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9 HORTON ST - BUILDING INSPECTION (2) _ 7 I'he('o...... huseus Callh of biassar Ilu,trd of Madding RCyulations ;Ind S mdards CI1'1' OF 'r klassachusetts State Building Cute. 780 CNIR SALEM IluilJing Permit ,\ppliauion To Construct, Repair. Rct�ovarte-t)r Cr lash u Rariwd ll, 111/f (b:C•or Tern-Piva:h Uu r o rt This Section For Off T•iul Use Onl OuilJing Permit Number. D e -IT, IJmg()Racial(Print N;unr) Signulure /� Uulc SECTION 1:SITE INFOR31ATION I.I Property Address,o sCQf 1.2 Assessurs,Sla dt p Parcel Numbers i' I.la Is this an acre trd slreet7 'a no AlV Numhcr Purcel Nunthcr IJ Zoning InforinuNont 1.4 Property Dimenslonas luniny District I'nipa+ed lls---`---_ Lot Arca(s III 4 Pmmuye Ill) I.5 BuIlding Setbacks(Ill From Yurd Side Yunlf Required Front Required - Provided Required Real Yurd1'rovideJ 1.6 Water Supply:IM.G.1.c. 40, §14) 1.7 Flood Zone Informations I.A Stwage Dlfposal System: Ihlblic❑ Pi Ulu❑ Zone: _ Oulaide Flood Zone? Check If cs❑ Municipal❑ On site Jispusul s).rlan ❑ 2.1 Owners o Record: SECTION Is PROPERTY OWNERSHIP' >' 'e Tr and/o(\L_ �tjemM.�} 0J9Jv Munu(Print) ('illy,5lifil P 9 N.�{on 979-7Yj-__Wl Nu.unJ Slrcel telephone 1:inutl Address SECTION!: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ E.sisting Building❑ Osvner•Occupied ❑ Repalrs(s) ❑ Iteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Spccily: Brief Description of Proposed Work': — �!' SECTION 4: ESTI,II.ATED CO,NSTRLICTION COSTS Itelll Ellin "I'd Costs: 11.4hur iutd.Maiterials) Official Use Only I OuilJing S 1. Building permit Fee: S Indicate how fee is determined: '. F:ieelrical S (3 Standard City+Turvn Application Fee 1 19unihing S ❑ Tula) Project Cush l Item 6)a multiplier '. Other Fees: - J. \ledi.mie.d ill\ \('I S List: //\l �It V0SIOnI S focal \Il peel: S n Ibtul I'rnject CnH: S ,3/68'✓ ChccA Vu. _. ___Check .\mount: . _ l',i,h \niounl: 0 P.lid in Full C3 Uutstallding 11.1l,utce Due: Sr:('1'll)NS: f'1)NSIRIICTIONSERVI( h'.S ql (bnseructiunSupeniiurLiccniel(SL) -- /979 .. __ _ J��j� icanec \unrbcr Plpicllnm IT.nc _ llorn_�v P- - --- S.uucol'CSl. lbd,lcr IIst OSI. I)Iwl•�chelulsl.__.__. -- .. \ ®r�✓e I)cscrlption I)PC No. ,u1J Strcat it 141rcslriacJ I IludJin s u l0 11,Uu0 at. Il.l /V ✓�Nty��O Il Hc.uictcJ I,v Pallid I)s5cllin l'igi l'onn,St}t�;,LII' H(' Htxdin Coscrin µ�S µ'inJow,utd Sidin '-' SF Sulid fuel Ilurniny Applianc¢s _ St9OBX 3 1�9 I II15111ullrtn Ileunllitiun rov lion rm;ula Jns /� fJ Registered Ilume Improvement Cuntrnctar IHIC) ,IPBL� � r � �l'O�r^`E' �roYfO IIIC ILcglSlroliun Nunlhct lispuntion I)atc IIIC Culnp n> Name or IIIC lie tart Ndma all 1:11 u' "o/ 1111 F'rnuil address No. wIJ SIN4 / p� C/O/ (ri/0 SOO° Ci ITown. State ZIP Tmlc hung SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.e. in2SC( ed with this application. Failure to provide Workers Compensation Insurance affidavit must be completed and submitt this affidavit will result in the denial of the Issuan of the building permit. Signed Affidavit Attached? Yes NO...........CI SECTION Tat OWNER AUTHRI OZATION TO BE COIIIPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property.hereby authorise to act on my be/half.in all matters relative to work authorized by this build ng permit application. )o fS Jot //2v.•lot SCe GrM D• a Print Ul�ncr's Nwne lElcctrunte Slynutlyas SECTION 7b:OWIVERI 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 applicationis true and accurate to the best or my knowledge and understanding.,l !� P �' I'rintOwncr'ior:\w aril¢J.