31 WEST AVE - BUILDING INSPECTION (2) I
OL
r The Commonwealth of Massachusetts i
' _ Board of Building Regulations and Stand RECEIVE[ FOR
Massachusetts State Building Code,1780=P E C T I Q N A L F�IPALITY
SE
15p Building Permit Application To Construct,Repair,Renovat2flf DJrfo}' a ReWwdMar2011
One-or Two Family Dwelling ' u A
9 This Section For Official Use Only
Building PeimitNttmber Date A fled:
11 _ 44�� �
v / `Building Official(Print Name) - Sigaahr rrN u✓ .. . . /Date
SECTION 1:SITE INFORMATION -
1.1 Pro arty Address: 1.2 Assessors Map&Parcel Numbers
/
Us.Isthisan accepted street?yes no Map Number PamelNumber
13 Zoning Information: 1.4 Properly Dimensions: `
' - ns: rr -
ZoningDistrict Proposed se - . . . LotAtea(sgR) Frontage(ft)
1.5 Budding Setbacks(ft) -
.FrontYard.. .Side Yards I. Rear Yard
Required Provided - .. Requited Provided Required _ . Provided
1.6 Water Supply:(KG_L a 4Q j54) 1.7 FlOod,Zeno Informatimi: I>8 Spwage D)sposal System:
Public❑ Private❑ Zone: Outside Flood Zone?Checkifyes❑. MunicipalElOn site disposal system ❑
SECTION2: PROPERTY OWNERSMII l
2.1 Owgert of Records
4rvva L�ehbN �a +i /rl�✓ OJ970
Name(pint) I city,State6 ar
31 }VcSf' ft•r-e-
No.and Sheet Telephone Etuail Address
SECTIONS:DESCRIPTION OF PROPOSED WOJW(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-( ccupied ❑ Repairs(s) ❑ lterahion(s) ❑ Addition ❑
Demolition . ' '❑ Accessory Bldg.❑ Number of Units Other Specify
Brief Description of ProgosedWork2. !
lam t iEWZM Att
n SECTION 4:ESTBYIATED CONSTRUCTION COSTS .
KMechanical
- Estimated COstS: -
or and Materials Official Use Only
$ _7 I. Building Peru[Fee:$ Indicate how fee s determined:
$ O Standard City/town Application Fee
❑Total Project Cost'(Item 6)x multiplier ` x
$ 2. Other Fees: $ I
(HVAC) $ List: L
(Fire
Su ression - $ ' a Total All Fees-$ ; ,
CheckNo.IfiM Check Amount: Cash Amount
6.Total Project Cost: $ a'7 0b = '.; , 0 Paid in Full " i 0 Outstanding Balance Due;_'
SECTION 5s CONSTRUCTION SERVICES
51 Construction Supervisor License(CSL) i v+ 77-7.-7 3. /
UcemeNumber Expiration Date
Name ofMHolder List.CSLType(seebelow) t4 tt�
.Eric W.Palm
Type Description
No.and Street
3 Hilton Street .' U Umesuicted to 35,000 w >i
=' .. Salem MA 61470 ' _ R .Reshicted MFaan1 Dwellia -
City/rown,State,ZIP .. M Masom -
RC RooSn Coverin
. WS WindowandSiding
Solid Fuel liances
IA-
r/"?1 Ie�,�t b -. Insulation
B�gApp ,
Telephone. Email address- D I Demolition
5.2 Registered Home Improvement Contractor(MC) l Q 3
Atlantic WeaU cni'dllviy L...
HICRegistcahon ,amber ExphatioaDate
Inc Company NameorE Venue
No.and Street - -Salem.. MA 0197.6 Email address
CiLyfrown,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.L c.152.§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure toprovide
this affidavit will result in the denial oftheIssuance ebuildingpermit
Signed AffidavrtAttacheil7 Yes.....,..... No..........13� .
