6 FRANCIS RD - BUILDING INSPECTION e _
The Commonwealth of Massachusetts
S_Ik;
Board ofBuilding Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revived,Nar 201/
One-or TWO-Family Dwelling
This Section For Official Use Only
Building Permit Number:
Date Applied:
Building OtTicial(Print Name). b' - Z � '
Signatpre- Date
SECT. I:SITE INFOR:VIATIONt
LI Property Address:
L rnr {az Cc S 1.2 Assessors hlnp& Parcel Numbers
a Is this an accepted street?yes_ ❑o btap P.umber
I%cruel Nun— �b�r --
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Ua�—
Lot Area(sy It) Frontage(R)
LS Building Setbacks(R)
Front Yard Side Yards
Provided Re
Require) Provide) Rear Yard Required aired
y Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information:
Public El Private Flood Zone?
Private❑ Zone: A. Sewage Disposal System:
_
Check if es❑ Municipal❑ On site disposal system ❑
2.1 Ownert of R SECTION 2: PROPERTY OWNERSHIPt
ehhord:
.�Gn(P�itu)nt) Yin1Sp hirl /L1 Q�ne c' 0f47a
r a s „ _ pUtyy,state,zip
No. m:J tbtrnGctn —K,1! 770 Z� l 1ll`(�
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED 1VORK'(check all that apply)
New Construction❑ Existing Building Owner•Occupied. I Re airs s ❑ Alterations ❑Demolition Accessory g F O O Addition ❑
❑ Accesso Bldg. ❑ Number of Units
Brief Description of Proposed Workz: .S —L Other ❑ Specify:
l-shy aivF
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs:
Labor and Materials Official Use Only
I. Building $
13 I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
3. Plumbing $ ❑Total Project Cosh(Item 6)x multiplier x
?. Other Fees: $
4. Mechanical ( re $ List: �
5. i\Iechanic:d (Fire
Su ression) $ Total All Fees:S
6. Total Project Cost: Lc,� Check No._Check Cash Amount:
f ❑Pail in Full ❑Outstanding Balance Due:
�?Cu.Q d'o � o►�d���
SECTION 5: CONSTRUCTION SERVICES '
---
nstruction Supervisor ay3s I
5.1 Co
License(CSL) License Number Expiration Date
rPv✓l�el!
seebelow)� —
Name ofCSL HolderList CSL'fYPe( ' r
?� .rype. Description
No.and Street U Unrestricted(Buildings u to 35,000 cu. It.)
It Itesmcted I&Z L L- ily Dwelling
M Nlason -
Cityfrown,Slate,ZIP RC Rootin Coverin
INS1Vindow and Sidin
SF Solid Fuel Burning Appliances
I Insulation
77U 3�°--.-F'b Email address D Demolition �7
'rele hone `/f/l(o
5.2 Registered Home Improvement Contractor(HIC) EI[C[icgist r Expiration Date
r �H CAI`
IIC Company Name or HIC�I �tstrant Name Email address
I
No. lid Street
I'F �SOt3 -7 2111
INtDD 'rele hone
Cit /Town,State,ZIP
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MtG t c 152.¢ 25C(
ompleted and submitted with this application. Failure to provide
Workers Compensation Insurance affidavit must be c
this affidavit will result in the denial of the Issuance of the building permit.
No........... 13
Signed Affidavit Attached? Yes ........../�
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
work authorized by this building permit application.
t9 act on my behalf,in all matters relative to
Date
Print Owner's Nmne(Electronic Signature)
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 i is application is true and accurate to the best of my knowledge and understanding. Y
U�` Date
Print Owner's Aut ized Agent's Nam (electronic Signature)
NOTES:
Will not have access to the arbitration
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 Other
important
Program),
program— o- —r guaranty fund under N�the Construction A.O Supervisor License
can be found ormation or'the at%�rogllaSS N 111-swwxfound at
7 When substantial work is planned,provide the info lm ction beloange, finished basement/attics,decks or porch)
Total floor area(sq. ft.) Habitable room count
Gross living area(sq. ft.)____-- Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Nuniber of decks/porches
'rype ofheating system Enclosed —Open
rype of cooling system
3. ""Ibtal Project Square Footuge'may be substituted for`"rotul Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dla
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print lAzibly
m Nae(9usinessiviga�niiationandiviidTduai): CWC-)2 ! I u Ori1C �CMCOELIN6 C��1�/�
Address: 8110 /fESiF P/1
City/State/Zip: Phone#: lclC-L7y-200
ArMI
en employer?Check the appropriate hoi: Type of project(required):
Im a employer with IS' 4. 0 1 am a general contractor and 1 6. ❑New construction
ployees(full and/or pert-time).' have hired the sub-contractors7. ❑Remodeling
2m a sole proprietor or partner- listed on the attached sheet r
ship and have no employees These subcontractors have 8. Demolition
working for me in any capacity. workers'comp.insurance. 9. Building addition
o wo ers comp.insurance
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1-am a homeowner doing all work right of exemption per MGL . I I.0 Plumbing repairs or additions -
myself.[No workers'comp. c. 15Z§I(4),and we have no t 2.0.Roof repairs
insurance required]f employees.[No workers'
... - comp.insurance required.] I3.❑Other ._
.Any applicant that checks box si a=also fin out the ration below showing their workers'omopesadon polity tafirmatiaa. ._
i Homeowners who rubmir this atndavit indicating they ate doing all work nal dreg hire anrts a coLbanom mini mbmit a new aSidavht indicating such.
tCaneaceets then check dds has most attached sa ddidoml sheet shoving the same of the subcommeors and their wohm'comp.policy information.
I airs an employer that is providing workers'compensation insurance for my employees Below is the policy and job.rite
information.
