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27 GALLOWS HILL RD - BUILDING INSPECTION (2) �q L1 '4©s3 ZZz°° The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards Massachusetts State Building Code,780 CbiR S Nt Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One-or Two-Family Dwelling This SectionForOffcial Use Only Building Permit Number:.�'.,," Date,Appked Bbildmg Official(Pant Noma) _ Signature Date SECTIOMY 6SITE INFORIN ATION " 1,1 I c ,sty iy Adr J LZ Assessors Map St Parcel Numbers l.la Is this an accepted street?yes w"r_ no Map Number Parcel Number 1.3 ogingInformation: 2 1 1.4 Property Dimensions: Zoning //District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Djaposal System: Zone: _ Outside Flood Z e7 ®/ Public Private❑" Check if es Municipal On site disposal system ❑ SECTION Z:;"PROPERTY'OWNERSHIPL 2, wnert of Record: �t�i=� 5�e�/ did �t4ili !I/1 O/�i7d Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTjof4 OF.PROPOSED3VORIO3&heck all that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Cl I Alteration(s) dj Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Othef ❑ Specify: Brief Description of Proposed Workr: Cl- z '/8'x SECTION 4: ESTIhLATED CONSTRUCTION COSTS-. Estimated Costs: Item Official Use Only-:., Labor and Materials 1. Building I•.Building Permit Fee:$' ` " "Cntiicate how fed isdetermined: 2. 6ltotric;d Oab ❑Standard,Cil iC 6uWn,AppiicationFee.. 'I'otal.Pio❑ jectCost ,(Item6)smultipGer x 3. Plumbing S 2. Other Fees: s t. \lachanical (IIV,\C) S 5;000 List: i. ;Mcchatrical (Firo S SnP 'lbWl:\ll Fees:.S Check No. _Cltcck Amount: ---Cash Amount: I'ufal I'rnject Citst: 3 ❑ Paid in Full ❑Outstanding Itol:utce I)ua: SECrION5: CoNs'fRuc'rioNSE !nfbcr • ' 5.1 Constructiun Supervisor License(CSL) CS-o7 146 vo/� iE rr—2 �r�LO _ License — C.e cation Date Name ofCSL Ifolder List CSLelow) Nu.and e Type . � Description ©/ ] D U Unrestricted(Building s u to 33,000 cu. R. 9 Q/x R Restricted IS:2 Fainily Dwellin City(fotvn,State,ZIP LI MInsulation RC rin WS idin, SF ing Appliances I'ele hone Email address U 5.2 Registered me Ipiprove pent C ntrnctor(HIC) _ r 3 �; XL rL HIC Registration Number Expira ion Date 111 t.�r an nm ur 1tlC�9 utraatt mne � No an ttrQt 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 c mpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuanc of the building permit. Signed Affidavit Attached? Yes.......... e No...........❑ SECTION 7a: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 7h: 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 in this application is true and accurate to kn vledge and understanding. Print Owner's or Authurized Agent's Name(Clec, Mile NOTES: I. An Owner who obtains a building permit to do his/her own work,or;n owner who hires an unregistered contractor (nut registered in the Home Improvement Contractor(HIC) Program),will not have access to the arbitration program or guaranty rind under M.G.L. c. I42A. Other important information on the HIC Program can be found at www.m:us.auv Information on the Construction Supervisor license can be found at www.mas .-ov_dlc; 2. When substantial work is planned,provide the information below: Total floor area(sq. It.) 1 7d f/ _(including garage, finished basement/m ics,decks or porch) Gros; living area(sq. ft.) /76�/�— )Iabitable room eount —� Number of lireph. ci. Number of bedrooms Number of bathrooms 7. ----- Number If halCbatlns l'cpa Of heating sy;tena ��i l N'amber of deck.,,'parches I')peofcoolingsygeua Foclosed. -- Open _-�_--- I. -fool. he ;nb;titut:,l t+ll 1'14.11 1'r0jed ('O;C CITY OF S.��i, ilt'J1SSACHLSETTS BUILD,NGDEPARTMENT 120 WASHINGTON STREET,31D FLOOR TEL (978)745-9595. FAX(978)740.9846 KI51BFR1 AY DRISCOLL i 06LU S.Piritzil MAYOR DIRECTOR OF Pt:BLIC PROPERTY/BI:IIDING CONUMIO.iER Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers Applicant information Pew Print.Legiblv' Name.(Businr iOrganizaiioNlndividmi): Address: City/State/Zip��P , Yo } Phone#: 7J 6'0 COIL Are y an employer'. Check the appropriate boxy Type of project(required): 1. t am a cm ins er with 4. 1 am a general contractor and t 6 p y ❑Np4constriaztion employees(full and/or part-time)." have hired the sub-contractors; 2.