\ymu'sNluuulhl¢ctnulic.Siynaluml NOT s nut registered%O i ubtal".n the a building uil g in per it to d Contractor IHIC) Program).In all�1on the a shave access to the artbitrationtlracror le pmyn it ur guarall) to nru un un he Cunlstrwi°n Supery Supervisor License information can be found at Prugrmn c>ntba111;ronJ at \\'lien substantial ourk is planned, pros ide the infu1ln`ti ud below: s;ff,se. linishcd bascntmtt attics,decks or pordiI rolal tiour area I sq. 11.1 - --- Ilabilabla room cutup arealsy. 0.t .t-... - .. Gnli; lising \umhcrol'hcJruunu \unlbcroflircplaccs .. ... _ -- \unlbcrol'hall'Kill" \uulhcral'halhramlls . . - \oluhcrol'dedks ponhci I)pe.Ilhc.tlingi),Icln 14nclo'cd —ltp¢n I 1 I`c I (OUllllt� �\UC In l "Ia.11 I'/ `ICGI \IIII;IfK I N1I.I4e Illlls he .IlhdlIIIICd tllr"romi l'rolc6 l'Sl" 14 CITY OF SALEM, NL-kSS.�aiUSETTS BUILDING DEPART\IEINT 120 WASHINGTON STREET, 3" FLOOR TEL (978) 745-9595 Rux(978) 740-9846 I(I\tSERI EY DRISCOLL MAYOR THo.Nw ST.PtERas DIRECTOR OF PUBLIC PROPERTY/BCILDL\G CONiSIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit # 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 MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of of in r v[�h ard,1�4-- (namc o tfacility) _ _--(addressor facility) siSnature F ermit applicant date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass govldla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �7 Please Print U bly Name(Businesamrgmizatlon/Individual): Pow c)2 H oYrt G I�E!'V)0 0 Egk 6 62o u/> Address: 2s01 TCtj f !,V S 7/ &10 Cb+fs;Er Plf /9013 City/State/Zip: Pbonc #: L1C - EN-51tC Are Vd an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 1.5, 4. 0 1 am a general contractor and 1 6. New construction employees(full and/or part-time).' have hired the sub-contmetors 7. ❑ Remodeling 2.0 1 am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These subcontractors have 8. ❑ Demolition working for me in any capacity, workers'comp.insurance. 9. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its 10.0 Electrical repairs or additions required.) officers have exercised thew 3.0 1 am a homeowner doing all work right of exemption per MGL I LE] Plumbing repain or additions myself.[No worknn'comp. e. 152. 1(4),and we have no 12.,QRoo!repair$ insurance required.)t employees.[No workers' 13.t+J` ether L(f/11IOOWy--' comp. insurance required.) •Anym apiaian tan cbeetnur a t b new also tin om ebe section below taCwlng mar wortets'Compawda+pwsy Infh®attam. r He eowieo woo suamil this of idavii indianns they ue doing all work sad thm hire auolde coalmams arms submit a orw af8dava tndiadog such. tCoatmsmn tan check this box ram aaadted an adthdooal scat showing the name orthe sub�nsaan anti their wodrees'comp.policy infomtadon. I am an employer rho:Is providing workirs'compensadon Laurance for my employees. Below Lr the policy and job site lnfonaaalon. Insurance Company Name,, HRRLiF sV1►-t-C L✓OKC-ST&;—' SN5 CO 2 Policy u or SeIMM.Lic.a WG QAaC e O O of 1 95 F�coirarioo Darr /O ! 13 Job Site Addres, Ho(` /i 5-1'e2- City/Statc2ip SOMA 0)970 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to segue coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to t 1,500.00 and/or one-year imprisomnent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a y e 'olator. Be advised that a copy of this statement may be forwarded to the Office of Investigations o e Dk for coverage verification. I do hereby c vn er e p ' i and penatder ofperjury that the Information provided above is true and correct lI 8 1Z Offidbi use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permittl-lcense 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#: POWER-1 OP ID: EL CERTIFICATE OF LIABILITY INSURANCE OATEsrts1112(MMI Y) otz 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,tho pollcy(los) 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 endorsomen s. PRODUCER NwANE CT Lacher&Associates Ins Agency PHONE Lecher Insurance Group ac Ne: 632 E Broad St P O Box 64398 o SS. Souderton,PA 18M Chad Lacher INBURe 3 AFFORDING COVERAGE NAIC0 a1SURERA:Harleysville Worcester Ins Co 26182 INSURED Power Home Remodeling INsumpte:Harleysville PreferredIns.Co 35696 Group,LLC Power Home Remodeling Group, INSURER C:Nationwide Mutual Ins Company 23787 Inc. INSURERD: ' 2601 Seaport Drive Ste S110 Chester,PA 19013 INSURENE: 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 MATH 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. 