41 FELT ST - BUILDING INSPECTION (2) g3ZS cis S i
The Commonwealth of Massachusetts »RECEMU. 5
Board of Building Regulations and Standac SPF IOH A� S Rv(CI"FY M
�i Massachusetts State Building Code,780 C R SALE 20I1
Building Permit Application To Construct,Repair, Renovate IMIP"lilk
(1 One-or Two-Family Dwelling
l� This Section For Official Use Only .
Building Permit Number: Date plied:
1 Building Official(Print Name) p Signature - Date
SECTION 1:SITE INFORMATION
1.1 P7rty A Grgsg: �} I 1.2 Assessors Map&Parcel Numbers
1.l 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)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
i
1.6 Water Supply:(M.G.L c.40,§54) 1.T Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zo ie: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system El
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerr of Record SNSctn /YN&f SS )kOhf'YI S t&1 2
Name(Print) City,State,ZIP
(11 f GI�- Sf.
7yti-su 9
No.and Street i Telephone Email Address
SECTION 3:DESCRIPiP10N OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: S7t� /oll� /
Brief Description of Proposed Work2:
SECTION 4?ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials y
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ElStandard City/Town Application Fee
❑Total Project Costa(Item x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
MAt � zI (S
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SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O -?J-7-7 y 3
L—icense Number Expiration Date
Name of CSL Holder
Eric W. Pt,hli List CSL Type(see below)
No.and Street f fifton Street Type Description -
Salem 1V1A 01970 U Unrestricted(Buildings up to 35,000 cu.f1.)
R Restricted l&2 FamilyDwelling
CityfFown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
� SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I L4
Atlantic Weeeci�sinn,r r[ HIC Registration Number Expiration Date
HIC Company Name or HICRrgi a Nam A'Vellle
No.and Street Ol Salem MA 01970 Email address
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 Issuance 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
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I,as Owner of the subject property,hereby authorize C�1r;+G C4 (VY1
to act on my behalf,in all matters relative to work authorized by this building permit application-
.Y.LIt�RM rj/�1A 11A Yp�.�OM� I I ✓ I �- IN
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I
By entering my name below,I hereby attestiunder the pains and penalties of perjury that all of the information
contained in d�»s pliption i true, to to the best of my knowledge and understanding.
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Print Owner's or Authorized Agent's Name(Electronic Signature) Date
I 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)Prog
ram),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
evw-w.mass.eovioca Information on the Construction Supervisor License can be found at www.mass.eovidns
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) i 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"
1
Massachusetts Home Improvement Sample Contract
This form satisfies all basic requirements of the states Home Improvement Contractor law,(MGL chapter 142A),but does not indude slaudard
lougunge to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obmha a copy
Massachusetts Consumer Guide to Horne Improvement"before agreeing to any work on your residence.You may obtain a five copy by calling the
Office of Consumer Affairs and Business Rwilation's Consumer Information Hotline of 617-p73-8787 m 1�88-2Obtain>or on our svebai in
Homeowner Information Contractor Information
N Co. yName
�uS�c,h �Ir.(Ss keener
Smst Address(do not aPost OlOce Bn address) Cmnuactmf Salesp N a
o -,L 5'77. 61'R kffasbp AVWUe
""town Smi. Zip Code Basins Address(mest inc l4H¢/ppet alldfeas)O1n7o
se/V4 O217G111 IVI!'1 7
DaytuneJJPh�o••nlle Esening Phone ""N Owa State Zip Code
97 S• ��y-s��
Meiling Add.(it differem farm above) Business Phone FederalEmployer 0 or S.sNumber --
r�nn�aaan�t mnrmrt car H•�rogorma Cmamm a4 m®i- Fein
m l�lao�q 3/�7� (0
.rmr¢emma some..
The Contractoragrees to do the following work for the Homeowner.
(Describe in derail the war:to completed,st zi4ing the type,bound and guide of materials to be used,lMtgddili a1 h f
c
A S
Required Permits-The following building permits are required Proposed Start and Completion Schedule-The following schedule will
and will be secured bythe commtlor as the homeowner's agent: be adhered to unless circumstances beyond the contractors control arise
(Owners who secure their own permits will be G
excluded from the Guaranty Fund provisions of Z Z7 Date when contractor will begin committed work_
MGL chapter 142A.)
JZAI_Date when coutracted work will be substantially completed.
Total Contract Prim and Payment Schedule
The Contractor agrees to perform the work,famish the material and labor specified above for the total sum of. �✓(/(/. (.)
Paymnemmmss will be made according to the following schedule:
S .� _ upon signing contract(not to exceed 1/3 of the total contract price or the cast of special order items,whichever is greater)
S by /_/_or upon compietum of
S�V�V/rV��" by IOc Aal�or upon completion of f p)Qi C2 Zry—
S�"1 V[/. upon completion of the contract. (Law forbids demara " g full payer t until contract is compl ed to both party's satisfaction)
The following material/equipment mutt be spatial S o psi
ordered before the cmuramed neck begins inorder
to meet the mmpletiom s,hedulct—) S t be t.o
NOTES:(•)including all firmnm charges(••)lawrounim that any deposit ordonu-psymmt required by the coomactor before work begins may
net exceed the rpeater of(a)one-third of the toil conoam prim m(b)the Wail cost ofany spatial equipment or custom made material
which most be special ordered in advance to raw the completion schedule.
