20 THORNDIKE ST - BUILDING INSPECTION (3) r
The Commonwealth of MassachusetpE C E I V E D
OF
Board of Building Regulations pQ T�t0W� AI_ SERVICES CITY M
Massachusetts State Building Code,780 CMR S
Revised dMar Mar 2011
0� Building Permit Application To Construct,RepaNJgc Ra1(eJQrPb bli?l33
One-or Two-Family Dwelling
This Section For Official Use Only
Cr- Building Permit Number: Date A ied:
(
r)-J h
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
ly , 1.1 Prop'erty Adylr �� 1.2 Assessors Map&Parcel Numbers
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(ft)
1.5 Building Setbacks(it)
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'
2.1 Ow 'of 12ecord: �/ kq Aq
GG ..r.✓ J t
Name(Print) City,State,ZIP
fool- lce_
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other pecify: Wfwdc+.lS'
Brief Description of Proposed Work2: 9/-/" (AS
Z1�S�zP.e �i GtJr �, iS ' 3 db7 H 8/- 96f &L. c
3 �bl t/u � .SI-GO ut
I P tr /-7 Ott'
SECTION 4:ESTIMATED CONSTRUCTIO COSTS
Item Estimated Costs: Official Use Only
Labor and�Materials)
1. Building $ gr Wv , I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityrrown Application Fee
2.Electrical $ `❑Total Project Cost'(Item 6)x multiplier' x
3.Plumbing $ 2. Other Fees: $ /9A
4.Mechanical (HVAC) $ List: /
5.Mechanical (Fire $ _
Suppression) Total All Fees: $ ==m
Check No.(]2,5ffheck Amount: Cash Amount
6. Total Project Cost: $ �G/ i CO,.i ❑Paid in Full ❑Outstanding Balance Due:
{�(at3x—p rA SRS'p—r C �Z2
X .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) R-7177 % Z S /�
License Number Expiration Date
Name of CSL Holder Eric W.Palm L'�/
List CSL Type(see below) If r
No.and street 3 Hilro Type Descriptionn Street -
Salem MA 01970 U Unrestricted Build n s u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
Cit // own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) q Z O O 311 Z,bco
Atlantic Weatherizraatniro�7n��,�L�LC HIC Registration Number Expiration Date
HIC Company�A Jwd"VA
No.and Street UISalem MA 0 1970 J Email address
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 Issuamcgo5fthe building permit.
Signed Affidavit Attached? Yes .......... V 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 C'11-rl 1 O�lwl
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner' ame(Eledhonic Signature) Date
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 th' pp4catio*tru�l ;rate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic 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.gov/oca Information on the Construction Supervisor License can be found at Aww.mass.aov/dvs
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"may be substituted for"Total Project Cost"
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Contractor Arbitration -
T'ne Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)ifthey have a dispute with a contractor. The same right is pol 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 helot. This claim 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
conceming this contract,the contractsjidayafti0the dispute to a private arbitration firm which has been approved by
the Secretary of the Execu&e 02`hrce of o net Affairs and Business Regulation and the consumer shall be required
to submit to such arbitrptipli-,a o'kld sachusetts General Laws,ch er 142A.
5
e
Horn#Amces Si store � 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(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 ifthe contractor they choose is not properly registered as prescribed by Inv.
Homeowners who secure their own building permits are automatically excluded from all Guaranty Fond 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. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty ofinerchzimidi lity 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 consumeAhomeowner 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 ormazked w void,deleted,or not applicable. One original signed copy of the contract with attachments is to
_ be given to the owner and the otherkept 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 contracS 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 himtherself
to be financially insecure,the contractormay require that the balance of fends not yet due be placed in ajoint escrow
account as a prerequisite to=tinning 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
617-973-8787,888-283-3757 or visit the OCABR website at huo://m%w.mass.^ov/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 Part:Plaza,Room 5170,Boston,MA 02116
617-973-8787,888 283-3757 or visit the HIC website at hrnPubnvw.mass.aov/ocabr!
