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12 SUNSET RD - BUILDING INSPECTION (4) The Commonwealth of Massachusetts °u1d Board of Building Regulations and Standards CITY OF ( Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 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: /2- l 1 I(,, 13 Building Official(Print Nime) Si~ Da SECTION 1:SITE INFORMATION ert 1.1 Propy A ress: 1.2 Assessors Map&Parcel Numbers / 2uniJe�l 1.1 a 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(11) 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 yesO SECTION 2: PROPERTY OWNERSHIP' ' 2.1 Owner'of Recta l ar✓`1 Ve11nlSo- 1 SGler,r Ali O/970 Name(Print) City,State,ZIP a sVti� P. q7k- No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: �y Brief Description of Proposed Work2: C-fi�in. /9l'1'�TPiAi7 4_ SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 1.Building $ 1500, 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee 'T ❑Total Project Cost,(Item 6)x multiplier x a 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Su ression $ Total All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due: � AI � SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) g?9 r7 7 y 2�//� License Number Expiration Date Name of CSL Holder Eric W.I'ohn List CSL Type(see below) (^ No.and Street 3 Hihon-Sted Type Description, Salem MA 01970 U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 744.81 tj 3 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC)_ /�n o�G JZ / Atlantic Weatherization,LLC HIC Registration Number Expiration Date MC Company Name or HIC ReOP& '. Mon Avenue No.and Street Salem MA 01970 /A —�V{4 •cJ y 2 Email address City/Town,State,ZIP Telephone J SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be com leted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuanc 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 1,as Owner of the subject property,hereby authorize ( ✓ L A lYh to act on my behalf,in all matters relative to work authorized by this building permit application. fee a /2 /3/t3 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' 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 true and accurate to the best of my knowledge and understanding. 12 �3 �J3 Print Owner's or Authorized Agent's Name(Electronic'Si nature) 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dp 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 half/baths 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" _@'me tsurr yq.�-�t�`�'L e � !! ass save PdRY4CiPA'nVS -...as'�..s^.,•r,,.=..••..�••. fAMRAMOR PERMIT AUTHORIZATION FORM 1, Larry Dennison ,owner of the property located at: (Owner's Name,printed) 12 Sunset Rd Salem (PropemyWeet Address) (CW) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed - below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's signature i1:12-ZIL Dace FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date - Oc L Rev.12132011 ' Lvsassaenusetts Home tmtorovemlent SamIID1e Contract iF EThm satisfies all basic imrnm afhe rate's Home huprovemrnt CantraaanLew(MGL rhap[ar 142A),hot does not inaodestandardeto protect homeowners. Seek legal advice lfuseessary. Any Jumm planning home improvements should first obtain a copy of"A uutts Consumer Guide to Home Improvement°butane agreeingto any work on awresidence.You m obtain a five f Consumer Affairs and Business Re y m' copy by calling the guWtion'aConsumer information Hollus et 617-973.8787 or 1-898-283.3757 or on am website. Homeowner Information Contractor Intermatinn Company Name r rr rsu)-� Sheet Address(do of men Port Omce Hox Wdre�) Cantnemrl Sdesp ALE e n Avenue Cityrrown area, Zip Code Boines Addrees(mustinclud a tad Pm 0�g70 SY`AM01970 Daytime Phone Ewnmg Phone CiH?own Slate 9 Q Zp ode Mailing Address(ftdiebeem6om above)' lousiness Ptone FedualE i erIDmS.S.Number 4"rtwlnwntmeaherte' Avc1m}vvta;t[nMubrP.y.Nvbs a�Ra'i�ttn IetM..i mtaencn here a rJll rtebneaan rvmkv ' The Contractor agrees to do the following work for the Homeowner. (D,nnibe in derail the wink in completed,specifying the type.beard,andd geeaaade of mutandstto be used, ddi' I h 'f ,) Required Permits-The following bundles permits are required Proposed Start and Completion Schedule-The following schedule will and wig be seated by the contractor as the homeowners agent be adhered to unless elamstmces beyond the contractors control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions of 20 Dam when contractor will begin MGL chapter 142A.) crmtraaed work. 7i 0 Dane when conmacted work will be substantially completed. Taml Contract Price end Payment Schedule r�I The Conmam to aragreas perform the work,famish the nmtaial and labor specified above fan the total m Z .an of ti�. 