6 UGO RD - BUILDING INSPECTION (2) Cam- l01 3 -7 o
The Commonwealth of Massachusetts INSPECTIONAL $W4{CgP
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR SALEM
.� ' R*seC�laTj5011
Building Permit Application To Construct, Repair, Renovate Or o t a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date App ed:
y.n nw �/3
Building Official(Print Name) Signature Date
SECTION /: SITE INFORMATION
`,0 1.1 Property Acl ress: 1.2 Assessors Map&Parcel Numbers
^1, 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 In Frontage On
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:
Zone: Outside Flood Zone?
Public❑ Private El Zone:
if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Reco {l:
OnZA\eS C-,0,\wV,X),X 0\0`to
Name(Print) City,State,ZIP
� i,J0,C) `� 6c>3- oGuL(
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Repairs(s) GT11 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description.of Proposed Work':
Cultiv.�\ C e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x 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: $ �� �j ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS CONSTRUCTION SERYICES:
5.1 Construction SupervisorLicense(CSL) OS.� r ( , C 01
—./.,L\f..a'C V\ N\(y'C��YI`1 License Number —1 l Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street .Type _ - :Description
N ����\__ AAA
Qa��G U Unrestricted(Buildings u el ing cu.ft.
v.-CJK , ��^''-\ R Restricted 1&2 Famil y Dwellin
Ciry/fown, State,ZIP M Masonry -
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
Sob p0'C) S� I Insulation
Telephone
Email address D Demolition
5.2 Registered Home Improvement
�e l� Contractor(HIC) I Registration
O�c I G
C� �AO`-n-f HIC RgistrationNumber Expiration Date
HIC Company Name or HIC Registrant Name
asc\
No.and Street AA
C'nes k c� \l* �010� So$' Email address
City/Town, State,ZIP Telephone
SECTION 6 WORKERS';CQMPENSATdONINSDRANCE AFF7DA SIT (M G L,:c 1$2 § 25C(b))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION7a 'QWNERAUTHORIZAATIONTOBECOMPLETE,D.WHEN
OWNER'S AGENT.OR:CON.TRACT J\AOI�R;APP,LIES=FOR
1,as Owner of the subject property,hereby authorize O KN<
to act on my behalf,in all matters relative to work authorized by this building permit application.
( p
t All-
Print Owner's Name(Electronic Signature) Date
;SECTION 76:OWNER'OR AUTIIORIZED,AGENT DECLARATION ,
By enteri g m n below,I hereby attest under the pains and penalties of perjury that all of the information
contained r s a cation is true and accurate to the best of my knowledge and understanding.
WS16
Print Owner's&XtKoAzed Agent's Name(Electronic Signature) Date
NOES
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an� x
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.gov/dps
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"
Project 31-58991 - Signed Sales Agreement https://nitro.powerhrg.com/projec"ocuments/4971836?pages=l
C�
Proiect 31.58991.Sign&ales Agreement 9JPEG(573 KB,850x1104)
Jeanath IN Antonio Gonzales
NATIONAL HEADQUARTERS ,;POWER 31'589GI
2501 Seapon dive Chafe.RA 19018 mat m r m July 02,2015
888-REMODEL�� nTlouglififiggBalllr
nU WG 1-
8-'-CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
euyor(a)'Inlwmation and DeSadPnOn a the Rrapdrly: Project Number'.3158991 July a2,2025
Jeaneth Gonzales (aa3183"w(Jeen9fh's Can) llv_1onmlaa)41ehoo.som
Antonio Gonzales (978)7"4 I*(Hone) E11iY'rO0°°°
SU90 Rd
G URORd;vA,OteTO
County:Elsa
Tavmahlp:
B iyer(s)listed above hereby jointly and severally agrees to purchase the gas anNOT servces of Power Home Remodeling Group
and its vendors("Contrei in accordance with the prices and terms described in this 6 page document and the Product
Specifications,which are Incorporated as part of the Agreement(wllacWely,this"Agmemenr). This Agreement represents a cash
sale of goods and services. Buyer(s)agrees mhe ay paedk for cost
ofpurchaseagds and services purchased as described herein,regardleas of
timing or approval of any financing Buyers)
Purchase Pried: $9,596.98 Pre instalia�e eInsp melon Dates:
&17117MIMI
Down Payment $0.00 Estimated Project Start:6 to 7 weeks
Balaton Due on $9,898.98 Substantial Completion: Estimated Project Completion:1 to 2 days
Matted of Payment: Other e,nuna7 adew.+®+or mneoxmae uanem mnownm same..NOT On.waerae.ouaw omen
CmVeckYe mMdrmllnGWeO h,®lculelvq Yma rRmm.See eelryNnMwm CpWtlona.
Buyer(s)hereby acknowledges receipt of a copy of the pamphlet,'rho Lead-Safe Certified Guide to Renovate Right",Informing
Buyers)Of(he potential risk of lead hazard exposure from renovation activity to be performed In or at Buyegsy Property,at the
add so written above.Buyers)received this pamphlet on the date of this Agreement,before commencement of work.
s Buyer(s)'Initials.
