78 WEBB ST - BUILDING INSPECTION (2) 12.S
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards RECEIVED
!. Massachusetts State Building Code,780CWPECTIGNAL "" `'k evised&vAsed EM
Mar 2071
Building Permit Application To Construct,Repair, Renovate Or Demolish a
^Q One-or Two-Family Dwelling aiii SEP 22 A `� 33
This SectionFor Official Use Only
Building Permit Number: Date A ied: -
1 -_Building Official(Print Name) Signature -
Date
SECTION 1:SITE INFORMATION - -
`�`� 1.1 Prope-r�ty�jAddr4ss:,�'bL Sa 1.2 Assessors Map&Parcel Numbers
1.1a Is this anaccepted 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'
2.1 Owk-'- -l'of ,i
Name(Print) W City,State,ZIP
78 lvehb St,
No.and Street Telephone Email Address
.SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
BriefDescripfon of Proposed World:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:Labor and Materia pfficial Use Only
ls
1.Building $ 023 7,j: 1. Building Permit Fee:$ Indicate how fee is determined:.
O Standard City/Town Application Fee
2. Electrical $ 3 - r - -
❑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.LUJ7 Check Amount: Cash Amount:
6.Total Project Cost: $ pZ j 7S: ❑Paid in Full ❑Outstanding Balance Due:
7-
• SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Y7 G 7-7
License Number Expiration Date
Name of CSL Holder
Eric W.Palm List CSL Type(see below)
No,and Street 3 ffliton Street Type _Description
U Unrestricted(Buildings u to 35,000 cu.ft
Salem MA 01970
R Restricted 1&2 Family Dwenin
City/Town,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(HIC)
atlantic Weatherize ion,LLC �Re Z U
HIC Comp r�� E HIC Registration Number Expiration Date
pgy Rlatrt�rtlLG A Name
Vt
No.and StreeSale 1MA 0 1970 Email address
City/Town,State,ZIP Telephone
SECTION6: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 Issuancegf4he building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR`APPLIES FOR BUILDING PERMIT
& O 1�
I,as Owner of the subject property,hereby authorize {/�74/P7-n
to act on my behalf,in all matters relative to work authorized by this building permit application. j
l
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 pedury that all of the information
contai Cis a�cat�' d accurate to the best of my knowledge and understanding.
Print Owners 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
eow+roca Information on the Construction Supervisor License can be found at�;•:•,•�.:•.mass.eov%<Ins
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.R) 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"
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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)-if they have a dispute with a contractor. The same right is not 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 contactor.utay s�(b-niaAhe dispute to a private arbitration fain which has been approved by
„to
the Secretary of the Executive Once of to er Affairs and Business Regulation and the consumer shall be required
ro submit to such arbit/atipp;a63pYafi Wachusetts G ral Laws,eha er 142A.
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 contactor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties.
Homeowner's Rights
A homeowners 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 if the contactor they choose is not properly registered as prescribed by law.
Homeowners who secure dmeir own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contactor Law. The contactor 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 contactor
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 can an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of othermatters on which the homeowner and contactor lawfully agree may be
added to the terms of the contact as long as they do not restrict a homeowners 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 contact with attachments is to
be given to the owner and the other kept by the contactor. Any modification to the original contract must be in writing
and agreed to by both parties.Concocted work may not begin until both parties have received a fully executed copy of
the contact,and the three day rescission period has expired!
Accelerated Payments `
A contactor may not demand payments in advance of the dates specified on the paymentschedule 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 offimds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contacted work V.ithdawal 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 ifyou 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 OCABRwebsite at htm:/hamnvmaas.aov/ocabr/
If you want to verify the registration of a contactor or ifyou have questions or need additional information specifically
about the contactor registration component of the Home Improvement Contactor 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 HfC website at httoJ/%nv N%mass.eox,/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration:
httn://db.state.maus/homeimorovementAicenseelistaso
For assistance with informal mediation of disputes or to register fatmat complaints against a business,call:
yonsumer plaint Section
r n fig` 4fie ZA +{tomey General
r t:
617-727-8400
AND/OR
Better Business Bureau
508-652.4800r 508-755-2548 or 413-734-3114
Vernon 2r-1Ir-W010
1'he commonwealti, of massaclztrsetts
Department ofdtadtEstr•[a[Accfde m
1 C01291'ess Street,Silite 100
Bostos,,M4 02 Z20I7
www.masseov/dia
11'orkers'Compensation nsuraTO BE FILED ILEDnee dav)t:Builders/Contractors/Eleetricians/Plumbers.AIicantlnformation 6VITH THE PER6HTTItYG AUTHORIT:'.