17- (.) Payycmentts�will be m this corn thus to the following schedule. S1lLSL'_upon signing contract(nut m exceed 113 ofthe total contra[price lit the cost of specialorder items,whichever is greater) S by_/_/_or upon completion of ` S IOOU' ' by l2./apr ?2oruponcompledanof S upon completion ofthe contract(Law forbids demanding full payment until contras rs completed to both parry's satisfaaim) The fellowdng matedaHequipment mart be special S � to be paid for tattered before the dontmcted work begins in order to meet the cmmpletion schedule.(••) - 5 ante paid( NOTES:(')Induding all 6nencechmges(••)Iaweequires dint an depmitardown-payment required dle annaetm befarework begins may not exceed thegreaterof(a)one-third elite tom contract price or(b)the actual cost olaery spedd equipmmn m emtom matte material which mot be special ordered in advance to meet the completion schedule H w N I ran warranty 6etnv v.vaaw•..n._.__.._..__ ❑N ❑Y all ffh N m Wth 1 to Subrintactors The conineoragrem to be solely responsible for completion oftha work described resanihm ofthe actions ofany third laWY/subeontractoradlized by the contractor. The eo bramor furNeragrees to be solely responsible for all payments to all subcontractors for Inaledal And labor order this aauement Contract Acceptance.Upon sisolng,this doammt becomes a binding coahactuader law. Unless m inavenomd within this doamat,the contras shin nat imply that any Sao or otherseemity intemshas been plead an the residence Review the fanowms caations and notices carefully before signing this contract, • Don't be prrssurPA into$igning tie cuntraa Take time to read and fully understand it. Ask questow ifsometting is anrlear, Make sure Nec tree h 1'du vemnt M . Thelawrequiresmwthomeimpravemmtcontractonand mbmntmeron to be ugistered with the Director of Home lmpmvemcnt CmtmamRegisbmtiom You may inquire about contracor registration by writing to the Director at 10 Park Plaza,Room 5170,Boston,MA 02116 m by calling 617-973-8787 or 888-283-3757. Dom the contractor have insurance? Ask the Contractor for his insurmen company brio mationso Nat you ere confirm average or ask to see s copy oft"proof ofinsurence"doclm mat • Know your rights and respordabilities. Rand the Important information an the reverse side ofthis form and get a copy ofthe Comer Guide to the Home improvement Contractor law.. You may ante!this agreement if it has bean signed at a place other than the contractors normal place ofbusuams,provided you notify the contractor in writing at hislher mein office or branch office by ordinary entail posted by telegram sator by delivery,not later am midnight ofthe third business day following the suing of this agreement See the attached entice of canceilatim form fan m!2hu atiurt ofthis right DO NOT SIGN THIS CONTRACT IF THERE ARE ANy BLANK SPACES!!! ' Twe idmaW wpiv ofawmttectmwthe cemprhod aM Biped.Ooecopy rhaddgo o drh✓memvmt the mhereapy rhetld trkept by nemvmurr. HOman" Srgoa - Cnnhaetara Srgnatnrs, - j2� ��3 I�3 IZ��r3 Dam Date Contractor Arbitration : The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an altemative to court action)if they have a dispute with a contractor. The same right is gQ 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 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 shall be required to submit to such arbitration asprovided.It Massachusetts General Laws,cha ter 142A. �Z2 �- Homeowner'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(MOL chapter 142A)and other consumer protection laws(i.e.MOL 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. It 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 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 must 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 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 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 agree 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 P2116 617-973-8787,888-283-3757 or visit the OCABR website at htrtt fwww mass eov/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 HIC website at htto•//www.mass eov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: http-//db.state.ma.us/homeimnrmmmomiceaseelistm For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or 413-734-3114 vet""zt-u2vtmc , The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 1 600 Washing on Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leetblr Name (Business/Organintion/ladividual): Atlantic Weatherization,LIC Address: oI KJeffersonAvenue City/State/Zip: Phone#: 71-/y-9A13 F22.