❑ ettu 1 am a sole propri or partner- listed on the attached sheet.t 7. Remodeling ship and have no employees . These subcontractors have S. 0 Demolition working.for me in any capacity. workers'comp.insurance. g. Building addition (No workers'comp.insurance S. ❑ We are a corporation and its 10.❑Electrical repairs or additions rvyuired.) officers have exercised their, 3.❑ 1 am a homeowner doing all work right of exemption per MGL1 I.Q Plumbing repairs or additions :myself.[No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs insurance required.]t . employea.[No workers' 13.Q Other comp insurance required:) , 'Any appilcum ihatchc*4 box el must also fill out the sections blow showing their waken'eornpemmioe policy information. mi I leuwnds who submit this effidavb indieatng 0*an doing all work end then him outswo contraemn marl submit a new affidavit it dieting wck !C,mi utonthatchec1 this lax must attached an additlutul'hod showing the aim or the mbeoramchas and their.worlmn`cc".policy iftrimnatics. I am an employer thatlr providing workers'compensadoabuarancefor my employees: Below is the po/liy and Jab site information. - lnsur4nce Company Name: Policy k or Self-ins.Lie.n: ����J6 `3�' -Expiration Date: Za / Job Site Address: -7 City/State/Zip: .Attach a copy,of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to securo coverage as required under Section 25A of MGL 6. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil petuddes 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 maybe forwarded to the Office of I nvestigations-or the DIA for insurance covcragoycriftcation. . I do hereby certify rder Ill alit - onaliks ofperfury that the information provided above is true and correca p Date: Phanrd• 9�p "����' �/� - OJreial asr only; Do not write in this area,to be completed by city or town ofJiehaL City or Town: Permit/Idcwue# Issuing Authority(circle one): 1.Board of Ileallh 2.Building Department 3.Citylfown Clerk A.Electrical Inspector S.Plumbing Inspector 6.Other. _ Contact Person: _------ Phone 1i: CITY OF tS"V-E,Nf itiL155.lCHL'SETTS E3t:=L` G DEP.1R'I ONT 120 1'(U3HLVGTO,V STREET 3� �O FLOO Z TEL (978) 745-9595 EY D2ISCOLl. FUt(978) 7•W9345 '<lSt0E.4L. , L�YOR "[�to►c�Sr.FtEwts DI3ECTOR of pt:ouC pROPERTY/BCIIALVG CO\LNIISSIONER Construction Debris Disposal At'tIdavit (required for all demolition :aid renovation work) In accordance with the sixth edition of the State Building Code, 730 C�LNiR section I 11.5 Dcbris, ;aid the provisions of MCL c 40, S 54; Building permit N is issued with the condition that the debris resulting from This work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL a l l 1, S I SOA. The debris will be transported by: (nanta )rhauler The debris will be disposed of in : (nnma at rrcility) (f(iJJress ur racilit%) sib;uamrr otpvrmlt,t pliamr Tb3sfo®satisfies all baucrequiremeote ofUtesta[esHomefmpmyemavtConhactorLaw .Ianguageto proiesthomeowverx Seelclegal adri<eifnecessary. (MGLrSapfer 142A�butdaesnotincfudestandard Massadnneffs Consumer(ladefo 73omolaaprovement"before �PersonPla�fagbomaimpioyemenls sbonld5sstohginacopypf^A r ' Office ofCoanmerAffays andldn�essRe ag'aein8tom wvdcoa outre$dence,Youma obtain afree co 'gnlalion's Consomerinfo®atioaHnflme at 617-973-Sy87 or 3-888-283-3757 oron ot¢�y�agthe �0ID¢eWIlep 1.ltfeYmaitDn ' Contractor]'nf'ormafion Name S v�14 PaoYxa,ae StrcetAddass(danvt meaYostO B¢tzddress - /0� /2G. �`1 ) ConhactodSel IOTI,. ary!Popa� C s JJ . 6 J CLIe{�l'a Smte Zip Code BusinessAddrae(..stinehrd sqeetaddqa) DaytimePkpne Q 7 D gd1em MA 019 0 �g Q BvmivgPhone G5ty/Toan MailmSAddress(Bdih'ermt5om above) . Iaysivess Phone FedealF�plvyaID mS.S Number �°rywmuwmenaod n'°'�`°`��'Q"ms��� ayenma:¢ rmn=.