0037,0039 FRANKLIN STREET - BPA B-13-912 1�
q �r ^ The Commoinvealth of Massachusetts
11 y
Board of Building Regulations and Standards SALOF
Massachusetts State Buildin Code 730 CV[R SdMar g f( :"- Revised Mar 2011
Building Permit Application To Construct, Repair, Renoyatelgir Demolish a
One-or Tivo-Family Dtvelling,i o-tt n t;
This Section For Official Use Only.
Building Permit Number: De Applied:',
Building Official(Print Name) j, Signature . - Date
SECTION I: SITE INFORMATION.
1.1 Property Address: , 1.2 Assessors Map& Parcel Numbers
K-
l.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 R) `'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 yesO
SECTION Z:. PROPERTY OWNERSHIP.
2.1 Ownert fRecord: ��'�
esL Gu n, P c.
Name(Prints I/ City,State,ZIP -
37 /-% fos 3.z�--ofy�
No. and d 3tr� Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check a that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work": lac — ( r� 'a Floor— Gtr;ma[ l
/60
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
[tem Official Use Only,
Labor and Materials
1. Building S I. Building Permit Fee: S Indicate how fee is determined:
❑ Standard.,City/Town Application Fee
2. Electrical 3 t
❑'Cata1 Project Cost (Item.6)x multiplier x
3. Plumbin, S 2, Other Fees: S
t. %lechanical (IIVAC) S List:
5. Mechanical (Fire S .
Sn t arcs iun) __ lbnl :\II Fees:.S
(p —-• � Check
heck l Nino. Check Aniuunt ---Cosh Amuuut
Pro PnllCotal i T —
Cl Outstanding I3:11nnce I)ua:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) y3
$7�?�---- - �--�-
_ License Number Expiration Date
Name of CSL I lu(dcr v � - List CSL Type(Sae below) U
M04 Street .
No. and Street Salem MA OPRO- - Type Description
U Unrestricted Duildin s u to 3i,000 cue R.
_ R Restricted 13e2 Fa 11 Dnwllin
Ciryi town, State,ZIP b! blasonr
RC Rootin Coverin
WS Window and Sidi—,
SF Solid Fuel Burning Appliances
0 71y`�ly.� I Insulation
lVe hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) Y� d�y 3 �� /
Atlan!ie,Nyeft`he1'Lantion, TIC MC Registration Number Expiration Date
I IIC Company Name or IiIC Reg"rRtM .ri A"vc1Ue
No. and Street Oda M 10 1 y M Email address
6)-2� ')4�xir.�
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 Issuanc the building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BBUILDING PERMIT
I, as Owner of the subject property,hereby authorize Ems_(
to act on my behalf, in all matters relative to work authorized by this building permit application. 1
Print Owner's Name(Electronic 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
contained in this application is true and accurate to the best of my knowledge and understanding. .
Print Owner's Jf Authurital:\gent's N nu(Electronic Signature) Date
NOTES:
I. ;\n Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Flonte Improvement Contractor(HIC) Program),will not have access to the arbitration
Program or guaranty fund under NI.G.L. c. 112A. Other important information on the HIC Program can be found at
www.nlass.eov oca Information on the Construction Supervisor License can be found at www.mass.,-,tV IL
2. When substantial work is planned,provide the information below:
Told door area(Sq. tt.) _(including garage, finished basentent/attics, decks or porcli)
(lR)S; living;IrCa (Sy. 111 —_ — Habitable room count
Number of tit-glace' .--_------ `'umber of bedrooms
Ntunbcrotbathromoi ._.— Numberothalt'baths
fvpe of heating Sy�tent _ _ ..-- ---___-- `'umber ofdeck / porches
pe of coaling cvstcnt F'ndased ()Pell
lord I'r"I I_eet 1, u_lra Fnot t ulay he ,ub;tinit 1 Ploject l o<t'.
f
Rightfax C3-2 3/11/2013 4 : 45 : 54 AM PAGE 2/'002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
T TIFICATE IS IS§UED 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.