71 TYPE OF INSURANCE ADOL SUBS INS&JMM POD MIMBER MMA7orrrm (MPNO lJMI78 GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 B X COMMERCIAL GENERAL LIABILITY MPAODOGOO59793N-1 09/22/12 10/01/13 PREMI ES -ao fit r 100,00 CWMB-MADE OCCUR MED EXP a sawn S 10,00 PERSONAL S ADV INJURY S 1,000,00 GENERAL AGGREGATE i 2,000,00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO i 2,000,00 POLICY X JFffT PR0. LOG ; AUTOMOBILE LIABILITY COMBINED IT 1,000,00 A X ANYAUTO BA00000089796N 09/22/12 10/01N3 80OR.Y INJURY(Par Pone) s ALL OWNED SCHEDULED BODILY INJURY(PW eotldad) S AUTOS NON-OWNED PROPERTY E i HIRED AUTOS P AUTOS Par S UMBRELLA DAB X OCCUR EACH OCCURRENCE S 10,000,000 C X EXCESS LIM I I CLAIMS-MADE CMBDOOOOO89794N 09/22/12 10/01/13 AGGREGATE S 10,000,000 LIED I I FtETrNTION$ S WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITYA ANY PROPRIETORPARTNERIEXECUTNE Y© N/A COOOOOO89796 UNI09/22112 10/01/13 E.L.EACH ACCIDENT $ _ 1,000,000 OFFICE MENBER E%CLUDEDT (Mandatory In NH) E.L.DISEASE-EA EMPLOYE i 1,000,000 DIm dwrrsoundw 000,000 .. ESC I OF OPERATIONS ION kekM ..__ ,_ E.L.DISEASE-POLICYLIMR i 1r A Mass Auto Policy BAGOOOOO18227P 09122112 10/01/13 Liability 1,000,00 Limit DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES wtlach ACORD 101,Addidonal Remake Schadulo,If more apace la requlrodl 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 120 Washington St AUTHO�RIZ�ED REPRESENTATIVE S Floor,Salem,MA 01970 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010106) The ACORD name and logo are registered marks of ACORD �� &mmowaleaa Office of Consumer Affa' and Business Regulation 10 Park Plaza - Suite 5170 Boston, I,v sachusetts 02116 Home Improver ontractor Registration Registration: 165616 vhE.—__ J Fir Type: Supplement Card { r Expiration: 3/18/2013 POWER HOME REMODELING ' IW\ ALLAN COLPITTS € 2501 SEAPORT DRIVE STE 13111;x, _ P.— fir; CHESTER, PA 19013 Update Address and return card.Mark reason for change UPS-CAI 0 sou -allows ❑ Address ❑ Renewal Employment Lost Card ITT P ! �✓Gf ��u�ra Office of Consumer Asfain&Boslom Regalation License or registration valid for individul use only @TOME IMPRO MENT CONTRACTOR before the expiration date. if found return to: ,k'a Office of Consumer Affairs and Business Regulation Registration., Typo' 10 Park Plaza-Suite 5170 I loop i-, _ - ,3„ Supplement Card Boston,MA 02116 POWER HOME . UP INC. ALLAN COLPITT :f 2501 SEAPORT D BS10 CHESTER,PA 19013'`�';L=�v' Undersecnmry Not valid witVsIgnature 401 Massachusetts -Department of Public Safety _ Board of Building Regulations and Standards Cnmoructinn Supen kor License: CS-001979 _ ALLANKCOLPMS 3 CHRIST7AN DR' NASHUA NH 0306:i '; sJ � F ' Expiration OS/07/2014 Commissioner about:blank s NATIONAL HEADQUARTERS NAlliam and JaserKne Tremblay 2soi Seaparrfnm.a,auer,RA i9w 4, ..,,,,.. �CJiXt R _ 30.57601 T^x." `lw r .e.,......y........ oomhat 15,2012. .... • •• MA HiilsiWstp CUSTOM REMODELING AND IMPROVEMENT AGREEMENT euyara.lmarrnauen - Project.Numtier.30.5780 October 15.2012 William Tremblay �101fAB `r` 4oselehine Tremblay (971t);7413921,(Nome) - 9'Hmtoa6l' Sal6m,MA:.O1aT0 'coumytEasrRl. Township: Bevels)listod.above hereby