24 LYNDE ST - BUILDING INSPECTION The Commonwealth oftMosachusetts
Board of Building Regulations and StandardsII�� CITY OF
Massachusetts State Building Code, 780 CMR 1 )5 SALEM
l� Revised,t/ur 1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or 71vo-Fami4lDwelling .
This Section ForOfBcial Use,Onlg:::,.;,'; ;.
Building Permit Number. Date:Applled
Building Official(Print Name).- Si lure - -
...... - Date
SECTION C:SITEYNFOPINIATION`
Els
Address: 1Z Assessors Map di Parcel Numbers
1�1 Ly
n a ted s[red?yes no M1lapNwnbernformatiou: l.d Praperty,.flimeusfgosa;ic Proposed Use - UfArea(sq ft) 4PMVidewd Setbacks(R)Front Yard site YaidsRearYordR uinid Provided - - , . . . ..eqRequired Provided. Requited
I.6 Nater Supply:(M.G.L e.-0o,§5d) 1.7 Flood Zone Information: 1.8 Sewagi-D posal System:
Public D Private O,- Zone: _ Outside Flood Zone?
Check if.csCl - - Municipal O On site disposal system D
SECTIONI: PROPERTVQ`WNERSMeV
2.1 O�vpertof¢acord•
I�rad.. 4harrl
`ttme(Prin�t) - - Ci .State -
J ty. .ZIP
/7-?'Zf o y 2Z
No.and Strut Telephone Email Address _
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all tbaE apply)
New Construction O Existing Building O f Owner-Occupied O Repairs(s) O Iterations) O Addition D
Demolition D A""...RIA O. Number of Units_ Other Spedfy:
Brief Description of posed Work':
S--
SECTIO[ a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials 9
1.Building g 1. Building Permit Fee:$ Indicatehow fee is determined:
2.Electrical S ❑Standard City/Town Application Feer
a Total Pioject Cost'(Item 6)x multiplies x
3.Plwnbing S P Qther Fees: S
d.�lechanicnl (HVAC) S List.•
5.Mechanical (Fire
Su ressiun) S Total All Fees:S
Check No.124 Check Amounts Cash Ainount:
6.Total Project Cost: S Falb p Paid in Fuli ❑Outshnding Balance Due:
i
SECTION 5: CONSTRUCTION SERVICES /
5.1 Construction Supervisor License(CSL) 1 ? Y I_7 y l/Z 3 b S
LicenseLicense Number Expiration Date
Name of CSL[folder
Eric W. FaltYt List CSL'rype(see below)
2 Raton'txd TYI* Description ._
No.and Street SS��BI �1�70 U Unrestdcud Duildin u to 35 000 cu. 11.
R Restricted I&2 Famil DWellin
Cityfrmvn,State,ZIP M Maso -
RC Rooli Covcrin
WS Window andSidin
SF Solid Fuel Burning Appliances
.-7 If Y- 9-/ (ij 3 : 1 insulation
Tel hone
Email address D Demolition -
5.2 Registered.Home Improvement Contractor HIC) t)Z�/{( Ct /2 /
FI[C Registration Number Expiration Date
HIC Cumpmy Hama _
Email address
No.mrd Street
Ci crown State ZIP Tel one
SECTION 6r WORKERS'.CONJPENSATION INSURANCE AFFIDAVTf(M:O.G:r 152 §25C(�},.
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide"
this affidavit will_result in the denial of the Isivance OfAh"id*litIng permit
Signed Affidavit Attached? Yes.......... No...........O
SECTION 7A:OWNER AUTHORIZATION TO BE.COMPLETED-WHEN' T;,
OWNER'S AGENT OR CONTItAGTORAPPLtES'FOR'BUILDING.['ERNiIT'
i,as Owner of the subject Property,hereb authorize Uri C, PQ u rn
tg act on my behalf,in all matters relative to work authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature) .
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
OT,, a lectrom I Signature) Date
Print Qwi er s ar r uthorrmd A�
NOTES:
1. An Owner who obtains a building permit[ado his/her own work,or an owner who hires an unregistered contractor
knot registered in the Home Improvement Contractor(HIC)Program);will>L have access to the arbitration dT _ -
- " fund under M.G.L.c. I J2A.Other rmporta—nt infarm lion on—tfie IC Program can ou
wtvw. n ss guaranty
ivww m•sss eov.'uca Information on the Construction Supervisor License can be found at www.mass._ovhlus .
2. When substantial work is planned,provide the information ibelow: , finished 6asementlattics,decks or porch)
(irosTotal door area a(sq.