IMPORTANT:If the certificate holder is an 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 and endorsement. A statement on this certificate does not confer rights to
the certificate holder In lieu of such endorsements .
PRODUCER CONTACT
NAME:
EASTERN INS GROUP LLC PHONE FAX
233 WEST CENTRAL ST (A/C,No,Ext): (A/C,No):
E-MAIL
NATICK,MA 01760 ADDRESS:
22MLW INSURER(S)AFFORDING COVERAGE NAIC4
------------
INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY
ATLANTIC WEATHERIZATION LLC INSURERS:
INSURER C:
INSURER D:
61 REAR JEFFERSON AVE INSURER E:
SALEM,MA 01970 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TOC ITHAT THE PO CI O INSURANCE i BELOW HAVEBEEN ISSUEDTO THEINSURED NAMED ABOVE FOR THEPOLICY 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 TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITSSHOWNMgY
HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD SUB POLICY EFF DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER IMMDMYYYY) (MM\DD\YYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE
CLAIMS MADE r7 OCCUR. PREMISES O(Ea occurrence)
RENTED $
ED EXP(Arty one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY E]PROJECT 0 LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea accident)
ALL OWNED AU r05 BODILY INJURY $
SCHEDULE AUTOS (Per person)
HIRED AUTOS BODILY INJURY S
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKER'S COMPENSATION AND X WC STATUTORY OTHER
EMPLOYER'S LIABILITY YIN UB.5B270121-13 03202013 03/20/2014 uMITS
ANY PROPERITOR/PARTNER/EXECUTNE M NIA E.L. EACH ACCIDENT $ 500,000
OFFICERNEMBER EXCLUDEDP
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
Ryes,descries under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED
93 WASHiNTON ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPR 7 TA VE �..- if -„-Y 4'.,.�-"T"�'
SALEM,MA 01970
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1B88-2010 ACID CORPORATION. All rights reserved.
aco o® CERTIFICATE OF LIABILITY INSURANCE DA7(MWOON"Y)
`..� 3/11/2013
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. THI&.CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy()es)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 endorsement(s).
PRODUCER C AME:N ACT Construction
Eastern Insurance Group LLC PHONE (508)651-7700 FAX
ll
i :
233 West Central Street E. IL
INSURE S AFFORDING COVERAGE NAIC#
Natick MA 01760 INSURERA:ALbella Protection Ins. Co. 41360
INSURED INSURERB:Arbella Indemnity Ins Co. 10017
Atlantic Weatheriaation INSURER C Nautilus Insurance Cc
61 Rear Jefferson Avenue INSURER O:
INSURER E
Salem MA 01970 INSURER F:
COVERAGES CERTIFICATE NUMBERMSTER 2013 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 TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR NSR ADDL SUER
TYPE OF INSURANCE iffmAm POLICY NUMBER IMNUD YEFF PPOLICOY EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY EAS Ee occumancal $ 50,000
A CLAIMS-MADE aOCCUR 8500042816 /20/2013 /20/2014 MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000
POLICY X PRO- LOC I $
AUTOMOBILE LUUNUTY COMBINED
MBIffa.c CEDISINGLE LIMIT 1,000,000
B ANY AUTO BODILY INJURY(Per Person) $
ALL OWNED X SCHEDULED 020015971 /20/2013 /20/2014 BODILY INJURY(Per actident) $
AUTOS AUTOS _
NON-OWNED PROPERTY DAMAGE
I
HIRED AUTOS X AUTOS Peraccident $
PIP-Basic $
X UMBRELLA UAS X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000
DED I I RETENTION 600047820 /20/2013 /20/2014 $
WORKERS COMPENSATION I WC STATU- O TIP-
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/PARTNERIEXECUTIVE❑ NIA E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L DISEASE-EA EMPLOYE $
U DESC RRIPTIO yes, IPTIOe under
N OF OPERATIONS balm E.L DISEASE-POLICY LIMIT E
C POLLUTION LIABILITY CPL2003786001 0/1/2012 0/1/2013 GENERAL AGGREGATE $1,000,000
EA POLLUTION CONDITION $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remaras Schedule,It more apace Ia required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF SALSM ACCORDANCE WITH THE POLICY PROVISIONS.
