3 HILTON ST - BUILDING INSPECTION 'fheCommonwealthofMassachusetts ECIU�.AEgEft 10Ej
Board of Building Regulations and Stan'dh"f�s CITY OF w
I LEIVI
Massachusetts State Building Code, 780 CMR id1far
�I y� P, iReailed Slru•2011
Building Permit Application To Construct, Repair, Renovawm1mo sh a
Cn One-or Two-Family Dfvel ing ... ,
J ' This SectionForOfiicialUseOn ' ;;.�,.;!:;, c
Building Permit Number, Date.A 1
P N' CIA,/ .. . /
I -Building Official(Print Name):• - Si Date
SECTION 16 SITE INFO"IATIOM
I.1 Property Add res : 1-2 Assessors Map dt Parcel Number
I.1a Is this an accepted street? es no Map Number,:; ' Parcel Number
1 3loning lnformation:f: 1.4 Property DletlsiRos �,s.ij3l jq Ir
Zoning District c Proposed Use - - Lot Area(sq R) s; t"e P t,k0fili (At) ..
1.5 Building Setbacks(R) `
Front Yard : Side Yaide ;dls�W
`Re 1.q lie - Providaf Required Provided-- . Requiredided1.6 Wnter Supply:(M.O.L a J0,§5d) 1.7 Flood2one taformatlont 1.8 Sesvege DlvZone: Outside Flood Zone?Public O Private❑. " "' MunieipW❑ qrt stem O,-
Cbedc ff es❑Pr'of rd:) - City,State,Zip -
Nret Telephone ISECTION 3:DESCRIPTION OF PROPOSED WORK'(Aeck W1I4 6praction❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Altertiooition ❑
❑ Accessory Bldg.O _ -Number of Units Other O Specify:
iption of Proposed Work-:
tSECTION 4:ESTIMATEDCONSTRUCTION COSTS Estimated Costs: Official Use Only `•
Labor and Materials)'
(.'Building S j Z I. Building Permit Fee:S indicate how fee is determined:
2. Electrical S ❑Standard City!fownApplication Fee
❑Total Project Cost.'(Item 6)x multiplier x
3. Plwnbing S P Qther fees: S
d.Mechanical (1-1VAC) -S List:
5.1%lechanical (Fire I $ ,
Suppression) Total All Fees:S
Check No.(22JZCheck Amount: Cash Amount:
6.TntulTroject Cost: S ❑Paid in Full ❑Outstanding Balance Due:
ry) ey�) S ( c1 �_
SECTION5: CONSTRUCTION SERVICES
5.1 Construction Superilior'Llctafsii jCSL) L 8 797'7 Y/ Z-7
License Number Expiration Date-
Name of CSL Holder art 01 U i list CSL'rype(see bclow)_�
ticW Palm Type: ,. Description
No.:urd Sweet .. 3 Hilton Street- - U Un—Mt eied Duildin a to 35,000 cu. R.
qai=MA 01970 R Restricted 1&2 Family Dwelling
City/ n;State,ZIP M Masonry
RC Roofin Covering
%VS WindowandSidi
SF Solid Fuel Burning Appliances
1 insulation
Telephone - Email address D Demolition'
5.2 Registered Home Improvement Contractor(HIC)
- Unit* W.eatheMllion,LLC HIC Registration Number Expiration Date
HIC Company Nam
No.and Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS!COMPENSATIONlNSURANCE AFFIDAVIT(M G I c:142.§25C(6)}..
Workers Compensation insurance affidavit mustbe corn d and submitted with this application. Failure to provide
this affidavit will-result in the denial of the Is§uance a building perntiL
Signed Affidavit Attached? Yes.......... No......... O
SECTION 7a.OWNER AUTH.ORI$ATION TO BE.COMPLETEU.W HEN',
OWNERS AGENT OR CONTRAC rOMAAPPLIES FOff"BUILDING.PERb11T''
1,as Owner of the subject property,hereby authorim
tg act on my behalf,in all matters relative to work authorised by this building permit application.
Date
Print Ot e( ecWn
SECTION 7111i OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all,of the information -
contairtag in this aptio and accurate to the best of my knowledge and understanding.
Print Owrn:r's or Authorized AltcWs Name(Electronic Signature) Date
NOTESt'
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not reaistered in the Home.Improvement Contractor(HIC)program);will Ug have access to the arbitration
program or guaranty fund under M.O.L.c. 142A.Otherimportanl iofarmofion on the H1Clrrogram can be toil
mT�t-- —
www mass eov'oca Information on the Construction Supervisor License can be found at wwe•.ntasssovldns
2. When substantial work is planned,provide the information below:
Total floor area(sq. fQ ' (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitnble room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halflbaths
Type of heating system Number of decks/.porches
Type of cooling system Enclosed Open
j. 'Total Project Square Footage"may be substituted 1'or"rued Project Cost"
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Contractor Arbitration
The Home Lnprovement Contractor Law provides homeovaseq with the right to initiate an arbitration action(as an
alternative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a
contractnr,however The contractor would have to resolve any dispute he/she has with a homewner in court unless
both patties agree to the optional clause provided below. This clause would give the eontractoe the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. I!