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUII DING PERMTr
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
�dtuar QOi>t A.. _. 7 /7
Print Owneft Name Signature) y - -.— - Date
SECTION 7W OWNERr OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that an ofthe information
contained inc.
n applica n is
grac�
to the best ofmy knowledge and understanding.
-7 /-7
'rintOwner'sorAnfhorrcedAgeat'sNaare(ElechonicSigoature) - Date
NOTES: .
1. An Owner who obtains a building permit to do his/her own works,or an owner,who hires an unregistered contractor
(not registered in the Home Improvement Contractor(IRC)Program),will not have access to the arbitration
program or guaranty fund uuderlvLG.L.o.142A.Other important information on the HIC Program can be found at
www.mass.goV/oca luformation on the Construction Supervisor License can be found atwww.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.&) (including garage,finished basemenUattiM decks or porch)
Gross living area(sq.fl.) Habitable room coma
Number of fireplaces_,, Number ofbedrooms
Number-of-bathrooms Number-ofhal6baths
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 -
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 pot automatically afforded to a
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner is court unless
both parties agree to the optional clause provided below. This clause would give the contractor the same right to r.
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,_tlte:eoptiactor•1[iaysubmi[the dispute to a private arbitration fun which Las been approved by
the Secretary of the Executiveffice_pFonsumet Affairs and Business Regulation and the consumer shall be required
to submit to such arbitxahohlastpMrdvirlde In Massachusetts General
Laws,ch ter 142A _ _
Homenwne Signature Contractor's Signature
NOTICE:The signatures o 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 resoltriion 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 agreemeaL However,homeowners
may be excluded from certain rights if the 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 contactor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An emmmerationof other matters on which the homeowner and contractor lawfully agree maybe
added to the terms orthe contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your cowumerhomeownerrights,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 toby both parties.Contracted work may not begin until both parties have received a fully executed copy of
ttie contract,and the three day rescission period has expired!
Accelerated Paymeuts
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems himlherself to be financially insetam% However,in instances where a contractor deems himlherself
to be financially insecure,the contractor may require that the balance of fiords 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 tights,or ifyou wish to obtain a free copy of "A Massachusetts Cansumar 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 2833757 or visit the OCABR website at httoahtnrw_mass.aov/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 websim at htm://w�vw.mass.aov/ocabr/
Go online to view the status of a Home Improvement Contractors Registmtion:-
htty-//d6 state gmusPoomeimnrovementAicenseelistaso -
For assistance with informal mediation of disputes m to register farmed complaints against a business,call:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
501F6524800,508-755-2548 or 413-734-3114 v.�jav 27-1111/1010
The Commonweallh of Massachusetts
Department oflndustrialAccidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual):_T
t'rrs:ociot-,
Address: 611 k efsen Avenue
City/State/Zip: a Apt
Phone#: 70GJ-e/y 3
Are yo employer? Check the appropriate box:
1. I am a employer with 4• ❑ I am a general contractor and I Type of project(required):
OF(full and/or part-time).* have hired the sub contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' y Building
[No workers' comp.insurance comp. insurance? ❑ g addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑R2of repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13. iher ,tJ4&n,
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 most submit a new affidavit indicating such.
tContractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that 1s providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: tw rt LA
Policy#or Self-ins. Lic.#: tg oZ 7Q 02 Expiration Date: ZO /Co
Job Site Address: 31 Wey-- Q, City/State/Zip: SetIel+7 tv yy
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 S250.00 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 under the pains ate p naltres ofperjury that the information provided above it true and correct
Signature- 64;—p I/� Date 7/7
Phone#: / 7 7G//'' 9-jif 3
O
fficial only. Do not write in this area,to be completed by city or town offrciat
n: Permit/License#
hority(circle one
health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
son Phone#:
page 3 of 3
CERTIFICATE OF LIABILITY INSURANCE
DATE(tiN/DDIYYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER" THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holtler is an ADDITIONAL INSURED, the policy(ies)must be endorsed.statement on this certificate If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement A
certificate holder in lieu of such endOmement(s). does not confer rights to the PRODUCER
9
CONTACT Construction
Insurance Group LLC NAME
233 West Central St PHONE (8010)333-7234 FAX
E-MAILf C NO:
D RESS:
Natick MA 01760 INSURE AFFORDING COVERAGE
INSURED INSURERA Arbella Protection Ins• Co. NAIL 6
Atlantic Weatherization
INSURER 8Nautilus Insurance Co 1360
61 Rear Jefferson Avenue INSURERC:
INSURER D:
Salem MA 01970 INSURER E;
COVERAGES CERTIFICATENUMBER3DLSTER 2015suRER F:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSUREDEVISION NAMED ABOB
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, _CERTIFICATE MAY BE ISSUED OR MAY VE FOR THE POLICY PERIODPERTAIN, THE INSURANCE AFFORDED BY 7HE POLICIES DESCRIBED HEREIN IS SUBJECT E ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS.OCUMENT WITH RESPECT ALL
WHICH THIS
ILTR
LTR TYPE OF III
GENERAL LIABILITY POLICY NUMBER POLIGI'EFF POLICY EXP
MMmDMryy MMIDO LIMITS
R COMMERCIALGENERAL LIABILITY EACH OCCURRENCE S 1,000,000
A CLAIMS-MADE a OCCUR 500042816 PRAEMISES Eaoms,ence S 50,000
/20/2015 /20/2016
MED EXP(AnY ane person) S 5,000
PERSONAL S ADV INJURY $ 1,000,000
GEN'L AGGREGATE IT APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICY X: PRD" L OC PRODUCTS-COMP/OP AGG S 2,000,000
AUTOMOBILE LLABII-nY S
A ANY AUTO COMBINED SINGLE LIMIT
Ea actidenl S 1 000 000
ALL OS x SCHEDULED BODILY INJURY(Perperson
AUTOS AUTOS 020015871 /20/2015 ) S
HIRED AUTOS x MMO,N-OWNED /20/2016 BODILY INJURY(Per a=idant) S
PerOS
OamtlmIDAMAGE S
X. UMBRELLA LU16 �i OCCUR PIP-Basic S
A EXCESS LIAB
CLAIMS-MADE EACH OCCURRENCE S 1,000,000
LIED RETENTIONS 500058654 AGGREGATE S 1,000,000
WORKERS COMPENSATION /20/2015 /20/2016
AND EMPLOYERS'LIABILITY S
ANY PROPR(ETOR/PARTNERSXECUTIVE Y IN WCSTATLL OTH-
OFFICER/MEMBER EXCLUDED,(Mandatary in NH) ❑ ryLp
If yes,dasmbe under EL EACH ACCIDENT S
DESCRIPTION OF OPERATIONS below EL DISEASE-EA EMPLO S
3 POLLUTION LIABILITY ELDISEASE-pOLICYLIMIr S
PL200378613 0/1/2014 0/1/2015 GENERAL AGGREGATE
$1,000,000