Esnrns warranty-Is on express wnrrantvh " o 'dedb M1 v ❑� ❑y ( 11 ftA b tat belt h ten 1
Subcontractors The contractor agrees to be solely responsible for completion of the work described regardless of the actions of my third
party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for
materials and labor under this atarmatent
Contract Aa'cepmnre-Upon signing,this document becomes a binding cantram under law. UNess otherwise noted withm this document,the
contract shall not imply that my lira or other security interest has been placed on the residence. Review the following cautions and notices
carefully before signing this contraR
• Don't be pressured into signing the contract Take time to read and fully tmdermand it Ask questions if something is nuclear.
• Make sure the contractor has a valid Hame Immovereat Contractor Registration. The haw requires most home improvement contractors and
subcontractors to be regstered with the Diremor ofHome Improvement ConvactorRegisuation, you may inquire about contractor
registration by writing to the Director at 10 Park Plaza,Room 5170,Began,MA 02116 or by calling 617-973-8787 or 88g-283-3757.
• Does the contractor have insurance? Ask the Contractor for his insurance company information so that you cat,confirm coverage,or ask to
see a copy ofa'yroofof insurance-document.
• Know yore rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement Contractor Law.
You may cancel this agreement if it has been signed at a place other than the contractors normal place ofbusiness,provided you notify We
contractor in writing at histber main office or branch office by ordinary mail pasted,by telegram seat or by delivery,not later than rnitinight of the
third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation ofthis right.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!!
`ITwo Nmmmt main ardr/e1m/verso mvn le1wm/Plead and s�nrd O�smW'sMuW3nm We homwnve.lAeodcwP!'shodd AelePtby the svoumnr.
Homowner's Signature Contractor s gramme
me
►Z�rs/i� i� ��
Dare Date z
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 patties 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 contractor[nay submit She dispute to a private arbitration firm which has been approved by
u,;.
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shad be required
to submit to such arbitration-as pmi,fif d lit Massachusetts General Laws,c ter 142A.
LAt1m Ah una,ICivYteM /
Homeowners 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 contractor. The homeowner may initiate alternative dispute resolution 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 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 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 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 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 may be
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 most 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 the three day rescission period has expired.
Accelerated Pavments
A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the
homeowner deems him/herseif 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 joint escrow
account as a prerequisite to continuing the contracted wo& 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 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 /ncabr-
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
617-973-8787.889-283-3 757 or visit the HIC website at huo:/Am w.mass_,Wocabri
Go online to.view the status of a Home Improvement Contractor's Registration:
oitn:;id'estate.ma.l�Poonleimurovement/licenseelist asp
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
A
_ Coos&ner Complaint Section
Offke�f the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-652-4800,508-755-2548 or 413-734-3114
V=ion 2.1-IIP 010
The Commonwealth of Massachusetts Print Form.
Deptrrdnent oflndustrial Accidents
Office oflnveshgadons
l Congress Street,Suite 100
Boston,MA 02114-2017 i
wwwu mass.gov/dia
Liop
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A2nlicant Information Please Print Leelbly
Name(Business/Organization/Individual): Atlantic Weatherizution,LLC
Address: 61 K Jefferson Avenue
Catem MA 01970 _
City/State/ ip: Phone
Are you employer?Check the�ppropriate box:
1. am a employer with 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/orpart-time).* have hired the sub-contractors 6- ❑New construction
2.(] 1 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'
[No workers'comp, insurance comp.insurance-t 9- ❑Building addition
required-1 5. 0 We area corporation and its 10.❑Electrical repairs or additions
3-❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp• right of exemption per MGL 12 Q Roo arts
insurance required]t c- 152, §I(4),and we have no
employees. [No workers, 13. ther__�ill� ilCtT�2kJ
comp.insurance required.]
"Any applicant that checks box#, must also fill out the section below slowing their workers'compemsation policy information_t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
emonnaaors that check this box must attached an additional sheet showing the name of the sub-:ontractors er
and state whethor not those entities have
employees. [Fthe sub-contractors have employees,they must provide their workers'comp.policy number.
lam an emplayer that is providing workers'compensation insurance for my employees Below is the policy and jab site
information.
Insurance Company Name: tit rr
Policy#or Self--ins.Lic-#_ L3 2-70 l Expirntion Date: J 3/
Job Site Address:_ FA-/11 Si—— City/State/Zip: ivy,2/7p
� sn
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration
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 S I,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 cerfi un flee ain: and al *ELM u that the IA(ormation provided above is true and correct
Sienature p Date /a /
Phone#: / 7 �- ��� �i L/ 3 r
O
fficialonly. Do not write in this area,to be completed by city or town glj£eid
n: Permit/License#
Issuingority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing inspector
son• Phone#:
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