9 VALE ST - BUILDING INSPECTION >70� C r- ) Z S '7 a
The Commonwealth ofmassaehuset-n,(1 A5 IL $EA '
9 Board of Building Regulations and Standrurds -.T CITY OF
A � Massachusetts State Building Code, 780 i1NR SALEM
AUG p �' J.ti/ur d01I
U I b e rse
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fmnily Divelling.
This Section ForOfl;chd Use 0nl' :
Building Permit Number. Date.Ap eds
-ouilding Official(hint Nampo. signature Date
SECTION 1:SITE1NFOtLKATION
I.1 PropQerty ►ddress: 1.2 Assessora,Nnp&Parcel Numbers
I.1a Is this an accepted street?yes no
1J 'Zoning Information: 1.4 Propertyji)lmeas(gns7:ji ,l• w It)
Zuningolsnict : Proposed use Lot Ama(sgit) ""F dtage(it) ,.
1.5 Building Setbacks(R) .
Front Yard Side Yeids - Rear Yard -
Required Provided I Required ProVlded. ,RegaiMit Provided
1.6 Water Supply:(tN.G.L c.40,§54) 1.7 Flood Zone Informations Lti Sewage Dtsposnl System:
Public O - Private O Zone: _ Outside Flood Zone? Municipd O On site disposalsystem O-
lfiedc U ._ _ . ..
SECT[ON2: PROPL+RTYOWNERSK1Pt'.
6Demolifion
of Record:
,Teri
l eIC7 SGICNn Y`�
OW,State,ZIP
/a Telephone Email AddressSECTION 3:DESCRIPTION OF PROPOSED WORK'(cheek all thattion O Existing Building❑ Owner-Occupied O -Repabi(s) 1] Iterstion(s)'a Addition O O [ Accessory Bldg.O NumberofUnite_ Other Specify:
Brief Description of Proposed Work=: _ ..
" 1, s2C,
SECTION a:ESTIMATED CONSTRUCTION COSTS :
item Estimated Costs: OMelal Use Onl
Labor and Materials y
1. Building S to M 1. Building Permit Fee:S indicate how fee is determined:
2.Electrical S O Standard City/Town Application Fee- -
O Total Project Lose(item 6)x multiplier x
3. Plumbing Is 111?Qther Fees: S
�.Mechanical (HVAC) S List:
S.Aechanical (Fire S
Su ression) Total All Fces:S
Check No.LA 7�heck Amount: Cash Amount:
6.Total Project Cost: $/f/ Q� . ❑Paid in Full ❑Outstanding> >Balance Due:
I
SECTIONS: CONSFRUCTION'SERVICES
S.1 Construction Supervisor Liccrise(CSL) ?� ^j �f 1Z 3
Lici:nse Number Expiration Date
Name of CSLllolder Efic,W.PArn List CSLType(see btlow)
'T T-rho Qtmet - TY ._, : - Desraiption -_
No.and Street Salem MA U 1970 - U UnresuicteJ BurMn up to 35,000 cu., ft.
R Restricted 1&2 Family Dwelling
City form,Smle,ZIP "' .M 1�tasoaRC
Roofn NS Window rA SF Solid Fuel Bunting Appliances
- 7 Y- 90 4 � - : 1 insulation
Telephone Emoil address D Demolition
5.2 Registered dome Improvement ContractortHIC)
- W' m LIC HIC Registration Number Expiration Date
HIC Company Name 111E
Email address -
Na.mid Street -
Ci Rown State ZIP Telephone
SECTION 6r%VORKERS'.COhInsa PENSATION INSURANCE AFFIDAd1'F(M:G:[::it 15�§2SC(6
Workers Competion insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance o uilding permit
Signed Affidavit Attached? Yes.......... No.......... O
SECTION lap OWNER AUTHORIZATION TO BE.COIYIPI.ETED.WHEN
O%VNER'S AGENT OR CONTRACTOILAPPLlE3 FOR"BUILDING.PERbII C
[,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application. . '
mom__ 7/i y
Date
Print lhvncr's Name(EleNrontc Signature)
SECTION 'b:OWNER'OR AUTHORIZED AGENT DECLARATION-
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
o - 7���
Print Owner s or r uthorizcJ 1 e I�rotronic Signature)
Date
NOTES:
I. All Owner who obtotns a building permit to do his/her own work,or an owner who hires on unregistered contractor
knot registered in the Home_Improvement Contractor(HICProgranl will rr have access,to the arbitration
program or guaranty Pond under M.G.L.c. Id2A.Otherimportant To1 orm on on.Ore FBC Prot ra—m can b'etb�ft a
www m:us.eov.'oca Information on the Construction Supervisor License can be.found at www.niass...uv/Jos .
Lof
substantial work is planned,provide the information below.
r area(sq. ft.) N (including garage, finished basementlattics,darks or porch)
ng area(sq. ft.) Habitable room count
f fireplacesNumber of bedrooms
f bathroomsNumber of hal0baths
ating system Number of decks/porches
oling'systeni Enclosed
Open
J. "Total Project Square Footage"may be substituted for"Total Project Cost" -
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Contractor Arbitration
The 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 coub"W. The as me right is not automatically afforded to a
contractor,however- The contractor would have to resolve any dispute he/she has with ahomeowner 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.
