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0016 DEARBORN STREET - BPA 14-369 L4 e-,t/-- LAOt L41m The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards \ C Massachusetts State Building Code, 780 CMR SALEM g Revised.tlur?0/l Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Divelling This Section For Official Use Only Building Permit Number: Date/Applied: to 7t813 SS Building Official(Print Name). Sigirature - Date SECTION 1:SITE INFORtNIATION LI Property Address: 1.2 Assessors Nlap 8r Parcel Numbers I (o AEl?i-bo�iN S'1' I.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 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 Owner'of Record: TOhA Frit1, SoflemlvA o101'70 �1me(Print) City,State,ZIP if¢ Oeerbo,)irr _ f- qu-7N5- $5,37, No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: Brief Description of Proposed \Vurk': Titsladl 3 ✓ ows- s & w SECTION 4: ESTUMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and p Materials) I. Building S Jr-/ I I/ I. Building Permit Fee:S Indicate how fee is determined: Electrical $ ❑Standard City/Town Application Fee �. - - ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S ? Other Fees: S / � 4. Mechanical (11VAC) S List: !�� 5. Nlechanical (Fire S Su ression) fotal All Fees: S Check No._Check Amount: Cash Amount: 6. 'rotal Project Cost: S 5g'r`i 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1,1761 6 7 1* A110tA C01nAf License Number Expiration Date Name of CSL Holder r !`� S�1� List CSL"type(see below) t41 3 r 1 11 O D✓ No.and Street Type ;. Description /V tY r ax�A PJq 030(,3 U Unrestricted(Buildings Li to 35,000 cu.It.) R Restricted 1&2 Family Dwelling Cityfrown,State,ZIP bl Nlisonry RC Roofing Covering F Window and Burning Siding SF Solid Fuel Doming Appliances (010— 5000 3y39 1 Insulation Talc hone Email address 1) Demolition 5.2 Registered Home Improvement Contractor(IIIC) 1/_A 16 3 )8 15 1A0Wer ��' ocldt;3 !0 IIIC Registration Number Expiration Date I IIC Coal_ oury Nape IC�"(iceis nt Name No.end Street d V Email address Ghtr�P4 000 (of0 -'gj4- !5$oc0 City/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 Iskuan a of the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN. OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize A I IGn 01f t9 act on my behalf,in all matters relative to work authorized by this building permit application. zoo& P+V See i on icq ids)t3 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED 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. AI l kr 'wo fa Print Owner's or Aut torized Agent's Name(Electronic Signatur Date NOTES: I. 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(IIIC) Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at www.mass.�Li v'oca Information on the Construction Supervisor License can be found at w%v%v.ni issuov.!dM, 2. When substantial work is planned,provide the information below: "total floor area(sq. R.) (including garage, finished basemmnt/attics,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"may be substituted for"Total Project Cost" CITY OF SAL.EM, 1�' NSSACHUSETTS BI:ILDLo G DEPARTMENT P 120 WASSIINGTON STREET,3' FLOOR TEL (978) 745-9595 FR.x(978) 740-9846 KIatBERI.EY DRISCOLL MAYOR THmw ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BCILDNG CONNISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: 160A* (name of hauler) The debris wiiJ''ll be/I disposed of in (name of facility) (address of facility) signature of p it applicant to/a8�i(3 _ date dcbrisaif dix The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers Applicant Information I (7 Please Print lAidbly Name(ausiaesarotpniintiorandiviTT //i mm): Po 1 E CI- ortil C C-MCDC-LlA/16 -/;&VP �Address: 2S-e'l efto r Ay, &/iE silo (. +ml-E/Z Y/ I /70/3 City/State/Zip: Phone#: (!C e7y—S-OC'0 Are Pif an employer?Check the appropriate box: Type of project(required): LTHI am a employer with IS' 4. 