208 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts N RECEIy 0 CrrY OF
Board of Building Regulations and Standardd SPECT1 DNA( SERVWUm
Massachusetts State Building Code,780 CMR
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate&1b1Nb'1iM �'. S 0
( One-or Two-Family Dwelling
\ This Section For Official Use Only -
Building Permit Number: Date plied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property�� 1.2 Assessors Map&Parcel Numbers
L l a Is this an accepted —tno Ma Number Parcel Number
ccep street?yes no P
1.3 Zoning Information: 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.G.L c.40,§54) 1.71 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zorie: _ Outside Flood Zone? Munici 1❑ On site disposal stem ElCheck if yes❑ spo system
SECTION 2: PROPERTY OWNERSHIl'r
2.1 r7rof Record: i
✓✓N Ve✓i�Zl s �ct /-2Wt
Name(Print) City,State,ZIP
2L8 700- 6Oa6
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORFO(check all that apply)
New Construction❑ Existing Building❑, Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ ! Number of Units_ Other Specify: J:KA Jr Ej0,1J
Brief Description of Pro osedWorkZ: i
er^
SECTION 4 ESTEVUTED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials Official Use Only
1.Building $ Ala) + — 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item-6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ a ( �• ❑Paid in Full ❑Outstanding Balance Due:
i
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C§L) 2 ]5-7-7
License Number Expiration Date
Name of CSL Holder
Eric W. i.;1111 List CSL Type(see below)---(A_
No.and Street 3 ifilton Street Type Description -
Salem MA 01970 U Unrestricted(Buildings up to 35,000 cu.R)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Coverin
WS Window and Siding
,,��. 714 y, SF Solid Fuel Burning Appliances
i I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) ' III U�-Ci /z' 1 '
Atlaatii' Weatherizstian, i T C HIC Registration Number Expiration Date
HIC Company Name or HIC&Gyi a Name�VellUe
No.and Street b1 Salem MA 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 ........'.. No...........0
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 ( r-,-C Ca !VYN
to act on my� behalf,in all matters relative to work authorized by this building permit application.
Kv �CnLL
4cJ l Z/Z7�/�/
Pnnt Owner shame Mectronic Signature) iDate
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I
By entering my name below,I hereby attestlunder the pains and penalties of perjury that all of the information
contained in thi pplication's true orate to the best of my knowledge and understanding.
j} r
�. 4
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.LI c. 142A.Other important information on the HIC Program can be found at
www-inass govioca 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 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"may be'substituted for"Total Project Cost"
i
Massachusetts Home Improvement Sample Contract
ETh"10-s.a.h5CIiesjh,�wmnem
requirementsofthestatesHomeImpmvemmtConmaor Law GL ch ter 14>
rif Seel:legal advice ifn aP is sh Dud doesobtinticopya'Aouideto Home eceaary- Any person plattoing home improves®ts should doss notainludeStmb
fall o ns mt.befoma�edng ro zero•twrk myour residence.You may obtain a free copy by calling the
um and Resinegs Remdati"'s Cnnnsmer Informudon Hodtvo n 6I]-9]3�]87 w 1-888887_;]5]w ov owsvebsitc.
Homeowner Informal'um Contractor Information
Vmna
CPmpasry Name
coo VerI`fa .S
Street Address,(do rwt IF U.address) Canuanad Salesp N
O e �, / 6i'RJet IAVMue
CinRoyn I State Zip Code •'`k: Businm Adder(roar inel M
cJQ, 'Ckh �r s]' ��l`tvl't1101970
Daytime Phone ¢ �7 &ming Phone CiryiTown Setat
7O " TAP Cade
Mailing Address(h diWeco from shave) Business Phone
FedeallnsployermwSS.Number -
lawmrytmNareme6wr nmelrye,�CmmnerP.r:hlm4s �/E�.��
��n.•ee,r r�a.o�9 i�
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The Contmetoragrees to do the following work for the Homeowner.