[] re vo as employer?Check the appropriate box- Type I am a employer with 25 4. 0 I am a general contractor and I Tie of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheet. 7. F1 Remodeling ship and have no employees These sub-contractors have working for me in any capacity. emplovees and have workers' g' ❑Demolition [No workers' comp.insurance comp. insurance.) 9. (] Building addition required.) 5. 0 We are a corporation and its I0.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 17❑ repairs employees. [No workers' 13.aOther__ wS'wirZ�� comp, insurance required.] *Any applicant that checks box+1 must also fill out the section below showing theirmorkers'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 attached an additional sheet showing the more of the sub-contractors and state whether or not those entities have cmnloyees. If the suh-contractors have employees,they must provide their workers'comp,policy number. t all'an employer that is providing workers'compensadon imarance for my employees. Below is tl:e policy and,job site information. Insurance Company Name: t'i d, Policy#or Self-ins.Lic.#: 5 B a2`Jp/a �t cc Expiration Date: .2.0// Job Site Address: foC ( t tv5 City/State/Zip: Yy,�zt11 #14 019 7 D 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 S1,500.00 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 for insurance coverage verification. I do hereby certify tinder file pains and penalties ofperiury that the information provided above is true and correct. Sienature: , Date: /Z /13 hone#: F[6. Other only. Do not write in this area,to be completed by city or town official. n: Permit/License# hority(circle one}: Health 2,Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: :acoR CERTIFICATE OF LIABILITY INSURANCE 3OR (MNVDDNY /711/2013013"' - `-� 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 endorsement(s). PRODUCER CNAME:O ACT Construction _ Eastern Insurance Group LLC PHONEC. (SO6)651-7700 FAX r 233 West Central Street - IE INSURE S AFFORDING COVERAGE NAIC It Natick AFL 01760 INSURERAArbella Protection Ins. Co. 41360 INSURED INSURER B Arbella Indemnity Ins Co. 10017 Atlantic Weatherization INSURERCNautiluS Insurance Cc 61 Rear Jefferson Avenue INSURER D: INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER*MSTER 2013 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. UI R I TYPE OF INSURANCEDDL SUER POLICY EFF POLICY EXP LTRIm POLICY NUMBER $INIDDPI"IM (MMIDDrYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISE Ea occurrence $ 50,000 A CLAIMS-MADE ❑X OCCUR 9500042816 /20/2013 /20/2014 MED EXP(Any one Person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- LOC $ AUTOMOBILE LIABILITY COMBINED ED SINGLE LIMIT 11000,00 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED 1020015B71 /20/2013 /20/2014 BODILY INJURY $ AUTOS AUTOS (Per accident) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Peraccident PIP-Basic $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LMB I I CLAIMS-MADE AGGREGATE $ 1,000,000 LIED I I RETENTIONS 600047820 /20/2013 /20/2014 $ WORKERS COMPENSATION WC STATU- OTH- ANDEMPLOYERS'LIABILnY YIN ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT E OFFICERIMEMBER EXCLUDED? NIA (Mandatory In NH) E.L DISEASE-EA EMPLOYE 8 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C POLLUTION LIABILITY PW003786001 O/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000 EA POLLUTION CONDITION $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ADORE,101,Additional Remarks Schedule,It more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SALEM ACCORDANCE WITH THE POLICY PROVISIONS. < 93 WASHINGTON STREET SALEM, MA 01970 AUTHORIZED REPRESENTATIVE Rosemary Fulham/Pt4A ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 onid1 m m Th.Ar npn mmn and Irmo am rnnio.mu d rnndra n4 Armin n fit Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen isor License: CS-087977 0 0 ERIC W PALM-�N 3 BUTON Sir' �r SALEM MA-019 0 -4 44 Expiration ' - Commissioner Ex P 04/23/2014 Oftiee A oa-IN 81B 8 ulr. . ego 1MIM HOME IMPROVEMENT CONTRACTOR Registration: ,,442089 Type. Expiration: 37l.?j2pus .Ltd Liability Corpor A TIC WEAtHER�O�Nt L O. ERIC PALM -, 1 I - 61RJEFFERS6NAUE�. --SALEM,MA 01970 Undersecretary