0 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the subcontractors 2. I am a sole proprietor or partner• listed on the attached sheet: ❑Remodeling ship and have no employees These stub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised thew 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL . 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 15Z§1(4),and we have no 12.[}.Roof repairs insurance required.)t employees.[No workers' 1).�Other lit//A��Oa+�s comp.insurance required) - 'A^y applicant dui checl�box a mug also fill out the teedea ximv showing their wodem'come�d^"policy Infmmation. r t{Onneownent wit mmhh this allida",indiatng they are doing all weak and thin him oanide contractors most submit a ocw affidavit imitating such. tt'onim=s than check this box most attached an additional shoe slowing the name of the Qlatemr once and their worm'comp•policy imfpm don. . I aim an emrployer that B providing workers'canW-radon Insurance for my employees. Below Is the paltry and job site information. Insurance Company Name. 14A�n_K L-E ySV 1 f. -C WoPZCE SMP— �/�/Jr' ttey M or Self-ins.Li C(} poe.all ' •` 00 a®6 0 a q 7q6 Expiration Dale: 10 / Job Site Addrea I(e Oeer borrn St City/State/zip. Sad em MA 01270 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited 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;'eolator. imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a y gainst Be advised that a copy of this atatemeat may be forwarded to the Office of Investigations o the D forcc coverage verification. I do hereby c un er e p and penaltler ofperjury that the hrformadon provided above is true and correct. aigilature: -A Dam lv l3 Phone Offieibl use only. Do not write in this area,to be completed by city or town ofciaL City or Town: PermitfUcense Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone H: POWER-1 OP 1D;AW CERTIFICATE OF LIABILITY INSURANCE DATE`MMNDnY Y) 09111113 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY 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), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. 1 IMPORTANT: If the certiflcate holder Is an ADDITIONAL INSURED, the pollcy(las) must be endorsed. It SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on th(s•certificate does not confer rights to the curate holder In lieu of such endorsema s. I PRODUCER 215-723.4378•coNracr Lacher&Associates Ins Agency NAME: Lacher Insurance Group g 215-723-6604 PHONE F .Ira 632 E Broad St P O Box 64398 L Souderton,PA 18964 A SSr , Chad Lacher NSURER AFFORDINGCDVERAGE two INSUeERA:Harleysville Worcester Ins Co 26182 INSURED Power Home Remodeling Group, INSURERS:Harleysville PreferredIns.Co 35696 LLC.PowerHomo Remodeling Group, INSURERC:Nationwide Mutual Ins Com an 23787 Inc. InsuRERo: ' 2501 Seaport Drive Ste 6110 Chester,PA 19013 UiSURER E: WBURERF• COVERAGES CERTIFICATE NUMBER: REVISION NUMBER_ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, 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 