Ls Agreement Conslhut05 Me entire agreement and understanding oneveen the parties,and this Agreement replaces any and ell
prior nagollahe ,reprasentallons,or agreements.either written or oral. No amendment,modification IS,waiver 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,inducting the 0.ve accompanying Notice
of cancellation forms,on the date first written above end 2)was orelly Informed of his/her right to cancel this transaction.
Buyers)also agrees and understands that If Buyers)finances the work with a third-party,the terms of that financing will be
contained on separate documents,including any finance charge.
Future promotions trot applicable.
DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES.
1 have read and recelred each page of tt iS 6 FIG.agreement, r
Powe Xom amodaling Group Bu ra) /, yar )
f07102115 /OVE12115 /07/02115
Signature f Remodeling Consultant S nature Igoe
Gregory Nolan Jeaneth Gonzales retie onzales
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 ATTACKED NOTICE OF CANCELLATION FORM FOR AN EDPLANATION OF
THIS RIGHT.
July 02.201516:59 11111111111111110 Page 1 of
1 of 1 8/5/2015 3:47 PM
NATIONAL HEADQUARTERS _ Jeaneth and Antonio Gonzales
Q
2501 Seaport Drive,Chester,PA 19013 _. , POWER 31-58991
July 02,2015
888-REMODEL
�• r •• •�•
MA HICK 168616
PRODUCT SPECIFICATIONS
Buyer(s)'Information and Description of the Property: Project Number: 31-58991 July 02,2015
Jeaneth Gonzales Date o/Agreement
Antonio Gonzales (603)831-0644(Jeaneth's Cel/)
j iv_gonza lez@yahoo.com
6 Ugo Rd (978)744-4486(Home) a-Mail Address 1 ,
Salem,MA,01970
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 Fri 7/17 between 10:10a and 11:10a.
Windows -SL 2700 Inclusions: Includes metal reinforced meeting rails and nighttime safety locks on double hung windows
only, welded corners, foam injected frames, Sashlite technology, Heatshield, Duraglass, exterior custom capping, installation,
clean up and haul away of all job related debris.
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($)has read the Product
Specifications.
I have read and received each page of this 2 page agreement.
Power Home Remodeling Group Buyer(s) Buyer(s)
/07/02/15 /07/02/15 /07/02/15
Signature of Remodeling Consultant Signature Signature
Gregory Nolan Jeaneth Gonzales Antonio Gonzales
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.
July 02, 2015 16:59 II II I IIIII IIIII II I II IIII IIII III IIIIII
Page 1 of 2
q
NATIONAL HEADQUARTERS - Jeaneth and Antonio Gonzales
2S01 Seaport Drive,Chester, PA 19013 - jTJOWER 31-55991
July 02, 2015
SiS-REMODELknid
.. ...
MA HICq 168676
Project Specifications
Windows: Living room 1 99.5"x55.5"
WINDOWS: Models SL 2700 Styles Bow Types 5-Cite Configs End Casements
OPTIONS: Color White/White: Grid Pattern: All Lites: Colonial: Contour I Removal Wood I Upgrade
Head,Seat and Jambs Pine I Additional Details None
vitae lei
Windows: kitchen 1 35.25"x36.5"
WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None
OPTIONS: Color-White/White: Grid Pattern: Both Sashes: Colonial: Contour I Removal Wood I
Additional Details None
Windows: Bathroom 1 27.25"x37.0"
WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None
OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour I Removal Wood I
Additional Details None
Windows: Girls room 1 31.25Sc44.75"
WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None
OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour I Removal Wood I
Additional Details None
Windows: Basement 1 31.5"x33.0"
WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None
OPTIONS: Color White/White: Grid Pattern: Both Sashes: Colonial: Contour I Removal Wood I
Additional Details None
July 02, 2015 16:59 III II I III I IIIII II IIII IIII IIII IIIII IIII
Page 2 of 2
POWER-1 OP ID: EL
,acoRO' CERTIFICATE OF LIABILITY INSURANCE DATEIM1/2014YI
09111/2014
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 CONTACT
NAME:
Lacher 8 Associates Ins Agency PHONE FAX
Lacher Insurance Group ac Na En:215-723-4378 AIc Na: 215-723-8604
632 E Broad St P O Box 64398 EWAIL
ADDRESS:
Souderton,PA 18964
Chad Lacher INSURERS AFFORDING COVERAGE NAIC N
INSURER A:Harleysville Preferred Ins. Co 35696
INSURED Power Home Remodeling Group, INSURER B:Harleysville Worcester Ins Cc 26182
LLC INSURER c:Nationwide Mutual Ins Company 23787
2501 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.