=RIPTION OF OPERAT70N5/LOCATIONS/VEHICLES(gBacN ACORD 701,AddlBonal Remarks Schedale,If MGM EA POLLUTION CONDITION $1,000,000
space is Mwimd)
!RTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
93 PMSHINGTON STREET ACCORDANCE WITH THE POLICY PROVISIONS
SALEPl, MA 01970 AUTHORIZED REPRESENTATVE
)RD 26(2010105) John Roegel/PMA
J25 r,mnnsl m O 1988-2010 ACORD CORPORATION. All rights reserved.ronle4nue1 marke of Ar`nRn
-- --•- .nn act vct
ILITY
IFI
ilil
DATEIMMi
T TE DO E IS ISSUEDRM A M19gTTE�R p�NF061UAE0®ONLY AND�CONFERS NO B,iGHT�S�U O�N E CERTIFICATE HOLDER THIS »
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY ARAEND,EXTEND OR ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
IMPOOR RODU FIC ND CER F CAT OLDER
terms and
conditions
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 and endorsement A
certificate holder in Ilea of such endorsemen s, statement on this certificate does not confer rights to the
PRODUCER
CONTACT
EASTERN INS GROUP LLC NAME:
233 W CENTRAL STREET PHONE FAX
(A/C,No,Ext:
NATICK,MA 0I760 E-MAIL
22MLW ADDRESS:
INSURED INSURER(S)AFFOROING COVEgAGE
ATLANTIC WEATHER INSURER A: AMSRICANZURICRINSURANCE COMPANY NAICe
RATION LLC � �"'
INSURER B:
INSURER C:
61 REAR JEFFERSON AVE INSURER D:
SALEM,MA 01970 INSURER E:
COVERAGES INSURER F:
CERTIFICATE NUMBER:
REQ OCEMENT TEAT THEPOLX SOFRISURANCE LISTED BELOW NAVES ENISSUEDTO THE aiSUgED RANEI)gaOYE FORTNE PpLICYP _
ANYUIDED YTHE,OL OR CONDITION OF ANYCONTpger OR OTHER DOCUMENT REVISION NUMBER:
AFFORDS°BY THE POLICIES DESCgIBm HEREIN SUBJECT TOALLTHETERMS,EXOLU310NS 4NO COWIUC THISSOF SUCH PCTEM LICIMLBE IS SHOWN MAY Xg'-- -UDEEN REDUCEDBwG
PAD CLAWS SUCH PCATE MAYBE SSUED OR MAYPE TT
MSR AIN THE BISUAANCE
LTR TYPE OF INSURANCE AOD Slla POLICY EFF DATE POLICY ExP DATE
L R POLICY NUMBEp p',ri GENERAL LIABILITY (MIN) "I (MSADDIWYYI Lmn6
COMMERCIAL GENERAL LIABILITY CH OCCURRENCE
CLAIMS MADE ❑OCCUR. $
AMAGE TO RENTED $
REMISES(Ea occunence)
GEN'L AGGREGATE LIMIT APPLIES PER: ED i(Any one person) $
POLICY _ ERSONAL a ADV INJURY $
PROJECT El LOC ENERAL AGGREGATE $
AUTOMOBILE UABILITY RODUCTS-COMP/OPAGG $
ANYAUTO .
ALL OWNED AUTOS COMBINED SINGLE $
LIMIT(Ea accidenn -
SCHEDULE AUTOS BODILY INJURY
HIRED AUTOS (Perperaon) $
NON-OWNED AUTOS BODILYINJURY $
(Per accident)
PROPERTY DAMAGE $
UMBRELLA LIAS OCCUR (Par accidel
EXCESS LIAS CLAIMS-MADE EACH OCCURRENCE
DEDUCTIBLE $
AGGREGATE $
RETENTION $ '
A WORKERS RCOMPENSATION pNp $
EMPLOYER LIABILITY yM _
ANY PROPER ROiLPAgTNEp/EXELUTIVE UBGB270121-15 Wrt(IR015 X WCSTATUTORY OTHER
OFFICERTJEMBEN EARTNE DT WA 0&20/2piB LIMITS
(Ma ,diiecr b NH) E.L EACH ACCIDENT UySCRIP ION urger $ SOO,QpO
DESCRIPDON OF OPERATIONS EeImv E.L.DISEASE-EA EMPLOYEE $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEMCLESRIESTRICRON E.L.DISEASE-POUCV LIMIT $
THIS REPLACES ANY PRIOR CERTIFICATE
ISSUED5!$PECIAI ITEMS 500,000
TO THE CERTORCATEHOLDER AFFECTING WORKERS COAtPCOVBRAGE.
CERTIFICATE HOLDER
CITY OF SALEM CANCELLATION
93 W.ASHINGTONST SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE BEFORE THE EXPIRATION DATE THEREOF,NOTICEWILLCBEGEL EDREp
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