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this comma[,the contractormax:syla iTt�the dispute to a private arbitration faro which has been approved by
the Secretary of the BxeeudW Office of o r Affairs and Business Regulation and the consumer shall be required
to sub t to such "hatipa. � sachasetts General Lays,oho er 142A. i
♦ m
Homeow¢eu's'Sigiature - ' ' - Contmcto>'s Signature I .,
NOTICE:The�signalures of the parties above apply only to the agreement of the parties to sit emative dispute
resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the parties-
Homeowner's Right
A homeowners rights under the Home hnprovement 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
may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permit are automatically excluded from all Guaranty Fund provisions of
the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a
timely and workmanlike mmnaer. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusets carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractorilmvfully agree maybe
added to the terms of the contract as long as they do not restrict a homeowners basic consumerrights. If you have
questions about your corrsumer/hdmeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract I
The contract must be executed in duplicate and should not be signed until a copy of all exhibifs'and referenced
documents have been attached. Parties are also advised not to sign the document until all blank sections have been
filled in or marked as void,deleted,or not applicable. 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 original contract mustbe in writing
and agreed to by both parties-Contracted workmay notbegin until both parties have received a fully executed copy of
the contrac5 and the three day rescission period has expired
Accelernted Payment -
A contractor may not demand payment in advance of the dates specified on the payment seh We in cases where the
homeowner deems him/herself to be financially insecure. However,in instances where a contactor deems him/limelf
to be financially insecure,the contractor may require that the balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work- Withdrawal of finds from said account would require the
signatures ofboth partim-
AdditionalInformation
If you have general questions or need additional information about the Home Improvement Contractor Law or other
consumer rigbts,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact:
Consumer Information Hotline i
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston,MA 02116
617-973-8787,S88-283-3757 or visit the OCABR website at hrm:flxv�%iv.mass.?ov/ocabr/
If you went to verify the registration of a contractor or if you have questions or need additionWinformation specifically
about the contractor registration component of the Home Improvement Contractor Law,cons et
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Pad:Plaza,Room 5170,Boston,MA 02116
617-973-8737,88$283-3757 or visit the HIC website at httn:/Avww massmov/ocabr/
co online to view the status of a Home Improvement Contractors Registration
htto�//dbstatema.us/homeimnrovement/licenseelistaso- j tom, ,
For assistance with informal mediation of disputes orm regism['formal complaint against a bi er sxcall &
gas +A.car
onsumer plaint Section
f5c- ` omey General
�- 617-727-8400
AND/OR
Better Business Bureau
508.6524800.508-755-7548 or 413-734-3114 f
vavoa 11-umn_oto
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/Organization/Individial): Atiautic UddicaLatiuti, LLC.
61 e orsoe Avenue
Address: Salem M a, '11 Q70
City/State/Zip: i Phone#: q7k" 7G1W' /t'/3
Are yo n employer?Check the ap�propriate box: Type of project(required):
1. 1 am a employer with '� 4. ❑ I am a general contractor and I 6. New construction
employees(full and/or part-time).* 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. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y p tY• 9. ❑ Building addition
[No workers' comp. insurance 1 comp. insurance.1
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per VIOL 12.❑ Roof r pairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13. t er,
comp. insurance 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 anew affidavit indicating such.
tContractors 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 subcontractors b`ave 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.
Insurance Company Name: C_L
Policy #or Self-ins. Lic.9:22 Expiration Date: 3/ZOLI -7
Job Site Address: J 77+Y//Z:1� S3< • City/State/Zip: 3e,le kh
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above.,
ue and correct.
Signature: Date: 3
Phone#• 7l'/y'- /Ll 3
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one): 11
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Massschuselts Department of Public Safely Construction Supervisor
i
Board of Building Regulations and Standards Restricted to:
License:CS 9879T7 less than 35-Bindings fof eet
use group which cocain
Canst ui;ajon$apanrl o- less than space. cubic feet(991 cubic meters)of .
,mM1ysl - enclosed space.
� q
ERIC IN PALM -
3 HILTON ST
SALEM MA 01970
M..nn CA, Exprratioa- FaOure to possesses current widen ofthe Massachusetts _
Commissioner 04/23/2018 smote JMWIng Code is cause for revocation dlthis license.
OPS Licensing informationvrsrt iMNW.MASS-GOV/DPS
4-_ `— - ^�J r.c�Fwnurnnr+c�r/ nJ6 Ida rrarr;ter. License or re is4 ado"valid for ind'mduf use only
Office of ConsunuA$ein&Business Regulation _ before the expiration date. If found return to:.
ME IMPROVEMENT CONTRACTOR - Office of Consumer ATfairsand Business Regulation
{ _ 3eg-rstration: 142089 Type- 10ParkPlaza-Suite 5170
WWicpbation:- .W12i20lt3 Ltd LiablMy Cotpor - Boston,NA 02116
ATLANTICwEATHERIZAtION-LLC.
ERIC PALM
61RJEFFERSONAVE
SALEM.MA 01970 Undersecretary Not valid withoutstgmatum
i