93 WASHINGTON STREET SALEM, MA 01970 AUTHORIZED REPRESENTATIVE
Rosemary Fulham/PIA
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved.
INS025 nmm5tm The ACfTRn name and Innn am mnis:ferod ma�Y�nF aCrTRn
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.tnassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Oiganizaflon/Individual): ATI ANTIC WEATHERIZATION, LLC
61RJEFFERSON AVENUE
Address: SALEM, MA 01970
City/State/Zip: Fi �9Ile ?45-2200
Are yo an employer?Check the appropriate box: Type of project(required):
1. I am a employer with a J 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors -
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t T ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp.insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infennatiou.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
tContractors that cheek this box must attached an additional sheet showing the time of the subcontractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. 1
Insurance Company Name: C l
Policy#or Self-ins.Lie.It: S 2�a+7 D Z Expiration Date: :5 `e2 3 hQ
Job Site Address: Sf- City/State/Zip: fA117 ell
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 and penalties of perjury that the information provided above is true and correct
Sitnature: Z, Date: 5
Phone#, 7Vy-R(Y?
Official use only. Do not write in this area,to be completed by city or town 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#:
Information and Instructions
Massachusetts General laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An,employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does Have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested;not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05 www.mass,gov/dia
Massachusetts Home Improvement Sample Contract
I I '
n ' This form S9lisfies all basicrequire�ents ofhe stare's Idnma Improvement Contractor Law(M(iL ctiapter.142A),but does notincludc aWnderd '
ImguageW protect homeowners(IISeek legal advice ifnecessary. Anyinmemplanning home improvements should first obtain"coy oY"A .
Massachusetts Consumer Guide t nee Improvement"before agreeing do my weak on you residence,You may obtain a free copyby ratting the
OSce of Consumm Affairs and B Mut Regulation0s Consumer Information Hodine at 617.973-8787 or 1-888.283-3757 or on our websife .
Homeowner hiformation Contractor Information - .
.a ama Comp
Name
J11 . G I +rle - P r
Shsrot Aticnst(d "ton ". rc's ox address) Conimeton 8elespersoN Owner sme, -
3? , Ir� s x , • Fa 61 R Jefferson Avenue
Cltyms State ZIP Code business Address(must include a streeggIft a,{A O 1970
. �/1 JJdd II�G�pl ll lYlt1 7 1/
Daytime Phone islhling Phone City/fown State Zip Code
Meiling Address(ft diffettatfromab.1') Eusinese shoos I Fodeml Employer M or S.S.Numbv
' Home Lrymwmru CeMn<twAeg.Num'+v Hary',uim Eue
' • inx nxui,c lhv<mer<M1ema
'" Impeo+•mms<""mr<�anhnw j
r' TbeContractorigreesto do the it'Ilowing worlrfor the Homeowner:.
(Dealbe in detail the wurk N complet ,speeifyiv9the type,bond.and guide of assaults to be used,Mg.gddinonal sheets rf neeessmy)
41,CAL k r�c F100 f 1 L a b., 5 ..
F,Go'r T� a t �ti�ls.
r
Required Permits•The followin )juildinglummits are required Proposed Start and Completion Schedule-The following schedule will
and will secured by the contact r as the homeowners agent: be adhered to unless circumstances beyond the coaknomr's.coatm]edge
(Owners YAm secure their ubvn permits will be ` 3
excluded from the Guara+Fund prov=10 sof J 17 / Date when contractor will begin contracted work
MGL chapter 142A.). f7' 3
Daze when contracted worlc wib be mbs=tlally completed.