Insurance Company Name. NJAR� s✓)LLEW6PC:E5TEe— �/�/s C6
Policy o er Self-ink.Lie.a; •�'C OO OO 00 d V_!C' r�}q6 Expiration Date lot i j•
Job Site Addres City/Stalerzip.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and explratlon 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 S 1,500.00 and/or one- eat imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a y e 'olator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations o the D for coverage verification.
I do hereby c un er e p and penalties of pedury that the infor madom provided above is true and correct.
aim A Date:
Plitt M
Officlhl use only. Do not write in this area,to be completed by city or row"official
City or Town: Permit/l-icense it _
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone N:
/hV
CITY OF Siv-F— I, tiL1ss.1CHUSETTS
?, r 131:=LNG DEP:IRTJLEYT
` 120 WASHLYGTON STREET, Y4 FLOOR
TEL (978) 745-9595
Fla(978) 740-9944
KEN�ERLEY DttISCOI.L
AAY0:1 TumLAs ST.PtERAa
DIRECTOR OF PUBLIC PROPERTY/BUILDLN(;CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
fn accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5
Debris, and the provisions of NfGL c 40, S 54;
Building Permit tk this work shall be is issued with the condition that the debris resulting from t 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by j'vfGL c
The debris will be transported by:
y � I
(name orheuler) .
The debris will be disposed or in
(name of aciility)
--��"
(address ot'taeility)
I
i knirlt
of permit applicant
,te
about:blank
NATIONAL HEADOUARTERS Maggie Rouse
1101 leapat 01W*Chener.PA 190 i3 2i��
WER 3D-96230
January 13,2014
888-REMODEL U Mn HICp 1®a1P
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyer.Information Project Number:30-96230 January 13.201a
Maggie Rouse r'wOOra°°'we
8 Francis Rd (508)783-7959(Mog9ieY Call) magrouse7a®hotmall.mm
Salem.MA,01970 (978)745.1490(Home) Eawnnds.n t
County:Essex
Township:
Buyar(s)listed above hereby jointly and severalty agrees to purchase the goods and/or services of Power Home
Remodeling Group("Contractor")In accordance with the prices and terms described on the from and the following four
pages of this agreement and any specifleatloh shoals,which are Incorporated as,part of the Agreement(Collectively,this
"Agreement").This Agreement represents a cash sale of goods and services.Buyer(s)agrees to pay the cost of the goods
and services purchased as described herein,regardless of timing or approval of any financing Buyerfs)may seek for their
purchase.Problems and Inquiries regarding this.Agreement should be directed to the Contractor at 1.888.73"335.
Purchase Pdra: $13,515.81 1 Pre Installation Inspection Date:
Down Payment: $0.00 om PM.la mMa on the l/sa hamxn 19:00a and 11:00.
Balance Due on $13,515.81 Estimated Project Start:5 to 6 weeks
Substantial Completion: Estimated Project Completion:2 to a days
Method or Payment Other DaeNteaompMbndala is W.1 meepe.nea.asenua)aN Comeesee rumor not Inmates,In
®'c,aating emo homes.gas Dmay Velmwn CaMNons on Mwee.
Buyers)hereby acknowledges receipt of a copy of the pamphlet"The Lead-Safe Cortifled Guide to Renovate Right",
Informing 8yy (a)of the potential risk of lead hazard exposure from renovation act"to be performed In Buyers home,
at the addrd rNteIt above.Buyer(s)received this pamphlet on the date of this Agreement,before Commencement of
vrork (Buyer's initials).
It is agreed and understood by and between the parties that this Agreement constitutes the entire understanding between
the parties,and there am no verbal understandings changing or modifying any of the terms of this Agreement.Buyet(s)
hereby acknowledges that Buyer(s)1)has road the entire Agreement and has received a completed,signed,and dated Copy
of this Agreement Including the two accompanying Notice of Cancellation forms,on the date Bret written above and 2)was
orelly Informed of his/her right to cancel this transaction.DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK
SPACES.
Future promotions not applicable.
I have reatl and recelved.gash page of this 5 page agreement
P or Home Re o elin Group / Buyer(s)
/ovt3na `� /� /Ovt3na
Signature of emodelln Consultant V Signature e
(Jeremy Yogel Maggie Rouse
YOU,THE BUYER(S),MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY
AFTER THE DATE OF THIS TRANSACTION. SEE THE N0710E OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.
January i3,2014 19:58 II�O IWIBI�IBI�u�Il IuII�OII�� Page 1 of 5
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement*Contractor Registration
w� Registration: 168616
{,i { e _ " Type: Supplement Card
0 ,�:. ! Expiration: 3/18/2015
POWER HOME REMODELING GROUP LLCau
JUSTIN SMITH
�
2501 SEAPORT DRIVE STE 6110 ��?�, r�-,s ,. -- f ;
CHESTER, PA 19013 - '
Update Address and return card.Mark reason for change.
$CA1 0 20m-05/11 Address ❑ Renewal ❑ Employment 0 Lost Card
�,<ee�eaawinomweallLe o�'C/uadoac�xuaelta
Mice of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
., Office of Consumer Affairs and Business Regulation
V' egistrat' !o 168616 Type: 10 Park Plaza-Suite 5170 -
Expiration�3M'8/20"15;;it Supplement Card Boston,MA 02116 '
POWER HOME REMODELINGORpUP LLC.
JUSTIN SMITH a'S,
2501 SEAPORT DRIVE?STE_BA90
CHESTER, PA 19013 Undersecretary Not valid without signature
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License. CS-093980
��
r,ri.v
O r Uri
JUSTIN W SMITW
399 ri Hartford 156
Uxbridge MA 01569
NO
Si,2 , ��"""''� Expiration
Commissioner 01/051`2016