12 FREEMAN RD - BUILDING INSPECTION (2) •
(A
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official UseOnly
Building Permit Number: 9W Applied:
A
Building Official(Print Name) #. - Signature - Sate_rn
SECTION 1:SITE INFORMATION o -•t
1 1.1 Prope Address: I 1.2 Assessors Map&Parcel Numbers N z
rT
-� 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number rVTl
�\01 1.3 Zoning Information: 1.4 Property Dimensions:
(�' Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) rJ 4t;i
T
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) 1.71 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSIRP'
2.1 caner of Re
Name(Prim) { City,State,ZIP
12 Ef t-Clrs�cn If 7R' r16- 8�1s0
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑I Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units_ Other Specify:
Brief Description of Proposed WQoor
Vl�:
f
SECTION 42 ESTIMATEUkONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
abor and Materials
1.Building $ I 1. Building Permit Fee:$ Indicate how fee is determined:.
2. Electrical $ ❑Standard City/Town Application Fee
Total Project Costa(Item 6)x multiplier x
3.Plumbing $ I 2. Other Fees: $
4.Mechanical (HVAC) $ List:-
5-Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ J 1(D -
❑.Paid in Full ❑Outstanding Balance Due:
SEN 1 l 12� -TO P',n . U-�
SECTIb N 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S 7 C-7—7 y 3
License Number Expiration Date
Name of CSL Holder
F;f1l: W. f:;dill List CSL Type(see below)
No.and Street Type Description
lfh
Salem MA 01970 U Unrestricted(Buildings up to 35,000 cu.ft
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
D 1 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ' 14���
HIC Company Name or H/� 'ttn HE HIC Registration Number Expiration Date
eft fSOA Avenue
No.and Street Salem lA 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........1. 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 lauthorize Er-, C a I(VY\
to act on my behalf,in all matters relative t C work authorized by this building permit application.
Qo..uQ �pCti�� 11 '2 2�1y
Print Owner's Name(Electronic Signature) I 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 is application is true and accurate to the best of my knowledge and understanding.
� 4Y ry �✓+�tiF /�lzz/�✓/
Print Owner'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 an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L1 c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.. (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) 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 I Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
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Contractor pJbitratiom - tint an arbitration action Was an
,he Home tmmro ement Cano-Actarlaw pmvides humannvets with the right m ini
alternative to court acdon)ifthe_v have a dtsputevvith a contractor_ The same right's ,1 a ot automatically afforded le s
comracmr,however. The connmctor}vnuld have to resolve any dtsautehershe hasvvi0r ahomcowna in cnur unless
both parties we to the optional chm' providedbelmV. This clam would give the catttraaortlte same ri�ttto
arbitration as is aftordedto ihehomeownerby the Home Itnprovemeat Contractor Late.
The wntracmr end the homemVeer hereby mutually agree in advance that in 0me goon the contractor has a dispute
coneersdag this contracr,the contractor may submit the dispute to a private orbimation.fum which has been apmoved by
the Secretary of the EcecutWe,Office of ConsumerAffalrs andBusimem Res+tlanon and the consumer shall be required
[o submit m such athitranon.as pMvi4d In Massachusets General Laois:chapter i` {
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Homeowners Sisnatum
Cont;a�toi's`Stgaattue
NOTICE:The signatures of the patties above apply only to the agtteentem of thepliMes to altemanve-dispute
resolution initiated bythe contractor, The homeownermaY initiate altemaiive dispu resolution even where dais
section is not separately sued by the parties_
Homeowner`s Rights
A homeonnee's riphisunder the Home Impmvemam Contractor Law(MGL chapter 142A)and outer However,homeowners
o consumer
protection laws(ie.`dGL chapter 93A)may not be waived in any nfi,even lip geese' d asntn ed be lavvners
may be excluded fiam certain rlghtsifthe contractor they choose u not properly rrom
Homeowners who secure their own building permits are automatically excluded f70in all Guaranty Fend provisions o
the Home improvement Contractor Law. The contractoris resconsibie for completing the week as desa ibeti in a
timely and work-manlike rnamrer. Homeowners may be entitled m otherspecific legal nghss if the contractor
wnrantees or provides an exPtess wen ad}'for wnrimmnship or materials. In addition to guarantees or wananties
provided by the contractor all goods sold in Massachusetts cam• m implied warranty ofinerchamtability and fitness inr
a particular purpose. An enumeration of othermaners on which thehomeawner and contractor lawMY Wee maybe
added to the terms of the contract as lone-as they do not restrict a homeowners basic consumer rtbm lfyou have
questions about your consumedhomaownerri¢_hts,contact the Consumer Infomtatron Helaine(listed below).
