. The Product Specifications may not be changed, modified,or varied in any way unless such changes are in writing and signed by both Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read the Product Specifications. I have read and received each page of this 2 page agreement. Power Home Remodeling Group Buyer(s) /09/20/14 /09/20/14 Signature of Remodeling Consultant Signature Daniel Abate Rick Coughlin YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. September 20,2014 11:28 IIIIIIIIIIIIIIIIIIIInIIIIlII11IIlIIIIIIIIIIIIIIII Page 1 of 2 NATIONAL HEADQUARTERS Rick Coughlin 2501 Seaport Drive,Chester,., -PA 190I3 _�,.. POWER 31-24763 - asn- September 20,2014 888-REM0DEL --- -- MA HICp 166618 Project Specifications Roofing: Whole House 1 1350.01x1.0' ROOFING: Models GAF Styles Architectural Shingles Types None Configs None OPTIONS: Color Charcoal I Removal Standard Shingle I Installation Details None OAFMaMIALA OORPORATION Charmal `A �i A : Aerial Measurement September 20, 2014 11:28 IIII IIIIIIIIIIIIIIIIIIIItllllllllllllll�lllllllll Page 2 of 2 ek \�\ The Commonwealth of Massachusetts INSPECTION L-Sfift f(� j Board of Building Regulations and Standards 1J�JW Massachusetts State Building Code,780 CMR SALEM 1J $$ pp lieyised a 2011 Building Permit Application To Construct,Repair,Renovate Or Demo is r-' 1' One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Prope!ty,Address: 1.2 Assessors Map&Parcel Numbers K ViGT1)i2L4 KD- L la is this an accepte 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' 2.1qwn er of rd: "AAaat AtzT7,u �A1,Q1 ��'). U 1`77 0 Name- City,State,ZIP is �1C7PA,41 120 g76-7V1.3STq No.and Street I Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify: Brief Description of Proposed W kz: z - _ {r` ���SPAS SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labof and Materials 1.Building $ IZ SS-':- 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (FIVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ 2 S L Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ t S ❑Paid in Full ❑Outstanding Balance Due: �� Tt� Eao►�� (l lab I SECTION 5: CONSTRUCTION SERVICES p 5.1 Construction Supervisor License(CSL) D 5-76 yS 9 I ' 1('AIM MD{-01,/4) License Number Expiration Date IN of CSL Holder ' 1 List CSL Type(see below) ll IS khtlaI rz,LL b iz No.and Street Type Description IJ, �(✓1�- t' " ' t71 Q Z 6 f2 U Unrestricted(Buildingsu to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Sb8 z6�-17156 1 Insulation Telephone Email address D Demolition 5.2 Registered ome Impr/�Q'vement Contractor(HIC) b 8� P(LIL I)'Yf °��1� flI[LIAi�i HIC Registration Number Expiration Date HIC CompanyName or HIC Registrant Name 1M ► i tn??,CT Sh �N , d S[ree[ - Email address r�Rj"�,dnrz So6 -z$u-ois;6 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 to act on my behalf,in all matters 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 her y a eqA r the pains and penalties of perjury that all of the information contained in this application is tru an acest of my knowledge and understanding. magic Y�VtwlAj- , 11-3o -ty - Print Owner's or Au orized Agent's N e Elec c 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor 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 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" 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):_ PQW Nt- p M Lz t?M16 PC-b1AX 6, 12P Address: 2501 &6A-(7012-L -D2 I V bz 110 City/State/Zip: G+C-Y IZ- P4 NO 13 Phone #: 5 08 �ZB� D] 5'Ib . F2.0 an employer?Check the appropria* box: Type of project(required): a employer with 4• ❑ I am a general contractor and I 6. ❑New construction loyees(full-and/or part-time).* have hired the sub-contractors a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling and have no employees These sub-contractors have g• ❑Demolition king for me in any capacity, employees and have workers' 9. Burl addition workers' comp.insurance comp. insurance.t ❑ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'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. tContactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below u the policy and job site information. ' i a 1 / Insurance Company Name:- t f{ ZL2 A,(SV Lt-CL IK DVt-G"'f fit A/f Policy#or Self-ins.Lie.