==me.mmaersn.m vv=aa n-Jm�smnomse , The Caatractoragrees to dothefollmingworltfor theHomeowner•,(Desodbe iv duail fhawmkfo eompletW, t Tlq band andP{ddeof ma tubdIta be ree dditi b eS'f .) ih/Sf�il/ l/iwr,l Wi rn✓I . �1 � Cel� t�o� SKl�i7�a� 4o . `. � his - Re9ufi'adPermiis-Thefollowingbuil�gPeamits azer - .. andwall be semaed byfleconhactarss the e'Q�ad PmPosed Startvnd Com Ie2on SchelNe- l •ei LUmeowna's agent be adheredtovn)eas ' P ThefoDow;ngs"edNewil) (Ow¢ers who se¢erethell'own pel'tnits will he eucamstances beyond the comractats control arise ascluded from the GvaraBtyy nd provisions of MGL ehapfer142wnhzctorvn716egn contractedwork .Data whey contracts wade will be snbstaatially wmp]eted. . Total ConhectPrice and Paymrot Srheduie 1ha Cmfreelnregrees topedona thewod,iinrdah thamalpisl evdlabm /y apetiSed aboveforthe[Dial sumoE ,�Q7'), r (�) Paymemswill bamadascwidingWtlmfollowingacltedule: SJ_o1XL Upon signingconhact(notto exceed W ofthatotal coat tpdm g the costofspecial Wderitm,whichevesis greater) $ by-1—/.L�/—1 anPon completion of J//'fTi (jl'�J f(�� S 000. uponcomPletimof&econtract (Lawforbidsd I amanding&illpayment�y eoutractismmpletedtobothpa Vy safisfac )- mdead befvethecoma�mPmeotm¢rt 6aspecial S epmd fomertthe completion scheAd )e8ius in order $ m a dfcr NOTES;(°) fiamca r5mgas(°a)faw mqunes tBd anYdepaatot dow rot cuxedth n-pzymeotrequites bytbaaovhaatorbefosowvrkbe's ma . Sraafaof(a)onethird ofthatuml covtmctpdco m(6)ihe actual cask of � Y •.whiclrmust 6e special ordaedin advaoeetomat theeompledm schedule avY spade)equipment orcustvm medamxmrial Br eftbetn ravfd h the av c ? ❑N SubconGatfam-The eenfrao(or all term ftb warren mustb ntlavb to tray erg tmc 6esdelyresponai6lefnr cemPleOmoftheworkdwmbedregardtem of the acfioas OfmyQnd PAY/sebcmhactorutilized bythe contractor. The conhactorfmtltes 'aI dIab under 's a¢eem t egreesto be solelyresponsrbleforallpaymmts to aE subcontractorsfor Coatwtsbaucepthvlythpomyu=aofs sa=it bewmesabia plaondmtb det)aw,Dnless otlterwisonotedwithintbisdoc=..t the v carom sbew,d i gthas contrmor otlrerseenrityinterastbas beenplaced oniheresid�ca Revim hefollowingcantims andnolim carefully b dare signing ffiia contract ° Deal bepmasmedinto sigoingth0wntract Tab fime to reed a d Cully Mferstmdit'Askquestions ifsomethingis unclear. . ° Isia -refhecontrac hoe validH r R Ara sub conhacfmatobametsterrdwsfh the Dnectnr ofHome . �Iawrequvesmosthomeimpmvement contractors and registifion bywritingto thaDneetarstlOPm&P �provementContractorRegis&d6on.you mayinquireaboOMut c ntr ° ctor DOM thetontrecfothaveiosusance7 Askthe ContracmrRforhisi7nswm 0,130stA MA�116 or bYcalling 617-973-8787 of 888-283-3757. see a copy ofa`proofoftosamncd•d,,,Met panyinfbrmafion sa thatyou ca¢coa5rm rgvyraga,orasktn ° %nowyrmrrightsandresponsr7nb'fiea Readthe7mpo taOtlnfo wtioamtharevemeside oftbis foffi andgetacopy ofthe Consumer Guide to daUHomeImprovemeotContractorLaw. You maytanceltbis agreem®tifithasbem signed atapbme odraihaatire eomm4olsnonnalpIacer77 dedyounotifytheo> tbismr tmghtofdret C�ll.6Y Date The Home7mprovement ContractorLawprovides homeowners withthe right to initiate an arbitration action(as an aitemafivetocourtaction)iftheyhavea dispute with acontractm: The same right is not automatically afforded to a contractor,however The contractor would-have to resolve any dispute hoahe has wrEa-homeowner in ocrurtunless • bothparties agree to the optional clause provided below. This clause would give the contractorthesamerightto arbitration as is afforded to the homeowner by the Homo Improvement Contractor law. The contractor and the homeownerherebymutually agree in advancethatin the event the contractor has a dispute concemingthis contract the contractor may submitthe dispute to aprivate arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachvsets General Laws,chapter 1 Homeowner's Wgriarilre, Contractor's Signature NOTICE:The sigmtures ofthe es above apply only to the agreement ofthe parties to alternative dispute resolution initiated bythe contractm Thehomeownermayinitiste alternative dispuberesolutione,enwherethis section is not separately signed by theparties. Homeowner's Rights _ A homeowner's rights underthe HomeImprovement 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 maybe excluded firm certaiaaghts ifthe 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 theworkas described,in a timely and workmanlike manner. Homeownemmaybe entitled to other specific legal rights if the contractor guarantees or provides an express wmm&y forworkomanship ormaterials. In additionto guarantees or warranties provided bythe contractor,all goods sold inMassachusetfs carry animplled warmarty ofinerchantability and fitness for a particularpurpose. An enumeration of othermatters onwhich the homeowner and contractor lawfully agree maybe added to the terms of the contract as