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12 GALLOWS HILL RD - BUILDING INSPECTION (3) The Commonwealth of Massachusetts r ',p,,_ 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 Use Only Building Permit Number: Date *plied: - 1 Building Official(Print Name) Signature MaT, SECTION 1: SITE INFORMATION �.. m 1.1Zroperty Addre s; 1.2 Assessors Map&Parcel Numbers N m I (�''Ru ,dd7t,c }2p. L l a Is this an accepted street?yes no Map Number Parcel Number rn Ct 1.3 Zoninginformation: 1.4 Property Dimensions: 5 Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) rr 1.5 Building Setbacks(it) 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?Check if yes[] Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: lo1M �jl,El,u I gYUt M4 01970 Name(Print) City,State,ZIP Iz IA"W's �1, 12n. 978-z1e—W1 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building Owner-Occupied Repans(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description f Proposed Work 2: Z SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 3 j. 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costs(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ 83,� Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ / ❑Paid in Full ❑Outstanding Balance Due: Servo No � s>=,�, r tof23 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) M DS'71^ cense Number Expiration Date Name of CSL Holder I f j�� List CSL Type(see below) y &j&bL Y No.and treet Type Description U Unrestricted(Buildings up to 35,000 cu.ft. """ "I "° r'�w • " "� �����) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Mason ry .i s RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances i='t•"S b�"�'c-0-n't7! 6 I Insulation r" aTele hone Email address D Demolition rn :5.2/lJ��egistered(,��ome Improvement Contractor(HIC) it / lf�Fl"Le G I V4L 901ro blew,,46 HIC Registration Number Expiration Date _HIC Corn y Registrant Name 7 f3'-�n.F SName or r �q- dSveet Email address ': _ Dyln � Dl7,rZ SOB'Zg0 'dlt� 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 restilt in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No...........❑ SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereb st r the pains and penalties of perjury that all of the information contained in this application is tru an ac ra to the best of my knowledge and understanding. 111 ►�121� 0'Z Print Owner's or Authorized Agent's Nhrfit4UbWr6ic 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.L.c. 142A.Other important information on the HIC Program can be found at www.mass. oe v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 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.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths 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" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizati�on/individual): Pt)W�('L 1{`��Ii roE' �(tM6DCLiAj6 6"010 Address: 2S0[ J Cp ft!!n 'Dal V J u 1TZr ] D City/StaWZip:_Gl+&JT_U&A N013 Phone#: S 08 -Z9 " 0) qb Are ygu an employer?Check the appropria+-box: Type of project(required): 1. I am a employer with� 4. ❑ I am a general contractor and I employees(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. 7. ❑Remodeling slip 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.: 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL insurance required.]t c. 152, §I(4),and we have no 12.❑Roof repairs employees. [No workers' 13.❑Other Comp,incnrance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation 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. iContmctors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-bo bactors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name-. [�: T'[AlZLC"yM1.L.fK,�n OK CCi S'i 1512 /At f �p Policy#or Self-ins.Lic.#:_ ZD L q o 6 67,o / 7 Expiration Date:: It')- 1- Z 0 Job Site Address:_��AUlt lµ) ki t t r t t City/State/Zip:cJ h(,Ew 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 r insurance coverage verification I do hereby erS and t e pains and p.V,tarlriev ofpc:jury that the information provided above is true and correct Signafore: Date: ✓�Z✓) Phone#: 5 D8" 7,80 r01 S Ofciarf use only. Do not write in this area,to be completed by city or town o iciaL 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#• in skfing- SL2700 DOUBLE HUNG WINDOW VINYL VINYL FRAME DOUBLE GLAZED FOAM FILL GRIDS LOW E/ARGON National Fenestration NFRC CPD#: NBP.K-14.00008-00002 Rating councV ® CR100107.21.01 00488344/001 • HELLIM I,Mo ENERGY PERFORMANCE RATINGS 0 . 2®� 0 . 26 ADDITIONAL PERFORMANCE RATINGS 0 .47 s1 :.oimlducr±;;Upulare I lnatmese:dunm con:5O010 acalkaaP NFFC Np<eourss fps OehlmlYdy Vllp'e pfMJ!I pPpeeleyn(C YRGI..pO1 J!