Execution of Contract
The contract must be executed in ' alcove and should not be signed unu7 a copy of all all
bla is sec referenced
documents have been atracha& parties are also advised not m sign the document rmtil all blanksectiens have been
filled in ormartmd as raid,deletad.or not applicable- One original s_aned cagy ofthe contractwith attachments s:o
be given to the owner and the othakeptby the contractor. Any modification to the original contract mist be in writing
and agreed to by both parties.Cnt acied workmay notbegin until both parties Itsve received a fully executed copy of
the contract and the thtee day rescission period has ea-phed
Accelerated Payments i
A contractor may not demand paytgents in advance of the dates specdred on the p rent schedule in cases where the
homeowner deems him the be financially hlse m-the balance its= due be placed tor
de a s macro elf
to be financially insecaa the contraemrmm regtthe ,-
account as a prerequisite to continuing the contracted nm& 'Withdrawal of funds from said account would require the
sigma esofbothparties.
Additional Information
If you have general questions or need additional information about the Home Improvement Contractor Ian or other
consumernghss,cell}nunishmobtainafreewpyof-A_messacbusetts Consumer Guide tbHomelmpmvemant'
conmcc
. ConsumerinformationHadine
Once of Consumer Affairs and Business Regulation
10 PakPlaza Room 5170.Boson.MA 02116
617-9rA787,888-2II3-3757orvtsittheOCABRwebsitea_
if you want to verify the registradon of a contractor or if You have questions or need additional information soecificalh
about the contractorre_eistration component of the Rome Improvement Conine i r Law,contact:
i
Oiiieetor of Home lmptotemetrt ContcacterRe-mstmnon
dfncz of Coasumer Affairs and Business Re-,gahon
lopakph. Room 5170,BostonNMA021I6
617-9Tj$78Z 888-383 37i7 or visit the 19C w2bsite'at.
Go onaine to dew the sm nu
ms ofaHame Improvement Caactors Reeistrationc
._i -- - - "''tc--=i•-•r_ •ter-,_;p::w-wits-�a
Forasmee withinfbrmat mediation ofdisputes or to retistar formal wmpiainss against a business,call:
sts
Constar=Complaint Section
office of the Attorney General
61?-737-SgOU
AND/OR
i Better Business Bureau
508-652-4800,50S-7i5-254&or?I3-T43114
The iComrrtonweaith of Massachusetts
Depar"nerxt oflndusirialAccidents
Of,face oflnve,%*ations
I Congress Street, Suite 100
Boston,MA 02114--20I9
Workers' Compensation Www'massgov/dia
A lie ant Inform Lion Insurance Affidavit: Builders/Contractors/Electriciam/-Plumbers
Vame (Businesdorganizas; . t Le 'blot.rtnd;hd„�): / ,1ah1y( - Please n
Address: Cr1 2. e
City/State/Zi
Are yo employer?Check the 11
�Q/�.7 O Phone#: 9? • 7Ll�/ �/y 3
IPpropriate boa:
employees am employer with 4. Q I am a general contractor and I Type of project(required):
(full and/or Part time). have hired the sub-contractors 6• ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees i These sub-contractors have 7. Remodeling
working for me in any capacity. employees and have workers' $' ❑Demolition
[No workers' comp.insurance comp. insurance.t 9. Building addition
u"ed'j 5.3• Q We are a corporation and its _ I0.El Electrical repairs or additions
I s a homeowner doing all work officers have exercised their myself. [No comp, right of exemption per MGL 11 0 Plumbing repairs or additions
insurancea required.]t c. 152> 4, 12.0§1{ ) and we have no Roof repairs
employees. [No workers' 13.�er w3 rn
*Any applicant that checks box.1 must also comp. insurance required.]
t Homeowners who submit this fill out the section below showing their warkm,compensation policy hd•Contractors that Cheek this affidavit indicating they.are do' P t submit must attached an additional sheet Showing and then trite outside contactors must submit a new affidavit indicating
employees. If the su-o.contractorshaveemployee,,drayHurstprovidewingrworkers•he name f the sub-connrsmts and state wh entities
ether or not those
I am an employer that Ls providing workers'co �'policy number.
infornuuion - C.n tion insurance for my employees Below Lr the poacy and job site
Insurance Company Name:_
tit,rr c
Policy#'or Self-ins.Lic.r:
'• FxPimtionDate:
Job Site 3Io20�/j
Address: rt-ee�a " le, n14
Attach a copy of the workers eompensatloa policy declaration a City/State/Zip:
Failure to secure co page{showing the policy number and
fine to coverage as required under Sectionl25A of MGL c. 152 can lead to the imposition of expiration date).