long as they do notresEct ahomeowner's basic consumer rights. If you have questions aboutyour.consamer/homeovmerrights,contact the ConsvmerinformatioaHotlme(listedbelow). Execution of Contract The contract must be executedin duplicate and shouldnotbe signeduntil a copy of all exhibits and referenced documents have been attached. Parties are also advised notto sign the docamentunfil all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contractwith 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 workmay not begin until bothpartieshave received a Billy executed copy of the contract,and the three day rescissionperiod has expired Accelerated Payments A contractor may not demand payments in advance ofthe dates specified on the payment schedule in cases where the homeowner deems him/herselftobe financially insecure. However,ininshances where a contractor deems ltim/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 aprerequisite to continuing the contracted work. Withdrawal of funds from said accountwouldrequirethe signatures of both parties. Additional Information Ifyouhave general questions orneed additional information about the Home Improvement Contractor Law or other consumer rights,or ifyou wish to obtain afree copy of'A Massachusetts Consumer Guide to Home Improvement" contact: ConsumerLnformationHotime _ Office of Consumer Affairs and Business Regulation 10 ParlcPlara,Room 5170,Boston,MA 02116 617-973-8787,888283-3757orvisittheOCABRwebsiteathttn://www nws.eov/ocabr/ If you want to verify the registration of a contractor or ifyou have questions ornced additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact Duector of Homelmprovement Contractor Registration Office of Consumer Affairs and Business Regulation 10 ParkPlaza,Room 5170,Boston,MA 02116 617-973-8787,888-293-3757 or visit the HIC website at bttu./Iwwwmass ao //ocabr/ - i Go onlmo to viewthe status of a Home Improvement Contractor's Registration: http•(/dbstatemaus/homeimorovement/licenseelistasn For assistance with informalmediation of disputes orto registerformal complaints P against a business,call: Consumer Complaint Section Office oftheAttomey General ' 617-727-8400 AND/OR BetterBusiness Brmeau 508-652-4800,508.755 2548 or 413-734-3114 v��zm-mmmnoro The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Orgmization/Individual): Address: 61 R Jefferson Avenue Salem MA 01970 City/State/Zip: Phone.#: 97k• `7 q-91Y 3 Are u an employer?Check the appropriate box: Type of project(required): 1.I� I am a employer with 2.� 4. 0 I am a general contractor and I t 6. ❑New construction employees(full and/or part-time).s have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• M Demolition working for me in any capacity. employees and have workers' 9. Buildingaddition [No workers'comp. insurance comp.insmance.t' ❑ required.] 5. ❑ We are-e-corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roo " insurance required.]t c. 152,§1(4),and we have no 4>'u ] to o workers' 13. Other employees.LI`1 comp.insurance required.] *Any applicant that checks box#1 roust also fill out the section below showing their workers'compeasationpoticy information. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraetors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entitles have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and job site. information. I Insurance Company Name: Z44 ✓ (C�✓1 Policy#or Self-ins.Lic../M // 7 6 a2 ?O I� � Expiration Date: Job Site Address: �D�P L ea C,h Sf City/State/Zip: SCt/E/y7 014 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 cerP under I palg en"es ofperjury that the information provided above is true and correct Signa[tue /7lq/ /tC/ Date: Io2IZ3 /3 _ Phone# Official use only. Do not write in this area,to be completed by city or town ogicial 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#: page 3 of 4 • I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-iarr License: CS-087977 ERIC W PALAd'%3HIL S_ SALE MA;-: r j " SALEM.MA�01970 — ,k � �w Commissioner - Expiration 04/23/2014 Office�l Cooser' uoego�"feu�o . HOME IMPROVEMENT CONTRACTOR Registration „142089 Type: Expiration 3ti2l2014. Ltd Liability Corpor E _ ; U!kWEATHERI2,A ON L L.C. ERIC PALM .- 61R JEFFERSON AVE ` SALEM,MA 01910 _ Uud