#: zD qC)o 667,0%7 Expiration Date: nn Job Site Address:_ 1S \fjcn f, ILh. City/State/Zip:'Tic C 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 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA r insurance coverage verification. I do hereby erti unde t e pains and p es ofpe jury that the information provided above is true and tarred Signature: 4 Date: Phone#: 5 ©8- ZRD r01 sjt OJTciat use only. Do not write in this area,to be completed by city or town qffichd City or Town: Permit(License# m Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PluElhnsjpeetor 6.Other Contact Person: Phone#: Office of Consumer Affairs trid Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts.02116 Home Improvement Contractor Registration Registration: 168616 Type: Supplement Card POWER HOME REMODELING GROUP LLO' Expiration: ins/zots MARK MORDINI 2501 SEAPORT DRIVE STE B110 CHESTER, PA 19013 Update Address and return card.Mark reason for change. CA; 0 20M-05n1 ❑ Address ❑ Renewal E Employment Lost Card Vf�e ¢omranc-i�oecc�a���izJr.2c%uoeGC fflg&W ffice of Consumer Affairs&Business Regulation License or registration valid for individul use only before thenation date. If found return to: ' ME IMPROVEMENT CONTRACTOR Office expiration of Consumer Affairs and Business Regulation Registration 168616 TYpe'� 10 Park Pla ite 5170 ' Expiration 3118=5._: Supplement Card Bos n, "lli' POWER HOME REMODELING GROUP LLC. MARK MORDINI ' 2501 SEAPORT DRIVE STE B110 g -- — CHESTER,PA 19013 Undersecretary va it out signature Massachusetts Department of Public Safety �f Board of Building Regulations and Standards ' Construction Supersisor aIt I License CS457645 v MARK E MORDR41-1 16 NEWELL DR N ATTLEBORO 14IA r �.4.-� Expiration . Commissioner 09/18/2015 POWER-1 OP ID:EL ,4�oRo CERTIFICATE OF LIABILITY INSURANCE DATE111/2 Y4 09/11I2014 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 IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT Lacher&Associates Ins Agency NAME PHONE FAX Lacher Insurance Group uc NP E,,,215-723.4378 ac No: 215-723.8604 632 E Broad St P O Box 64398 E-MAIL Souderton,PA 18964 ADDRESS: Chad Lacher INSURERS AFFORDING COVERAGE NAICIt INSURER A,Harleysville Preferred Ins.Co 35696 INSURED Power Home Remodeling Group, INSURER B:Harleysville WorcesterInsCo 26182 LLC INSURER c:Nationwide Mutual Ins Company 23787 Chester, Seaport Drive,Suite B110 Chester,PA 19013 1 INSURER D:Penns vania Manufacturers 12262 NSURERE: NSURER F: 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 TYPE OF INSURANCE ADDLSUB POLICY EFF POLICY EXP - POLICYNUMBER (MMIDDIfffYI IMMIDDIYYYYILIMITS A X COMMERCIAL GENERAL W1BILnY EACH OCCURRENCE $ 1,000,00 CLAMS-MADE T OCCUR MPAOOOOOO89793N 10101/2014 10/01/201$ pREMISES Ee oc E"nce $ 1,000,00 MED EXP(Any one person) $ 16,00 PERSONAL B AN INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY FX]jEa LOC PRODUCTS-COMP/OPAGG $ 2,000,00 OTHER $ AUTOMOBILELIABILITY COMBINED SINGLE LIMIT Ea accident) '$ 1,000,00 I tltlent B X ANY AUTO BA 00000089796N 10I0112014 1010112015 BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per aCodant) $ NONAWNEO PROPERTY DAMAGE HIRED AUTOS AUTOS Peramdem $ S UMBRELLXUAB X OCCUR EACH OCCURRENCE $ 10,000,00 t! X EXCESSLIAP1, CLAIMS-MADE CMB00000089794N 10101/2014 1010112016 AGGREGATE $ 10,000,00 DED I I RETENTION$ I $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERS'LIABIUW YIN X STATUTE ER D My OFFICEOPRIETER.EXCLUDEWECUTV FYI NIA 2014006620967 10/01/2014 10/0112016 E.L.EACHACCIDENT $ 1,000,00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 Us' yes,descnba under DESCRIPTION OF OPERATIONSeel. E.L.DISEASE-POLICY LIMIT $ 1,000,00 g Mass Auto BA 00000018227P 10/01/2014 10/0112015 Auto Liab 1,000,00 B NY Auto - BA 00D00074849R 1010112014 1010112015 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Romance Schedule,may be attached If mom space Is required) CERTIFICATE HOLDER CANCELLATION SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Salem 3rd Floor AUTHORIZED REPRESENTATIVE 1al Washington St e24 /���� . Salem,MA 01970 � � •�p� ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD about:blank v NArIONAL HEADOUARrERS Nancy Msrbn zsol se.,peu D.,re rmuec;n roots OWER - 31-23409 �_�.,.... :. _• Septamhnr 09,2014 888-REMODEL. µ MAwallassle CUSTOM REMODELING AND IMPROVEMENT AGREEMENT auyar(al'hdemlatlon and Descdlttbn of dm property: Project Number:31-23409 sophnobar 00,M14 Nancy Martin d'aN"pa>°�a Ir 15 Vktmy Rd oel 218-0IJs/Nancya Coll) maNn.mncyanna49mail.comm saNm,MA,01970 (970)7414W(fame) County: ,may Township: 1 C� Buyer(s)listed above hereby jointly and severally agrees to purchase the goods andfor services of Power Home Remodeling Group and Its vendora(-Contractor-)in accordance with the prices and terms described in this 5 page document and the Product Specifications.which are incorporated as part of the Agreement(collectively,this'Agreement), This Agreement represents a oash sale of goods and services. Buyer(s)agrees to pay the cost of the goods and services purchased as described herein,regardless of timing or approval of any financing Buyer(s)may seek for their purchase. Purchase Prim:. $12.562.16 Pre installation Inspection Dates: Donn Payment $0.00 _ Tue&21 Mlrnxn I2Wp and 1:30P Balance Due on $12,652.16 Estimated Project Start:3 to 4 weeks Substantial Completion: - Estimated Project Completion:1 to 2 days Method of Payment Check pNahll od:mWe�a NmedefiMe men ell aomnotimi dam me NOf afse eue>xa.ac*.Owe - CanuadNa mmdnol lndWRl in raloaeEiN lieu rmrtma.Sea OeUyNnkemmi COMisemt Buyer(a)hereby acknowledges remipt of a copy of the pamphlet,"The LeadSafe Certified Guide to Renovate