13 OAK VIEW AVE - BUILDING INSPECTION :1)2,S
The Commonwealth ofM 1 V SERVICES
Board of Building Regulationtan 11
ards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
yynn A 11: 21 RevisedMar2011
Building Permit Application To Construct,Rem, R�tlovae Or Demolish a
_ 1 One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Datepplied:
4-- / l
1 Building Official(Print Name) Signature - - Date
„^ SECTION 1:SITE INFORMATION
1.1 Pro erty Address•�/ 1.2 Assessors Map&Parcel Numbers
lJG �V /Y�J
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 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.I.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 yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 O er of Rec d:
Name(Print) �— City,State,ZIP
ra Oak vim A-L' 7YO- 7581
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other �fy:
Brief Description of
Pr/9posed Work:
—c
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.L1.2LCheck Amount: Cash Amount:
6.Total Project Cost: $ .Z•1-t 0 _ ❑Paid in Full ❑Outstanding Balance Due:
�� 2 3
a�
1
SECTION 5: CONSTRUCTION SERVICES
t rKame
nstruction Supervisor License(CSL)
�7y-ri y/z3/i�
License Number Expiration Date
f CSL Holder Enc W.Palm List CSL Type(see below)
Street J n1ton Sftet Type Description
Salem MA 01970 U I Unrestricted(Buildings up to 33,000 f
Ctty/I'own,State,ZIP R Restricted 1&2 Fainity Dwellin
M Masonry
RC Roofm•Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition G
5.2 Registered Home Improvement Contractor(EIC) !y 7,0 p g 3I Z 1(P
eHantic
III(,CompggyNaWyBffeaJtIFheCriPAVd LNLCme
HIC Registration Number Expiration Date
No.and StreetSaleM
Email address
Ci /Town,State.ZIP Telephone
SECTION 6: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 Issuance a building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN -
O
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �t p rev/tit
to act on my behalf,in all matters relative to work authorized by this building permit application.
t f t �12
Print Ormer's Name( ectronic Signature) Date
SECTION 7b:-OWNER'OR AUTHORIZED AGENT'DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain d in this applicat�s a and accurate to the best of my knowledge and understanding.
rr Iry
Print wrier's or Authorized Agent s Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or anEan
who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), t have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important infoon the HIC Program can be found at
Information on the Construction Supervisor License found at „_i,,;2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,fibasementlattics,decks or porch)Gross living area(sq.ft.) HabitablcountNumber of fireplaces NumberroomsNumber of bathrooms Number /bathsType of heating system Numberks/porchesType of cooling system EnclosedOpen3. "Total Project Square Footage"may be substituted for"Total Project C
TIM C0Y1zm01zwe0jtlz of I�lrassaclzzasers
DepaM Went of11dtast ialAccidents
I Congress street,ss?pze 100
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W-Orkers'Compensation insurance Affidavit: t3eilders/Contractors/Electricians/RIa,•nbers.
TO BE FILED WITH THE P_F%j-gTTLYG AiITHORjf4'.
A aolicant information Please Print Legibly
Nagle(BusinesJOr�-anizatiozz(Individual): AiEtr^,CiC vJ�'.�'r,_ ;z�•�„�
(
Address:
City/State/Zip: Phone 4: q?9 e
Are you n employer?Check the appropriate baa
Type of project(required):
1. + f am a employer nith �� employees(lull and/or part time).°
7. Q New construction
1.❑1 am a sole proprietor or partnership and have no employees working for-me in
any capacity.[No workers comp.insurance required.] - �- Q Remodeling
3.Q I am a homeowner doing all work myself[No workers'comp.insun•.nce required.]r 9- lr❑� Demolition
4.�1 am a homeommer and will be hiring contractors to conduct all work on my property. 1 hill 10 u Building addition
F_
that all contractors either haveuvders compensation insurance or are sole
propnemm whfi no employees. 1 LQ Electrical repairs or additions
S.Q I am a general contractor and l have hired the sub-contractors listed an the attached sheet. 12.Q Plumbing repairs Or additions
These sub-conhactom have employees and have workers'comp.iuuvmne,: 13.QRoo-repairs
6.�(We are a rorpomtion and its o dicer have exercised is
right Of exemption per MGL c. I4-• O[her J�J dE �-t6 Cts
151• 1(?),and we have no employees.INo workers comp,insurance mquired.j
'Anv applicant that cheeks box @ I must also fill out the section below showing theirworkers compensation police iniorma[ion.
T Homeonmerstubo submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheetshotving the time of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their tvarkers'comp.policy number-
I atir an earpioJrer that is providing Ivorkers'cottzpetzsation 1bsaYarecef0r my
infortnation. enrplayees. Below is the policy and job site
Insurance Companv Name:
_. LUrtl^,�r1
Policy-or Self-ins.Lic.§:_ 70 f '
Expiration Date: ,3 06
Job Site Address: . j QQ V I'e;�j A—e� City/State/Zip:�� Cyt
r_ttach n copy of the workers'compensation policy declaration pave(sholvina theotic
p y number and expiration date).
Failure to secure coverage as required under MGL c. 152,sR25A is a criminal violation punishable by 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$350.00 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 do hereby cern` -zde�tlre�r7 s at t Icier obverl�rty drat the itaforrnetioa provided above is tree and correct
Signature:
Dare:
Phone � '�.!.