R.) Habitable room count
Num living area ces tt.) Number of bedrooms
Number of fireplaces Number of hal0baths
Typeoumber of bathrooms Number of deckst porches
type of treating system Enclosed Open
'type of cooling m
syste
.t. "Total Project Square Footage"may be substiatted fur"•rutal Project Cost'
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Contractor Arbitration
The Home Improvement Contractor Lmv provides homeowners with the right to initiate an arbitration action(as an
alternative to court action)ifthey have a dispute with a contractor The some right is aotautomauically nffbrdW to a _
contractor.howiever. The contractor would have to resolve my dispute he/she has with a homeowner in court unless
both parties agree to the optimal clause provided below. This clause would give the contractor the same right t0
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 co tos,�nayr iNLe dispute to a private arbitration firm which has been approved by
the Secretary of tp�E v �" _e;'41411$b$�frCdesrgnerAff lift and Business Regulation and the consumer shall be rzquired
to submit tosuch arbttadMas<s,� l&achusetts General laws,chapter 142A.
Horneavmegs rgn Con c s'Mmature �w
NOTICE:The signaturw 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 homeowmees rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer
protection laws(Le.MGL chapter93A)may not be waived in anyway,aver by agreement. However,homeowners
may be excluded from certain rights ifthe contractor they choose is not properly registered as prescribed by law.
Homeowwvers who secure their own building permits are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a
timely and workmanlike manner Homeowners maybe entitled to other specific legal rights if the contractor
guarantees or provides anexpress w-m-aaty forwndonanship or materials_ 7n addition m guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of othermatters on ivhiob the horneonmerand contractor lawfid]y agree maybe
added to the terms of the concoct as long as they do not restrict a homeowner's basic consumer rights. Ifyou have
questions about your consumer/honteownerrights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in duoficate 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 ormadsd as void,deleted,ornot applicable. One original aimed copy ofthe 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 to by both parties Cantracted work may not begin until both parties have received a fully executed copy of
the contract and the three day rescission period has expired;
Accelerated Payments
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 him/herself
to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a join escrow
account as a prerequisite to continuing the contracted work Withdrawal of funds firm said aecotmtwould require the
signatures of both parties.
Additional Information
If you have general questions rrneed 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 Plate Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCABR website at htm.,/Awmzv.mas.sovlocal r/
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 ContractorLaw,contact:-
Director
ontactDirector of Home Improvement ContraetorRegisttation
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973.8787,888-283-3757 or visit the BIC website at htW.//umnv mass.eov/ocabd
Go online to view the status of a Home Improvement Contractor's Registratios-
htm://db.state_manstliomeimorovement(licensmlistaso
For assistance with informal mediation ofdisoutes or to register formai complaints against a business,call:
- = _ ConsuWer�Complaint Section
-A „>v - 0;3icii e Attorney General
617-727-8400
AND/OR
Better Business Bureau
508652-0800,508-755-2548 or 413-734-31I4
Vavw 21-11fJ'�[D
The Commonwealth of Massach usetts
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
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
AT@�tSP l J aClictu�ttuti,LLC
6J K e cestm Aaelltle
Address: %Jelin \4 A 1)1970
City/State/Zip: Phone#: �j 7 k' 71W- W—/ 5
Are yo n employer? Check the appropriate boa: Type of project(required):
1.LZI am a employer with 7 < 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.El a sole proprietor partner- tractors have
shipip and have no employees
These sub-contractors 8. E] Demolition
working for me in any capacity, employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.]
5. ❑ We are a corporation and its 10.E] Electrical repairs or additions
officers have exercised their 11.❑ Plumbing repairs or additions
3.❑ I a homeowner doing all work right of exemption per MGL
myself [No workers' comp. 12.❑ Roof r pairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' l3. ther� s c/4�I dv
comp. insurance required.]
*Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information.
9 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors drat check this box most attached an additional sheet showing the name or the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information. �7 /
Insurance Company Name: CiGf Yr GL J
Policy#or Self-ins.Lie.#: `5 16 02-7 O /2- J (�1 Expiration Date: 3// oll
Job Site Address: o2 C1 CC4C— J% City/State/Zip: Sr"
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 certify under the pains andpenalties ofperjury that the information provided above is true and correct.
a � ✓i g
Signature: =
' (/ d' f Date: �(a
Phone 97 9�� 7��J- Citi 3
Official use only. Do not write in this area, to be completed by city or tows: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#:
CERt@FI(�A�'E OF 6AB9Ne8 INSURANCE DATE my"'?)
THIS CERTIFICATE IS ISSUED AS A MATTER OF ihiFpPoylAT10N ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO THIS
CERTIFICATE DOES NOT AFFIF INS lELY OR NEGATNELY 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), AUTHORED
REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder i- 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 endorsemeM(s).