(Dntribe in detail the wwt-toamiPlesod.speafying the rype,bran4 ssdIDadeof noteisD to be useQ tld"' I.616u,y -
f
YSea n y envoy
Required Permits-The following buildingpermits arerequired Proposed Start and Com uetionSebedule-
andwdlbesecuredbythewo, anor as the homeoxnets aemt-. beadh ro"less cirmr tances n'e following schedule
(Owners who secure theirown permits will be beyond the contractor's control arise
excluded from the Guaranty Fund provisions of I Daze When Contractor still begin tra conctedvrk
a MGL chapter 142A-)
'3 Date xhm c"traaed rmrk xa71 be substmtia0y completed.
Tout Cortratt Pece"d PaymmtSrhedtde �r�'
The Contractor agrees m perform the xvd;,fumish the mmerial and labor specified above far the rota)sum of. _� ti(/ .
P4imortspxill be made according to the following shodWe:
S �Pm signing contract(not IC,erzceed 113 of the total contract price or the cost ofspecial order items,whichever is greater)
S by!_! or upon completion of ,(�.
S1yLLL/_ by 1___dlr upon completion of s U l �
S `
upon completion of the contrast, (law forbids demur, 'ng full Payroll
ay" t"tit contract is won ) be to bosh F party's satisfaction)
Thefaliawing vmtedel/squipmrm man be spatial g to paidf
ordered before if. unroof node bane in order
to mar the cmnplati®scheduleton S be pas or
NOTES:(')rmaccadlheruncecharge(,.)Iswrryuetatid am•depmit err down-payment rcquiredbythecomr beforenart nsma•grratvaf(a)one-third ofthemral comae price"f ire actual can oral � I
nfiich malt hespaial ordeed in advavcemmen rim completion sehedme army equiPmentmnuYom maderrmraial
Freres tV n _r brine nrov'ded M A t r' O Y ❑Y ( t or a
b Dent an-
Th traon agrees to be solely responsible for completion of the work desm' re m
party/subcontractor utilized by We contractor. The monaaw further a gaNless ofNe a n subcontractors
third
materials mid l agrees to be solely responsible for all paymevts to an subcontractors for
C tit tt ptcePm UP signing,b document becomes e bindingbeen
p a""tt alder law. UWes othemasc noted svithir,this document,the
contract shall not imply this any lion or other severity interest has Gem placed on fire residence.Review Wa following cautious and notices
care(Wly before signing this contract
• D"4 be Pressured into signing the cour t Take time to read and fully Understand iG Ask questions ifsomedua is"dear.
• Make sure me ronrranM ham. val'd H me h" van C"tra ab . 7Le Imv g.
mbmaactors to be registered with the Dtrectw ofldume impmvemmt ist t n- Tl regtu+as most home impmvemmt contractors and
egistratioa You may inquire about contractor
registration by writing m the Dhecror at 10 Palk Pura,Room 5I70,Bosom,MA 02116 or by calling 617-973-9787 or 888-283-3757.
• Does the coonattor have fmvrance7 Ask the Contractor for his insurance compmy information so that you eon confirm coverage,or ask to
sat a copy ofa•proof ofirr,ormace'document.
• KamvYom tights and responsibilities. Read the IMPonaW information"the reverse side ofthis fans and get a copy of the Consumer
Guide to the Home Improvement Cmtraaor Law.
You ropy cancel this agreement iFit Dos tram signed at a place othertban rite contractafs normal ace of basin contracmrin Writing athisrher main office wbranch office by ordinary mail � .provided you notify fire
third business day following We si 'goFthis Posed,by telegrmn salt err by delivery,nW latadmn midnight of the
agreement Sce the attached entice ofrancdlation font form esplaaation ofthis right
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY gLAN]<SPACES:!!