}dEiBtMnpp lV d(uPtl SMp(PIY+IGnllppidl(ppppppl aptld /ipJu(Ip�p�lPeaiLil(�f pGYil YII mdpUid(IWP!mPf3ldWE fW CJI lePlGtlU(1lOPYC fndp(E ullGfNl�eYl ` L wVv ldrc Glp. Office of Consumer Affairs lind Business Regulation 10 Park Plaza - Suite 5170 Boston. Massachusetts 02116 Home Improvement Contractor Registration . . Registration: 168616 Type: Supplement Card Expiration: 3/18/2015 POWER HOME REMODELING GROUP.LLC -, MARK MORDINI 2501 SEAPORT DRIVE STE B110 CHESTER, PA 19013 Update Address and return card.Mark reason for change. t: 20M-05/+.1 i - D Address ❑ Renewal ❑ Employment ❑ Last Card (:k �G�r..rrw cf /�rzaaac�uwelYo Trice of Consumer Affairs&Business Regulaiion 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 Integistmlion 16616 Type'- 10 Park Plat ite 5170 � Expiration. wm20'i;?...:: Supplement Card Bos n. 0211 iVVER HOME REMODELINt-GRbUP LLO. t ,RK MORDINI )l SEAPORT DRIVE'STE 6110 (ESTER,PA 19013 Undersecretary Nvali it out signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards - + Construction Supenisor - ]t'� +"� License: CS-057645 I r MARK E MORDINI ' 19 NEWELL DR � N ATTLEBORO MA c �,.�.• �ll,61 .�rif'" Expiration Commissioner 09/18/2015 POWER-1 OP ID: EL ,4`cofzo CERTIFICATE OF LIABILITY INSURANCE D09/11ATE /2014 YI I 09I11I2014 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. 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 an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT Lacher&Associates Ins Agency NAME PHONE FAX Lacher Insurance GroupINC No Ell.215-723-4378 A/c Nu: 216-723-8604 632 E Broad St P O Box 64398 E-MAIL Souderton,PA 18964 ADDRESS. Chad Lacher INSURER(S)AFFORDING COVERAGE NAICN INSURER A:Harleysville Preferred Ins.Co 35696 INSURED Power Home Remodeling Group, INSURER B:Harleysville Worcester Ins CO 26182 LLC 2501 Seaport Drive,Suite 6110 INSURER C:Nationwide Mutual Ins Company 23787 Chester, PA 19013 INSURER D:Pennsylvania Manufacturers 12262 INSURER E: INSURER F: 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 TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDIYVYY MMIDD/YVYY LIMITS A RXCOMMEIRCML GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE Fx� OCCUR MPA00000089793N 10101/2014 1010112015 DAMAGEMISEESTOREa N ED PR occunence 8 1,000,00 NED EXP(Any one person) S 15,000 PERSONAL B ADV INJURY S 1,000,00 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 23000,00 JETPRO- LC 2,00030OPOLICY OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000300 Ea accident) B X ANY AUTO BA 00000089796N 10/0112014 10/01/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED P BODILY INJURY(Per accident)AUTOS AUTOS ( ) $ HIRED AUTOS NON-OWNED PROPERTY student)DAMAGE $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1 O,000,OO C X EXCESS LIAB CLAIMS-MADE CMB00000089794N 10/0112014 10/01/2015 AGGREGATE $ 10,000,00 DED I I RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 2014006620967 10/01/2014 10/0112016 E.L.EACH ACCIDENT $ 1,000300 OFFICERIMEMBER EXCLUDED? O N I A (Mandatory In NH) E.LDISEASE-EAEMPLOYEE $ 1,000.00 DESCRIPTION OF OPERATIONS below If yes deacelbe under E L DISEASE-POLICY LIMIT $ 1,000,00 B Mass Auto BA 00000018227P 10/01/2014 10/01/2016 Auto Liab 1,000,00 B NY Auto BA 00000074849R 10/01/2014 1010112015 DESCRIPTION OF OPERATIONS I LOCATIONS(VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Salem 3rd Floor AUTHORIZED REPRESENTATNE 120 Washington St Salem,MA 01970 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD about:blank NATIONAL HEADOUAR TERT Thomas Begin 2501 Seaport O'rve,CM1esPAyw9013 3r�� r POWER 31-23766 88&ODEL September 11,2014 WCa taaata CUSTOM REMODELING AND IMPROVEMENT AGREEMENT Bayaney Isdo_gran and DaeMpaon of nub Pmpprry Project Number.31-23768 - - salMmeer a,m14 ,s Thomas Begin 197a12104681 rC4,diws Win rz Gaims His Rd Salem,MA 01e10 County:Es Township:. ' Buyer(s)gated above hereby Ontly and severally agrees to purchase the goods aridior services of Power Home Remodeling Group and Its vendors CCOntractoo In accordance with the prices and terms described in this 6 page document and the Product Specifications,which are Incorporated as pan of the Agreement(callecdvely,this'Agreemard). This Agreement represents a rash sale of goods and services. Buyens)agrees to pay the cost of the goods and services purchased as described herein,regardless of timing or approval of any financing Super(s)may seek for their purchase. Purchase Prioa: S6,82220 Pre Installation Inspection Dates: Dam Payment sum - Estimated Project Start:B to 7 weeks Balance Due on