INSR TYPE OF INSURANCE ADOL SUBR POLICY NUMBER MMIODY/YYYY MMI�DYIYYYY LIMITS
TR
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 13000300
CLAIMS-MADE � OCCUR MPA00000089793N 10101/2014 1010112015 PREMISES Ea occurrence $ 1,000,00
MED EXP(Any one person) $ 15,00
PERSONAL B ADV INJURY $ 13000,00
GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00
POLICY� PRO LOC PRODUCTS AGG $ 2,000,00
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLELIMIT $ 13000300
Ea accidem
B X ANY AUTO BA 00000089796N 10101/2014 10101/2015 BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per acadent) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Pera¢ident
UMBRELLA LIAR I X OCCUR EACH OCCURRENCE $ 103000,00
C X EXCESS LIAR ri CLAIMS-MADE CMB00000089794N 10/01/2014 1010112015 gGGREGATE $ 10,000,00
DED RETENTION$ $
WORKERS COMPENSATIONI PER
AND EMPLOYERS'LIABILITY STATUTE ERH AD ANY PROPRIETORIPARTNERIEXEGUTIVE YIN 2014006620967 10101/2014 1010112015 EL.EACH ACCIDENT $ 1,000300
OFFICERNEMBER EXCLUDED? N/A
L.(Mandatory in NH) E. DISEASE-EA EMPLOYEE $ 13000,00
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1,000300
B Mass Auto BA 00000018227P 1D101/2D74 1010112015 Auto Liab 1,000,00
B NY Auto BA 00000074849R 10101/2014 10/0112015
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IACORD 101,Additimud Remarks Schedule,may be attached If more 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 AUTHIOORRI:ED REPRESENTATIVE
120 Washington St 1 �C/\Salem,MA 01970
9)1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(20114101) The ACORD name and logo are registered marks of ACORD
CS457645
1S PTEWr LL DR -
Gorrtnti�e,'.e,.�c 0911812O15
- �'A' ffice of Consumer AfT in&Business Regulafion
OME IMPROVEMENT 4CCNTRAC7OR
Registration:';1466635 TYPr'"
ExpiratloP1: J1tJ1037 Eupplemem
POWER HOME REMODELING CRCUP LLC.
MARK MORDINI -
2501 SEAPORT DRIVE STE B110
CHESTER, PA 19013 -
Undersecretary
rLIC
(993 Q is,sra
�r.,'aARK F Y�bat -ram w
?` ale DR
N AfiTLE$OROUGH,MA 61760 3525': -
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®P3ny�(fall aralpr pore amc).=
1�T fpronrieEor or Parm=h*snahaveme emplcyeea wovdng for me iL �. C?t'e L.e"li`u6to71
V kvr 5 c�P.inmrmmce xe9iwei�J 1 �- F emodeling
4 =.�1�z�2omeov�,ei acing di v,oTL mysoll[fee vemk�`comp.in_.�mct r�amca.j i I 9. pL-I?emolibcr�
�( '-C 3 e^m�$omeovmer ad wilt be 2vring cvmzcaarr is oonaixx all worE;on � ( I�i C�nii 20ni�o7
rn.�.ac x4iai ali conuaczors either Dare•roieer_' a7 PToP'etty. l wild ��'
3r�Pn-.-tor=ati ve emP7oyeea. `'9Li� ion irE.a�,et m.�.e:cie i i.C €sklicd 7eijFj7�inY nfltii7on=
`--L P ew a gencri ssmtrrcm�a 7�u.'tar�c iht ea�cnnnacxrn:kss9r,�oamcprp a3eez. i 1•.C :�bia 7ey�ni7g 07 244itoZa
These_abeerrrtr-� krovc c�rrnioyees a+x have uarkem' 1_
6.�4de z*c wrpnraaox sna its offcris have exercises iLey rigi,t oTcaempiion per R7G1<.eo L
�•0 Otter
132 F i 0):ano we have no emylo} s. [ho workerx'wm IDs
p tasm�reyuireri)
Any apphomt thEt che.. box t muse also$tl oat the srnon below shoving the¢workers'comPensa'tinn policy infomiabon.
'Homwners who submit this affidavu ind==nog they are doing all work and an hire outride canvactcrs mnra MInnrt a new affidavit mdicatmg ML.
1Contractors tLat check this boa must attached ea additional¢beet showing the msma of the sub-co empkoyees. If the wh-conhactors have employeos,they must protide their workers'comp.policy n etors and sdete whether or not those effii0es have
I am an employer that is provdding workers'compensation insurance or ,
iriforrrartlor:. f r+9 employees Below is the podicy and job side
Insurance Campany Name: egk' U.LF O&Z '
2 NvcLz GP
Policy#or Self-ims.Lic.fr: �D ►y Lt® �� ZD�� i
. { Expiration Date:_ jS'l ®f
Sob Site Address:he /G() �� S a�
Attach a copy of the t corkers' AeYA
compensation pansy dedaratian a(showing
the pD"cip:
P� ( vying the policy nrtmber mud expu•aiimu tAtate).
Failure to secure coverage as required under MGL c. I52, §25A is a criminal violation punishable by a fine uP to S1,SOO.DD
and or°ne Yeaz imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.DD a
day against the izolator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for i>setrance
coverage v -' h
I do hereby ld the padas and perudties of perju ' utf that the '� ormalion provided above is true and correct
D
3i e: S/lf ate:'moue# 5 ad—?,E6 156
Official use only. Do rwt write in this area,to be completed by cify or town official -
City or Town: Peradt/I.icense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department a.CityffDwo Clerk 4.Electrical Inspector S.Pluuabing Inspector
6.Other
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