TERMH, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. ITR TYPE OF l4suaANCE B P POUCY NUTAftER M YF°FF MP pCY EXP LIMITS GENERAL LIABRAt7 EACH OCCURRENCE $ 1,Q00,000 $ X COMIMILIALGEHERAWABIUIY PA000000H9793N-9 10/01/13 10/01114 R ISESM,gg,Re,xa $ 100000 CINMsiAADE I rul A I OCCUR f MEDW ane erW) $ 10,00 PERSORALSADVNJURY It .1,000,00 GENERAL AGGREGATE'. $ •2,000,00 GEN•LAGGREGATE LIMB AIMPEIt ) .PRODUCTS-COMPMP AGG $ 2,000,000 POLICY X lFil'TPRO. LOC t $ AUTOMOBILE LIABILITY COMBINED SINGLE UMFT ,1000000 A X ANYAUro A00000089796N 10/01/13 ;10f01114 BODILY INJURY(Perperam) ; Ap�S"AJED SCHEDULED AUTOS BODiLYNJURY{Perealdalu) $ HIR®AUTOS NON•OYMED PROPERTY DAhfAGE AUTOS _ Peracydant $ i S UMBRELLAUAS IX i OCCUR EACHOCCURRENCE $ 1Q,000,O00 C X E8cE$$UAS CMBODOOODS9794N 10/01113 10101/14 AGGREGATE $ 10,000,001 Dec, RETENTION AND EMPSCORS.LIATION BILITY X WC TAN- OlH- pW EMPLOYERS'PARTNER A OFRUOAE.-ABRIPARTNDED?ECUrNErY COOOOOO89795 10IOV13' 10101/14 E.LEACHACCIDENT $ 1,000,000 OPRCEFUtAEMSER EXCLUDED? � NIA (Mandelary In NHi EL DISEASE-EA EMPLOY $ 1,D00,00 tt yyaa55 dasrdcewder DE4CRIPTION OF OPERATIONS below ELDISEASE-POLICYUMT $ 1,000,00 A Mass Auto Policy _ BA0000o018227P 1010I 13 10101/14 Liability 1,000,0 A NY Auto Policy BACIOOGO074849R 10/01113 10101/14 Limit DESCRIPTION OFOPEFt4TIO1IS I LOCATIONS f VEHICLES{Attach AGDRD 1%,Atltll9anP1 R•wdcs So2tadvfe,U matespara lc req,tlred) 1 - , CERTIFICATE HOLDER CANCELLATION SALEM SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED, IN ACCORDANCE wrhH THE POLICY PROVISIONS. " Salem 120 Washington St AUTHDR2EDREPRESENTATIVE• . :. - . ... 3rd Floor ��/•- O/-�p alem,MA 01970 4-^'�`�l �--• ' ©1088.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD "s Office of Consumer Affairs nd Business Regulatio' n k >`�1 10 Park Plaza - Suite. 5I70 Boston, Massachusetts 02116 `"Home Improvement Contractor Registration Registration: 168616 Type: Supplement Card POWER HOME REMODELING GROUP LLC Expiration: 3/18/2015 ALLAN COLPITTS 2501 SEAPORT DRIVE STE B110 CHESTER, PA 19013 scn, Update Address and return card. Mark reason for change. :: 2rnn-os"i UpdateAddress Reneeal - Employment Lost Card ,� /L.. I'. .,.,,,./// � .. /6....../.,.,n, �-�,,,�fTae of Consumer Affairs R Business Regulation Wwwo'SA-legistration: TLicense or registration valid for iudividul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 169616 Office of Consumer Affairs and Business Regulation .t.,. Type: 10 Park Plaza-Suite S170 + Expiration: 3/18/2015 POWER HOME REMODELING GROUP LLC. Supplement t.ard Bostan.D1A 02116 ALLAN COLPITTS s.. 2501 SEAPORT DRIVE STE El 10 CHESTER, PA 19013 — Under:.ecretary ?Otlid w' I ut signature AM Massachusetts -Department of Pupi:C Safety Board of Building Regutatrons and Standards (-n.t ru,ni,n �aujwn w-r UCenSe CS-001979 y - ALLAN K COLPITTS a 3 CHRISTIAN DR NASHUA NH.03063 j d4 Cornna<,s,one - 0510 7/2 0 1 4_ about:blank NATIONAL HEADOUARTERS John Fdtz 2501 SeapmL e A.UrnChen PA 19ai3 rc-. O 30-87407 1 ;8$8-REMODEL sepremaar2e;zot3. —_ 'L. , fM N;ta.�f t6 CUSTOM REMODELING AND IMPROVEMENT AGREEMENT { &ryas Information. Project Number:30-87407 septemb.1128,200 John FrItt (978)SM2768.