PRODUCER
Eastern Insurance Group LLCi CAME-. Construction
233 West Central St PHONE , (800)333-7234
FAX
E2MLL A1C No
A DESS:
Natick MA 017I60 INSURE S AFFOROINGCOVENAGE
INSURED msURERAArbella Protection Ins. Co. 413 ICS
Atlantic Weatherization MSURERDNantiluis In.c„rance CO
61 Rear Jefferson Avenues INSURER C:
INSURER 0:
Salem NLrL 019'70 INSURER E:
COVERAGES CERTIFICATE NUMBER3iaster 201 INSURER F:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
REVISION NUMBER:
INDICATED. NOTWITHSTANDING ANY REOI/1REMEItrF, 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 ANO CONDITIONS OF SUCH POLICIES.LIMITS SHOWN NIAY HAVE BEEN REDUCED BY PAID CLAIMS_
INSR
LT T'PE OF INSURANCE 0
GENERAL UAmLDY PDUCY NUMBER MPoM/Up EFF MPO�UDCY EXP
LIMBS
X COMMERCIAL GENERAL UABILITy �� EACH OCCURRENCE S 1,000,000
A CLAIMS-MADE ® DA A OCCUR PR N S aom cope S 50,000
' 500042816 /20/2016 X 0/0 /20/2017 CONTRADLIAB17STq MEDEXPf onePerson) S 5,000
X CG0001 1 10/O1 TiORH � PERSONALa ADVINJURY S 1,000,000
GENT AGGREGATEUMITAPpUES PER: ':`i GENERALAGGREGATE S 2,000,000
POLICY X PRD LOC !1 PRODUCTS_COMPIOPAGG S 2,000,000
AUTOMOBILE LIABILITY
5
A ANY AUTO GOMBI SINGLE LIMIT S 1 000 000
ALL OWNED Ea acatl I
AUTOS X ASGUFiDE6pin cn '' 020015871 BODILY INJURY(PerPanson) S
X HIRED AUTOS X AUTOSMEO /20/2016 /20/2017 BODILY INJURY(Perac., S
PPe awtlenD�A E S
X UMBRELLA UAB X OCCUR PIRBastc S
A EXCESS UAB
CLAIMS-MADE EACH OCCURRENCE 5 1,000,000
OED RETENTIONS 10,00 1 600058654AGGREGATE S 1,000,0
WORKERS COMPENSATION /20/2016 /20/2017 00
AND EMPLOYERS'LUIBILRY S
ANY PROPRIETORIPARTNER/E(EounvE YIN WC STATU- D
OFPCERNEMBER EXCLUDED, ❑ MIA
(fflyantlatory in NH) EL EACH ACCIDENT S
DESCRI ON OF OPERATIONS below
EL DISEASE_EA EMPLOY S
B POI;LTJTION ELDISEASE-POLICY LIMIT 5
00378614 0/1/2015 0/1/2016
EA POLLUTION CONDITION $1,000,000
'DESCRIPTION OF OPERATO /LOCAt1a GENERAL
$1,000,000TIS/VEHICLES
(I eb ACOR0707,A4tlXional RemaRa Sehetlule,Omore spare is eequl
L
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF CATFM THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DPT rS2tam IN
VISIONS,
93 WASHINGTON STREET ACCORDANCE WITH THE POLICY PRO
SAJZM, NA 01970 AUTHORIMM REPRESENTATNE
I'. CORD 26(2010/05) John Tiaegel/SNS+ -�- �-
IS025 nn+nns,n�
ndinrnan..�,.,e�„a I„����e ro�i aH���$4 ArnlxnORD CORPORATION. All rights reserved.
vv0 rax berver
6, TIFICATE OF LIABILITY INS
URANCE DATE
IFIC O cis ISSUED ASA MATTER OF INFORAAATfON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELYI OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE
OR RODUCER AND THE C RTI CATE H OLDER.
PORTANT:and conditions of the poliIf the certificate holder is an%1D
the terms an )MONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
cy,certain policies may require and endorsement A statement on this certificate does not confer rights to
such endorSement s_
the certificate holder to lieu of
PRODUCER
CONTACT
EASTERN INS GROUP LLC NAME:
233 W CENTRAL STREET i PHONE FAX
(A1C,No,Ext): (A1C,No}:
NATICIC,MA 01760
E-MAIL
22MLW ADDRESS:
ii
INSURED INSURER(S)AFFORDING COVERAGE
ATLANTIC WEATHERIZATION LLC '! INSURER A: AM1iRR[CpNZURtCHiNsuaaHce coMPaNv MAIC rt
INSURER B.-
INSURER
:INSURER C.