Total CanlrsetPrice and Paymet�Schedule
11te Contractoragrees to.perfermi wart;famish the encomia]mdlebor specified above for the total sum of
Payments will be tpadc uccorddmg Out,fo1lowing4rhedule:.
§ 1206--Puponsigringeon�L - 113 - -
Scf(n6t fo"eieeed -'ofthe tdml't6vtreEtprice3S"Ehe cd§t'ofspetli"7 order i etmms,whioobefa`m grZeter
$ by m upon completion of -
0� — r
§ _by //y, m upon completion of -t� + "• V ur b -
§ yy�. uponcompledov bl'thecontract (Lawforbidsdemmdingfullpaymeutm'-Murat is compel etedto both patty's satisfaction"
The following meWdaVequitun' must be special 8 weepei fo
ordered be..the edso actcd win'k(k n giru in order "asJ�s"4pC
to meet the completion schedule.!') $ to be p d or +
NOTES:(e)In.1%xiig oil finance che;icv("e)Law requhea that any deposit or down-payment requhed by the connector before work begins may r
not exceed the gnaw offs)one-third oftho total contract price or(b)the actual cost of airy special equipment m custom once mutant
which must be special citi(i ul in advance to meet the compictim schedule.
E W -I trl [vhl id dlw th t ter QNE]Y (,It Ur fth N tbEt her 1 t)
subcontractors•the contractor agrees to be solel sipormble for completion ofee work described regardless of the actions ofany third `
party/subcontractor utilized by the Uatraomr. The contractor further agrees to be solely responsible for all payments toall subcontractors for
ten I ill 6 d his em [
Contract Acceptance-Upon signifik, this document becomes"binding contractunder law. Unless otherwisenctedwithin this docummt,the
contract Shall not imply that any ll 6r other security interest has been placed on the residence. Reviewthefollowingeautionsardnotices
cmElhlly before signing this covtra -
e Don't be pressured indo signiny+he--tract,Take time to read and fully understand it Ask questions if something is unclear.
e Maim thecontractor h Ili!gd Home Initorovement Contractor Registration The law requires mostbome impmvemevt cmt actors and
subcontractors to be registeredoJ ith the Director of Home Improvement Contractor Registration.You may inquire about contractor
registration 6y writing to the Drector at 10 ParkPWza,Room 5170,Boson,MA 02116 or by calling 617-973-8787 or 888-283-3757.
Does the contractor have fnsmedce7 Askthe Contractor forhis insurance company information so that you can confirm coverage,or ask to
see a copy of e'proof ofinsuoLec"document
e Know you rights and responsibilities. Read the Important Information m the reverse side of this form and get a copy of the Consumer
Guide to the Home Improvement ConaaotorLaw.
You may cartel this agreement!fit has been signed at a place other thm the commandoes normal place ofbusiness,provided you notifythe
contractor in writing at Weber mainldffice or breach office by ordinary mail posted,by telegram sent or by delivery,not later thm midnight ofthe
@ird business day following the signing ofthis agreement Seethe attached notice of cancellation form form-planation ofthis right
DO NOT SIGI;r THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! -
. '/ IWoidcnticaloppi<a ofNa cpptractmvth wmpletrA eMrigoea One wpy rhoWL gobtMbovuownu,]fu aNv cM 1ir W/dbes�eApl-by Neon treror
m
Hoeowner's Signature Contractor's" rgnnmre�
Date Y� Date
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners with the right to initiate anigbitration action(as an
alternative to court action)if they have dispute with a contractor. The same right is r141 automatically afforded to a '
coatractor,however. Tire contractor would have to resolve any dispute he/she has with alto eowner in court unless -
both parties agree to the optional clause provided below. This clause would give the contrtor 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 gqgntractor has a dispute
conceriling this-ioonlract,theeohtractbrmhy submit the dispute to a private arbitration fiat jvhich has been approved by
the Secretary pf.the Exectutve.Office�of Consumer Affairs and Business Regulation and thb consumer shall be required
to submit to.such arbitration as provided In Massachusetts General Laws,chapter 142A.