Go online to view the status of a Home Improvement Contractor's Registration
htto•//db state mnus/homeimurovement/licenseelistasu -
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
;M,'Co inner plaint Section ,
Mee,' orney General
. '
617-727-8400
AND/OR
Better Business Bureau
508-652-U00.508-755-2548 or 413-734-3114
Vusian27-IV P010
The Commottwealtlt ofMassacliusetts
Department oflndustrialAccidents
1 Congress.Street,.Suite 100
Boston,MA 02114--2017
www.massgov/dda
«'orkers'Compensation Insurance Affidavit.Builders/Contractors/Electricians/Plumbers.
Alicantlnformation WITH TO BE FILED THE PERMITTING AIITHORITy.
Name (Business/Organization/Individual): r E(t+dlilL' ��*k�a - Please Print Iegibly
LL(.
Address: F� K Jencyi,[ra Amw
City/State/Zip: Phone#: ?
rR 9 - 741c/ _ Bftq
Arc you a employer?Check the appropriate box:
I. am a employer weh,� omployees(full and/or part-time).° Type Of project(required):
2.[31 am a sole proprietor or partnership and have no employees working forme in 7- ❑New,construction
any capacity-[No workers'comp.insurance required.] - 8. 0Remodeling
3-�I am a homeowner doing all work myself.[No workers comp.insuranre required.)t 9. ❑Demolition
4.❑I am a homeovner and will be hiring contractors to conduct all work on my property- I will 10 E]Building addition
ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 1 L[]Electrical repairs or additiJ
5.®1 am a general contractor and 1 have hired the sub-comractms listed on the:attached sheet 12.❑Plumbing repairs or additi
These sub-contractors have employees and have workers'comp,insurancz: '13-❑Roo-r�erp�airs /
6.❑We are a corporation and its officers have Mmised their right of exemption per MGL c. I�- her 1 A)C•tJ!,152,$I(4),and we have no employees.[No workers'comp.insurance required.)
•Any applicant that checks box>fl must also fill out the section below showing their workers'compensation policy information new affidavit indiptine such.
+Contractors that Check this box must attached an additional sheet shoving the name of the sub-contraetors and state whether or
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a
not thorn entities have
employees. If the sub-contractors have employees,they must provide their workers'comp-polity number.
r am an enrploJ er that is providing workers compensation ms2•ancefor a0r employees Below is the policy and job site
information.
Insurance Company Name:_u tr i C k
Policy#or Self-ins.Lic.#: „5-6 2-70 d
_II h"tie'' nn Expiration Date: ,3
Job Site Address:_CQ 1 hGY' S
City/State/Zip:_JG'i.Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of DIA for insurance
coverage verification.
d do hereby certify under the pains axd pe;ral(ies o,j�rer(�rry t/iat the it formation provided above is true and correct.
Si
..�1 P7
Date: 9
Phone 9- . 7 44
Official rue ondJ: Do not write in this area,to be completed by cio or tolprr official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person•
Phone#:
tl�®0��® - - - -
CERTOFICA 'E OF LOARIL0`Y WSUMINCE 3 IE oiIDITYYV)
' THIS CERTIFICATE IS ISSUED AS A N/Ai7ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRB9ATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POIJClfS
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(5), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certifirata holder is an ADDITIONAL INSURED,iha 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
CONTACT Construction
);astern Insulaace Group ISC N ME
PHONE (800)333-7239 233 West Central St Ic FAX
N
EMAIL
ADDRESS
Natick Iyflt 01760 INsu 5 AFFDRpiNGC011ERAGE naca
INSURED UISURERA1iY'bella Protection Ins. Co. -1360
Atlantic Weatherization INSURER BNaltilns