Right",informing Buyer(s)of the potential risk.of lead hazard exposure from renovation activity to be performed In or at Buyer(s)'Property,at the ad swritten above.Buyer(e)received this pamphlet on the date of this Agreement,before commencement of work. ad Initials. This Agreement constitutes the entire agreement and understanding between the parties,and this Agreement replaces any and all prior negotiations,representations.or agreements,either written or oral. No amendment,modification or waiver of this Agreement shall be valid or effective unless in writing and signed by both parties. Buyer(s)hereby atlmaNledges that Buyer(s)1)has read the entire Agreement and has received a completed,signed,and dated copy of this Agreement.Including the two accompanying Notice of Cancellation forms,on the date first written above and 2)roes orally Informed of his/her right to cancel this transaction. Buyer(a)also agrees and understands that If Buyer(s)finances the work with a third-parry,the terms of that financing will be contained on separate documents,including any finance charge. Future promotions not applicable. DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES. I have road and received each page of this s page agreemont ft e R odic ing Group ar(s) �'�' /09109/14 9114 Sigrfature of Remodeling Consultant Signatureµ°--me°Michael Sasso Nancy Martin YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEETHE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. SeptemberD9,.2014.10:09 IIIIIfI�11I��11111WI�WIISMBtl�I Page 1 of 5 1 of 1 9/302014 7:01 AM r NATIONAL HEADQUARTERS Nancy Martin 2501 Seaport Drive,Chester, RA 19013 FOWLER 31-23409 888-REMODEL September 09,2014 rr .. . MA HIC#168616 PRODUCT SPECIFICATIONS Buyerts)'Information and Description of the Property: Project Number: 31-23409 September 09,2014 Nancy Martin Dateol'Agm ireet 15 Victory Rd (508)246-0439(Nancy's Cell) martin.nancyanne@gmall.comm Salem,MA,01970 (978)741.3664(Home) E-Mail Atlamsa i County:Essex Township: Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification sheets, in accordance with the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications (collectively,this"Agreement"). Pre Installation Inspection Date:Your pre installation inspection is tentatively scheduled for Tue 9123 between 12:30p and 1:30p. i Roofing -GAF Inclusions: Includes Timberline Ultra HD Lifetime shingles with 50 year non prorated labor warranty.Also includes removal of existing shingles, installation of F-Style drip edge, Weather Watch ice and water shield, Deck Armor breathable roof deck protection, Pro Start starter strip, Snow Country ridge vent exhaust, Timbertex premium ridge cap shingles, PowerVent intake ventilation, all flashing where needed and 6 nails per full shingle. All steep slope installation 3 applications used only where applicable, roofs below a 4/12 slope and flat roofs do not apply. Clean up and haul away all job (� related debris. To protect our clients, Power HRG includes at no additional cost, the removal and replacement of up to 300 square feet of soft or rotted roof decking if needed.Any additional wood replacement needed, over and above the 300sq/ft we provide,will be done at a cost to the homeowner of$3.22 per sq/ft. (Buyer initials ) For Example: After the shingles have been removed, if we find there is a need to replace 325 sq/ft of wood, Power HRG will pay for the first 300sq/ft. It is the responsibility of the homeowner to pay for the cost of 25sq/ft of replacement wood at$3.22 per sq/ft,which in this example is$80.50. It is agreed and understood by and between the parties that the Product Specifications, along with the Custom Remodeling and Improvement Agreement,constitutes the entire understanding between the parties, and replace any and all prior negotiations, representations, or agreements,either written or oral. The Product Specifications may not be changed,modified,or varied in any way unless such changes are in writing and signed by both Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read the Product Specifications. I have read and received each page of this 2 page agreement. Power Home Remodeling Group Buyer(s) /09/09/14 /09/09/14 Signature of Remodeling Consultant Signature Michael Sasso Nancy Martin YOU,THE BUYERS),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. September 09,2014 16:09 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIII III Page 1 of 2 NATIONAL HEADQUARTERS Nancy Martin 2501 Seaport Drive,Chester,PA 19013 _ %`�OWER 31-23409 - - September09,2014 888-REMODEL MA HIC#168616 Project Specifications Roofing: Whole House 1 1350.0'x1.0' ROOFING: Models GAF Styles Architectural Shingles Types None Configs None OPTIONS: Color Hunter Green I Removal Standard Shingle I Installation Details None 0ORPQRA41®M Hunter Green 14 14 jam- 11[7v c cf® ►� Aerial Measurement September 09, 2014 16:09 IIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Page 2 of 2