[to
e contactor and the homeowner hereby mutually agree in advance that in the event the contractor bas a dispute
cerning this contract,the contt��ect(S,K�oly�e dispute to a private arbitration fate which has been approved by
Secretary of t E{ 'Y�4I� fCddsarperAffa Affairs and Business Regulation and the consumer shall be required
ubmit to such at'�ihati aNp tpj &#achuseM General Laws,chapter 142A.
� ,meowner's signature - C s rgaan,RTICE:The signafimac of the patties above apply only to the agreement of the parties to alternative dispute
lution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the patties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer
Protection laws(i.e.MGL cbapter93A)may not be waived in anyway,even by agreement_ However,homeowners
maybe excluded from certain rights if the contractor they choose is not pmperly registered as prescribed by law.
Homeowners who secure their ovm building permits are automatically excluded from all Guaranty Food 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 orprovides an express wanaoty'for workmanship ormaterials. in addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts rmxy an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of othermsttem on which the homeowner and contractor lmwfuIIy agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. Ifyou have
questions about your consrmrer/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 ormarked as void,delcted,ornot applicable. One original signed copy ofthe contract with attachments is to
be given to the owner and the otherkept by the contmctor- Any modification to the original contract must be in writing
and agreed to by both patties.Contacted workmay 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 iarases where the `
homeowner deems him/herselfto be financially insecure. However,in instances where a contractor deems him/herself
to be financially insecure,the contractor may require that the balance of foods not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of fimds from said account would require the
signatures of both parties.
Additional Information .
If you have general questions orneed additional information about the Home Improvement Contractor Law or other
consumer rights,or if you wish to obtain a fiee copy of "A Massachusetts Consumer Guide to Home Improvement" -
contact: -
Consumer lnformationHotline - -
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 hqo:/Avw%vmass.eov/ocabr/
If you want to verify the registration of a contractor or if y6uhave questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractorlaw,contact -
Director of Home Improvement ContractorRegistmtion
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
61l-973-8787,888 283-3757 orvisit the HIC website at htto://mv%%mass.sov/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
-
http://db.statemaus/homeimpro%, ment(licanseelistzg
For assistance with informal mediation of disputes or to register format complaints against a business,call:
' C " omplaint Section
OfIT60 Attorney General
617-727-8400
AND/OR
Better Business Bureau
50"52-4900.508-755-2549 or 413-734-31 I4
vasmzt-vt>zn�to
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Armlicant Information Please Print Legibly
Name (Business/Organization/individual):
Atiantie Wiathctu�+lttiti, LLl
61 e rrstn; Avunuc
Address: Salem \n n 111970
City/State/Zip: Phone #: 61 7 k- 7,(W- F/1V
employer? Check the appropriate box: Type of project(required):
Are yo n
1. am a employer with�' 2/ 4. [] I am a general contractor and I 6 New construction
employees(full and/or part-time)." have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- These sub-contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
o workers' com insurance comp. insurance.
[N p� 10.❑ Electrical repairs or additions
required.] 5. � We are a corporation and its
officers have exercised their 11.0 Plumbing repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. 12.0 Roof r pairs
insurance required.]t c. 152, §1(4),and we have no 13 ther,�//Sc%�w�
employees. [No workers'
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.
}Contractors that check this box must 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 most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information. //
Insurance Company Name: Lf Yr G L,
Policy # or Self-ins.Lic. #: q5�6 o2 /7 D /Z I Expiration Date: 3/ZU/I �
V
Job Site Address: 1 a le— �t ' City/State/Zip: <5>: /.
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 for insurance coverage verification.
I do hereby cerdfV under thepains aandggp��enalties ofperjury that the information provided above is true and correct.
Signature P__1l'� Hd Date 7 Z /
a
Phone#
Official use only. Do not write in this area,to be completed by city or town official
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#•
Massachusetts Department of Public Safety Construction Supervisor
Board of Building Regulations and Standards Restricted to:
087977 Unrestricted-Buildings of any use group which cwtain
License: CS- 977 Construction less than 35,000 cubic feet(991 cubic meters)of -
Supervisor enclosed space.
ERIC W PALM
3 HILTON ST
SALEM MA 01976
� Failure to possess a current edition offfieNlassachusn"s
�.sn CA— Expiration: Stale Building Code is cause for revocation of fiMsGcrose-
Commissioner 04/23/2018 UPS Licensing information drsM WM.MASS•GOV/DPS
?Jlr"ourutormr rrld�r�<-fTr� rr�a;r Liceose or registration valid for individnt we only
''�O£SceofConsomerAffairs&BuslnessRegulation _ before the espiratioodate• Iffound return to•- .
OME IMPROVEMENT CONTRACTOR Office of Cousamer'"airs and Business Rcgo1at<oa
a (registration: 1420B9 Type: loParkPlam-Suite5170
�" p)rai3on: 3ri2r2o18& LW Liab)lily Corpor _ Boston,P A 02116
ATLANTIC WEATHERIZA7IONLI-C-
ERIC PALM
61RJEFFERSONAVE :a_c •• -----dw
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