61 Rear Jefferson Avenue INSURER C:
INSURER D
Salem NA 01970 INSURER E:
COVERAGES CERTIFICATENUMBERMSTER 2015suRERF:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMOD ABO%IEFOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING AIW REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PFJ27AIN. 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 AD LTR TYPE OFINSURANCE
E MM/00 EFF PPO UU p(p
GENERAL UA8ILTTY POLICY NUMBER UBmS
Pi COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
CLAIMS-MADE OCCUR 500042816 /20/2015 /20/2016 PREMIS Ea D S 50,000
MED EXP(Any one Paean) s 5,000
PERSONAL SADVINJURY $ 11000,000
GEN'L AGGREGATE LRAITAPPLIES PER: . GENERALAGGREGATE $ 2,000,000
POLICY e"i PRO' COC PROOUCTS-COMP/OPAGG IS 2,000,000
AUTOMOBILE LIABILITY S
COM WE SING LOW
ANY AUTO Ea a=Idara S 1 000 000
ALL OWNED SCHEOUIED BODILY RUURY(Perperson) $
AUTOS AUTOS 020015871 /20/2015 /20/2016
o HIRED AUTOS 'a NON•OWNED BODILYINIURY(Perawde o s
AUTOS
PROP ERTYDAMAGE
era I S
ii UMBRELLA UAB
a OCCUR PIP-Saste S
EXCESS UAS CLAIMSNIADE EACH OCCURRENCE S 1,000,000
DIED RETENTIONS 600056654 /20/2015 20/2016 AGGREGATE S 1,000,000
WORKERS COMPENSATION
AND EMPLOYERS'UAMUTY S
ANY FROPRIETORIPARTNERIEEXECII If WC STATU- OTH-
OFFICERNEMSER EXCLUDE00 ❑ N/A
(Myandatary in NH) EL EACH ACCIDENTS
0 SCRIPT O NT N OF OPERATIONS Mm,
EL DISEASE_EA EMPL s
POLLUTION L2c38ILITY EL DISEASE-POUGY LIMIT S
L200378613 0/1/2014 0/1/2015 GENERALAGGREGATE
$1,000,000
HL POLLUnON CUNOmON $1,000,000
iCRIPTION OF OPERA77ONS/LOCAnONS/VEI0CLE6(Allies,gCORD101 Additional Rerliad e.H
teSchatlutmom spare is required)
2TIPtCATE HOLDER
CANCELLAi70N
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF StaLI THE EXPIRATION DATE THEREOF, NOTICE )HILL Be DELn/EREp IN
ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGToN STREET
SALE`', 1/! 01970 AUTHOR17E0 REPREBENTATNE
John Soegel/PMA
RD 25(2010/OS)
2.5 mm�ns'm TT,o nrnrxn., (01988-2010.ACORD CORPORATION. All rights reserved.
aeon and loon Rrn rroniefnreH nF IM11no l
ili AGmTAW duafified in All 50 States MR
t?
h �y
D 1
- O(]ua!itfed
1
OftLiv 4
®RC
VINYL DOUBLE HUNG
IMPERIAL LS
ymop Double Glazing.Argon Fili.Low E.Grids
—_--— SLL..-29M152-00102
ENERGY PERFORMANCE RATINGS
U-Factor (U.S./I-P) Solar Heat Gain Coeffident
ADDITIONAL PERFORMANCE RATINGS
Visible Transmittance Condensation rZesistance
® 7
idanvfacl sHWlates that these railings conform to applicable NFRC procedures Fo•
dem•m•ni=n'.•••cla pnXLic[Performance. NFRC MtkngS are dete:mined Fora:ism fPt of
.. _wpllLionS a110 a SPECifK Prod'I(t 54E. NFRC does not r.>OmmN%7 anY FM::!?
cu aoes not warrant the: itability or any product fof any;pennc rr-s.Consult manufacturer's
•Iite "a f_i other product performance information.
..nfrc.
13185S5.060
Nlassaehuseits -DeDaitment of Public Safety
Board of Building Reanlav-ons and Standards
Construction wirer s;snr ,-
_icense: CS4MT7
ERIC W PALM
3 HILTON ST
Setem MA 019707
. . �.ba•_ ----- , 04/23I2016
Unresbrfcted-3mldmgs afwr we Swap wNch `
contain less than 35,000 cubic feet(991ml of
enclosed space
Ceiiumto possess current eMon of the Massachusetts
State Building Cade is cause for revocation of this license.
For OPS(ioensingit5ortmaaonvidc wvn Um.6ov/DPS
9iee oFConsvmerAO'nhs&Busmess Regtbfion
BtI1E ROVENIENTCON7RACTOR
d-Neg d on: 142089 Type
^pitation:. 3M2/2016 Lid Liability Corpo:_.
ATLAN-nC VVEATHER2ATION LLC.
ERIC PALM -
-61RJEFFERSONAVE
SALEM,MA 01970 Trndersecretuy
License or registration valid for®dividni use onty '
before the expiration date. Ufound return to-
Office of Consume-ASsirs and BWftm RegnLnbon -
24 Yank Pia -Suite 51T0
Boston,NA 02116
Notvai'idwithoatsrgnatuse .
L _