(JW$nS CW) {I 16 Deelboum at SWem,NA 0181e (ON)7454s32 i CWWEs To'v,aship: Y Buyer(s)listed above hereby jointly and soveralry agrees to purchase the goods anNor services of Power Home { Remodeling Group("Contractor")In accordancevM theprkes and terms described on the front and the following four pages of this agreement and any specnicdtlon sheets,which are lncorporatedas part of the Agreement(collectively;this Agleemerrt"l.Title Agreement represents a cash saleLof goods and services.Buyer(s)agrees to pay the cost of the goods and services purchased as.described herein,regardless of fining or approval of any financing Buyer(s)may seek for their S purchase.Problems and 1nguMes regarding this Agreement should be directed to the Contractor at 1$89-73"335. I i `{! EamhesePdcai ` R'ii971.16 1 Pre Installation Inspection Date: Down Payment: SeJle PopnrenAaifieon tw tm/sermsan ro6areM 1l:s)e .I i Belnnce.Oue on 45;97.i.t8 Estimated Project Stark 8 to 7 weeks subs(ansol cempleaon; - 'Estimated Project Completion:T to 7 days MealeC,ofPaymaM; OMar DUMP comreaon"agnolerlmesereeoempceevaWe«meceaxr9maml mcweaam I 1 <acUrolmg nnleRames,,seenaar4mknwa conoawemreverx j Buyer's)hereby acknowledges receipt of a copy of the pamphlet,"TlieLead-Safe Certified Guide to Renovate Righl", ) informing Buyers)of the potential risk of land hazard exposure from renovation activity to be performed In Buyer's home, 1 i at the a written above.Buyers)recelved this pamphlet'an the date of this Agreement..before commencement of 1 work. r (BuyaYs Initials). - 1t is agreed and understood.by and between the pardesthat this Agreement constitutes the entire understanding between the parties,and there are no verbal understendings'changing or modifying any of the terms of(his Agreement Buyer(s) a hereby cmowledges thatauyer(s)1)has read!he Millie'Agreement and has received a completed,signed,and dated copy of this Agreement,Including Me two accompanying Noace:of Cancellation forms,on the date first written above and 2)was oraltyinformedof hlslherrightto cancel this transaction.OO NOT SIGN THIS-AGREEMENT IF THERE ARE ANY BLANK. Yi SPACES. Future.promotions notappitcable.. '! 'i i t 1� i I he"wed and mcstvaa each pages of this 5 page agreement i r Power Home Remodeling Group Buyer's) ea ..ems ':/oa t � gn 0912&13 SlgnaNrao„ a tleJingGdnsultnsullant SlignalzFeI MatthewGargano. John Frits fi ,YOU,THE:BUYER(s),MAY CANCEL•THis TRANSAc'nON AS ANY TIME PRIOR TO MIDNIGHT OF rKE THIRD Gusmass DAY e .AFTER THE DATE OFTHtS TRANSACTION. ses THE NOTICE OF CANCELLATION FORM FOR AN EXPLANATIOI4 OF THIS RIGHT. §eptember38,20)3'10ag. I illlllll ll�lllll 111 �l ��lll lQl 111 .Page I of 5 E ° t 1 of 1 10/15/2013 7:05 AM NATIONAL HEADOUARTERS John Fritz 2501 Seaport Drive, Chester, PA 19013 t, �O�XIER 30-87407 *. M �d� September 28, 2013 ZI88-REMODELu .. ... MA HIC#168616 Project Specifications Windows: Kitchen 1 38.75"x37.25" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color Cocoa/White: Grid Pattern: None I Removal Wood I Additional Details None fS Windows: Bathroom 1 21.75"x37.25" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None 6 OPTIONS: Color Cocoa I White: Grid Pattern: None I Removal Wood I Additional Details None Windows: Garden 1 46.0"07.0" WINDOWS: Models SL 2700 Styles Garden Types None Configs None OPTIONS: Color Cocoa/White I Removal Wood I Additional Details None September 28, 2013 10:19 IIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIII dw p, Batch ID. Order#/Line# CERTIFIED ' • U-Factor(U.S.11 P) It Solar Heat Gain Coefficient -Visible Transmittance Condensation Resistance I�I�sat_a� 'l4.. ewd.S { I •.nm !;� 'twq e.. �.. r IMB o K OM WIN 5 Fiji Mm �a71p � 1 �[Hpdg�'' ' '�% } y�1W dP. ��� tl}h, %K.SI •v N j