Homeowner's Signature Contractor's Si
NOTICE:The signatures of the parties above apply only to the agreement of the parties t9 alternative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute res94fflon even where this -
section is not separately signed by tliq parties.
Homeowner's Rights
A homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A� d other consumer
protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement.,I However,homeowners
may be excluded from certain rights it,tile contractor they choose is not properly registered p prescribed by law.
Homeowners who secure their own buildingpermits are automatically excluded from all Guaranty Fund provisions of
s the,Home Improvement Contractor Law. The contractor is responsible for completing the ork as described,in a
timely and workmanlike manner. Homeowners may be entitled to other specific legal righoif the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to arantees or warranties
provided by.the contractor,all goods sold in Massachusetts carry an implied warranty of mcbanmbility and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contraptor 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 Hotl'i'e(listed below).
Execution of Contract - -
The contract must be executed in dllplicirt and should not be signed until a copy of all a its and referenced
documents have been attached. Parties are also advised not to siol the document until aIlIaauk sect ons have been
filled in or marked as void,deleted,or not apply--able. 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 on ' contract
. . -and-agreed to bybothyffities-e4ntmare-BwoiKm yno egrnunt ar_t"[e`s'^have ie21 red a fully executed copy of the contract,and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment 5'hedule 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 duel t a placed in ajoint escrow
account as a prerequisite to continuing the contracted work Withdrawal of funds from s#account would require the
signatures of both parties. - x
Additional Information
If you have general questions or need'additional information about the Home Improverric. Contractor Law or other
consumer rights,or if you wish to obtain a free copy of "A Massachusetts.Consumer Guide to Home Improvement"
contact:
j
ConsumcrInformation Hotline
Office of Coi> ffairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116 j
617-973-8787,888-283-3757 or visit the OCABR website at htto•//www ri r ss eov/ocabr/
If you want to verify the registration of a contractor or if you have questions or need additonal information specifically
about the contractor registration component of the Home Improvement Cont actor Law,cpRtact:
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room5170,Boston,MA 02116
617-973-8787,888-283-3757 or visit the HIC website at btm-//www.mas1.go_vLocabtL
Go reline to view the status of a Home Improvement Contractor's Registration:
htm//db state ma us/homeimprovementtHg!inseelist asp
For assistance with informal mediation of disputes of to register formal complaints ag ' a business,call: - -
Consumer Complaint Section
Office of the Attorney General
617.727-8400
AND/OR
Better Business Bureau �I
508-652-4800,508-755-2548 or 413-734-3114
Version 2.1-11)2=01a
it
Unrestricted-Buiidings Of any use group which ; y :Niassecf.usetts -Depart'mem of Pu 11c^2FE11
contain less than 35,000 cubic feet(991d)of Hoard of Bu idirg Regulations and Standards
enclosed space. i t13t5?iiL'edal:tin l:s a1?' F
license:C"87977
ERIC W PALL-' r-
3HMTONST,
SAI.EM MA-01970 /t
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Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
ForoPsumminginformationvisit w -Maw.Gov/DPS
Ccm!slissiorer 04/2312014
License or registrefion valid for individul use only " % �nr ,
before the expiration date. If found return to: Office of nsamv
3r Office of Consumer Affairs and Business Regulation HOME IMPROVEMENT CONTRACTOR
Registration: .442089 Type
10 Part[Piaza-Suite 5170
Soston,IYLA02116 _ Expiration 341=014 Ltdltabi0lyCorpor,i
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A IC WEATHERIZATION:LLC.
ERIC PALM _
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,,. 100A'�1 61RJEFFERSONAVE
Not valid without srgna re _ SALEM.MA 01970 - Undersecrelar9
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