Official Ilse onl}c Do tzat zvrite ill this area,to be completed by cir5r or totvtr official
Cft''y or Tot:
Permit/ticense r
9,M;B10 Authority(circle one):
I.Board of wealth 2.Building Department 3.Cityf-porn Cleric 4.Electrical inspector S.pi Tubing gaspeetor
;.Other
Contact Person:
Phone 9:
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Contractor Arbitration
The Home Improvement Contractor Low 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 coptr qc y.ltay p4br, the dispute to a private arbitration firm which has been approved by
the Secretary of the ExecalM.0 =off 0 Affairs and Business Regulation and the consumer shall be required
to submit to such arbifratip�,afo sachusetts General Laws,clut'llisr 142A.
Homeowners Signature 11 r' - Contractors Signature
NOTICE:The signatures 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 homeowners rights order 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 contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permits are automatically"eluded 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 emided 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 contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree maybe
added to the terms of the contract as long as they do not restrict a homeowner's 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 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.Contracted work may not begin until both parties have received a fully executed copy of
the contract,and Ore three day rescission period has expired!
Accelerated Payments
A 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 hinithmelf
to be financially insecure,the contractor may require that the balance of funds 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 ofboth parties.
Additional Information
If you have general questions or need 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 Plaza,Room 5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the OCABR website at htto://%n"v.mass.00v/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 website at htro:/h%M1v v.mass.-oi,/ocabr/
Go online to view the status of a Home Improvement Contractor's Registration
http,//db.state.m&us/homeimprowment/licensm1 istasn
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
g41 j" onsuiner plaint Section
?.r i ffi omey General
- - 617-727-8400
AND/OR
Better Business Bureau
508-6524800,508-755-1548 or 413-734-3114
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COVERAGES INSURER F:
CERTIFICATE NUMSER: s2i�TR 2015
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOLN HAVE BEEN ISSUED 70 THE INSURED VNAMEOp BOVE FOR THE POLICYll
GERTIFICA N NUMBER:
NOAY BE TAIdDINC-ANY REQUIRENIEtlT• TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WifICH THIS
CERTIFICATE MAY 8E ISSUED OR MAY PER THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERIviS.
L CLUSIOMS AND COAIDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS&
LTR TYPE OFIPJ5URANCE IA I uB
GEPollE
NERAL LIABILITYWSR IAN POLCYNUAME$IP8MIDMBER FF POLICY EI:P
0 I C1P81DOIYWYI LItd1A
COrtaMERCIAL CENERAL LIAalLnY EACH OCCURRENCE s 1,000,000
I CLAIMSAIADE I ANAGET
OCCUR 9500042816 PREMISES Ea •�--• 5 50,000
u /20/2015 /20/2036 MEDEX,(AnYpnep�) IS 5,000
PERSONAL&ADV[NJ URY I$ 1,D00,000
GEN'L ACGREGGAAT7E LI- APPLIES PER: GENERAL AGGREGATE S 2,000,000
POLICYI= I1 17 Loc ( PRODUCTS-COMP/OP AGG 5 2'000,000
Aui01110alLE LIABILITY 5
a 'ANY AUTO COMBINED SW ULE L.1
Ea ae9dent 5 1 000 000
ALL OECD _ SCHEDULED
AUTOS ADT03 02001$872 BODILY W.IURY(Pa,pvsvn} )s
10N-0I /2012013 /20/2026
J HIRED AUTOS I AUTOS / Ula BODILY WJURY(Pa,atfid:.lp) S
�_ I PROPERTYOANAGE I
(Pe�actitlenl S
UCi6p,ELL0.UAB I =-I PIP-Base is
UR
EXCESS LIA6 III OCC
CLAIhiSiMOE EACH OCCURRENCE Is 1_111101000
DFO IRET—.NTIONS -6000586SALAGGREGATE S 1'000'000
4VOP.ICERS COMPENSATION /20/2015 /20/2026
ANTI EJPLOYeR5'UABILI t: I I S
ANY PF•OPRErOP✓pARTNE JuECUTIt-c 'VIM I WCYSTA'fU-I tJDi_I
OFyCEFJUE-'I EnCLUDEDT a d1fA I
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Iffes.de: in NHj EL EACH ACCIDENT
IfYes. be antler S
iDESCRIPTION OFOPEFEgTtONS b1I EL DISEASE-EA EMPLO. S
�OL',u'?'SOLP � 152_T,21c I
?L2003783 EL DISEASE-POLICY Ul s
O/1/20±
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62 � ? 0/1/2016
GENERALAGGREGATE 51'000'000
CRIrnON DF OPERATIO
NS,LCCATIONSUIsEA POLLUTION CONDITION $1,000,000
Cipa[Attach ACORD 101,AtltllUoml ReaaP,ts Sehetlale,U,,m spaeera taquitetl)
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SHOULD AN`!OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
(-'==� OP $�.T.rnR THE EXPIRATION DATE THEREOF, NOTICE WILL
93 )a Sfz2£VC--••=0�? 32`FC�,gJ^• ACCORDANCEtMTH THEPOL)C;'PROVIS1oNS. BE OELNEREO IN
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3 EMTON ST ATLANTIC WEATHERIZATION LLC-
Salem KA 01976;
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61R JEFFERSON AVE
04123/20'16. SALEM,MA 01970 UndersccmtnrY
Unrestricted-Buildings of any use group which
,foritairl less than 35,000 cubic feet(991M3)of License or registration valid for individuI use only
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Failure to possess a current edition of the Massachusetts
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