s6,832.20 Estimated Projact Completion;I to 2 days Substantial Complainer. euye4al adoutaEpetla saeratle wan aNmmpMam a�eaan NOtatMaamlm,Oolaya Method WPeY^tB^t AdIOr CanearAfa c9nuMMlntleeeo lnwaaaredmthamea.Sea oamrnmtmonn rNndla.a Buyer(s)hereby acknowledges receipt Me copy of bte pamphlet,'The Lead-Safe Certified Guide to Renovate Right,informing r Buyer(s)of the potential risk of lead hazard exposure from renovation activity to be performed in or at Buyer(s)'Property,at the ariftes written above.Buyer(s)received this pamphlet on the date of this Agreement before commencement of work. Buyer(sy Inttials. Th Agreement constitutes the entire agreement and understanding between the parties,and this Agreement replaces any and all prior negotiations,representations,or agreements,eaher written Dr ontl. No amendment.modiflpalfon or walver of this Agreement shall be and or effective unless In writing and signed by both parties. Buyers)hereby acknowledges that Buyer(s)1)has read 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 first wttten above and 2)was orally IMomted of Mather right to cancel this transaction. Buyer(s)also agrees and understands that 0 Buyer(s)finarmas the work with a thhd-party,the terms of that financing will be ,contained on separate documents,including any finance charge. - Future promotions not applicable. - ' DO NOT SIGN THIS AGREEMENT IF THERE ARE ANY BLANK SPACES. ve read and received oath page of thIs S page agreement Ho dd coup Buyers) dons l ant S�1tlgH 1114 Signature of Remodeling Consultant Signtiturt Steven Salllarge rn Thomas Begin { a a YOU,THE BUYER(Sh MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. ,a rSeptember 11,2014 21:48 -- Page 1 015 6a r i 1 of] 10/22/2014 6:32 AM 4 NATIONAL HEADQUARTERS Thomas Begin 2501 Seaport Drive.Chester, PA 19013 � , pQWER 31-23766 `" `r S.,y1O1AO Qeniv°'•"��^' September 11,2014 888-REMODEL MA HIC#168616 PRODUCT SPECIFICATIONS Buyer(s)'Information and Description of the Property: Project Number: 31-23766 September 11,2014 Thomas Begin - oa�eoray�eemem 12 Gallows Hill Rd (978)210.5681 (Cheryl's Cell) Salem,MA,01970 County:Essex Township: Buyer(s)listed above hereby jointly and severally agrees to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with the prices and terms described in the Custom Remodeling and Improvement and the Product Specifications (collectively,this"Agreement"). Pre Installation Inspection Date:Your pre installation inspection is tentatively scheduled for TBD. Windows-SL 2700 Inclusions: Includes metal reinforced meeting rails and nighttime safety locks on double hung windows only,welded corners,foam injected frames, Sashlite technology, Heatshield, Duraglass, exterior custom capping, installation, clean up and haul away of all job related debris. It is agreed and understood by and between the parties that the Product Specifications,along with the Custom Remodeling and Improvement Agreement,constitutes the entire understanding between the parties,and replace any and all prior negotiations, representations,or agreements, either written or oral. The Product Specifications may not be changed, modified,or varied in any way unless such changes are in writing and signed by both Buyer(s)and Contractor. Buyer(s)hereby acknowledge that Buyer(s)has read the Product Specifications. I have read and received each page of this 2 page agreement. - Power Home Remodeling Group Buyer(s) /09/11/14 /09/11/14 Signature of Remodeling Consultant Signature Steven Baillargeon Thomas Begin 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 ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. September 11, 2014 21:48 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIII IIII IIIIII Page 1 of 2 NATIONAL HEADQUARTERS 'jp Thomas Begin 2501 Seaport Drive.Chester,PA 19013 OWER*' 31-23766 September 11,2014 888-REMODEL .. .. ... MA HIC#768676 Project Specifications Windows: living room 1 94.0"x42.0" WINDOWS: Models SL 2700 Styles Bow Types 4-Lite Configs End Casements OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details Special Options (ie.Full Screen,Obscure Glass,etc)Full Screen Double Hung I Obscure Glass Double Hung: Both Sashes I Specialty Color No I Different Color Capping No I Trim Options No I Frame Options No I Remove and Reinstall No JnV&Vw Windows: KITCHEN 1 16.0"x35.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None Windows: KITCHEN 1 16.0"x35.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Wood I Additional Details None September 11,2014 21:48 IIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIII IIIIIIIIIII Page 2 of 2