Name(Business/Organization/lndividual): Ula tt0 v !'lease Print j 'biv
�J� vcr•.avSdE.La l
Address: ^). R JWerafv� aP[C IP3�
City/State/Zip:
Mch=ks .
0 a employer?Check the appropriate Phone#: fq 7 9 - 7 q
PP priate box:
!am a employer with employees(full and/or n,' TYPO Of project repa time).= ( gnired):am aassole roprietoror partnership and have no employees workingforme in �- 0 New construction
ny [No workers comp.insurance required.) s- 0 Remodeling
zrn a homeowner doing all teork myself.[No workers'comp.insuranre required.]tam a homemtmer and tall be hiring canimctors to condom all uod;on m 9' 0 Demolitionsure that all contractors either have workers'compensation insurance or are Olen Iunll ]0 0 Bui)diog additionoprietors with no employees. I l.❑Electrical repairs or additionsm ageneralructo, aveerand(havehiredtheve workersctors listed on the-attached sheet12- Plumbing
ese sub-contractors have employees and have Workers'comp.insuranc:: 0 ��Pairs Or additions are a corporation and its officers have esemised their right of exemptionperMG6c. 4 ❑ th repairs.x If-t),and we have no era to ees. I�- ther CU— ,rt6 tP Y [No workers'comp.insurance required.]
cant that checks box trl mutt also fill out the section below showing[heir workers'cum eowners whe submit this affidavit indicating they are doing all work and then hire outside contractors mutt submit a new
employe ors that check this bus must attached an additional shcet shmving the name of the sub- p nsahon polity bra t a new
employees. Ifthe heck this
have era attached
an additional
must affidavit in titles g such.contractors and state whether or not those entities have
Y Provide their workers•camp,polity number.
I am an errrploper that is Providing,workers'crnetto lyrforrnation. u for nrp eyplo}eel- Beloty is the poiyty}i aadjob site
e Insurance Company Name: ---7 i1V'i r-I,
Policy#or Self-ins.Lie.#:__ ,-43 1970 a F
�� Expiration Date:
Job Site Address: �k �,//�
Attach a copy.of the workers compensation policy declaration page(shotvi gr the policy number and expiration date)-
Failure to secure coverage as required under IVIGL c. I52, e
and/or onetyear imprisonment,as well as civil penalties in the fors a criminal rm of a STOP WORK ORDERation [andla fine of p to 5350.00 a
day against the violator.A copy of this statement may be forwarded to the Office Of Investigations of the DIA for insurance
coverage verification.
I da herebycertr r f�nder the v nn®Irioe n£nn, rrru that
the[nfonnat[oil prordded above[ trite and correct
Sienature-
Phone#- 7 Date- q Z
Officiar use on[y. Do not ipr[te in this area,to be cotnp[eted by city or tolvir o�clid
City or Town.
Issuing Authority(circle one): Permit/License# -
I.Board of Health Z.Building Department 3.CitylFown Cie 6.Other rk 4.Electrical Inspector S.Plumbing Inspector
Contact Person:
Phone#:
' ) �A.assachuss±ts -Oeoart ne?Ii Of Public 52fe.v
Board of Building Reaulatior!s and Standards ,
CP..asErs: na
.,Cense: CS4)67977
n
I&1uC W PA.1M
3 EnTON ST {y
Salem MA 0197i b✓,d�'
rissienar 0412312016
UnmsWcted-Bufl, diftgs Ofany use group Which `
contain less*an 35,000 cubic fed(991m)of
enclosed space_
AIII
� Esilu2Yo possess a current eMon of the Massachusetts
Stave Building Code is causeforrevocation of this license_
Ear OPs Umrmoginhmna6onvait wniw.Mass.eavloPs
_ ---_ r-J"31e`frrcvr»mnraen/l�or/ ��icrrrrlrr elG r
Of mofConsomwAfaft&BusmewRegvlation
NY ME MPROVPENT COITMCTOR
_. istration: 142069 Type
'ration:.- 3M212016 Ltd LtabW Cotpa-'
ATLANTIC tNEATHERIZATION LLC. -
ERIC PALM _
61R JEFFERSON AVE
SALEM.MA 01970 T;mde�ereiary
Uceose or registration valid for individul use only -
before the expiration dais. Iffound return to:
office ofConsnmerA.ffairs and Business Regulation .
loperkPioza-Smre5170
3ostou,MA 02116
Notvalidwithbatsignamre