jointly and severally agrees to purchase the goods,andfor services of Power Home Remodeling Group("Contractor")In accordance with the prices and terms described on the from"end the following four pagss of this agreamentord any specification sheets,which am incorporated as part o{the Agreement(collectively,this. i - `Agreement"):This Agreement reprosenis:a.ceah sale of goods and services.Buyer(s)ogress'to pay th,cost of the goods fi and service8 purchased as described herein.regardless of timing or approval of any financing Buyers)may seek for their I purchase.PIZems and Inquiries regarding thlir Agreement shodid be directed to the Contractor at 1.868.736•6335. , Purchase Price. $3,167.72 1 Pm installation Inspection pats. DovmPayment $0.00 ourPMwfiaro.W m+luM4ealwa-.isopa "Sop Balance Dbo'on .E3,167.Y2 Estimated Prdjact8tart:6:to 7 weeks Substantial Completion: Estimated,Project Completion;1to'2 days 'Metlrodol'Paymanc Check ,.anfim,a eompwipn".b na clam amm .0a ,,Iwyarp Cunatt,a✓a mntrmngr mifuie h ovailattna Umo rremea:aem fAzWlnkndxn CaMieomort,imnRa. t3uyer(s1:horebY acknowledgos receYptof a wpyof thepamphiot;'"The LeadSafe Certified Guide to Renovate RIgM": •` infornrfng:Buyer{s),oFtha,pctangal riskct 1¢ad ha7arda%pcsurofromronovatlon aaiWryto'bspartorined�In:Buyers home, at the ad s Wi abavo.Boyer(s)received this pamphlet oaths date oP drls-Agreement,before commancomant of, work. -�yf 1 d {Boyers lnmeis>.. it Is agreed and understood''-by anIf It raen the parties that this Agreemantconetltutes the entire understandings between the paNse tindtham am no verpat undemtanq(ngs changlrrg or modliying arty of the terms:o4 thfs Agreement.Buyer(s): ' hereby acknowledges Drat Buyer(s)1)has read the entire Agrearfl¢rdand has-recelvedasdmptetad signed,and dated copy g Mass of Cancoliatlon farms,on the data BrstwNtten above and 2)was ofthia-Agieenlent,Inciudin thatwo accompanying orally Informed of hisiharright to cancel this tmneaction.WNW SIGN TN13 AGREEMENT THERE ARE ANY BLANK SPACES. Future promotions not applicable. 3 c-• I have read and received each page of4Ma'S,page agreement. - r Home Remodaling Group r' Buyer(s) ,FTt�yerit IIQI15112. /10H5/'12 G /10/15/12. Signature SalosAa0rhantalive nature,. Signaturfi eremyYogel WIIIIam or Josephlne Tremblay YOU,TH SUYER(S);MAY CANCEL.THIS TRANSACTION AT ANY TIME PR1OR to Mt"Hr OF THE THIRD BUSINESS DAY , AFTER THE DATE DF THIS TRANSACTIDN.;SEE THE NOTICE OF CANCELLATIONFORM.FOR AN EXPLANATION OF THfSRIGHT.. IIII IIII III(mII�IIIII I�'(I IIII�II October 15.2012'16:32 (�uIf�III�IIW� I�IWl�l00 Page 1 of 5, 1 of 1 11/7/2012 7:04 AM NATIONAL HEADOUARTERS William and Josephine Tremblay 2501 Seaport Drive, Chester, PA 19013 . a POWER 30-57601 a October 15,2012 888-REMODEL MA HIC#168616 Project Specifications Windows: Master 1 27.0"x48.0" - Windows:Master 1 27.0"x48.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Aluminum/Vinyl I Additional Details None Windows: Master 1 27.0"x48.0" Windows:Master 1 27.0"x48.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Aluminum/Vinyl I Additional Details None Windows: Bathroom 1 30.0"x32.0" Windows:Bathroom 1 30.0"02.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Aluminum/Vinyl I Additional Details None Windows: Guest 1 26.5"x48.0" Windows:Guest 1 26.5"x48.0" WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None OPTIONS: Color White/White: Grid Pattern: None I Removal Aluminum/Vinyl I Additional Details None October 15, 2012 16:54 IIII IIIIII II IIIIIIII I IIII IIIIIIII III II III Page 2 of 2 vCERTIN - -,FA JvAn � 9i7t1(C7]4$ 3C46i(I.16�CS: YlsItIaTra am]tta--.W ?.y4 C01"»Cit�atl9RftC5I5MMcaa Q'/{i•(�1 • 441�,�1°a "• �,. 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