61 REAR JEFFERSON AVE ' INSURER D:
SALEM,MA 01970 INSURER E:
COVERAGES ' INSURER F-
TE
-
IFyTHAT THE
REVISIONNUMBER:
LICIESO C6URANOE��MBEfl:
ANY AEOUIgEpAENT,T6IN OA CONDRION OF 4NY CORigpCr OR OTHER pO�GTa1NE�Nr ATO THE E79lDit7)NAL1ID
4FFOgDED BV THEPOLIGES OESCq®Ep WITH gESPECT70 Al10VE FOA THE POU CY PER OD INDICA
PAO CLNMS. NERE6V6SIlBJECT T041,LTHE TEgMtR,NXCLUSIDNS ANDCONpgjrlpySCEAI�ICATEINAYBN NAYP TAINOTHESRMC
EINpLpmSSHOWN MgHBE. ERICEDy
LTO TYPE OF LVSUggNCE AOD SUB POUCYER O4TE PpIfCY EXP DATE
L A POLICY NUNSER IL4.SODIYYW
GENERAL LIABILITY 1 (NlAomwyvl Lours
COMMERCIAL GENERAL LIABILITY CH OCCURRENCE
CLAIMS MADE OCCUR. S
DAMAGE TO REP17E0 §
PREMISE§(Ea Dttunence)
GEN'L AOGgEGATE LIMTTAPPUES PER. EXP(Aryone Person) §
POLICY ®PgOJECi LOC PERSONAL&ADV INJURY §
® GENERAL AGGREGATE
AUTOMOBILE LIABILITYS
PRODUCTS-COMP✓OP AUG $
ANYAUTO ! i
ALL OWNED AUTOS
COMBINED SINGLE §
SCHEDULE AUTOS IMT(Ea actltleN)
j HIRED AUTOS SODILYINJURY §
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NON-OWNED AUTOS f (Pat Person)BODILY Ry §
(Peraccident)
' ! PROPERTYDAMgGE §
UMBRELLA LIAR (Per accident)
OCCUR
EXCESS LIAR CLAIMS-MADE j EACHOCCURRENCE
DEDUCTIBLE AGGREGATE S
RETENTIONS ` $
A WORKER'SCOMPENSgT10N ANp y $
EMPLOYER'S LIABILITY $
ANY PROPERITORIPARTNEIVEXECUTIVE YIN UB-SB270121-16 T WC STA
OFFICERVAENBER EXCLUDED? 03202016 0320/2017 ,WC ST TUTORY �OTHER
NI
(NanEdeINBl ! + E.L EACH ACCIDENT
D Yes,DESCRIPTION
unser I S SSU ODD
OESCgIPnON OF OPE RATIONS bow I El DISEASE-EA EMPLOYEE
)ESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/gESTRICTON6/SpECIAL ITEMS L 500,000
S 500,000
E. DISEASE LIMIT §
"His REPLACES ANY PRIOR CERTO7CATE ESSURD TO: , "'ATE HOLDER AFFBCI'MG WORKERS COMP COYBRAGH.
'ER TIFICATE HOLDER
CITY OFSALEM ! CANCELLATION
93 WASHINGTON ST SHOULD ANY OF THE ABOVEDESCfil6EpppLICIES BE CANCELLED c
INACCO DAQ=rUIHE E%PIRAT TH DATE THEREOF,NOTICE WILL BE DEWERED
' IN ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM•MA 01970 - AUTHORIZED REPR -
9 VE F
:ORD 2$(2010105) The ACORD name and loge are registered
marks of ACORD1
1283-2010 ACORD CORFIORAT10N. Aii rights reserved_ 1
Massachusetts Department of Public Safety Construction Supervisor
IV, - Board of Building Regulations and Standards
o_.� Unrestricted-Buildings of any use group which contain
Restricted to-.
License: S less than 35,000 cubic feet(991 cubic meters)of .
ConstructionnSupervisor enclosed space.
ERIC W PALM -
3 HILTON ST
SALEM MA 01970
"^� (,A_ Expiration: FmT��Possess is
Causeedrion oaken 1this cense
- �missioner P Stare Building Codecs cause for revocation of this license.
04/23/2018 - DPS Licensing information visa W W W.MASS.GOUIDPS
License or reghb ation valid for mdividnt use Only -
�1 Office of Consumer Affairs&Basin=Regulation before the expiration date. If found return to:.
TOME IMPROVEM(TR CONTRACTOR - Office of Consumer AH'eirs and Business Regulation
-gegistration: 142089
Type: -10 Park Plana-Suite 5170 -
F, pira0on: 3/1212018 Ltd Liability Corpor Boston,NIA 02116
ATLANTIC WEATHERIZATION=.L L.C.
ERIC PALM
61RJEFFERSONAVE �c�_vr•---- tf'�' J/ ( � -
SALEM,NIA 01970 Uadersecremry Not valid without signature
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