UP ut $1-00.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK p ORDER and a fine
In allies of
es to bons 0 a day against the violator. Be
Investigations of the Dpen
IA for. advtsed that a COPY of this statement may be forwarded to the Office a
insurance coverage verification
I do hereb certi der the a
20,
afties o 71 r ury that the in ormadou provided above is true and correct
S• store _ tv3 .
• - �, ,tea ,., 1
Phone#: - - Date: . - _../_I ZZ
9 7 7y�0- Sly 3 - -
offrciaiuse only. Do not write in this area,to be coin feted
P by city or sown offciaL
City or Town:
Issuing Permit/License#
g Authority(clrcle one):
I.Board of Health 2.Building Department 3.Ci /T 6.Other rty own Clerk 4.Electrical Inspector 5.Plumb'
Contact Person mB Inspector
Phone*
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FICIA- I OF LIABOUTY INSURANCE
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GENL AGGREGATE MMRAPPLI i PER50}IALS ADV INJURY
ES aER:- S 1,000,000
POLM X PR i GENERALAGOREGATE
AUi'pMO81LE LIA9IUTT 1°C ( S 2,000.000
ANYAUTO
PRODUCTS-COMPIOPAGG s 2,000,000
$ S
AUTOS 02002SB71
AUTOS WED X SCHEDULED COtdB1 Sf UMI
X UTOS X /20/2014 BODILY INJURY(Perpe ) S 7- OOO 000
HIRED AUTO$
�OSVINED I /20/2015
BODILY INJURY(PWJJWy Al) S
X UMBRELLA LIAR v PROPE Ty G
�a P aq E
OCCUR - Jan S
EXCESS LIA B
CLAfiAS-i FIP-Bast S
DED WORKERS R , S AAP EACH OCCURRENCE S1,000,000
8 000
CONPEN 60005 1,000
AND EMPLO SA7i0N - ,000
YERS•UABILTfY 865411 /20/2014 '/20/2015 AGGREGATE S 1,000,000
Q711=ETORRMAARTUMVZeOUTWE YIN S
(6W d4 'Yin NH)EXCLUDED,- ❑ NIA WC STA'fU_ 077i
K�aa.EaSGiTeuader
D-SCRU n OF OPERgTiONS netnyy E-LEACHACCIDENr
C POLLUTION S
LIABILITY I EL DI$EASE-EA EMPLOY=
S
I
00378602 EL DISEASE-POLICY UM 0/1/2a13 O/1/2014 S
� GEN ERALAGGRGATE
DESCWPnON OFOPERgTiONS/LDDATONSlVf711CLE$ ' � EA POLLUTION CONDITION `41,OOO,QQQ
(Attach ACORD TDi.AaaNuaal Itemaelo Sehediala,Umo $1,000,000
apace Lq'mgylre�
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ERTIFICAI E HOLDER
CANCELLATION
CITY OF SAZEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE
THE EXPIRATION DATE THEREOF, NOTICE LLED BEFORE
9CaT VM�INGTON STREET. ACCORDANCE YdrtH THE pQUCy PROVISIONS. WILL BE DELIVERED IN
MA 01970
AUTHORQEp REPRESENrAiIVE
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ORD 26(s090/05) Roneld Cleaves/ p
T/'¢A!'-r1Rn name¢neL innn aro a ® ¢8 f QI�nORD CO ORATION-RP .ORA All ry rights rese
mrehroA rrm
ad.
t Massachusetts-Depariment-af Pubiic Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-OM77
FMC w PALM
Salem 1VIA 01970=
92 „� .;i �"`:. Expiration -
Commissioner 04123120116
C'y�e Vonurroirrrrrall�o�C f�ra4rrc�rr r!h :
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OIFim,f CoosamerAffairs&BosiaessReguladoaME IMPROVEMENT CONTRACTOR
ishation: 142oa9 Type:ira6on: ::3/122016. Ltd Liability Corpo:,
ATLANTIC WEATHERIZATION'CL.C. -
ERIC PALM - -
61R JEFFERSON AVE Q -
SALEM.MA01970- Undersecretary ,