Tnoidmtiaa rope ardemmr>amwhcampkay ad siyvM Oc o+NsmvWgo male Eommsw.nc�o0c ropy shadd h>+H be tle onrramn
etameonmer s St
Canimam a eg"tare
I Z 7i I vi 17/ 22 I Date Dme
Contractor Arbitration
The Home Improvement Contractor Law provides homeowners 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
contractor,however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless
both patties agree to the optional clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Home Improvement Contractor Law-
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute
concerning this contract the contractor)ney submit the dispute to a private arbitration firm which has been approved by
the Secretary of the Executive Of k6 of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitration prbvidddlit Massachusetts General Laws,chIgier 142A.
t,10AA41 uu// .
Homemvnees Si re Contractor's Signature
NOTICE:The signatures of the patties above apply only to the agreement of the parties to alternative 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 Rights
A homeowner's rights under the Home Improvement 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 property 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 the work as described.in a
timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for avorkmanship or materials. In addition to guarantees or warranties
provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfiilly agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have
questions about your consumer/homeowner rights,contact the Consumer Information Hotline(listed below).
Execution of Contract
The contract must be executed in dunlicate and should not be signed until a copy of all exhibits 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 must be in writing_
and agreed to by both parties.Contracted work may not begin until both parties have received a frilly executed copy of
the contract and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the payment schedule in rases where the
homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/berself
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 funds from said account would require the
signatures of both parties.
Additional Information
IFyou have general questions or need additional information about the Home hnprovement Contractor Law or other
consumer rights,or if you wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact
Consumer Information Hotline
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 5170,Boston.MA 02116
617-973.8787-888-283-3757 or visit the OCABR website at btto:%t=. t c.ma<:ere r`rc:hr
If you want to verify the registration of a contractor or ifyou have questions or need additional information specifically
about the contractor registration component of the Home Improvement Contractor Law.contact
Director of Home Improvement Contractor Registration
Office of Consumer Affairs and Business Regulation
10 Park Plaza,Room 517%Boston,MA 02116
617-973-8797,888-283 3757 or visit the HIC website at hitmiruAac.ma»^_or ocabri
Go online to view the status of a Home Improvement Contractor's Registration:
htin:;dbs[etc.maacltomehnnmvertent/6ccns�-list.asn
For assistance with informal mediation of disputes or to register formal complaints against a business,call:
Consuumer Complaint Section t
Offib4f the Attorney General
617-727-8400
AND/OR
Better Business Bureau
508-6524800.509-755-2548 or 413-734-3114
v„vm zt-t rn��to
The Commonwealth of Massachusetts Print Form.
Department oflndustrial Accidents
Office oflnvestigatdons
I Congress Street,Suite 100 I
Boston,MA 02114-2017
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(BusineWorganizatioNindividual): Atlantic Weatherizatiull,LLC:
Address: 61`je ll Avenue
SalPrahQ110[970
City/State/Zip: Phone#: 978' 7qt-(- YI 3
Are you an employer?Check the appropriate bog:
4. I am a Type of project(required):
1. I am a employer with ❑ 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
shipand have no employees These sub-contractors have
�P Y 8. ❑ Demolition
working for me in any capacity. employees and have workers' Building[No workers' comp.insurance comp.insurance.# 9. ❑ g addition
required.] 5. ❑ We are a corporation and its 1013 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL
insurance required.]t c. 152,§1(4),and we have no 12.❑ Roof repairs
employees. [No workers' 13.�er JN$to�a>L i7r.J
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 a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employes. If the subcontraemrs have employees,they must provide their workers'comp,policy number.
lam an employer that is providing workers'compensation insurance jar my employees Below is the policy and job site
information.
Insurance Company Name: &&t r i G h
Policy#or Self-ins.Lic.#: �5'1 rrah 7 O 12 1 Expiration Date: ,J b O
Job Site Address: &4— City/State/Zip: sa/ei-vi
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 5250.00 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 hereb cerd der the ins allies o perjury that the ht ormatton provided abo is true d correct
S to 2 I.lq
Phone#:
[6.
�cial use only. Do not write In this area,to be completed by city or town ojllaai
ty or Town: Permit/License#
uing Authority(circle one):
Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Otherntact Person: Phone#•
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